HEALTH CARE ETHICS

MODULE 3

DEATH, DIGNITY AND DEATH WITH DIGNITY

A. DIGNITY - in Latin, DIGNITAS

‒ Worthiness and nobility
‒ Undignified” And “indignity”
‒ Indignities” Being inflicted on people or things/convey of some type of
insult or affront.
‒ When a swan is put into human clothes for an advertisement, or when
christ had the ironic term “inri” Nailed above his head on the cross.
‒ As part of a role, rather than to you as a person
‒ Ballet dancer who uses her skills to make money as a lapdancer might be
said to affront her own dignity
B. DEATH
‒ Four senses of the term “death”.
‒ Non-being—the rather mysterious state of being dead;
‒ Transition—the point at which one moves from being to non-being;
‒ Process—the period leading to death. This is not entirely straightforward
as we are in this process from the moment of conception. In practice it
usually means a period in which there is an awareness of what will end a
particular person’s life and, roughly, when.
‒ The fact of mortality—death as a universal truth that attaches to us all.
C. DEATH WITH DIGNITY
‒ Attaches to the second and third senses of death.
‒ Death without indignity
‒ Specific affronts - playing loud rap music to someone who loves only
classical music, or jeering at someone who is incontinent, or using “baby
names” To an old general
‒ For example, if one were to engage in euthanasia without consent
(“involuntary euthanasia”) then this would look like an affront to someone’s
dignity (even if he would have chosen that option had it been offered); it
looks as though one has “put someone down” Like a dog.

INDIGNITIES are affronts to human dignity, and include such things as serious pain
and the exclusion of patients from involvement in decisions about their lives and
deaths

DEATH WITHOUT INDIGNITY

 Another example of an affront to human dignity would be failing to tell someone
of his terminal diagnosis in order to avoid upsetting him. This is an affront
because it removes the ability for him to make choices about his own life
 Not all affronts to human dignity will be imposed by human agents, however;
disease processes that take away an individual’s ability to reason might also be
seen in this way. A death without indignity will be one in which these types of
affront do not occur

DEATH WITH DIGNITY

 If someone is subject to involuntary euthanasia, or lied to about his diagnosis,
then he is wronged, affronted; but he may still live his life, and die his death, with
(greater or lesser) dignity in the face of that indignity
 Dignified death will be something earned
DEATH / DIGNITY
 The term “death - apply to the process of dying.
 The term “dignity - apply roughly to someone who lives well (in the Aristotelian
sense of living in accordance with reason).
 Dignity - function of someone’s personal qualities and that a death with dignity is
a personal achievement
‒ Not something that can be conferred by others, such as health care
professionals. By contrast, indignities are affronts to personal dignity

HEALTH CARE PROFESSIONALS ROLES

1. Not to impose such indignities
2. To minimize them, wherever possible

EUTHANASIA
 (from Greek: εὐθανασία; "good death":
 εὖ, eu; "well" or "good"
 + θάνατος, thanatos; "death")
 It is the practice of intentionally ending a life to relieve pain and suffering

PROLONGATION OF LIFE. Prolonging treatments in cases of severe brain damage

and terminal illness

CLASSIFICATION OF EUTHANASIA
1. VOLUNTARY EUTHANASIA is legal in some countries.
‒ It is conducted with the consent of the patient
2. NON-VOLUNTARY EUTHANASIA (patient's consent unavailable) is illegal in all
countries. Also known as CHILD EUTHANASIA.
3. INVOLUNTARY EUTHANASIA (without asking consent or against the patient's
will) is also illegal in all countries and is usually considered murder.
‒ PASSIVE EUTHANASIA (known as "pulling the plug") is legal under some
circumstances in many countries.
‒ ACTIVE EUTHANASIA, however, is legal or de facto legal in only a
handful of countries

HISTORY OF EUTHANASIA
 SUETONIUS – historian 1 ST usage of euthanasia - who described how the
Emperor Augustus, "dying quickly and without suffering in the arms of his wife,
Livia, experienced the 'euthanasia' he had wished for.
 FRANCIS BACON – 17th Century
 First used Euthanasia in a medical context - to refer to an easy, painless, happy
death, during which it was a "physician's responsibility to alleviate the 'physical
sufferings' of the body.
 OUTWARD EUTHANASIA- a spiritual concept,
 Which regards the preparation of the soul
 With "the painless killing of a patient suffering from an incurable and painful
disease or in an irreversible coma”.
 MARVIN KHOL and PAUL KURTZ'S definition of it as "a mode or act of
inducing or permitting death painlessly as a relief from suffering
 The third element incorporated into many definitions is that of intentionality
‒ The death must be intended, rather than being accidental, and the intent of
the action must be a "merciful death
DRAPER DEFINITION OF EUTHANASIA MUST INCORPORATE FOUR
ELEMENTS
1. An agent and a subject
2. An intention
3. A causal proximity, such that the actions of the agent lead to the outcome
4. An outcome
‒ Euthanasia "must be defined as death that results from the intention of one
person to kill another person, using the most gentle and painless means
possible, that is motivated solely by the best interests of the person who
dies

MICHAEL WREEN (1987) - Philosophy professor at Marquette University

 Person A committed an act of euthanasia if and only if :
‒ (1) A killed B or let her die
‒ (2) A intended to kill B;
‒ (3) the intention specified in (2) was at least partial cause of the action
specified in (1);
‒ (4) the causal journey from the intention specified in (2) to the action
specified in (1) is more or less in accordance with A's plan of action;
‒ (5) A's killing of B is a voluntary action;
‒ (6) the motive for the action specified in (1), the motive standing behind
the intention specified in (2), is the good of the person killed.
‒ (7) The good specified in (6) is, or at least includes, the avoidance of evil",
although as Wreen noted in the paper, he was not convinced that the
restriction was required

HISTORY EUTHANASIA
 Ancient Greece and Rome
‒ MID-1800S - , the use of morphine to treat "the pains of death" emerged,
with John Warren recommending its use in 1848. A similar use of
chloroform was revealed by Joseph Bullar in 1866.

FELIX ADLER, CIRCA (1913), the first prominent American to argue for permitting
suicide in cases of chronic illness
 1930s in Britain.
‒ The Voluntary Euthanasia Legalisation Society was founded in 1935 by
Charles Killick Millard (now called Dignity in Dying). The movement
campaigned for the legalisation of euthanasia in Great Britain.
‒ In January 1936, King George V was given a fatal dose of morphine and
cocaine to hasten his death. At the time he was suffering from cardio-
respiratory failure, and the decision to end his life was made by his
physician, Lord Dawson. Although this event was kept a secret for over 50
years, the death of George V coincided with proposed legislation in the
House of Lords to legalise euthanasia.

