Thread: Death and Dying: Medical, Legal and Ethical issues

Death is an inevitable end to life. Those of us involved closely with management of ill and critical patients will witness death of patients, which can be a painful experience.

Death being what it is, it is surrounded by many issues. Medical issues related to diagnosis of death, legal and ethical issues relating to diagnosis, organ donation, and 'do-not-resuscitate' (DNR) status, for example.

Let us discuss these issues briefly here.

First response reserved for later use, if necessary.

diagnosis of death:

depends upon fulfillment of:

a)preconditions: patient is deeply comatosed
=hypothermia,acid base imbalance,metabolic/ endocrinal abnormalties EXCLUDED
=no suspicion of depressant drugs
=patient is maintained on ventilatory support
=diagnosis of the disorder has been firmly established and patient is suffering from irreversible brain damage

b) test to confrim brain death
=pupils are fixed and not reacting to light
=corneal reflex absent
=caloric test absent
=no motor response to adequate stimulation
=no gag reflex
=no respiratory movement when the patient is disconnected from the ventilator and pCO2 rises more than 6.7kPa

diagnosis is made by 2 experianced doctors---1 consultant and another consultant/specialist

Death:
An individual who has sustained either (1) irreversible cessation of circulatory and respiratory functions, or (2) irreversible cessation of all functions of the entire brain, including the brain stem is dead.

Brainstem death:
1) unresponsiveness, absent brainstem reflexes (eg, pupillary, caloric, corneal, pharyngeal), and absence of effective respiratory movements in the presence of adequate oxygenation and arterial pCO2 of 60 mm Hg
2) clinical or neuroradiologic evidence of an etiology adequate to explain the clinical findings
3) adequate observation period to guarantee irreversibility
4) exclusion of reversible factors that can confound assessment, such as drug intoxication or body core temperature less than 90°F
5) use of serial exams or confirmatory tests (eg, EEG, blood flow studies) to assist in diagnosis in situations of clinical uncertainly, but these are not routinely required for diagnosis.

Dying
Dying may be marked by deterioration over a long period of time, punctuated with bouts of complications and side effects. However, dying usually follows other time courses. Sometimes, a person being treated aggressively for a serious illness in a hospital abruptly worsens and is known to be dying only a few hours or days before death.

Death
Today, death is often seen as an event that can be deferred indefinitely rather than as an intrinsic part of life. Medical procedures commonly extend the lives of people who have such diseases as heart disease, cancer, stroke, chronic obstructive pulmonary disease, pneumonia, and dementia, often giving them many years in which quality of life and function are quite good. Other times, procedures extend life, but the quality of life and function decline.
Talking about the likely outcomes of illness, including death and dying, is an important part of health care.

causes of death: includes homicide, suicide, misadventure or any natural diseases/illness.

Diagnosing death:
- Apnoea with no pulse and no heart sounds, and fixed pupils.
- If on ventilator, brain death may be diagnosed even if heart is still beating.
- Brain death is death of brainstem, recognized by establishing:

• deep coma with absent respirations
• the absence of drug intoxication and hypothermia
• the absence of hypoglycemia, acidosis and electrolytes imbalance
• tests: all brain stem reflexes should be absent
• other considerations - repeat tests after a suitable interval e.g 24hrs. The doctor diagnosing brain death must be a consultant , the opinion of one other doctor should also be sought.

Organ donation:
- the point of diagnosing brain death is partly that this allows organ to be donated and removes with as little damage from hypoxia.

After death:
- inform consultant. Inform the relatives. Sign death certificates promptly. If cause of death is by suicide, violence, injury or unknown, inform apropriate authorities e.g police department.



Sometimes, in spite of treatment, a condition or illness will cause death. In those cases, patients can decide what they want to be done and not to be done. Patients can decide whether they want treatment that might prolong life or whether they prefer to stop treatment, which could mean dying sooner but more comfortably. They may want to plan their own funeral.
Care at the end of life focuses on making patients comfortable. They still receive medicines and treatments to control pain and other symptoms. Some patients choose to die at home. Others enter a hospital or others. Either way, services are available to help patients and their families deal with issues surrounding death.

