The End of Life

What is death?
What is a good death?
How will we all die?
“He who has a why to live can bear with almost
any how” (Nietzsche)
“Everyone knows they’re going to die, but
nobody believes it” (Andrew Lustig)
“ He passed away “ – termed used for “he died”
or to avoid facing the reality of death
 What is death?
Death anxiety – describes fear of the
prospect of dying.
According to Yalom, individuals avoid facing
their own morality in two defenses:
a. Against death is through immorality projects,
where people literally throw themselves into
commendable projects, their work, or raising
children.
b. Though dependence on a rescuer role,
believing that another person can provide
one with a sense of safety or protection from
death
 What is death?
Strangely enough, it is not being dead; rather,
it is the process of dying. Fears of losing
control of your body, suffering increasing pain,
losing the ability to do things you love to do,
being able to make decisions about your
medical care, being separated from loved
ones: Those are the ways that fears of dying
become real. Death is something that pushes
the edge of our comprehension (Spiegel)
 What is death?
Death signifies the end to a person’s living
embodiment.
Death is a haunting mystery to be discovered rather
than a comforting scene with the presence of family
members and other hovering over them (Hester)
Whatever type of death a person is to experience – a
good death; an anticipated death; a sudden
unexpected death; or a painful lingering death – most
of the time, people do not have a choice to how they
will die. Individuals, meanwhile, need to shift the focus
from thought “that we die” toward “how we die” so that
people can place considerable thought on future
decisions about end-of
 Euthanasia
Mercy killing
Good death
Easy death
Two major types of euthanasia
a. Active euthanasia – occurs when persons
commit an act to end a life. e.g self-
administered lethal injections of medications
ordered by a physician in physician-assisted
suicide
 Euthanasia
b. Passive euthanasia – when person allows
another person to die not taking any action to
stop death or prolong life. E.g. withholding
some type of treatment that would prevent
death
Two category of euthanasia
a. Voluntary – occurs when patients with
decision-making capacity authorize physicians
to take their lives.e.g. physician-assisted
suicide
 Euthanasia
b. Nonvoluntary – occurs when persons are not
able to do or not express their consent about
someone ending their lives.
Euthanasia is a morally right and humane act
on the grounds of mercy, autonomy and justice
(Battin)
The principle of mercy is based on two
obligations: the duty not to cause further pain
and suffering and the duty to act to end
existing pain or suffering
 Euthanasia
The principle of autonomy – is based on the
thought that health professional ought to
respect a person’s right to choose and
determine a suitable course of medical
treatment
The principle of justice is based on how
unsalvageable providers of care believe a
permanently unconscious person is; there is
moral justification in providers performing
euthanasia on patients that they regard as
unsalvageable.
Definition
of
Death
 A person who is dead is one who has
sustained either
a. Irreversible cessation of circulatory and
respiratory functions
b. Irreversible cessation of all functions of
the entire brain, including the brain stem
 Four Different Conceptions of
Death
Traditional – a person is dead when he is no
longer breathing and his heart is not beating
Whole – brain – death is regarded as the
irreversible cessation of all brain functions…
no electrical activity in the brain, and even
the brain stem is not functioning
 Four Different Conceptions of
Death
Higher-brain – death is considered to involve the
permanent loss of consciousness.. Someone in
an irreversible coma would be considered dead,
even though the brain stem continued to
regulate breathing and heartbeat
Personhood – death occurs when an individual
ceases to be a person. This may mean loss of
features that are essential to personal identity or
for being a person
Criteria to establish whole-brain
death
Flat EEG with other tests that document
the absence of cerebral blood flow
Fixed and dilated pupils
Inability to breath without mechanical
support
Absent brain stem reflexes
Advance Directive
Is a written expression of a
person’s wishes about
medical care especially care
during a terminal or critical
illness
 Living will
Are written documents that direct treatment in
accordance with a client’s wishes in the event of
terminal illness or condition
Each state has a requirement for the living will
Problems arise in living will – vague language,
contain only instructions for unwanted
treatments, lack a description of legal penalties
for those people who choose to ignore the
directives of living will, and when living will are
legally questionable as to their authenticity
 Medical Care Directive
Is not a formal legal document but provides
specific written instructions to the physician
concerning the type of care and treatments
that individuals want to receive if they
become incapacitated
Advantage: physician use them as guide to
know what incapacitated patients want in
terms of specific health care treatments
 Medical Care Directive
Disadvantage: people cannot possible
anticipate every medical problem that may
occur in their future.