NAZI EUTHANASIA PROGRAM

 Hartheim Euthanasia Centre, where over 18,000 people were killed
 In modern terms, the use of "euthanasia" in the context of Action T4 is seen to
be a euphemism to disguise a program of genocide, in which people were killed
on the grounds of "disabilities, religious beliefs, and discordant individual values
 24 July 1939 killing of a severely disabled infant in Nazi Germany was described
in a BBC "Genocide Under the Nazis Timeline" as the first "state sponsored
euthanasia
 The "euthanasia campaign" of mass murder gathered momentum on 14 January
1940 when the "handicapped" were killed with gas vans and killing centres,
eventually leading to the deaths of 70,000 adult Germans

EUTHANASIA DEBATE
 1949 New York State Petition for Euthanasia and Catholic opposition
 6 January 1949, the Euthanasia Society of America presented to the New York
State Legislature a petition to legalize euthanasia, signed by 379 leading
Protestant and Jewish ministers, the largest group of religious leaders ever to
have taken this stance. A similar petition had been sent to the New York
Legislature in 1947, signed by approximately 1,000 New York physicians
 Euthanasia opponent Ezekiel Emanuel, proponents of euthanasia presented four
main arguments
‒ That people have a right to self-determination, and thus should be allowed
to choose their own fate;
‒ Assisting a subject to die might be a better choice than requiring that they
continue to suffer;
‒ The distinction between passive euthanasia, which is often permitted, and
active euthanasia, which is not substantive (or that the underlying
principle– the doctrine of double effect–is unreasonable or unsound); and
‒ Permitting euthanasia will not necessarily lead to unacceptable
consequences.

LEGALITY OF EUTHANASIA
 West's Encyclopedia of American Law states that "a 'mercy killing' or euthanasia
is generally considered to be a criminal homicide“ and is normally used as a
synonym of homicide committed at a request made by the patient
 PHYSICIAN SENTIMENT
‒ 2010 survey in the United States of more than 10,000 physicians found
that 16.3% of physicians would consider halting life-sustaining therapy
because the family demanded it, even if they believed that it was
premature.
‒ Approximately 54.5% would not, and the remaining 29.2% responded "it
depends". The study also found that 45.8% of physicians agreed that
physician-assisted suicide should be allowed in some cases; 40.7% did
not, and the remaining 13.5% felt it depended.
 RELIGIOUS VIEWS
‒ Christianity
‒ Broadly against
‒ The Roman Catholic Church condemns euthanasia and assisted
suicide as morally wrong. It states that, "intentional euthanasia,
whatever its forms or motives, is murder. It is gravely contrary to the
dignity of the human person and to the respect due to the living God,
his Creator". Because of this, the practice is unacceptable within the
Church.

INVIOLABILITY OF HUMAN LIFE

 Inviolability or sanctity of life is a principle of implied protection regarding aspects
of sentient life that are said to be holy, sacred, or otherwise of such value that
they are not to be violated. This can be applied to both animals and humans or
micro-organisms , for instance in religions that practice Ahimsa, as both are seen
as holy and worthy of life.
‒ AHIMSA (Ahinsa) means 'not to injure' and 'compassion' and refers To a
key virtue in Hinduism and Jainism. The word is derived from the Sanskrit
root hiṃs – to strike; hiṃsā is injury or harm, a-hiṃsā is the opposite of this,
 i.e. cause no injury, do no harm. Ahimsa is also referred to as nonviolence,
and it applies to all living beings—including all animals—in ancient Indian
religions.

WHY WE MUST FIGHT FOR THE INVIOLABILITY OF LIFE?

 How Should We Value Human Beings?
 John Keown - distinguishes three different approaches to the value of human
beings
1. Quality of Life view - some human lives are not worth living.
2. The Inviolability of Life view - that intentional killing is not ethical and
should not be legally permissible, yet that it is often acceptable to withdraw
life support
3. The Vitalistic view, every effort must be made to extend the duration of
human life. In this view, the cancer patient must employ all possible
medical options in order to remain alive, even if such options are
psychologically repugnant, physically painful, or experimentally untried

EUTHANASIA AND SUICIDE

 Both fall under end-of-life care in many countries, there is still a huge difference
between the two
 SUICIDE - the act of intentionally causing one's own death/ intentionally killing
oneself.
‒ arises from the lack of motivation to live./ illegal./ from Latin suicidium -the
act of taking one's own life.
‒ personal problems such as relationship issues, depression, and
employment to more societal issues such as poverty.
a. Suicide is committed by the individual who is subjected to the
killing/euthanasia committed by another individual.
b. Suicide is a harsh and sudden action whereas euthanasia takes place
after a thorough deliberation with people concerned.
c. Suicide does not take place with a constructive thought whereas
euthanasia takes place with a constructive thought.
d. Suicide is considered as illegal but euthanasia is not.
 Suicide is the 10th leading cause of death worldwide.
 Mental disorders; Depression; Bipolar disorder; Schizophrenia; Personality
disorders; Anxiety disorders; and substance abuse—including alcoholism and
the use of benzodiazepines are risk factors
 IMPULSIVE ACTS
‒ from financial difficulties, due to stress, or bullying. Trouble with
relationship
 Approximately 0.5% of people die by suicide.
 In a given year this is roughly 12 per 100,000 people

KINDS OF SUICIDE
1. ATTEMPTED SUICIDE or NON-FATAL SUICIDAL BEHAVIOR is self-injury
with the desire to end one's life that does not result in death.
2. ASSISTED SUICIDE is when one individual helps another bring about their own
death indirectly via providing either advice or the means to the end.
3. SUICIDAL IDEATION - thoughts of ending one's life but not taking any active
efforts to do so.
4. In a MURDER-SUICIDE (or homicide-suicide), the individual aims at taking the
life of others at the same time.
5. A special case of this is EXTENDED SUICIDE, where the murder is motivated by
seeing the murdered persons as an extension of their self
RISK FACTORS
 Mental disorders/Illness
 Drug misuse/Substance misuse
 Psychologycal State
 Cultural, family and social situations
 Genetics
 Previous attempts and self-harm
 Childhood trauma
 Problem gambling
 The ready availability of a means to take one's life,
 A family history of suicide
 The presence of traumatic brain injury
 Media

EUTHANASIA VS ASSISTED SUICIDE

1. Practice
2. Decision-Making
3. Degree of Involvement
4. Complexity
EUTHANASIA ASSISTED SUICIDE
The act of deliberately ending one’s life The act of intentionally aiding or
to relieve persistent pain or suffering encouraging a person to commit suicide
The decision to commit suicide is made The decision to commit suicide is made
by either the patient or a third party by the patient
A third party is the primary agent in The patient is the primary agent in
committing suicide committing suicide
Involves actions that are typically more Involves actions that are typically simpler
complex in nature in nature

SUICIDE PREVENTION
 As a suicide prevention initiative, this sign promotes a special telephone
available on the Golden Gate Bridge that connects to a crisis hotline.
 A suicide prevention fence on a bridge
 SUICIDE the 10th leading cause of death in the US In 2017,
‒ 47,173 Americans died by suicide
‒ In 2017, there were an estimated 1,400,000 suicide attempts
‒ In 2015, suicide and self-injury cost the US $69 Billion
 Additional Facts About Suicide In The Us
‒ The age-adjusted suicide rate in 2017 was 14.0 per 100,000 individuals.
‒ The rate of suicide is highest in middle-age white men in particular.
‒ In 2017, men died by suicide 3.54x more often than women.
‒ On average, there are 129 suicides per day.
‒ White males accounted for 69.67% of suicide deaths in 2017.
‒ In 2017, firearms accounted for 50.57% of all suicide deaths.

EUTHANASIA AND ASSISTED SUICIDE

 EUTHANASIA: A doctor is allowed by law to end a person's life by a painless
means, as long as the patient and their family agree.
 ASSISTED SUICIDE: A doctor assists a patient to commit suicide if they request
it.
 Passive euthanasia is when life-sustaining treatments are withheld. The
definitions are not precise. If a doctor prescribes increasing doses of strong
painkilling medications, such as opioids, this may eventually be toxic for the
patient. Some may argue that this is passive euthanasia.
 ACTIVE EUTHANASIA is when someone uses lethal substances or forces to
end a patient's life, whether by the patient or somebody else.
 Several different interpretations and definitions. One is: "Intentionally helping a
person commit suicide by providing drugs for self-administration, at that person's
voluntary and competent request."