Death and Dying

Definition of death:

A death is one that is: free from avoidable distress and suffering for patients, families, and caregivers; in general accord with patients' families' wishes; and reasonably consistent with clinical, cultural, and ethical standards

Causes:

• Tobacco Usage
• Physical inactivity
• Alcohol consumption
• microbial agents and toxic agents
• Motor vehicle accidents
• incidence involving firearms
• Sexual behaviour
• illicit usage of drugs

Diagnosis of death person:

1) no gag reflex
2) no corneal rerflex
3) pupils are fixed and not responding to light
4) negative caloric test
5) no respiratory movement
6) no motor response following stimulation
….. it is made by 2 experienced doctors ----1consultant and another consultant/specialist

condition when patient is comatosed:

1) hypothermia
2) patent on ventilatory support
3) no suspicion on depressant drugs
4) acid base imbalance
5) metabolic and endocrinal abnormalities excluded.

Components of death:.
1. Pain and Symptom Management:
Many people fear dying in pain. Fear of pain and concerns about inadequate pain management can cause a significant amount of anxiety and distress for both the dying patient and their family.
Many times this anxiety can be relieved or at least lessened with appropriate reassurance and clear decision making strategies.
2. Clear Decision Making:
Patients feel more empowered when allowed to participate in decisions about treatment options. In other words patients want to have a say in their treatment plans.
Fear of pain and concerns about poor symptom management can be reduced by good communication and determining a clear decision plan with the patient, their family and physicians.
Clear plans discussed before hand help reduce the chance of needing to make difficult decisions during the midst of a crisis, when people may be more emotional and less capable of thinking clearly.
3. Completion:
For many people Completion, or finding meaningfulness at the end of life, involves reviewing their life, resolving conflicts, spending time with family and friends, and the chance to say goodbye.
In western culture Completion is often an individual life review that then gets shared with family and friends. With other cultures Completion may involve other members of the dying person's community and certain cultural rituals that are important parts of the dying process and coping after the death.
Issues of faith also important are individualized. Cues need to be taken from the patient how these might be expressed.
4. Contribution to Others:
Many people at the end of life have a desire to contribute to others. These contributions can be gifts, time or knowledge.
As the end of a person's life draws nearer, many people finally discover what is important to them in life; they discover that personal relationships are more important than professional or monetary gains and want to share these significant insights about life (learned from dying) with others. "
5. Affirmation of the Whole Person:
With end of life care, it is important for health care providers to affirm or recognize the patient as a unique, whole and complete person (mind, body and spirit). It is important for providers to consider the person in the context of their lives, their values and their personal preferences...and not just as a disease, a case or a patient.
These personal, touching relationships with patients and families are often what allow healthcare professionals to continue working in this challenging area of medicine.
Findings:
The results of this study helped confirm four important themes that were already known in palliative care:

• Pain and Symptom Management
• Clear Decision Making
• Preparation for Death
• Completion

Two new unexpected themes about a good death were also discovered from the study:

• Contributing to Others
• Affirmation of the Whole Person

12 principles of good death:
1.To know when death is coming, and to understand what can be expected.
2.To be able to retain control of what happens.
3.To be afforded dignity and privacy.
4.To have control over pain relief and other symptom control.
5.To have choice and control over where death occurs (at home or elsewhere).
6.To have access to information and expertise of whatever kind is necessary.
7.To have access to any spiritual or emotional support required.
8.To have access to hospice care in any location, not only in hospital.
9.To have control over who is present and who shares the end.
10.To be able to issue advance directives which ensure wishes are respected.
11.To have time to say goodbye, and control over other aspects of timing.
12.To be able to leave when it is time to go, and not to have life prolonged pointlessly.
How to recognize active dying
Active Dying is the final phase of life, which is usually measured in months, weeks, days or hours. Once a person has entered the actively dying phase, the focus of their care shifts from aggressively treating medical problems to providing comfort or palliative care.
Family, friends and caregivers tending to the needs of a loved one in his or her final stages of life often want to know how they may recognize that the end is near, the final days or hours are approaching or the person is "Actively Dying."
Some of the more common symptoms that occur during the last days or hours of life are listed below.
Difficulty: N/A
Time Required: 5 - 7 minutes to read.
Here's How:

