Lesson 8

• Dignity of death and dying

  Painful and personal experiences for those that are dying and their loved ones
• Death


  The end of life of an organism or cell, in human and animals<|>Manifested by the permanent cessation of vital organic functions (including heart beat, spontaneous breathing and brain activity)<|>Defined as the irreversible cessation of all vital functions especially heart, respiration, and higher brain function
• 3 basic principles of death

  • Permanence: people cannot come back to life after they die
  • Universality: all living things will eventually die
  • Non-functionality: The functions of a living being cease after death
• Dying


  Approaching death
• Care of death and dying

  • Meeting the needs of dying individuals
  • Assessing the physiological signs of approaching death
  • Physical care
  • Psychological care
  • Social care
  • Spiritual care
• Belief and attitude about death in relation to age

  • Infancy to 5 years: Does not understand concept of death, believes death is reversible, temporary departure or sleep
  • 5 to 9 years: Understand death is FINAL, believes death CAN BE AVOIDED, believes wishes and unrelated actions can be responsible for death
  • 9 to 12 years: Begin to understand own mortality, expressed in after life and fear of death
  • 12 to 18 years: May still hold concept from previous developmental stages, may seem to reach "adult" perception of death but be emotionally unable to accept it
  • 18 to 45 years: Has attitude towards death influenced by religious and cultural beliefs
  • 45 to 65 years: Accept own mortality, encounters death of parents some peers experiences
  • 65 years and above: Fears prolonged illness, sees death as having multiple meaning, (eg. freedom from pain, reunion with already diseases family member)
• Role of the nurse (Hospice nurse) during active dying phase


  To support the patient and family by educating them on what they might expect to happen during this time, addressing their questions and concerns honestly
• Stages of death

  • Algor Mortis: Postmortem temperature change after someone has died, falls 1.8F per hour until it reaches room temperature
  • Rigor Mortis: Stiffness of the body that occurs 2 to 4 hours after the death of a person, starts with the involuntary muscles (heart, bladder and so on)
  • Livor Mortis: Skin becomes discolored and looses its elasticity, tissues become soft
• Legal aspects of death

  Death must be certified by a physician<|>In unusual death, an Autopsy (postmortem examination) may be required
• Care of the body after death

  • Make the environment clean
  • Body appear natural and comfortable
  • All equipment and supplies should be removed
  • All tubes in the body be clamped/ removed according to hospital policy
  • All soiled linens must be removed
• Euthanasia


  The practice of intentionally ending a life in order to relieve pain and suffering<|>The painless killing of a patient suffering from an incurable and painful disease or in an irreversible coma<|>When a doctor induces the death with a lethal injection, of a patient who is suffering unrelievably and has persistently requested the doctor to do so
• Types of euthanasia

  • Active (positive) euthanasia: Terminally ill patient deliberately or directly terminates their life
  • Passive (negative) euthanasia: Allows oneself to die without taking any medications or by refusing medical treatment
  • Voluntary euthanasia: With the consent of the patient
  • Non-voluntary euthanasia: When the person is unconscious or otherwise unable to make a meaningful choice between living and dying
  • Involuntary euthanasia: When the person who dies chooses life and is killed anyway
• Classification of euthanasia

  • Active and voluntary euthanasia: Physician, spouse or friend terminates the patient's life upon their request
  • Passive and voluntary euthanasia: Terminally ill patient is simply allowed to die upon their request
  • Active and non-voluntary euthanasia: Physician, spouse, friend, or relative decides the terminally ill patient's life should be terminated
  • Passive and non-voluntary euthanasia: Terminally ill patient is simply allowed to die, as requested by immediate family members or the attending physician
• Euthanasia is in itself a grave moral evil, since it is contrary to the meaning of human life, a gift and an inalienable good
• It becomes morally permissible to let someone die as you would in passive euthanasia
• Facts about euthanasia

  • In classical Athens, kept a supply of poison for anyone who wished to die
  • Euthanasia is legal in three countries worldwide: Belgium, Luxembourg, and Netherlands
  • Physician assisted suicide and euthanasia are legal and widely practiced in the Netherlands where about 9% of all deaths were a result of physician- assisted suicide or euthanasia in 1990
• Importance of euthanasia