ASSISTED SUICIDE
 The role of palliative care
 Pain is the most visible sign of distress of persistent suffering, people with
cancer and other life-threatening, chronic conditions will often receive palliative
care. Opioids are commonly used to manage pain and other symptoms.
 The adverse effects of opioids include drowsiness, nausea, vomiting, and
constipation. They can also be addictive. An overdose can be lifethreatening.
 REFUSING TREATMENT. A patient can refuse treatment that is recommended
by a health professional, as long as they have been properly informed and are
"of sound mind.“
 The HIPPOCRATIC OATH. "I will neither give a deadly drug to anybody who
asked for it, nor will I make a suggestion to this effect.“ "If it is given me to save a
life, all thanks. But it may also be within my power to take a life; this awesome
responsibility must be faced with great humbleness and awareness of my own
frailty."

CONTROVERSY
 Various arguments are commonly cited for and against euthanasia and
physician-assisted suicide
 Arguments for
‒ FREEDOM OF CHOICE: Advocates argue that the patient should be able
to make their own choice.
‒ QUALITY OF LIFE: Only the patient really knows how they feel, and how
the physical and emotional pain of illness and prolonged death impacts
their quality of life.
‒ DIGNITY: Every individual should be able to die with dignity.
‒ WITNESSES: Many who witness the slow death of others believe that
assisted death should be allowed.
‒ RESOURCES: It makes more sense to channel the resources of highly-
skilled staff, equipment, hospital beds, and medications towards life-saving
treatments for those who wish to live, rather than those who do not.
‒ HUMANE: It is more humane to allow a person with intractable suffering to
be allowed to choose to end that suffering.
‒ LOVED ONES: It can help to shorten the grief and suffering of loved ones.
‒ WE ALREADY DO IT: If a beloved pet has intractable suffering, it is seen
as an act of kindness to put it to sleep.

DYSTHANASIA means "BAD DEATH" and is considered a common fault of modern

medicine.
 Occurs when a person who is dying has their biological life extended through
technological means without regard to the person's quality of life used when a
person is seen to be kept alive artificially in a condition where, otherwise, they
cannot survive; sometimes for some sort of ulterior motive
‒ "Difficult or painful death, used to indicate the extension of the dying
process through treatment that only prolongs patients' biological life. It has
neither quality of life nor dignity. It can also be called Therapeutic
Obstination"
‒ Slow, anguishing death with much suffering
‒ Distancing one from death. does not benefit patients
 ‒ You invest something else in patients, only that you're going to do things
that will not favor them
‒ Dying in a cruel manner

ORTHONASIA - Death at the right time, neither disproportionately abbreviating nor

extending the dying process
 A more positive dimension of the right to die and consists of dying humanely,
peacefully, an ideal death. It is the process of the humanization of death and
alleviation of pain, but it does not abusively prolong death with the
implementation of futile treatment, which would cause more suffering to terminal
patients.
 Orthonasia is the practice of not avoiding patients' death, rather it ceases
investments that extend life at a medium term
 Orthonasia is not applied to cases limited to intense suffering of any nature,
whether it is pain or discomfort. It means suspending measures only related to
the concept of therapeutic obstination, focusing on the maintenance of well being
and taking necessary measures to meet this goal
 EUTHANASIA ("to kill after being asked to, to accelerate death")
 ASSISTED SUICIDE ("to help committing suicide")
 DISTHANASIA ("slow death with lots of suffering")
 ORTHOTHANASIA ("natural, correct death")
 The first two concepts are interpreted as crimes in our country, regulated by
article 121 of the penal code as HOMICIDES.
 The search for these means is closely related to fear of pain, loneliness or family
abandonment, and by rejection of the coldness and impersonality permeating the
assistance to many of our end-of-life counterparts
 So, we once more understand the mandatory indication of palliative, correct and
safe care in a society which shall not fail to the point of having its participants
asking for the right of dying because they are not cared for.
 PALLIATIVE CARE is a powerful alternative to the proposals of legalizing
euthanasia or assisted suicide.

ADMINISTRATION OF DRUGS TO THE DYING

 Pharmacotherapy During the End of Life: Caring for the Actively Dying Patient
‒ Knowledge of pharmacotherapy interventions provided at the end of life is
crucial to optimize care of actively dying patients
‒ The use of less-familiar medications, barriers to medication administration,
and inappropriate pharmacotherapy at the end of life can have deleterious
results
‒ Although goals of treatment may vary between patients, some issues
related to end-of-life symptom management are common
‒ These issues include, but are not limited to, the management of pain,
death rattle/hypersecretion, delirium, agitation, and dyspnea.
‒ The ability to recognize end-of-life symptoms allows the health care
professional to avoid a delay in providing maximal patient comfort.
‒ The inability to administer a medication at the end of life is a barrier to
providing adequate patient care.
‒ Intravenous (IV) access may be discontinued as a result of end-of-life
goals, and oral access may be limited because of impaired swallowing
ability or altered mental status
‒ In the absence or limited availability of IV and oral access, alternative
routes of medication administration can be used
‒ Alternative medication formulations used at the end of life can allow
medications to be delivered buccally, sublingually, rectally (PR), as
nebulized inhalations, transdermally, or topically
 ‒ In emergent situations or when alternative routes of administration are not
possible, non-IV parenteral routes may be considered. n medicine,
specifically in end-of-life care, palliative sedation (also known as terminal
sedation, continuous deep sedation, or sedation for intractable distress in
the dying/of a dying patient) is the palliative practice of relieving distress in
a terminally ill person in the last hours or days of a dying patient's life,
usually by means of a continuous intravenous or subcutaneous infusion of
a sedative drug, or by means of a specialized catheter designed to provide
comfortable and discreet administration of ongoing medications via the
rectal route.
‒ Palliative sedation is an option of last resort for patients whose symptoms
cannot be controlled by any other means. It is not a form of euthanasia, as
the goal of palliative sedation is to control symptoms, rather than to
shorten the patient's life.
‒ A typical drug is midazolam, a short acting benzodiazepine. Opioids such
as morphine are not used as the primary medicine since they are not
effective sedative medications compared to benzodiazepines.
‒ However, if a patient was already on an opioid for pain relief, this is
continued for pain relief while sedation is achieved.
‒ Other medications to be considered include haloperidol, chlorpromazine,
pentobarbital, or propofol. TItrated sedation might speed death but death
is considered a side effect and sedation does not equate with euthanasia

ADVANCE DIRECTIVES
 An advance healthcare directive, also known as living will, personal directive,
advance directive, medical directive or advance decision, is 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.
In the U.S. it has a legal status in itself, whereas in some countries it is legally
persuasive without being a legal document
 A living will is one form of advance directive, leaving instructions for treatment.
Another form is a specific type of power of attorney or health care proxy, in which
the person authorizes someone (an agent) to make decisions on their behalf
when they are incapacitated.
 People are often encouraged to complete both documents to provide
comprehensive guidance regarding their care, although they may be combined
into a single form.
 An example of combination documents includes the Five Wishes in the United
States. The term living will is also the commonly recognised vernacular in many
countries, especially the U.K

