END-OF-LIFE

1
END-OF-LIFE

• BASIC CONCEPTS
• THOU OWEST GOD
• A DEATH

2
QUALITY OF LIFEA FORMULA SHAW, 1986/1994

• QL NE X (H S)
• NE --- NATURAL (PERSONAL) ENDOWMENT
• H --- CONTRIBUTIONS OF THE HOME
• S --- CONTRIBUTIONS OF SOCIETY

3
QUALITY OF LIFEESSENTIAL FEATURES SPITZER ET
AL., 1981

• ACTIVITY (WORK, PLAY, STUDY) --- INVOLVEMENT IN
  OCCUPATION
• TASKS OF DAILY LIVING --- ORDINARY LIFE
  ACTIVITIES
• HEALTH (FEELING OF WELL-BEING) --- PERCEPTION OF
  ONES OWN HEALTH
• SUPPORT FROM FAMILY AND FRIENDS
• PSYCHOLOGICAL, SPIRITUAL OUTLOOK ON LIFE

4
QUALITY OF LIFEWAYS OF TALKING

• THE SUBJECTIVE SATISFACTION EXPRESSED OR
  EXPERIENCED BY AN INDIVIDUAL IN HIS/HER PHYSICAL,
  MENTAL, AND SOCIAL SITUATION
• THE SUBJECTIVE EVALUATION BY AN ONLOOKER OF
  ANOTHERS SUBJECTIVE EXPERIENCES OF PERSONAL LIFE
• THE ACHIEVEMENT OF CERTAIN ATTRIBUTES HIGHLY
  VALUED IN OUR SOCIETY, AS REFLECTED IN A SOCIAL
  AND CULTURAL BIAS ABOUT THOSE FACTORS WHICH
  CONTRIBUTE TO A LIFE WORTH LIVING
• A LEVEL OF CAPABILITY AND ACTIVITY WHICH
  CONTRIBUTES TO THE INDIVIDUALS ABILITY TO
  FLOURISH
• FLOURISHING --- THE FULFILLMENT OF THE POTENTIAL
  AN INDIVIDUAL MAY POSSESS FOR MEANINGFUL
  EXISTENCE BEYOND MERE SURVIVAL

5
MEANS FOR EXTENDING LIFE

• ORDINARY (PROPORTIONATE)
• ALL MEDICINES, TREATMENTS, AND OPERATIONS, WHICH
  OFFER A REASONABLE HOPE OF BENEFIT FOR THE
  PATIENT AND WHICH CAN BE OBTAINED AND USED
  WITHOUT EXCESSIVE EXPENSE, PAIN, AND OTHER
  INCONVENIENCES
• EXTRAORDINARY (DISPROPORTIONATE)
• ALL MEDICINES TREATMENTS, AND OPERATIONS, WHICH
  CANNOT BE OBTAINED WITHOUT EXCESSIVE EXPENSE,
  PAIN, OR OTHER INCONVENIENCE, OR WHICH, IF USED,
  WOULD NOT OFFER A REASONABLE HOPE OF BENEFIT.
• ONE CANNOT IMPOSE ON ANYONE THE OBLIGATION TO
  HAVE RECOURSE TO A TECHNIQUE WHICH IS ALREADY IN
  USE BUT WHICH CARRIES A RISK OR IS BURDENSOME.
  SUCH A REFUSAL IS NOT THE EQUIVALENT OF SUICIDE
  OR HOMOCIDE ON THE CONTRARY IT SHOULD BE
  CONSIDERED AS AN ACCEPTANCE OF THE HUMAN
  CONDITION.