 Durable power of attorney
Is a legal written directive in which a
designated person is allowed to make either
general or specific health care and medical
decisions for a patient
Has the most strength for facilitating health
care decision
There should be a durable power of attorney
for health care decisions on his or her own
behalf
 Deciding for Other
When patients can no longer make competent
decisions, families may experience problems in
trying to determine a progressive right course of
action
The ideal situation is for patients to be
autonomous decision makers but, when
autonomy is no longer possible, decision making
falls to a surrogate
Surrogate/proxy – either chosen by the patient,
is court appointed, or has authority to make
decisions
 Deciding for Other
Before any decision are made by a proxy, there
needs to be appropriate dialogue among the
physician, nurses, and the proxy.
Surrogate or proxy is either chosen by the
patient, is court appointed, or has other authority
to make decision
Proxies may not be able to distinguish between
their own emotions and concerns for patients or
they may have monetary motives for making
certain decisions
 Deciding for Other
It is the responsibility of nurses and physicians to
be observant for these kinds of motives or
concerns and then to look for therapeutic ways to
deliberate with the proxy
Three types of surrogate decision making:
a. Standard of substituted judgment – is used to
guide medical decisions that involve formerly
competent patients who no longer have any
decision-making capacity
 Deciding for Other
b. Pure autonomy standard – based on a
decision that was made by an
autonomous patient while competent but
later drifts to incompetency
c. Standard of best interest – based on the
goal of the surrogate’s doing what is best
for the patient or what is in the best
interest of the patient
 Medical Futility
Futile – represents pointless or
meaningless events or objects
When a health care provider cannot have
reasonable hope that a treatment will be of
benefit for a terminally ill person, the
medical treatment is considered to be
futile care.
 Cardiopulmonary resuscitation (CPR)
 Medications
 Medical Futility
 Mechanical ventilation
 Artificial feeding and fluids
 Hemodialysis
 Chemotherapy
 Other life-sustaining technologies
Right to Die and Right to Refuse
Treatment
Well-informed patients with decision-making
capacity have an autonomous right to refuse and
forego recommended treatments
Most of the time there are no ethical or legal
ramifications if a person decides to forego
treatment
The courts uphold the right of competent
patients to refuse treatment
Health care professionals need to make certain
that the patient’s decision is truly autonomous
and not coerced
Right to Die and Right to Refuse
Treatment
Health care professionals may find it very
difficult to accept a competent patient’s
decision to forego treatment
Withholding and withdrawing Life-
Sustaining Treatment
Nurses need to give compassionate and
excellent care to patients. No matter what
decision is made, family members and patients
need to feel a sense of confidence that nurse will
maintain moral sensitivity with a course of right
action
Nurses ethically support the provision of
compassionate and dignified end-of-life care as
long as nurses do not have the sole intention of
ending a person’s life
Alleviation of Pain and Suffering in
the Dying Patient
Attempting to relieve pain and suffering is
a primary responsibility for nurse and
providers of care.
Patients fear the consequences of
disease, that is, they fear pain, suffering,
and the process of dying
 Rule of Double Effect
It is defined as the use of high doses of pain
medication to reduce the chronic and intractable
pain of terminally ill patients even if doing so
hastens death
Nurses may have conflicting moral values
concerning the use of high doses of opioids,
such as morphine sulfate and other medications.
In times when nurses feel uncomfortable, they
need to explore their attitude and opinions with
their supervisor and when appropriate, in clinical
team meetings.
 Terminal Sedation
Is a phrase that did not appear in the literature
until the 1990s
No clear consensus regarding its meaning
“When suffering patient is sedated to
unconsciousness, usually through the ongoing
administration of barbiturates or
benzodiazepines. The patient then dies of
dehydration, starvation or some other
intervening complication, as all other life-
sustaining interventions are withheld.” (Quill)
 Terminal Sedation
TS has been used in three situations:
a. To provide relief of physical pain
b. To produce unconsciousness before
withdrawing artificial food and fluids
c. To relieve suffering
Nurses are not to have the sole intent of
ending a person’s life. Nurses need to evaluate
the intentions of physicians’ orders to the
extent possible and the intentions of their own
actions when giving care to patients in
questionable TS situation.
 Physician-Assisted Suicide
The act of providing a lethal dose of medication
for the patient to self-administer
Special guidelines relating to the Death With
Dignity Act in Oregon were written by the ONA
for nurses who care for patients who choose
physician assisted suicide. The guidelines
includes maintaining support, comfort and
confidentiality; discussing end-of-life options with
the patient and family and being present for the
patient’s self-administration of medications and
during the death.