LIVING WILL
 The oldest form of advance directive
 First proposed by an Illinois attorney, Luis Kutner, in a law journal in 1969
 In the U.S., The Patient Self-Determination Act (PSDA)[13] went into effect in
December 1991, and required healthcare providers (primarily hospitals, nursing
homes and home health agencies) to give patients information about their rights
to make advance directives under state law.
 A living will usually provides specific directives about the course of treatment
healthcare providers and caregivers are to follow
 May forbid the use of various kinds of burdensome medical treatment.
 Used to express wishes about the use or foregoing of food and water, if supplied
via tubes or other medical devices
 Used only if the individual has become unable to give informed consent or
refusal due to incapacity
 An example of a statement sometimes found in a living will is: "If I suffer an
incurable, irreversible illness, disease, or condition and my attending physician
determines that my condition is terminal, I direct that lifesustaining measures that
would serve only to prolong my dying be withheld or discontinued."
 More specific living wills may include information regarding an individual's desire
for such services such as analgesia (pain relief), antibiotics, hydration, feeding,
and the use of ventilators or cardiopulmonary resuscitation
 LATE 1980s - public advocacy groups became aware that many people
remained unaware of advance directives and even fewer actually completed
them.
 The PATIENT SELF-DETERMINATION ACT OF 1990,which attempted to
address this awareness problem by requiring health care institutions to better
promote and support the use of advance directives
 Living wills proved to be very popular, and by 2007, 41% of Americans had
completed a living will. In response to public needs, state legislatures soon
passed laws in support of living wills in virtually every state in the union.
 "SECOND GENERATION" ADVANCE DIRECTIVES” - the "HEALTH CARE
PROXY APPOINTMENT" or "MEDICAL POWER OF ATTORNEY”

SECOND GENERATION ADVANCE DIRECTIVES

 Allowing an individual to appoint someone to make healthcare decisions in their
behalf if they should ever be rendered incapable of making their wishes known
 “DURABLE POWERS OF ATTORNEY FOR HEALTH CARE"
‒ The appointed healthcare proxy has, in essence, the same rights to
request or refuse treatment that the individual would have if still capable of
making and communicating health care decisions
‒ The primary benefit of second-generation advance directives is that the
appointed representative can make real-time decisions in actual
circumstances, as opposed to advance decisions framed in hypothetical
situations, as recorded in a living will
 "HEALTHCARE PROXY APPOINTMENT" DOCUMENTS”
‒ deficiencies in "second generation" advance directives were also soon
noted. Primarily, individuals faced problems similar to those that
handicapped living wills – knowing what to tell the proxy decision-maker
about one's wishes in a meaningful way

THIRD GENERATION ADVANCE DIRECTIVES

 Designed to contain enriched content to assist individuals and their appointed
agents, families, and physicians to better understand and honor their wishes. \
1. VALUES HISTORY by Doukas and McCullough, created at the
Georgetown University School of Medicine, first published in 1988, and
then more widely cited in an article in 1991
‒ The Values History is a "two-part advance directive instrument that
elicits patient values about terminal medical care and therapy-specific
directives."
‒ The goal of this advance directive is to move away from a focus on
specific treatments and medical procedures to a focus on patient
values and personal goals.
‒ Another values-based project was later published by Lambert, Gibson,
and Nathanson at the Institute of Public Law, University of New
Mexico School of Law in 1990
‒ It continues to be made available via the Hospice and Palliative Care
Federation.
‒ One persistent challenge of third generation based values documents
is to show a linkage between the elicited values and goals with
 medical care wishes, although studies have demonstrated that values
regarding financial and psychological burden are strong motivators in
not wanting a broad array of end-of-life therapies
2. The MEDICAL DIRECTIVE created by Emanuel and Emanuel of
Massachusetts General Hospital and Harvard Medical School.
‒ It is a six-page document that provides six case scenarios for advance
medical decision-making.
‒ The scenarios are each associated with a roster of commonly
considered medical procedures and interventions, allowing the
individual to decide in advance which treatments are wanted or not
wanted under the circumstances. Several criticisms regarding this
advance directive have been expressed.
‒ Primarily, it prompts individuals to make medical treatment decisions,
which they are typically not equipped to make.
3. The FIVE WISHES DIRECTIVE. the best known third generation advance
directive
‒ This document was developed in collaboration with multiple experts
with funding from the Robert Wood Johnson foundation, and is
distributed by the organization Aging with Dignity.
‒ The document was endorsed by Mother Teresa of the Sisters of
Calcutta and by the Chief Justice of the Florida state supreme court.
‒ The document meets statutory criteria in 42 states.
4. the LIFECARE ADVANCE DIRECTIVE.
‒ The most recent third-generation advance directive
‒ In creating this document, researchers reviewed more than 6,500
articles from medical, legal, sociological, and theological sources.
‒ The conclusion was that advance directives needed to be based more
on "health outcome states" than on rosters of medical treatments and
legal jargon.
‒ Building upon the insights gleaned from the literature review, an
advance directive document created, tested in a study involving nearly
1,000 participants, and then comparison tested against other popular
advance directive forms.
‒ The results indicated greater patient/proxy decision-making accuracy,
and superior comprehensive content as compared with other
documents tested
‒ The primary criticism has been that it is very lengthy and tedious to
complete.

