Death and Dying: Medical, Legal and Ethical issues

Death and Dying

We are alive, therefore we will die. This is the simplest, most obvious truth of our existence, and yet very few of us have really come to terms with it. The dying process is unique to each individual. The actual date or time of death is unpredictable.

Death and dying find a way of impacting our daily living. We see images of real or fictional death when watching television or movies. Death can impact us on a personal and a cultural level. In End-of-Life, Hospice or Palliative Care the focus is on "living" until the end, living each moment, rather than on "dying" or the dying process. Coping with the loss of a loved one is often one of the most difficult challenges a person may face.

A sudden death occurs without any forewarning; it is unanticipated. A traumatic death, in addition to being sudden, can also be violent, mutilating or destructive; it can be random and/or preventable or may involve many deaths. This sudden, accidental, unexpected or traumatic death shatters the world as we know it; they leave the survivors feeling shaken, unsure and vulnerable.

As future doctors and healthcare workers, we definitely will face situations pertaining to death and dying process. I believe we need to respect patients, patient’s relatives and treat them with utmost care, and love when they are dealing with death or the dying process.

Death and Dying: Medical, Legal and Ethical issues


Death can be simply defined as the cessation of life, often seen as a gradual process at the cellular level (in multicellular organisms) where tissues of varying ability are deprived of oxygen. It can be also said as cessation of integrated tissue and organ functions . In humans, death (thanathology) was once defined as the cessation of heartbeat (cardiac arrest) and of spontaneous breathing, but the development of CPR and prompt defibrillation have rendered the previous definition inadequate because breathing and heartbeat can sometimes be restarted. This is now called "clinical death". In the current medical scene where a definition of the moment of death is required, doctors and coroners usually turn to "brain (cerebral) death" or "biological death":

People are considered brain dead when the electrical activity in their brain ceases ; associated with loss of cerebral and brainstem functions (manifested by absence of responsiveness to external stimuli, absence of brainstem reflexes and apnea ). Diagnosis is confirmed by two recognised general practitioners, 6 – 12 hours apart and if possible, supported by an isoelectric EEG for at least 30 minutes with exclusion of hypothermia (rectal temperature <35 C) and poisoning by CNS depressants(narcotics, hypnotics or tranquilisers). There should be no abnormalities in serum electrolytes, acid-base balances, glucose levels or metabolic/ endrocrine causes of a comatose state.The diagnosis of etiological disorder should be firmly established.

Dying refers to an ongoing process which is as variable as the birth process. It is a common term used in context of people in advanced stages of a terminal illness who experience many similar symptoms as they approach the end of life, regardless of the cause.

These changes can be both physical and emotional such as excessive sleepiness and weakness,breathing changes (eg. periods of rapid breathing alternating with short episodes of apnea) ,visual and hearing changes including hallucinations.
There may be also decreased appetite as the metabolism slows,urinary and bowel changes; such as concentrated or bloody urine and constipation; and sometimes temperature changes. The emotional changes include becoming depressed, subdued, disinterested with surroundings and socially dissociated.Dying people may also experience symptoms specific to their illness.




In the legal point of view during dying and at the onset of death, two documents are important in extending personal control over medical care when a person becomes incapacitated; a living will and a durable power of attorney for health care. Both documents are called advance directives because they direct, in advance (when the person is capacitated), decisions about aspects of medical care to be carried out during any period when the person can no longer effectively communicate those decisions. An advance directive becomes effective only after incapacity has been determined.

If no advance directive has been prepared, someone must be appointed to take control of medical care decisions. In such cases, doctors and hospitals usually turn to the next of kin. In the event where the issue is referred to court, control is usually given to a family member..

A living will expresses a person's preferences for medical care (it is called a living will because it is in effect while the person is alive). The liable time for creating a legally effective will varies according to countries. To be valid, a living will must comply with state law and be written in a standardized way. It can be prepared in such a way to indicate preferences for aggressive medical treatment or prevent heroic attempts to extend life.