 Physician-Assisted Suicide
Nurses may not inject the medications
themselves, breach confidentiality, subject
others to any type of judgmental
comments or statements about the
patient, or refuse to provide care to the
patient.
 Rational Suicide
Is a self-slaying based on reasoned choice and
is categorized as voluntary active euthanasia
Siegel stated that the person who is
contemplating rational suicide has a realistic
assessment of life circumstances, is free from
severe emotional distress, and has a motivation
that would seem understandable to most
uninvolved people in the person’s community
 Rational Suicide
For nurse to endorse any suicide seems
contradictory to good practice, because
traditionally nurses and mental health
professionals have intervened to prevent
suicide
 Rational Suicide
According to Rich and Butts there are no clear
answers to this ethical dilemma but interventions
become unique to each situation. Interventions may
include everything from being asked to provide
information regarding the Hemlock Society to being
asked about lethal injections. Autonomy and
beneficence need to be considered when nurses are
deciding on interventions for persons who are
planning rational suicide.
Moral problems encountered by
nurses:
Communicating truthfully with patients about
death because they were fearful of destroying all
hope in the patient and family
Managing pain symptoms because of fear of
hastening death
Feeling forced to collaborate with other health
team members about medical treatments that in
the nurses’ opinion are futile or too burdensome
Moral problems encountered by
nurses:
Feeling insecure and not adequately
informed about reasons for treatment
Trying to maintain their own moral integrity
throughout relationships with patients,
families, and co-workers because of
feeling that they are forced to betray their
won moral values
Management
of
Care
 The compassionate Nurse with a dying patient
a. Physical and emotional pain management
b. Core principles for end-of-life care
3. Because death is an essential human
passage, nurses must acknowledge and
respect the passage. Nurses, significant others
and patients themselves have an impact on
how that passage occurs
4. Always consider whether or not patients
actually desire an optimal level of pain
management and sedation to relieve pain and
suffering and respect their wishes. Patients
may wish for a balance between alertness and
level of comfort so that they can chat and feel
the presence of others
3. Palliative care should be comprehensive and
flexible for pain and symptoms management.
Treatments are warranted to enhance quality
of life
4. Avoid offering treatment options or any other
options that are unrealistic. Dying patients
are very limited as to their choices and
options and do not need to be offered
treatment options that do not have any
beneficial effects
5. Be respectful of the time that patients
and family members need for coming to
terms with their loved one’s death, and
for their own spiritual practices
6. Be respectful of time that is needed for
family members or significant others to
grieve, to come to terms with their loved
one’s death, and for their own spiritual
practices
7. Give attentive end-of-life care to dying
patients so that the ones who are
grieving can witness the nurse’s impact
on the facilitation of human passage.
The sight of well-cared-for dying loved
ones promotes emotional and physical
well-being among the grieving family
members and significant others
8. Avoid universal precautions and
expectations for dying patients. Every
death and death narrative is unique
“There is such an absoluteness to death.
Harsh words cannot be taken back.
Promises is unfulfilled can never be
completed. One cannot even say
goodbye. Facing the absoluteness of
death can be a tremendous stimulus to
life. If it is important, do it now… Say what
you mean to say. Settle old grievances.
Accomplish what needs doing, sooner
rather than later… Death is so
overwhelming that it is rather humbling.
There seems to be so little one can do
about it . Strangely enough, we always
resort to the same comfort: our sense of
caring about one another. In some sense,
we huddle together. Our bond of caring
forms a kind of talisman against the power
of death. Although, ultimately, each of us
has to face death alone, it is a tremendous
relief to do some of the work with
someone else. A good hug or some
shared tears may not save a life, but it will
make you feel more alive (Spiegel)
c. Spiritual considerations
- Spirituality is one of the most important aspects of end-
of-life nursing care, but often nurses feel helpless
when it comes to providing the right type of spiritual
care for their patients
- Spirituality is the one of the essential to nursing care
which is included in the palliative care
- According to Dossey and Guzzetta, spirituality is a
unifying force of a person; the essence of being that
permeates all of life and is manifested in one’s being,
knowing, and doing the interconnectedness with self,
others, nature and
God/Life/Force/Absolute/Transcedent
- Six categories and specific nursing
interventions for spirituality care:
1. Kindness and respect
2. Talking and listening
3. Prayer
4. Connecting
5. Quality temporal nursing care
6. Mobilizing religious or spiritual resources
- There are no completely “right” ways to
help a person die because of
individualized dying processes
- The involvement of nurses in decisions
about death becomes more complex
everyday as more technology is
incorporated into the dying process.
Family members and patients must be
involved with all ethical decisions that
are made