LEGAL SITUATION BY COUNTRY

A. AUSTRALIA - The laws regarding advance directives, powers of attorney, and
enduring guardianships vary from state to state. In Queensland, for example, the
concept of an advance health directive is defined in the Powers of attorney act of
1998 and Guardianship and Administration act of 2000. Tasmania has no
specific legislation concerning advance healthcare directives.
B. CANADA - Health Canada – Canada's federal health agency – has
acknowledged the need for a greater investment in palliative and hospice care
as the country faces a rapidly growing population of elderly and terminally ill
citizens - In 2008, The Advance Care Planning in Canada: A National
Framework and Implementation Project was founded - The goal was to engage
healthcare professionals and educate patients about the importance of advance
care planning and end of life care
C. EUROPEAN UNION - is a 2008 paper summarizing advance health care
legislation on each country in the European Union with a shorter summary for
the U.S.; a 2009 paper also provides a European overview
D. ENGLAND AND WALES - people may make an advance directive or appoint a
proxy under the Mental Capacity Act 2005.
‒ This is only for an advance refusal of treatment for when the person lacks
mental capacity; to be legally binding, the advance decision must be
specific about the treatment that is being refused and the circumstances in
which the refusal will apply.
‒ To be valid, the person must have been competent and understood the
decision when they signed the directive.
‒ Where the patient's advance decision relates to a refusal of life-prolonging
treatment this must be recorded in writing and witnessed.
‒ Any advance refusal is legally binding providing that the patient is an adult,
the patient was competent and properly informed when reaching the
decision, it is clearly applicable to the present circumstances and there is
no reason to believe that the patient has changed their mind.
‒ If an advance decision does not meet these criteria but appears to set out
a clear indication of the patient's wishes, it will not be legally binding but
should be taken into consideration in determining the patient's best
interests.
E. GERMANY –On 18 June 2009 the Bundestag passed a law on advance
directives, applicable since 1 September 2009. Such law, based on the principle
of the right of self-determination, provides for the assistance of a fiduciary and of
the physician
F. ITALY – On 14 December 2017, Italian Senate officially approved a law on
advance healthcare directive that came into force on 31 January 2018.
‒ Controversy over end-of-life care emerged in Italy in 2006, when a
terminally ill patient suffering from muscular dystrophy, Piergiorgio Welby,
petitioned the courts for removal of his respirator. Debated in Parliament,
no decision was reached. A doctor eventually honored Welby's wishes by
removing the respirator under sedation
‒ The new law permitted a judicially appointed guardian ("amministratore di
sostegno") to make decisions for an individual. Faced with a 70-year-old
woman with end-stage Lou Gehrig's Disease who was petitioning the court
(with the support of her family) to prevent any later use of a respirator, the
judge appointed her husband as guardian with the specific duty to refuse
any tracheotomy and/or respirator use if/when the patient became unable
to refuse such treatment herself.
G. The NETHERLANDS – , patients and potential patients can specify the
circumstances under which they would want euthanasia for themselves. They do
this by providing a written euthanasia directive. This helps establish the
previously expressed wish of the patient even if the patient is no longer able to
communicate.
‒ Apart from the will in writing of the patients, at least two physicians, the
second being totally unrelated to the first physician in a professional matter
(e.g. working in another hospital, no prior knowledge of the medical case
at hand), have to agree that the patient is terminally ill and that no hope for
recovery exists.
H. SWITZERLAND – there are several organizations which take care of registering
patient decrees, forms which are signed by the patients declaring that in case of
permanent loss of judgement (e.g., inability to communicate or severe brain
damage) all means of prolonging life shall be stopped. Family members and
these organizations also keep proxies which entitle their holder to enforce such
patient decrees.
I. UNITED STATES - all states recognize some form of living wills or the
designation of a health care proxy.
 ‒ The term living will is not officially recognized under California law, but an
advance health care directive or durable power of attorney may be used
for the same purpose as a living will.
‒ A "report card" issued by the Robert Wood Johnson Foundation in 2002
concluded that only seven states deserved an "A" for meeting the
standards of the model Uniform Rights of the Terminally Ill Act.
‒ Surveys show that one-third of Americans say they have had to make
decisions about end-oflife care for a loved one.
‒ In Pennsylvania on November 30, 2006, Governor Edward Rendell signed
into law Act 169, that provides a comprehensive statutory framework
governing advance health care directives and health care decision-making
for incompetent patients.
‒ As a result, health care organizations make available a "Combined Living
Will & Health Care Power of Attorney Example Form from Pennsylvania
Act 169 of 2006."
‒ On July 28, 2009, Barack Obama became the first United States President
to announce publicly that he had a living will, and to encourage others to
do the same. He told an AARP town meeting, "So I actually think it's a
good idea to have a living will. I'd encourage everybody to get one. I have
one; Michelle has one. And we hope we don't have to use it for a long time,
but I think it's something that is sensible
J. INDIA - Indian Supreme Court on March 9, 2018 permitted living wills and
passive euthanasia.
‒ The country's apex court held that the right to a dignified life extends up to
the point of having a dignified death

ADVANCE DIRECTIVES/ LIVING WILL

 Are written, legal instructions regarding your preferences for medical care if you
are unable to make decisions for yourself. Advance directives guide choices for
doctors and caregivers if you're terminally ill, seriously injured, in a coma, in the
late stages of dementia or near the end of life.
 POWER OF ATTORNEY
‒ A medical or health care power of attorney is a type of advance directive in
which you name a person to make decisions for you when you are unable
to do so. In some states this directive may also be called a durable power
of attorney for health care or a health care proxy.
‒ Depending on where you live, the person you choose to make decisions
on your behalf may be called one of the following:
1. Health care agent
2. Health care proxy
3. Health care surrogate
4. Health care representative
5. Health care attorney-in-fact
6. Patient advocate
‒ Choosing a person to act as your health care agent is important. Even if
you have other legal documents regarding your care, not all situations can
be anticipated and some situations will require someone to make a
judgment about your likely care wishes.
‒ You should choose a person who meets the following criteria:
1. Meets your state's requirements for a health care agent
2. Is not your doctor or a part of your medical care team
3. Is willing and able to discuss medical care and end-of-life issues with
you
4. Can be trusted to make decisions that adhere to your wishes and
values
 5. Can be trusted to be your advocate if there are disagreements about
your care
6. The person you name may be a spouse, other family member, friend
or member of a faith community. You may also choose one or more
alternates in case the person you chose is unable to fulfill the role.

MEDICAL DECISIONS YOU SHOULD TALK WITH YOUR DOCTOR BEFORE

WRITING A LIVING WILL
 CPR
 Mechanical Ventilator
 Tube Feeding
 Dialysis
 Antibiotics/ Antiviral Medications
 Comfort Care / Palliative Care
 Organ and Tissue Donations For Transplantation
 Donating Your Body For Scientific Study
 Do Not Resuscitate And Do Not Intubate Orders

CREATING ADVANCE DIRECTIVES

 Review your advance directives with your doctor and your health care agent to
be sure you have filled out forms correctly. When you have completed your
documents, you need to do the following:
 Keep the originals in a safe but easily accessible place.
 Give a copy to your doctor.
 Give a copy to your health care agent and any alternate agents.
 Keep a record of who has your advance directives.
 Talk to family members and other important people in your life about your
advance directives and your health care wishes. By having these conversations
now, you help ensure that your family members clearly understand your wishes.
Having a clear understanding of your preferences can help your family members
avoid conflict and feelings of guilt.
 Carry a wallet-sized card that indicates you have advance directives, identifies
your health care agent and states where a copy of your directives can be found.
 Keep a copy with you when you are traveling

REVIEWING AND CHANGING ADVANCE DIRECTIVES

 New diagnosis. A diagnosis of a disease that is terminal or that significantly
alters your life may lead you to make changes in your living will. Discuss with
your doctor the kind of treatment and care decisions that might be made during
the expected course of the disease.
 Change of marital status. When you marry, divorce, become separated or are
widowed, you may need to select a new health care agent.
 About every 10 years. Over time your thoughts about end-of-life care may
change. Review your directives from time to time to be sure they reflect your
current values and wishes.

PHYSICIAN ORDERS FOR LIFESUSTAINING TREATMENT (POLST)

 The document may also be called provider orders for life-sustaining treatment
(POLST) or medical orders for life-sustaining treatment (MOLST).
 Issues covered in a POLST may include:
1. Resuscitation
2. Mechanical ventilation
3. Tube feeding
4. Use of antibiotics
5. Requests not to transfer to an emergency room
 6. Requests not to be admitted to the hospital
7. Pain management
 A POLST also indicates what advance directives you have created and who
serves as your health care agent. Like advance directives, POLSTs can be
cancelled or updated

DNR or END OF LIFE CARE PLAN

 DO NOT RESUSCITATE (DNR), also known as no code or allow natural death,
is a legal order, written or oral depending on country, indicating that a person
does not want to receive CARDIOPULMONARY RESUSCITATION (CPR) if that
person's heart stops beating. Sometimes it also prevents other medical
interventions.The legal status and processes surrounding DNR orders vary from
country to country. Most commonly, the order is placed by a physician based on
a combination of medical judgement and patient wishes and values.
 An AUTOMATED EXTERNAL DEFIBRILLATOR (AED) is a portable electronic
device that automatically diagnoses the life-threatening cardiac arrhythmias of
ventricular fibrillation (VF) and pulseless ventricular tachycardia, [1] and is able
to treat them through defibrillation, the application of electricity which stops the
arrhythmia, allowing the heart to re-establish an effective rhythm

ETHICS ON DNR (Do Not Resuscitate)