A power of attorney for health care for decision making is a document in which one person (the principal) names another person (the agent, or the attorney) to make decisions about health care and only health care. A power is durable if it remains legally in force, even when the principal becomes incapacitated. It is more flexible and comprehensive than a living will. It allows one to designate a surrogate decision maker, presumably a friend or relative, to make the medical decisions when he/she loses the ability to make them

Advance directives however has its limitations. For example, an older adult may not fully understand treatment options or appreciate the consequences of certain choices. Sometimes, people change their minds after expressing advance directives and forget to inform others. In other times they may be too vague or outdated to guide clinical decisions. In these conditions good communication can resolve many problems. Health care providers should readily share information regarding patient’s illness and treatment options .

In the ethical point of view, advances in medical technology have often created medical dilemmas especially in life sustaining treatments like CPR and assisted ventilation where treatment only prolongs life. An informed person who is capable of making medical decisions may refuse life-sustaining treatment, such as cardiopulmonary resuscitation (CPR), intensive care, transfusions, antibiotics, and artificial feedings. An informed refusal should be respected, even if the person’s life may be shortened as a result and even if the person is not terminally ill or in a coma.

Cardiopulmonary resuscitation (CPR) may be an effective treatment for unexpected sudden death, but it is not effective for people whose death is expected. Older adults generally do poorly after CPR because of serious illnesses and decreased functional status.

When CPR is medically pointless and thus ethically inappropriate, a patient should not be offered the choice between CPR and no CPR. Instead, the physician should generally write a do-not-resuscitate order and explain why CPR is not indicated. When CPR might be of benefit, the physician must make sure that all concerned are aware that the likelihood of survival is low even if CPR is administered.


Artificial feeding can become an even greater problem in severely mentally disturbed individuals who consistently refuse food offered by hand or who are unlikely to suffer hunger or thirst. Tube feedings can also cause medical complications, such as pneumonia if the artificial nutrition is breathed into the lungs

Because individuals often pull out feeding tubes, demented individuals on tube feedings are often physically restrained (ie, strapped down). This removes what little dignity and independence these people have left. Sedation or "chemical restraint" might seem more acceptable on the surface, but often have unacceptable side effects.

Active euthanasia (also called mercy killing) is only legal in Belgium. Requests for it generally arise because individuals suffer uncontrolled pain, demand more control over their care, or fear abandonment. However, many terminally ill people who have requested euthanasia change their minds after pain has been relieved. Self-administered pain medication (eg, PCA morphine pump) can help to both relieve pain and provide a feeling of control, which is central to a person’s comfort.

There is great potential for abuse with active euthanasia. Because of this, opponents say that allowing voluntary euthanasia might all too easily lead to involuntary euthanasia of helpless people. Also, some feel that physician involvement in euthanasia may undermine trust in doctors, because doctors should be viewed as healers, not life takers. Active euthanasia should be distinguished from the withholding or withdrawal of treatment, which is sometimes termed "allowing to die" or "passive euthanasia.".It is legal worldwide.

Most suicides are impulsive acts that are not well thought out. Also, people who seriously consider suicide usually suffer from depression. Because individuals who are incapacitated by depression cannot make informed decisions, family and friends are quite likely to get involved and seek medical advice. Physicians have traditionally felt it their duty to intercede or prevent suicide. In addition, many physicians believe that assisted rational suicide is unethical for the same reasons that they oppose active euthanasia. undermines a person’s trust in doctors.

For some people, however, suicide might be considered a rational choice. For example, a rational person might consider suicide if he or she has widespread cancer and unbearable symptoms that cannot be improved with medication. A person in this situation may feel that continuing to live with a progressive illness of this type is degrading, and may want to have control over his or her death. In most states, the law prohibits assisted suicide. However, the US Supreme Court has decided that physician-assisted suicide is not necessarily unconstitutional, leaving each state to settle the issue for its residents. For example, physician-assisted suicide has been legal in Oregon since 1997, although experience has shown that it is a rarely used alternative

Death and dying


DEATH:
The cessation of life; permanent cessation of all vital bodily function.
It can be divided into:
1.Somatic death means the cessation of vital cellular activity.
2.Brain death in short means the complete absence of any sort activity,
function or reflexes of the entire brain.
To certify a person to be brain dead the following should be present: -
ü Pupils are fixed and not reacting to light
ü Corneal reflex absent
ü Caloric test absent
ü No motor response to adequate stimulation
ü No gag reflex
ü No respiratory movement when the patient is disconnected from the ventilator and pCO2 rises more than 6.7kPa

2 experienced doctors---1 consultant and another consultant/specialist is always required to certify that the patient is brain dead.

