Legal Definitions of Death

An early legal definition of death was the cessation of the heart and lung
wherein the two were so interrelated that the cessation of one leads to the cessation of another,
followed by the cessation of all cognitive activity, all other brain functions,
and all responsiveness in general.

The cessation of the heart and of breathing was the simplest

to identify and the easiest test of life, and it became the acceptable definition of death.
Today, the majority of deaths in the United States are determined by this traditional
definition of death.

With medical technological advances, resuscitative devices, increased complexities of

life, and organ transplants, the heart–lung definition of death was found insufficient. Death is
a continuum, and different parts of the body die at different times. The heart may stop before
or after the client dies.

For example, in a heart attack victim, the heart stops beating, but the client does not die
immediately. Approximately 3 to 4 minutes pass before there is irreparable
brain death. At this point, the client is dead. Once the brain dies, there is no need for the
other body organs, and they die at various intervals.

Ethical Considerations

One ethical view is that euthanasia is murder because of either omission or commission.
Tied closely with this view are some religious beliefs that only God has the right to decide at
what moment a person should die and that euthanasia violates the command “Thou shall not
kill.” Some religious groups believe suffering is part of the divine plan for every person; others
believe that their faith cannot possibly tolerate a bad death for anyone.
The possibility also exists that clients pronounced incurable may recover, which would be
impossible if euthanasia already had been committed. Clients suffering greatly may request
to die on the spur of the moment with little thought of the ramifications.

Some people believe that legal euthanasia or physician-assisted suicide would weaken the
moral fiber of the country and may lead to such actions for eugenic reasons. If we can justify
death for one individual to prevent further suffering, why not for infants with severe disabilities
who have no possibility of a “normal” life? Consider the circumstances of an infant born
with severe congenital defects and intestinal obstructions requiring surgery.

The medical staff and parents may decide not to operate and let the infant die. Allowing this to
occur is not easy. It means watching a tiny infant gradually dehydrate and suffer from infection,
perhaps for a period of days. The ordeal can be terrible. Parents are protected from this
experience, but the medical staff is not. Many physicians and health professionals ask, “Would it
not be more merciful to inject the infant with a lethal dose of medication that would cause
death to come quickly and painlessly and prevent the suffering?”
Perhaps even more personal and difficult questions are “How do I want to die?” “What
kind of lifesaving measures would I want?” “Do I prefer active euthanasia or physician-assisted
suicide?” “Can I stand to suffer?” “Do I have any control over my own death?” “Do
I have a right to die as I choose?” “What would I want health professionals to do for me?”

The Role of Health Professionals in Health Care

Health care employees will make life-and-death decisions in personal relationships

with their families and friends, but rarely in any professional capacity.
They often, however, may be involved in conversations with clients or their families who are
struggling with the question. They also may be sounding boards to physicians involved in
the decision-making process. Certainly the law should be followed, religious and cultural
practices considered, and the clients’ rights protected when possible, but no clearly established
guideline is available.
Clients who willingly and openly discuss their beliefs and wishes concerning their own
deaths should be encouraged to complete living wills or physicians’ directives and durable
power of attorney documents. Legal counsel should be recommended to people if appropriate.
Clients should not be made to feel ashamed or guilty because of their feelings about
death, no matter how much they differ from your personal feelings.

Health professionals must be understanding and compassionate. Every attempt must be

made to respect the feelings of clients and their families. Families should be allowed to express
any guilt they may feel in making decisions. A clear picture of the circumstances, explained
by the physician in words clients can comprehend, can alleviate much of that
problem. Clients who have strong feelings about having their lives prolonged should be
encouraged to make their wishes known.

When health professionals are confronted with situations or questions they cannot handle,
consultations and referrals should be sought. Attorneys may be called, and medical societies
may offer assistance. Hospital ethics committees may be valuable. Hospital chaplains, staff
psychiatrists, and social workers are specially trained to help others with these personal and
processional issues. Decisions of the kind discussed in this chapter weigh heavily on the
minds of those involved. That weight should not be allowed to become too great.

Summary

Choices about dying are best made while living whenever possible. Legal documents should
be executed and shared with loved ones, family members, and health professionals in order
to ensure that personal wishes are followed. These choices are not easily made unless there
is a willingness to discuss the issue of death and what measures are to be taken when dying.
If death can be viewed as another stage in life, even if the final one, it will be easier to have
this discussion. Health professionals are bound to abide by the wishes of their clients within
legal parameters.
 “ Death is not the greatest loss in life.
The greatest loss is what dies inside us while
we live. ” Norman Cousins

Death is the final stage of life. Dying is a process or a preparation for the final conclusion
—death. For some, dead is a four-letter word not to be discussed; to others, the word represents
an unpleasant reality difficult to think about or plan for. Some handle the concept realistically
and well. In many respects, the way people face their dying or their death may be determined by
how they live.

Most health professionals will work with clients who die and will respond to their
surviving loved ones. How health professionals face this process may also be determined, in part,
by how they face their own life and their own death.