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BENEFITS

• THE POSITIVE RESULT FOR A FUNCTIONAL IMPROVEMENT
  IN THE QUALITY OF LIFE OR THE ACHIEVEMENT OF A
  PARTICULARLY DESIREABLE GOAL WHICH AN INDIVIDUAL
  WILL EXPERIENCE AS THE RESULT OF A HEALTHCARE
  INTERVENTION

• COMPLETE RECOVERY
• REMISSION OF DISEASE PROCESS
• IMPROVED QUALITY OF LIFE
• COMFORT
• RESTORATION OF CONSCIOUSNESS
• IMPROVED PERFORMANCE ACTIVITY
• RETURN TO A PREVIOUS LEVEL OF FUNCTIONING
• MAINTENANCE OF A MINIMALLY DECENT QUALTIY OF LIFE
• FIGHTING A DISEASE
• EXPERIENCING A LESS DISTRESSING DYING
• COST/RESOURCE SAVINGS
• CONTINUED BIOLOGICAL EXISTENCE

7
BURDENS

• THE SUFFERING ONE MUST ENDURE AS THE RESULT OF AN
  INTERVENTION IT MAY TAKE A PHYSICAL,
  PSYCHOLOGICAL, SPIRITUAL, OR MORAL FORM

• TOO PAINFUL
• TOO DAMAGING TO BODILY SELF AND FUNCTIONING
• TOO PSYCHOLOGICALLY REPUGNANT TO THE PATIENT
• TOO RESTRICTIVE OF PATIENTS LIBERTY AND
  PREFERRED ACTIVITIES
• TOO SUPPRESSIVE OF PATIENTS MENTAL LIFE
• TOO EXPENSIVE

8
WEIGHING BENEFITS AND BURDENS

• WHAT IS THE GOAL OF THE INTERVENTION?
• WILL THE GOAL BE ACCOMPLISHED?
• RELATION OF GOAL TO PATIENTS LIFE-STYLE CHOICES
• THE BENEFITS OF THE INTERVENTION?
• RELATION OF BENEFITS TO LIFE-STYLE CHOICES
• ARE BENEFITS WORTH THE BURDENS?
• THE BURDENS OF THE INTERVENTION?
• RELATION OF BURDENS TO LIFE-STYLE CHOICES
• ARE BURDENS TOLERABLE?
• DO BURDENS MINIMIZE BENEFITS?
• WHO MOST DIRECTLY BEARS THE BURDENS?
• WILL THE PATIENT HAVE TO BEAR THE BURDENS ALONE?

9
ACTIVE - PASSIVE EUTHANASIAOLD STYLE

• ACTIVE
• DOING SOMETHING/TAKING THE INITIATIVE
• DIRECT CAUSE IN PRODUCING THE EFFECT OF DEATH
• E.G. GIVING A LETHAL INJECTION
• PASSIVE
• NOT DOING A SPECIFIC THING/ALLOWING SOMETHING TO
  HAPPEN
• INDIRECT CAUSE IN PRODUCING THE EFFECT OF DEATH
• E.G. WITHHOLDING OR WITHDRAWING AN INTERVENTION
• ALLOWING THE NATURAL COURSE OF EVENTS TO FOLLOW

10
ACTIVE - PASSIVE EUTHANASIANEW STYLE

• ACTIVE
• DOING x DOING SOMETHING
• PASSIVE
• DOING NON-X DOING SOMETHING
• BOTH INVOLVE TAKING AN INITIATIVE AND PRODUCING
  THE SAME END
• UTILIZE DIFFERENT MEANS
• BOTH INVOLVE A DOING --- MINIMALLY A MENTAL
  ACTION
• MORAL EQUIVALENTS BUT MAY HAVE DIFFERENT
  PSYCHOLOGICAL EFFECTS
• ACTIVE MAY BE MORE HUMANE THAN PASSIVE SINCE
  SUFFERING IS TERMINATED SOONER