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.

Ethically, the doctors main role in providing are to the dying can commonly be divided into 2: - "beneficence" - benefit the sick," and "nonmaleficence." -"do no harm" in the process of helping the patient. These principles are reflected in medicine’s chief goal, which is to help the sick by lessening the suffering that is often associated with their diseases, but at the end of the day the patient plays the most important role in deciding the faith of his/ her life by deciding about forgoing life-sustaining intervention (patient autonomy).

Euthanasia is an act in which a physician directly and intentionally causes a patient’s death by medical means. When the physician performs euthanasia with the consent of the patient, it is called voluntary euthanasia. When euthanasia is performed without patient choice, such as may be the case with incapacitated patients; it is called nonvoluntary or nonchoiceeuthanasia.

"People imagine that they are not afraid of death when they think of it while they are in good health" - Marcel Proust

As a thought experiment, place a finger in your left supraclavicular fossa and feel there the node of Virchow, telling of some gastric malignancy, as if it was a death warrant. Perhaps you just have 4 months left. Live with this knowledge for a day or two and see how it changes your attitude to family and friends on the one hand and the million irrelevances which clutter our minds on the other.
As the weeks unfold, you may experience thoughts and feelings that are knew to you but all to familiar to your patients. And as the months and years roll by, and you find yourself sitting opposite certain patients, put that finger once more on that metophorical node and turn it over in your mind, and it will turn you, so much you are sitting not opposite your patient but beside him.
But there is only so much comfort you can bring in this way, as, in the end, you cannot tame death.

-Oxford Handbook of Clinical Medicine-


Stages of acceptance of death:

• Shock and numbness
• Denial
• Anger
• Grief
• Acceptance - longing for death as the patient moves beyond the reach of wordly cares.

Diagnosing death:

• Apnoea with no pulse and no heart sounds, and fixed pupils.
• If on ventilator, brain death may be diagnosed even if the heart is still beating, via the UK brain death criteria which states that brain death is death of the brainstem recognized by establishing:
  - deep coma with absent respirations
  - the absence of drug intoxication and hypothermia
  - the absence of hypoglycemia, acidosis and urine and electrolytes imbalance

Death and Dying

The death of a loved one is a severe trauma, and the grief that follows is a natural and important part of life. No two people grieve exactly the same way, and cultural differences play a significant part in the grieving process. For many, however, the most immediate response is shock, numbness, and disbelief. Physical reactions may include shortness of breath, heart palpitations, sweating, and dizziness. At other times, there may be reactions such as loss of energy, sleeplessness or increase in sleep, changes in appetite, or stomach aches. Susceptibility to common illnesses, nightmares, and dreams about the deceased are not unusual during the grieving period.

Emotional reactions are as individual as physical reactions. A preoccupation with the image of the deceased, feelings of fear, hostility, apathy, emptiness, and even fear of one's own death, may occur. Depression, diminished sex drive, sadness, and anger at the deceased may occur. Bereavement may cause short- or long-term changes in the family unit and other relationships of the bereaved.

It is important for the bereaved to work through their feelings and not avoid their emotions. If emotions and feelings are not discussed with family members, friends, or primary support groups, then a therapist should be consulted to assist with the process.

Do-not-resuscitate (DNR) orders can be incorporated into an advance directive or by informing hospital staff. Unless instructions for a DNR are in effect, hospital staff will make every effort to help patients whose hearts have stopped or who have stopped breathing. DNR orders are recognized in all states and will be incorporated into a patient's medical chart if requested. Patients who benefit from a DNR order are those who have terminal or other debilitating illnesses. It is recommended that a patient who has not already been considered unable to make sound medical decisions discuss this option with his or her physician.

DEATH AND DYING

Definition of dying: The ending of a life. The time when a person is facing impending death, whose anticipated life expectancy is measured in days or weeks. The final or ending phase of life, which depending on the person, may last for years, months, weeks, days or hours. This is the time when the focus of care shifts from aggressively treating medical problems to providing comfort or palliative care.