Living with Dying

Dying is a personal event. No two people die alike. Some die very quickly whereas others
have time to plan for their deaths. Most hope for an easy death. To attempt to identify particular
models for the “best” way to die is fruitless. None exists. Each person is unique, and the
life experiences brought to the situation are varied. However, some helpful generalizations
can be made.

1. The way people live is often mirrored in the way they die.
2. People with useful support systems, such as friends, family, and faith in life, may find
this support helpful in dying.
3. Experiencing the death of someone close brings the reality of dying more into focus.
4. Intellectual preparation for dying, such as writing a will, an obituary, or planning a funeral
may ease the fear of death.
5. Relationships with families and friends change.
6. Basic personalities usually remain unchanged, but moods may vary radically.
7. Personal goals are reevaluated.
8. Pain, suffering, and dependence are feared most by the dying.
9. Dying is not a casual experience.
10. The age of dying persons in part determines their reaction to death.
11. Persons who experience chronic disease or disability face their immortality more acutely
than others.
12. Cultural mores influence attitudes toward death.

Suffering in Dying

Generally, everyone says they would prefer dying peacefully in their sleep or dying suddenly
without warning or pain. In truth, most of us will lose our lives more gradually. Old age, debility,
even senility may creep in before we realize that we have lost much of what we valued
in our faculties. We may be diagnosed with a life-threatening illness that we believe will
cause our death. Some will suffer in pain and agony. Some will be the object of medical
experimentation and technology. It is this fear of suffering, the fear of dependence, the fear of
loss of control, the fear of leaving loved ones, and the fear of pain that scares us most about
death. Short-term suffering presents a set of problems different from those of long-term
suffering.

This can best be seen in the following situations:

Example 1
A 45-year-old teacher learned in June that chronic myelocytic leukemia accompanied
by blastic transformation was destroying his body. The prognosis was poor. Hospitalization
and chemotherapy followed, with severe side effects and pain. He died 2
months later, never returning home.

Example 2
A 50-year-old electrician was diagnosed as having cancer of the colon. Surgery followed,
and a permanent colostomy was established. Postoperatively, the client did well
and later returned to work part-time. Within a year, cancer metastasized and complications
resulted. Consultation with specialists recommended only symptomatic treatment.
Her pain required massive doses of analgesics to keep her comfortable for the
remaining 6 months. The electrician was unable to return to work but remained home
until about 6 weeks before death, when she was again hospitalized.
ln a comparison of these two examples, time, costs, and dependency are three variables to
consider. Obviously, the time of pain and suffering was longer for the electrician than for the
teacher. The severity, however, cannot be compared. Overall costs are far greater for the
electrician than the teacher, but nothing is known of insurance coverage or family resources.
Either situation could be a financial burden on survivors. Dependency of these clients on
their friends and family is somewhat different. The teacher had to depend on someone to
take care of any personal matters, which might include job, children, and finances, for
approximately 2 months. The electrician, however, was dependent on family for physical and
nursing care in the home. She also needed someone to take care of personal matters from
diagnosis to death, approximately 18 months.
Even the length of time is difficult to establish. Time is relative; that is, 2 months and 18
months may both be considered short term when compared with an individual in a state of
semiconsciousness for 4 or 5 years.

Use of Medications
Medications are used by the suffering when dying in both the hospital and at home. The
greatest difficulty with medications arises in long-term suffering. Medications are given for
many reasons, including analgesics for pain, sedatives for sleep, and specific medications for
the particular disease condition. Antidepressants and tranquilizers also may be prescribed.
Medications are to be respected for their intended action and the client’s needs.
Problems arise when family members, friends, and even health professionals circumvent
or question the physician’s orders for medications. This is often disastrous for the client. All
people who are most like themselves. The more the disease impairs the physical and mental
persons close to the client ought to understand the physician’s orders and the use of the
prescribed medications. Family members should know the reasoning of the physician so that
any questions arising are not misunderstood. For example, imagine the fear a loved one feels

when the pharmacist says, “Do you know this is a near-lethal dose?” Unless the loved one

knows that this amount is needed to keep the pain level of the client bearable, the loved one
may withhold the medication and even begin to distrust the physician.

Family members need to understand that medications may be given in different

dosages, frequencies, and combinations for one dying client than for another. Age, weight,
illness (whether chronic or acute), and the client’s threshold for pain all influence a physician’s
choice of analgesics.

Sometimes physicians and health professionals are reluctant to prescribe or administer

medications even though they are within the approved dosage range. In fact, in some cases

health professionals will administer less than the prescribed dose because they believe

what was prescribed was too much. Some may fear the client will become addicted. Physicians

may see opioid orders or prescriptions as crimes, not as treatment issues. They fear
investigation. The client or family may want to use less than the amount prescribed because
they believe it is too much. Clients may wait too long to ask for pain medication, thinking they
“can handle it.” All have the potential of working against the clients’