1. The body systems slow down.
Decrease in urine output (amount), change in color of urine.
Decrease in blood pressure.
Inability to swallow food or fluids.
Speaking decreases.
Person stops responding to questions.
2. Decrease in appetite and thirst.
Along with inability to swallow, decreases in appetite and thirst affects the amount of food or fluids taken by mouth.
3. Nausea and vomiting.
Will also contribute to the decrease in appetite.
Nausea and vomiting can be side effect of some of the pain medication, which can be managed by adjusting the medication or the dosing.
4. Change in breathing patterns.
Breathing patterns may become becomes irregular--shallow breaths followed by deep breath, periods of panting
Cheyne-Stokes breathing pattern develops - several rapid breaths, followed by time of no respirations.
Difficult or painful breathing, shortness of breath (dyspnea)
Gurgling - noisy and moist breathing
Congestion - Building up of fluids in the lungs

Death:
1. The end of life. The cessation of life
2. The permanent cessation of all vital bodily functions.
3. The common law standard for determining death is the cessation of all vital functions, traditionally demonstrated by "an absence of spontaneous respiratory and cardiac functions."
4. The uniform determination of death. The National Conference of Commissioners on Uniform State Laws in 1980 formulated the Uniform Determination of Death Act. It states that: "An individual who has sustained either (1) irreversible cessation of circulatory and respiratory functions, or (2) irreversible cessation of all functions of the entire brain, including the brain stem is dead. A determination of death must be made in accordance with accepted medical standards."

Dying
Dying refers to the body's preparation for death, which may be very short in the case of accidental death, or can last weeks or months in some patients such as those with cancer.

End of life care is often overlooked in busy day-to-day medical practice. Physicians need to recognize that death is inevitable for many medical conditions despite aggressive treatment. Optimal end of life care begins with an honest discussion of disease progression and prognosis.

End of life care is an important topic that unfortunately has been overlooked in the past. In the process of striving to achieve better understanding and treatment of medical conditions, modern medicine often fails to recognize the inevitability of disease progression despite aggressive medical management. The result is that physicians sometimes fail to provide adequate supportive care for their patients near the end of life. It must be recognized and emphasized that the spectrum of patient care includes appropriate care for patients who are terminally ill in addition to preventive care, diagnosis, and medical care.

Terminally ill patients are those whose expectancy is relatively short and whose treatment has shifted from a curative regimen to supportive or palliative care. The World Health Organization defines palliative care as “the active total care of patients whose disease is not responsive to curative regimen”. The goal is to achieve the highest quality of care for the patient and family.

The prognosis of a patient with a life-limiting disease should be estimated according the best available medical data, and physicians should be honest and forthright in discussing this information with the patient and family. The prognosis of malignant diseases can usually be determined from the staging of the disease. The prognosis of chronic nonmalignant diseases must be based on clinical progression as documented by serial medical assessments, history of multiple emergency room visits or hospitalizations over the past 6 months (or nursing assessment of progression in homebound patients), and a recent decline in functional status as determined by clinical assessment, decreased performance test results, and a high dependence during the activities of daily living. Documented recent impairment of nutritional status related to the terminal process can also be utilized for assessment.

With continuing advances in and reliance on medical technology, end of life care is often overlooked. Physicians have to recognize that, for certain diseases, death is inevitable despite aggressive treatment. Initiation of end of life care begins with an honest discussion of disease progression and prognosis. By coordinating the care with the family and a hospice program, terminally ill patients can achieve relief of pain and other unwanted symptoms, leading to a good quality of life for their remaining time.

Medical issues related to diagnosis of death, in other words from my point of view diseases that the patient might have that will lead him to a certainty of death however the duration is not certain. Simply meaning, patient may live longer than the estimated duration of survival.
Never the less, there are patients who are not diagnosed to be death, but due to circumstances or other inevitable cause, they may die. There is a saying that ‘death comes like a thief’ where by one would not know when death comes to them.

Other medical issue is regarding the management of certain hospital on patients who comes in emergency basis who requires immediate medical attention. Due to lack of responsibilities by the doctors themselves, such as not attending to them may cause patients to lose their lives. Even surgical error, which is the fault of a doctor could lead to complications subsequently death. Besides doctors, certain facilities that should be up to the optimist level especially in tertiary hospital are not up to the mark, which may be useful in diagnosing a patient, that could save a his or her life.

All hospitals will have certain protocols that should be followed in managing a patient based upon their diseases, however despite following the protocols some patients may die. Legally, doctors may escape from getting sued, but these may train the doctors to always follow the book not their instinct in what they think is right, that may or may not help the patient. Most doctors, chose to be on the safe side, by following the protocols given by the hospitals because at the end of the day who would want to live a life with constant lawyer notices in their door step.