Definition of death: 1. The end of life. The cessation of life. (These common definitions of death ultimately depend upon the definition of life, upon which there is no consensus.) 2. The permanent cessation of all vital bodily functions. (This definition depends upon the definition of "vital bodily functions.")Vital bodily function is A. An essential bodily function. B. A key function for life. C. A function required by most, if not all, people.. 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." This definition was approved by the American Medical Association in 1980 and by the American Bar Association in 1981

MEDICAL, LEGAL AND ETHICAL ISSUES:

PRINCIPLES REGARDING DEATH AND DYING
The American Medical Student Association:
1. BELIEVES that patients have the right to refuse treatment when they have been fully informed of the consequences, even if such refusal results in the patient's death;
2. BELIEVES that patients who are comatose, and in whom there is no reasonable expectation of recovery, have the right, through prior written documents such as living wills, to refuse treatment and to be allowed to die and not be kept alive by artificial means;
3. SUPPORTS a statutory definition of death, and BELIEVES that such a definition should consist of a dual system of criteria, including the cessation of circulatory and respiratory function or brain death criteria, as outlined in the United States Collaborative Study of Cerebral Death and the so-called Harvard Group Study, which should only be applied when all reversible causes and conditions such as hypothermia and drug intoxication have been excluded;
4. BELIEVES that the quality of life is an important parameter in the health care management of the patient with terminal or severe chronic illness and, further, SUPPORTS the use of medications that are necessary to relieve a terminally ill patient's suffering despite their having an inseparable dual effect of hastening the patient's death. (1993)
5. BELIEVES that the role of the physician primarily responsible for the care of the terminally ill should extend beyond the patient to those close to the patient when his/her needs for counseling and support arise;
6. BELIEVES that counseling and support services should be offered to immediate family members or significant others by staff and physicians in cases of sudden or emergency room deaths.
7. STRONGLY URGES all medical schools and residency programs to offer electives to educate medical students and residents in issues of death and dying. (1996)
8. BELIEVES that all patients have the right to know all options available to them before they make end of life decisions. These options include, but are not limited to, hospice care, withdrawal of treatment, continuation of treatment, comfort measures and self-deliverance. The patient should be made aware of the implications of each of these options. (1996)
9. BELIEVES that counseling and support services should be made available to physicians and medical students who are dealing with issues of death and dying, whether the issues are related to patient care or their personal lives. (1996)
10. SUPPORTS an interdisciplinary approach to the study and care of patients with active, progressive, far advanced disease for whom the prognosis is limited and the focus of care is the quality of life. AMSA further RECOGNIZES the multidimensional nature of suffering, with an ultimate goal of responding to this suffering with care that addresses all of these dimensions and communicates in a language that conveys mutuality, respect and independence. (1997)

Advance Directives
Individuals have a moral and legal right to limit or forgo medical or life sustaining
treatment (including the use of artificial feeding, mechanical ventilators, cardiopulmonary resuscitation, antibiotics, dialysis and other invasive technologies). Individuals who lack decision-making capacity have the right
to have surrogates use advance directives to assure this right.
The two common forms of advance directives are a living will and a durable power of
attorney for health care. A living will states the individual’s choices for future medical
care decisions. The durable power of attorney allows the individual to designate a surrogate, usually a trusted family member, to make
specific treatment decisions for them. The surrogate should make decisions consistent
with what they think the individual’s wishes would have been. In the absence of written
advance directives, care providers should try to learn about the individual’s wishes from family members as a basis for making their decisions.

Treatment Withdrawal/Refusal
If there is an identified surrogate, families should be contacted and involved in the
decision-making process. Care providers should work closely with the family, in cases
where a substitute judgment must be made, to interpret advance directives. If there is a
lack of knowledge about the individual, care providers should base a decision on what they feel is in the best interest for that individual.
If necessary, the importance of respecting the individual’s wishes should be clarified for
the family. Clinical ethics consultants or the facility’s ethics committee may offer assistance in facilitating consensus. An individual’s right to refuse or withdraw
any treatment, including treatment for life-threatening illness (infections,
hemorrhaging, heart attacks, etc.), is not the same as assisted suicide or euthanasia.
In fact, aggressive medical treatment may seem torturous to the individual because
of his or her lack of orientation to the surroundings and lack of understanding
of the intentions of care providers.

The care providers should:
Facilitate early communication with older patients to understand their end-of-life wishes.
Respect the end-of-life wishes of the individual. If these wishes conflict with the care provider’s personal beliefs, consideration should be given to the transfer of care to another provider. Confer with ethics consultants or ethics
committees in cases where there is no consensus with the family.