 In many institutions it is customary for a patient going to surgery to have their
DNR automatically rescinded( TAKE AWAY or REMOVE)
‒ Patient AUTONOMY compromised.
‒ When a patient or family and doctors do not agree on a DNR status, it is
common to ask the hospital ethics committee for help
‒ There is accumulating evidence of a racial bias in DNR adoption
‒ Principle of beneficence takes precedence over patient autonomy
‒ When a medical error happens to a patient with a DNR
‒ How patients reach the decision to agree to a DNR order
‒ Discontinuation of an implantable cardioverter defibrillator (ICD) in DNR
patients in cases of medical futility
‒ Less care for DNR patients

DNR
 DNR implies the omission of action, and therefore "giving up”- be retermed Allow
Natural Death.(AND) is ambiguous whether it would allow morphine, antibiotics,
hydration or other treatments as part of a natural death
 New Zealand and Australia, and some hospitals in the UK, use the term NFR or
Not For Resuscitation.
 Resuscitation orders, or lack thereof, can also be referred to in the United States
as a part of Physician Orders for Life-Sustaining Treatment (POLST), Medical
Orders for LifeSustaining Treatment (MOLST), Physician's Orders on Scope of
Treatment (POST) or Transportable Physician Orders for Patient Preferences
(TPOPP) orders, typically created with input from next of kin when the patient or
client is not able to communicate their wishes
 Another synonymous term is "not to be resuscitated" (NTBR).
 Recently in the UK it was common to write "Not for 222" or conversationally, "Not
for twos". This was implicitly a hospital DNR order, where 222 (or similar) is the
hospital telephone number for the emergency resuscitation or crash team.

DNR USAGE BY COUNTRY

 A 2016 paper reports a survey of doctors in numerous countries, asking "how
often do you discuss decisions about resuscitation with patients and/or their
 family?" and "How do you communicate these decisions to other doctors in your
institution?"
 Doctors' Approaches to Communication about Resuscitation
COUNTRY DISCUSS WITH PATIENT TELL OTHER DOCTORS
OR FAMILY THE DECISION
Argentina Rarely Oral
Australia Most, Half Oral+Notes+Pre-printed
(2), Notes
Austria Half Notes
Barbados Half Oral+Notes

Belgium Half, Rarely Notes+Electronic

Brazil Most Oral+Notes

DNR USED IN 0THER COUNTRIES

A. MIDDLE EAST - DNRs are not recognized by Jordan.
B. Physicians attempt to resuscitate all patients regardless of individual or familial
wishes.
‒ The UAE have laws forcing healthcare staff to resuscitate a patient even if
the patient has a DNR or does not wish to live. There are penalties for
breaching the laws.
‒ In Saudi Arabia patients cannot legally sign a DNR, but a DNR can be
accepted by order of the primary physician in case of terminally ill patients.
In Israel, it is possible to sign a DNR form as long as the patient is dying
and aware of their actions
C. UNITED KINGDOM - DNACPR form as used in Scotland
D. ENGLAND AND WALES -, CPR is presumed in the event of a cardiac arrest
unless a do not resuscitate order is in place. If they have capacity as defined
under the Mental Capacity Act 2005 the patient may decline resuscitation,
however any discussion is not in reference to consent to resuscitation and
instead should be an explanation
‒ Patients may also specify their wishes and/or devolve their decision-
making to a proxy using an advance directive, which are commonly
referred to as 'Living Wills'.
‒ Patients and relatives cannot demand treatment (including CPR) which the
doctor believes is futile and in this situation, it is their doctor's duty to act in
their 'best interest', whether that means continuing or discontinuing
treatment, using their clinical judgment.
‒ If they lack capacity relatives will often be asked for their opinion out of
respect.
E. SCOTLAND -, the terminology used is "DO NOT ATTEMPT
CARDIOPULMONARY RESUSCITATION" or "DNACPR".
‒ There is a single policy used across all of NHS Scotland.
‒ The legal standing is similar to that in England and Wales, in that CPR is
viewed as a treatment and, although there is a general presumption that
CPR will be performed in the case of cardiac arrest, this is not the case if it
is viewed by the treating clinician to be futile.
‒ Patients and families cannot demand CPR to be performed if it is felt to be
futile (as with any medical treatment) and a DNACPR can be issued
despite disagreement, although it is good practice to involve all parties in
the discussion
F. UNITED STATES - the documentation is especially complicated in that each
state accepts different forms, and advance directives and living wills may not be
accepted by EMS as legally valid forms.
 ‒ If a patient has a living will that specifies the patient requests DNR but
does not have a properly filled out state-sponsored form that is co-signed
by a physician, EMS may attempt resuscitation.
‒ The DNR decision by patients was first litigated in 1976 in In re Quinlan.
‒ The New Jersey Supreme Court upheld the right of Karen Ann Quinlan's
parents to order her removal from artificial ventilation.
‒ In 1991 Congress passed into law the Patient Self-Determination Act that
mandated hospitals honor an individual's decision in their healthcare.
‒ Forty-nine states currently permit the next of kin to make medical decisions
of incapacitated relatives, the exception being Missouri.
‒ Missouri has a Living Will Statute that requires two witnesses to any
signed advance directive that results in a DNR/DNI code status in the
hospital
G. CANADA - Do not resuscitate orders are similar to those used in the United
States. In 1995, the Canadian Medical Association, Canadian Hospital
Association, Canadian Nursing Association, and Catholic Health Association of
Canada worked with the Canadian Bar Association to clarify and create a Joint
Statement on Resuscitative Interventions guideline for use to determine when
and how DNR orders are assigned.
‒ DNR orders must be discussed by doctors with the patient or patient
agents or patient's significant others. Unilateral DNR by medical
professionals can only be used if the patient is in a vegetative state.
H. AUSTRALIA - Do Not Resuscitate orders are covered by legislation on a state-
bystate basis.
‒ In Victoria, a Refusal of Medical Treatment certificate is a legal means to
refuse medical treatments of current medical conditions. It does not apply
to palliative care (reasonable pain relief; food and drink). An Advanced
Care Directive legally defines the medical treatments that a person may
choose to receive (or not to receive) in various defined circumstances. It
can be used to refuse resuscitation, so as avoid needless suffering.
I. ITALY - DNRs are not recognized by Italy. Physicians must attempt to
resuscitate all patients regardless of individual or familial wishes.
‒ Italian laws force healthcare staff to resuscitate a patient even if the patient
has a DNR or does not wish to live.
‒ There are jail penalties (from 6 to 15 years) for healthcare staff breaching
this law, e.g. "omicidio del consenziente".
‒ Therefore in Italy a signed DNR has no legal value.
J. TAIWAN - patients sign their own DNR orders, and are required to do so to
receive hospice care

END OF LIFE CARE

 Planning ahead
 Why plan ahead Advance statement about your wishes Advance decision: living
will Lasting power of attorney
 Your well-being
 It covers what to expect, thinking about your wishes for your future care, and
looking after your emotional and psychological wellbeing
 - What you can expect from end of life care?
 This section contains information about what end of life care involves and when
it starts and things you may want to think about.
 These include financial issues, and how and where you want to be cared for, for
example:
1. Care at home
2. Care in hospital
3. Care in a care home
 4. Hospice care
 PLANNING AHEAD FOR THE END OF LIFE - sometimes called advance care
planning, and involves thinking and talking about your wishes for how you're
cared for in the final months of your life. This can include treatments you don't
want to have
‒ Why plan ahead: how you and your family, friends and carers can benefit
from planning ahead for your future care.
‒ Advance statement: to let people know your wishes.
‒ Advance decision to refuse treatment: if you don't want certain kinds of
treatment in the future, you can make a legally binding advance decision.
‒ Lasting power of attorney: you can legally appoint someone to make
decisions about your care in the future if you become unable to make
decisions yourself.
‒ Making a will: make a will.
 YOUR WELL-BEING - Looking after your health and well-being is important
when you're living with a terminal (life-limiting) condition
‒ Answer questions you may have about pain and other symptoms, and
provide ideas for coping:
‒ Coping with a terminal illness: information, sources of support and tips
from experts on how to cope with a terminal diagnosis.
‒ Managing pain and other symptoms: find out how pain and other
symptoms, such as constipation, can be managed. Includes self-help
suggestions.
‒ Ways to start talking about the fact you are dying: ideas on how to bring up
the topic of your illness and the future.
‒ Physical changes in the last hours and days: talks about changes to your
body that may happen in the last stages of life.