Under doctors’ ethics, it is said that one doctor must not comment on another doctor’s way of managing a patient because it is ethically wrong. A doctor in my context is specialist, where by he is in charge of a particular patient at that point of time. No one would be there to correct him, if he was wrong in managing or diagnosing a case that may be fatal for the patient. So much so, for doctors that are highly egoistic who thinks he is highly in depth of medical knowledge.
They are certain criteria’s for patient whose in need of organs, because it doesn’t work in first come first serve basis. It goes upon, patient who needs it urgently and availability at a particular time. Despite of availability, organ rejection may also be one of the factor of death which in certain cases is inevitable.

Patient who are sure to be dead in few years or months after being diagnose to have cancer with distant metastasis, it is best to give them a good quality of life in their final years of life. A good quality of life, meaning pain free, able to eat , past motion and everything else like a normal human being in their day to day life.

A pride of being a doctor is when we can actually save patients who are impending death, and that you have revived him, will be appreciated not only by your patient but also their family members for a long time.

DEATH AND DYING

Death means cessation of all vital bodily functions. It is inevitable and with all our advances in the modern world, we can still only prolong it but cannot stop it. As many would remember a famous movie called ‘Final Destination’ gave the message that, you can cheat death but cannot conquer it.
In our medical profession, we come across death very often. It can be sudden caused by the common heart attack to the even more common road traffic accidents; or expected as in late stage tumors. In this perspective, death is the end state and dying is the process leading to that state. Both of these words, death and dying is shrouded in various legal and ethical issues.
In medical literatures we would come across these two terms somatic death meaning cessation of vital cellular activity and brain death which in short means the complete absence of any sort activity, function or reflexes of the entire brain. In our modern setup, we now get many situations in which the patient is on ventilators but is already brain death.
Brain death is confirmed when all brain stem reflexes like reactive pupil, carbon dioxide stimulation to respiration, gag and corneal reflexes are absent. It is also confirmed when an EEG shows no waveforms for 30 minutes. Here, it is important to rule out hypothermia and CNS depressants intoxications as this would mimic brain death. The confirmation should be done by two consultant doctors, one being a specialist registrar and this can be repeated after 6 to 12 hours if required.
Dying is a little trickier, for many patients with chronic progressing illness like malignancy, there will be a time when it will be futile for any intervention and it may be more dangerous if done, as death is already on the cards for them. It is important for us as doctors to identify this phase of dying and inform the patient (if appropriate) and also family members to be prepared. In this phase some steps in the management should be taken, some of these are stopping unnecessary drugs, symptom relieve if required, ensure awareness of the patient and family members of the situation and plan and accommodate any spiritual and religious believes. It is important to assess the patient’s condition after disclosing this unfortunate predicament as many may go through depression, denial and depersonalization. Anyone will be scared when they know they will die soon. Some take it strongly some crumble and make their condition worse or accelerate their death
The tricky part is when the ethical issues come in. There are 3 main principles which come into play in the dying phase and death is inevitable; honouring the patient’s wishes; providing more benefit than harm; legal and fair. Very often these principles conflict, example is it legal to respect the patient’s wish to pull the plug, then to let him suffer more by prolonging the life or provide an illegal treatment based on patient’s wishes. In many western countries the patients wishes are taken into a great consideration, however in many parts of the world this is not followed and many aspects such as legal, humane and moral issues are also considered.
In my opinion when I am dying, I would choose to stop treatment if it’s not going to improve my condition and if by prolonging my life it is going to make me bedridden or suffer even more, I would take death willingly. I do believe in respecting the patient’s wishes. This should be kept in mind, when the patient is incapacitated, and with impending death it is important to find out if there were any legal documents on how the management should be continued or if the patient has told his/her close relations on what he/she wishes. Of course it must be confirmed and completely disclosed that the condition is not reversible, no improvement can be achieved in all practical purposes and keeping the patient is going to be harmful than beneficial. Many issues such as euthanasia has also become important to discuss as whether it is contradicts ethics and the individual’s desire.
As much as varied each and everyone’s opinion may be, it is vital to follow the rules and principles drawn out by the government in that particular setup as it covers the interests of that society’s cultural, religious social believe. A balance should be achieved with what the patient wants and what’s best for the family and the patient, also keeping the legal, ethical and moral in mind, when it comes to death and dying.