Neurological Determination of Death

Trillium Gift of Life Network endorses recommendations from the 2003 Forum on Severe Brain Injury to Neurological Determination of Death, which was coordinated by the Canadian Council for Donation and Transplantation. These notes, based on the CCDT Forum, are valid for patients over 1 year of age.

Physicians performing neurological determination of death (NDD) must hold full and current licensure for independent medical practice in Ontario. This excludes physicians with (only) an educational license. NDD cannot be delegated. The physician must have skill and knowledge in the management of patients with severe brain injury, as well as NDD. For the purpose of donation for transplantation, a physician who has had any association with the proposed transplant recipient that might influence the physician’s judgement must not take part in NDD.

For post-mortem donation for transplantation, NDD must be confirmed by two physicians. Each physician should fill out a separate Confirmation of Neurological Determination of Death form.If performed at different points in time, full clinical examinations, including the apnea test, must be performed for both physicians’ assessments. The legal time of death is marked by the first confirmation of NDD.

Neurologic function must be absent due to a known proximate and irreversible cause. There must be definite clinical and/or neuroimaging evidence of an acute CNS event compatible with death via a neurologic mechanism (either intracranial hypertension or primary direct brainstem injury). NDD without ancillary testing is not recommended in the first 24 hours after hypoxic-ischemic brain injury, if no neurologic activity has been observed after the event.

Where feasible, the examination should be performed in the absence of confounding factors, which might prevent the observation of neurologic responses and/or mimic death. Potentially confounding factors include, but are not limited to, shock, hypothermia, drug intoxications, administration of cycloplegic or muscle relaxant drugs, neuromuscular pathology, and severe endocrine, metabolic or electrolyte disorders. Potentially, confounding factors must be reviewed in the context of the primary etiology and the clinical examination. Clinical judgement is required.Motor activity must not be present, with the exception of spinal reflexes. Motor activity includes, but is not limited to, spontaneous or stimulated breathing, coughing, seizures, and posturing. Spinal reflexes are observed more frequently in the lower extremities, are reproducible on repeated stimulation in the same location on the extremity, and are not associated with movements in other extremities or above the clavicle. Where uncertainty exists regarding the nature of a movement, which may be a spinal reflex, ancillary testing is warranted.

Examination for eye movement on irrigation of the tympanic membranes should be done with the head elevated 30º above horizontal, with at least 50 mL of ice water, and with at least 5 minutes between stimulation of the first and second tympanic membranes.
Optimal performance of the apnea test requires a period of preoxygenation followed by 100% oxygen delivered via the trachea upon disconnection from mechanical ventilation. The physician(s) performing NDD must continuously observe the patient for respiratory effort. Arterial blood gas values of PaCO2 ≥ 60 mmHg, increase of PaCO2 by ≥ 20 mmHg, and pH ≤ 7.28 must be observed at the time of completion of the test. Caution must be exercised n considering the validity of the test in cases of chronic respiratory insufficiency or dependence on hypoxic respiratory drive.

When minimum clinical criteria cannot be completed or confounding factors cannot be corrected, an ancillary test may be performed. In this context, if examination according to the minimum critical criteria (to the extent possible) is compatible with death, an ancillary test demonstrating the global absence of intracranial blood flow confirms death. The only acceptable ancillary tests at present are radionuclide cerebral blood flow imaging and 4-vessel cerebral angiography.

Do Not Resuscitate


A Do Not Resuscitate, or DNR order is a written order from a doctor that resuscitation should not be attempted if a person suffers cardiac or respiratory arrest. Such an order may be instituted on the basis of an advance directive from a person, or from someone entitled to make decisions on their behalf, such as a health care proxy; in some jurisdictions, such orders can also be instituted on the basis of a physician's own initiative, usually when resuscitation would not alter the ultimate outcome of a disease.
Any person who does not wish to undergo lifesaving treatment in the event of cardiac or respiratory arrest can get a DNR order, although DNR is more commonly done when a person who has an inevitably fatal illness wishes to have a more natural death without painful or invasive medical procedures.
It is commonly mistaken that a DNR means resuscitation would be successful.Therefore, medical students and doctors alike are being encouraged to be realistic with patients and their families when it comes to discussing such a sensitive topic as DNR orders, as it is thought that many wrongly believe resuscitation to be a risk-free guarantee to life.