11
PRINCIPLE OF DOUBLE EFFECTACTIONS WITH TWO
EFFECTS ONE GOOD, ONE BAD

• ONE MAY NOT WILL EVIL DIRECTLY
• ONE MUST INTEND THE GOOD EFFECT BUT MAY PERMIT OR
  TOLERATE THE EVIL EFFECT
• E.G. REMOVAL OF VENTILATOR TO PRODUCE COMFORT
• E.G. THERAPEUTIC LEVELS OF PAIN MEDICATION
• GOOD EFFECT MUST NOT COME ABOUT AS A CAUSAL
  RESULT OF AN EVIL ACTION
• E.G. KILLING THE PATIENT TO ACHIEVE PAIN RELIEF
• THERE MUST BE A PROPORTIONATE REASON FOR THE
  PROCEDURE

12
VOLUNTARY AND INVOLUNTARY

• INVOLUNTARY
• ACTIVE --- CONSTANT MEDICAL PROHIBITION
• PASSIVE --- ACCEPTED AS W/W IN HOPELESS CASES
  (BENEFICENCE)
• VOLUNTARY
• ACTIVE --- EQUIVALENT OF SUICIDE STRONG MORAL
  PROHIBITION
• NO CONSTITUTIONAL PROTECTION
• REFUSAL OF TREATMENT, NOT SUICIDE
• PASSIVE --- ACCEPTED AS TREATMENT REFUSALS
  (AUTONOMY)

13
WHY ACTIVE EUTHANASIA NOW?ASSISTED SUICIDE AND
ALTERNATIVES

• TO AVOID PAIN
• PAIN MANAGEMENT
• WITHHOLDING/WITHDRAWING TREATMENTS
• T0 AVOID A PROTRACTED DYING PROCESS
• SUPPORT PATIENT IN TREATMENT REFUSALS
• EXPLORE POSITIVE AVENUES OF PERSONAL GROWTH
• TO AVOID INSTITUTIONS WHERE PATIENT WILL NOT BE
  ALLOWED TO DIE
• CREATE ENVIRONMENTS TOLERANT OF A VARIETY OF
  DEATH-STYLES
• UTILIZE WIDE RANGE OF ACCEPTABLE MEDICAL
  PRACTICES
• ASSESS BENEFITS REALISTICALLY
• RESPECT PATIENT AUTONOMY
• TO AVOID EXCESSIVE EXPENSES
• RESPECT TREATMENT REFUSALS
• ASSESS BENEFITS REALISTICALLY
• UTILIZE LOW TECHNOLOGY INTERVENTIONS
• TO AVOID HUMILIATION AND INDIGNITY IN DYING
• EXPLORE WAYS OF PROMOTING DIGNITY
• EXPLORE AVENUES OF HOPE IN A LIMITED CONTEXT

14
TERMINAL PALLIATIVE SEDATIONA FORM OF OR
ALTERNATIVE TO EUTHANASIA?

• RIGHT TO CONSENT TO OR REFUSE TREATMENTS PSDA
• GOAL OF MEDICINE RELIEF OF PAIN AND SUFFERING
  CAUSED BY MALADIES
• TREATMENT TO PROVIDE BENEFITS OR REDUCE BURDENS
• PAIN
• SUFFERING
• ADEQUATE PAIN CONTROL
• HASTEN DEATH
• PROLONG LIFE

15
TERMINAL SEDATION AND DOUBLE EFFECT

• TWO EFFECTS --- ONE GOOD, ONE UNDESIRABLE
• CANNOT ACHIEVE GOOD BY IMPROPER MEANS
• INTEND THE GOOD EFFECT CANNOT WILL EVIL
  DIRECTLY
• MUST BE PROPORTIONATE REASON
• RELIeVE INTRACTABLE PAIN
• PRODUCE UNCONSCIOUSNESS BEFORE TERMINAL WEANING
• RELIEVE EXISTENTENTIAL SUFFERING
• INTENTION DIVIDING INTENTIONS
• RELIEVE PAIN AND SUFFERING/NOT CAUSE DEATH
• SEDATION RELIEVE PAIN
• WITHHOLD/WITHDRAW NUTRITION AND HYDRATION
  NONBENEFICIAL