  As human beings, we are endowed with the freedom of choice, and we cannot shuffle off our responsibility upon the shoulders of God or nature. We must shoulder it ourselves. It is our responsibility.<|>If we are free to make the our own choices of how to live, we should also be able to make our own choices of how to die. The power belongs to the patient.<|>Debilitating illnesses, such as cancer, are currently on the rise. The more people diagnosed with these illnesses directly correlates to the number of people faced with the euthanasia issue.
• Arguments for euthanasia

  • An act of mercy
  • It provides a way to relieve extreme pain
  • Prolonging the suffering – an act of cruelty
  • It provides a way to relief when a person's quality of life is low (dignified death)
  • Frees up medical funds to help other people
  • It is another case of freedom of choice
• Arguments against euthanasia

  • Euthanasia devalues human life
  • Doctors have a problem with euthanasia because they have sworn an oath that does not allow them to take part in the killing of people
  • Sometimes it is not clear if an ill person really wants to die
  • Euthanasia should only take place if someone really wants it or if they understand how ill they are
• Suicide


  The direct and willful destruction of one's own life<|>It is direct insofar as the primary object of thee act is the killing oneself<|>It is willful insofar as it is deliberate, voluntary and intentional<|>It is destructive insofar as the means of terminating one's own life, more often than not, violent, brutal or very harsh
• Physician assisted suicide


  The suffering person dies with another person's help<|>Refers to cases where the person who is going to die needs help to kill themselves and asks for it<|>It may be something as simple as getting drugs for the person and putting those drugs within their reach<|>The physician assisted suicide must be accepted if the intent of all involved are goodwilled and righteous<|>Physician-assisted suicide is morally wrong because it contradicts strong religious and secular traditions against taking human life
• Application of ethical theories to euthanasia

  • Natural law ethics: Considers suicide as self-murder, an individual has no right to murder himself/herself as he/she has no right to murder someone else
  • Utilitarian's principle of utility: May justify euthanasia if suffering becomes too much to bear or the person becomes a financial burden due to a prolonged, incurable disease
• Dysthanasia


  Undue prolongation of life and delay of the occurrence of death which in effect lengthens the suffering of the person
• Orthothanasia


  Allowing death to occur, or letting die
• Orthothanasia is different from euthanasia, where the death of the patient is directly intended and caused
• Possibilities for allowing to die

  • When the treatment to prolong life is useless or futile for the patient
  • When the prolongation of life or the postponement of death is unduly burdensome for the patient and their family
  • When the patient needs painkillers or medical sedation, which does not intend the death of the patient
• Palliative sedation


  The practice of relieving distress in a terminally ill person in the last hours or days of the dying patient's life, usually by means of a continuous intravenous or subcutaneous infusion of a sedative drug
• Advance directive


  A legal document in which a person specifies what actions should be taken for their health if they are no longer able to make decisions for themselves because of illness or incapacity
• Forms of advance directives

  • Living will (health-care directives)
  • Health care proxy
  • Power of attorney
• Advance directives

  • Prevent unnecessarily prolonged painful hospitalization
  • Prevent unnecessary prolonged comatose or vegetative state
  • Prevent the burden of rising medical costs
  • Release the responsibility of loved ones for difficult decisions
• Do Not Resuscitate (DNR)


  A specific physician order that means no CPR or electric shock will be performed to restart the heart in the event of cardiac arrest
• Do Not Intubate (DNI)


  A specific physician order that means no breathing tube will be placed in the throat in the event of breathing difficulty or respiratory arrest
• DNR/DNI orders apply only to resuscitation
• Role of a nurse in DNR/DNI

  • Health care team member in the process of making informed choices
  • Responsible for verification and witnessing of consent documents
  • Assists patient and families
  • Supports surrogate decision makers
  • Provides physiologic, psychological, emotional, and spiritual care
• Medical futility


  Proposed therapy should not be performed because available data show that it will not improve the patient's medical condition
• "If we live, we live for the Lord, and if we die, we die for the Lord. Therefore, whether we live or die, we belong to God.": 'Romans 14:8'