ETHICAL RESPONSIBILITIES OF NURSES by CLAYTON BROWNE

1. RESPECT FOR OTHERS - A nurse must respect the dignity and value of
patients and colleagues, and treat all persons equally regardless of personal
attributes or medical condition. Related to this is the responsibility to always
respect the patient's right to self-determination in her medical care.
2. COMMITTMENT TO PATIENT - One of a nurse's primary ethical responsibilities
is to work with the patient to provide care that maximally enables the physical,
emotional and social well-being of the patient.
‒ A nurse is also responsible for protecting and advocating for patient safety
and rights, especially in terms of upholding the highest standards of
patient privacy and confidentiality according to the law
3. HONESTY AND SELF-INTEGRITY - Nurses also have an ethical responsibility
to be honest with patients and colleagues, and to maintain self-integrity and high
personal moral standards. By the same token, nurses have a personal
responsibility to maintain professional competence and strive towards personal
and professional growth so as to provide the best possible care to patients.
4. PROFESSIONAL RESPONSIBILITIES - A nurse also has a number of ethical
responsibilities relating to the profession of nursing and her specialty.
‒ One key responsibility is to always strive to improve both health care
environments and conditions of employment to maximize the quality of
health care delivery.
‒ Nurses also have a responsibility to work with the public and other medical
professionals to foster local school or community, national and
international efforts to improve health care systems on all levels.
NURSING ROLES AND RESPONSIBILITIES ETHICAL DECISION MAKING
PROCESS
 Ethical decision-making refers to the process of evaluating and choosing among
alternatives in a manner consistent with ethical principles. In making ethical
decisions, it is necessary to perceive and eliminate unethical options and select
the best ethical alternative.
 The process of making ethical decisions requires:
‒ COMMITMENT: The desire to do the right thing regardless of the cost
‒ CONSCIOUSNESS: The awareness to act consistently and apply moral
convictions to daily behavior
‒ COMPETENCY: The ability to collect and evaluate information, develop
alternatives, and foresee potential consequences and risks
 Good decisions are both ethical and effective:
‒ ETHICAL DECISIONS generate and sustain trust; demonstrate respect,
responsibility, fairness and caring; and are consistent with good citizenship.
These behaviors provide a foundation for making better decisions by
setting the ground rules for our behavior.
‒ EFFECTIVE DECISIONS are effective if they accomplish what we want
accomplished and if they advance our purposes. A choice that produces
unintended and undesirable results is ineffective. The key to making
effective decisions is to think about choices in terms of their ability to
accomplish our most important goals. This means we have to understand
the difference between immediate and short-term goals and longer-range
goals.

NURSING ROLES AND RESPONSIBILITIES

 Diversity in Dying: Death across Cultures
‒ Whether it is seen in personal terms or trans-personal terms, whether it is
Heaven or Nirvana or Happy Hunting Ground or the Garden of Paradise,
the weight and authority of tradition maintains that death is just an
alteration in our state of consciousness, and that the quality of our
continued existence in the afterlife depends on the quality of our living
here and now. - John Smith
 CULTURAL COMPETENCE is a term that nurses have learned is a necessary
part of providing good nursing care to patients.
‒ The population of the United States is becoming more diverse, and nurses
should be both knowledgeable and comfortable providing care to a diverse
range of patients.
‒ Diversity includes issues related to a person’s ethnicity, sexual orientation,
age, gender, and socio-economic class (ELNEC, 2010).
‒ Nurses who care for patients nearing the end of life should have a good
understanding about the various beliefs and traditions held by various
cultures about death and dying.
‒ This is something that is not always thought of in nursing school, but it is
essential information to know when caring for patients who are dying.
NURSING ROLES AND RESPONSIBILITIES ETHICAL DECISION MAKING
PROCESS
A. Making Ethical Decisions: MODEL
‒ The "Character-Based Decision-Making Model" model, developed by the
Josephson Institute of Ethics, can be applied to many common problems
and can also be used by most individuals facing ethical dilemmas.
‒ THREE STEPS:
1. All decisions must take into account and reflect a concern for the
interests and well being of all affected individuals ("stakeholders").The
underlying principle here is the Golden Rule — help when you can,
avoid harm when you can.
2. Ethical values and principles always take precedence over nonethical
ones.- are morally superior to nonethical ones. When faced with a
clear choice between such values, the ethical person should always
choose to follow ethical principles.
‒ Perceiving the difference between ethical and nonethical values
can be difficult. This situation often occurs when people perceive a
clash between what they want or "need" and ethical principles that
might deny these desires. If some rationalization begins to occur,
this situation is probably present.
3. It is ethically proper to violate an ethical principle only when it is clearly
necessary to advance another true ethical principle, which, according
to the decision-maker's conscience, will produce the greatest balance
of good in the long run.Some decisions will require you to prioritize
and to choose between competing ethical values and principles when
it is clearly necessary to do so because the only viable options require
the sacrifice of one ethical value over another ethical value. When this
is the case, the decision-maker should act in a way that will create the
greatest amount of good and the least amount of harm to the greatest
number of people.
B. Making Ethical Decisions: OBSTACLES
‒ Learn about some common rationalizations that can cloud our judgment
when we are involved in making tough ethical decisions.
1. IF IT'S NECESSARY, IT'S ETHICAL: This approach often leads to
ends-justify-the-means reasoning and treating non-ethical tasks or
goals as moral imperatives.
2. THE FALSE NECESSITY TRAP: "Necessity is an interpretation and
not a fact." We tend to fall into the "false necessity trap" because we
overestimate the cost of doing the right thing and underestimate the
cost of failing to do so.
3. IF IT'S LEGAL AND PERMISSIBLE, IT'S PROPER: This substitutes
legal requirements for personal moral judgement. This alternative
does not embrace the full range of ethical obligations, especially for
those involved in upholding the public trust. Ethical people often
choose to do less than what is maximally allowable but more than
what is minimally acceptable
4. IT'S JUST PART OF THE JOB: Conscientious people who want to do
their jobs well often compartmentalize ethics into two categories:
private and job-related. Fundamentally decent people may often feel
justified doing things at work that they know to be wrong in other
contexts.
5. IT'S FOR A GOOD CAUSE: This is a seductive rationale that loosens
interpretations of deception, concealment, conflicts of interest,
favoritism, and violations of established rules and procedures.
 6. I WAS JUST DOING IT FOR YOU: This rationalization pits values of
honesty and respect against the value of caring and overestimates
other people's desire to be "protected" from the truth. This is the
primary justification for committing "little white lies."
7. I'M JUST FIGHTING FIRE WITH FIRE: This is the false assumption
that promise-breaking, lying, and other kinds of misconduct are
justified if they are routinely engaged in by those with whom you are
dealing. This rationale compromises your own integrity
8. IT DOESN'T HURT ANYONE: This rationalization is used to excuse
misconduct when violating ethical principles so long as no clear and
immediate harm is perceived. It treats ethical obligations as simply
factors to be considered in decision-making rather than as ground
rules.
9. EVERYONE'S DOING IT: This is a false "safety in numbers" rationale
that often confuses cultural, organizational, or occupational behaviors
and customs as ethical norms.
10. IT'S OK IF I DON'T GAIN PERSONALLY: This justifies improper
conduct for others or for institutional purposes.
11. I'VE GOT IT COMING: People who feel overworked and/or underpaid
rationalize that minor "perks" (acceptance of favors, discounts,
gratuities, abuse of sick leave, overtime, personal use of office
supplies) are nothing more than fair compensation for services
rendered.
12. I CAN STILL BE OBJECTIVE: This rationalization ignores the fact
that a loss of objectivity always prevents perception of the loss of
objectivity. It also underestimates the subtle ways in which gratitude,
friendship, anticipation of future favors and the like affect judgement.

C. • Making Ethical Decisions: CORE ETHICAL VALUES

Learn how six key ethical values can help you build character in yourself and others.
TRUSTWORTHINESS - deserving of trust or confidence; dependable; reliable: The
treasurer was not entirely trustworthy. See more.
RESPECT - also called esteem, is a positive feeling or action shown towards
someone or something considered important, or held in high esteem or regard
RESPONSIBILITY - moral, legal, or mental accountability
FAIRNESS - lack of favoritism toward one side or another
CARING - Feeling and exhibiting concern and empathy for others
CITIZENSHIP - the quality of an individual's response to membership in a community

RELIGION BELIEFS PREPARATION FUNERAL

PERTAINING TO OF THE BODY
DEATH
CATHOLIC Beliefs include that the Organ donation Cremation
deceased travels from and autopsy are historically
this world into eternal permitted. forbidden until
afterlife where the soul 1963.The Vigil
can reside in heaven, occurs the evening
hell, or purgatory. before the funeral
Sacraments are given mass is held. Mass
to the dying. includes Eucharist.
If a priest is not
available, a deacon
can lead funeral
services. Rite of
committal takes
 place with
interment.
PROTESTANT Belief in Jesus Christ Organ donation Cremation or burial
and the Bible is central, and autopsy are is accepted.
although differences in permitted. Funeral can be
interpretation exist in held in funeral
the various home or in church
denominations. Beliefs and led by minister
include an afterlife. or chaplain.
JEWISH Tradition cherishes life Autopsy and Funeral held as
but death itself is not embalming are soon as possible
viewed as a tragedy. forbidden under after death. Dark
Views on an afterlife ordinary clothing is worn at
vary with the circumstances. and after the
denomination (Reform, Open caskets are funeral/burial. It is
Conservative, or not permitted. forbidden to bury
Orthodox). the decedent on
the Sabbath or
festivals. Three
mourning periods
are held after the
burial, with Shiva
being the first
seven days after
burial.
BUDDHIST Both a religion and way Goal is a peaceful Family washes and
of life with the goal of death. Statue of prepares the body.
enlightenment. Beliefs Buddha may be Cremation is
include that life is a placed at bedside preferred but if
cycle of death and as the person is buried, deceased
rebirth. dying. Organ should be dressed
donation is not in regular daily
permitted. Incense clothes instead of
is lit in the room fancy clothing.
following death. Monks may be
present at the
funeral and lead
the chanting.
NATIVE Beliefs vary among Preparation of the Most burials are
AMERICAN tribes. Sickness is body may be done natural or green.
thought to mean that by family. Organ Various practices
one is out of balance donation generally differ with tribe.
with nature. Thought not preferred. Among the Navajo,
that ancestors can hearing an owl or
guide the deceased. coyote is a sign of
Believe that death is a impending death
journey to another and the casket is
world. Family may or left slightly open so
may not be present for the spirit can
death. escape. Navajo
and Apache tribes
believe that spirits
of deceased can
haunt the living.
 The Comanche
tribe buries the
dead in the place
of death or in a
cave.
HINDU Beliefs include Organ donation Prefer cremation
reincarnation, where a and autopsy are within 24 hours
deceased person acceptable. after death. Ashes
returns in the form of Bathing the body should be
another, and Karma. daily is necessary. scattered in sacred
Death and dying rivers.
must be peaceful.
Customary for
body to not be left
alone until
cremated.
MUSLIMS Muslims believe in an Embalming and Burial takes place
afterlife and that the cremation are not as soon as
body must be quickly permitted. Autopsy possible. Women
buried so that the soul is permitted for and men will sit
may be freed. legal or medical separately at the
reasons only. After funeral. Flowers
death, the body and excessive
should face Mecca mourning are
or the East. Body is discouraged. Body
prepared by a is usually buried in
person of the same a shroud and is
gender. buried with the
head pointing
toward Mecca.

NURSING ROLES AND RESPONSIBILITIES

 Treat people compassionately
 Listen to people
 Communicate clearly and sensitively
 Identify and meet the communication needs of each individual
 Acknowledge pain and distress and take action
 Recognize when someone may be entering the last few days and hours of life
 Involve people in decisions about their care and respect their wishes
 Keep the person who is reaching the end of their life and those important to them
up to date with any changes in condition
 Document a summary of conversations and decisions
 Seek further advice if needed
 Look after yourself and your colleagues and seek support if you need it

THE CRUCIAL ROLE OF NURSES IN PALLIATIVE CARE

 PALLIATIVE NURSING means being available to the patients 24 hours a day to
manage their pain and discomforts and to provide support to the families
A. TEACHER - Health educator
B. PSYCHOLOGIST / COUNSELOR
‒ Patients who are at the last stages of their lives need all the support they
can get.
‒ Nurses aren’t just skilled in providing care, but they are also considered
the best when it comes to providing emotional support.
 ‒ They know therapeutic communication like the back of their hands and
the best ways to use it to make their patients feel better.
‒ They can encourage patients to verbalize their feelings and concerns.
‒ They help make patients be more open about the things they worry
about without making them feel judged.
C. CAREGIVER - Nurses are considered the primary caregivers of their patients.
When a nurse is assigned to one patient, he is essentially responsible in
making sure his patient is physically well.
‒ This role includes assessing pain levels, giving appropriate medications,
providing non-pharmacological pain relief and feeding.
‒ When a patient is no longer capable of caring for himself, nurses assist
in performing activities of daily living.
‒ They help patients in grooming and hygiene to make them feel better
about themselves.
D. ADVOCATE - one of the most challenging roles nurses have when it comes
to palliative care.
‒ Most family members and health care providers choose aggressive
treatment choices when it comes to acute conditions in an attempt to
help patients.
‒ Unfortunately, however, this isn’t always what patients want.
‒ During these times, nurses are expected to advocate for their patients
and speak up for them.
‒ In certain cases, nurses advocate for families, too.
‒ Nurses help families clarify their goals and make them reconsider what
their patients would have wanted.
‒ They give families a clearer picture of the reality and its implication to the
patient.
‒ In the event that death is imminent, nurses help families with the process
of acceptance.
E. MESSENGER - help patients in establishing advance care planning decisions
1. By asking - asking questions that are most wrenching to both patients
and families
2. By listening - get an idea about your patient’s wishes.
3. By guiding - responsibility to guide your patient’s ++decision-maker
about the treatment options that are available, their implications, benefits
and drawbacks.