EndofLife Issues

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End-of-Life Issues
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Withholding or Withdrawing Treatment

• The mentally competent adult has the legal right
  to request that treatment be withdrawn or
  withheld even if this will result in death
• Nothing active done to end pts life
• Nature permitted to take its course

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Nancy B

• 24-year-old mentally competent woman
• Totally permanently paralyzed from Guillan-
  Barre syndrome
• After 3 years of living as a ventilator
  dependant quadraplegic, she requested that her
  ventilator be disconnected
• Quebec Superior Court ordered that she could not
  be treated against her will
• Died of respiratory arrest due to Guillan-Barre

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Assisted Suicide

• Pt mentally competent to end his/her life because
  of deteriorating condition but requires
  assistance of a 3rd party
• Not legal in Canada
• Legal in Oregon since 1997
• Under consideration in California, Vermont, and
  Britain, 2005

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Assisted Suicide in Canada Sue Rodriguez

• 42-year-old mentally competent woman with A.L.S.
• Still able to breathe independently
• Paralysis was progressing
• Requested she be allowed a lethal injection
• Despite courts objection, she achieved her goal
  of death by assisted suicide

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Canadian attitudes about AS1995 Gallup Poll

• 75 Canadians support doctor assisted suicide in
  cases where life immediately threatened by
  disease that causes great suffering.
• 57 also believe doctor assisted suicide should
  be permitted in non-immediate life threatening
  cases

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Canadian attitudes re AS

• Angus Reid Poll 1997
• 3 in 4 Canadians support the concept of
  terminally ill people having the right to die for
  people who wish to end their own lives.

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AS in Oregon 1st year, 1998

• 23 pts received prescriptions for lethal meds
• 15 died after taking the meds
• 6 died from underlying illnesses
• 2 still alive in Jan 99

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AS in Oregon 1st year, 1998

• Requests for AS associated with loss of autonomy
  and bodily functions not with fear of intractable
  symptoms or fear about financial loss

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AS in Oregon, 2004

• Since 1997, 208 deaths, approx. 11000 deaths
• 2004, 60 prescriptions for lethal doses
• 35 died after using drug
• 13 died naturally, 12 remained alive at year end
• Feb 2005 Bush administration files challenge to
  Oregon law in US Supreme Court

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Suicide

• It is not a crime to commit or attempt suicide in
  Canada.
• It is a crime to abet, counsel or aid someone to
  commit suicide.

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Euthanasia

• a good death
• Mercy Killing
• Legal (under stringent conditions) in the
  Netherlands and Belgium (Sept., 2004)

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Euthanasia in Canada (Law Reform Commission,
1983)

• Involves the commission of an act that directly
  results in the death of a person murder

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Dr. Nancy Morrison, Halifax, 1997

• 65-year-old with terminal CA
• Ventilator dependant in severe pain
• Family agreed that patient should be taken off
  life support and allowed to die
• Patient did not die quickly as expected
• Injections of Nitroglycerine KCl
• Charged with murder -thrown out - no jury would
  convict

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Robert Latimer, 1993

• Only Canadian to serve jail time despite number
  of precedents for leniency

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Nurses Experiences with AS

• Asch, 1996 1600 critical care nurses - 16
  reported participation in AS or euthanasia
• Ferrell et al, 2002 2333 oncology nurses
• 30 support legalizing AS, 23 support
  legalizing euthanasia, 3 had helped pts obtain
  prescriptions for lethal meds, 3 administered
  lethal injections

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Nurses Experiences with AS

• Leiser et al, 1998 428 nurses serving AIDS pts
  15 participated in AS or euthanasia
• Matzo Emanuel, 1997 440 oncology nurses 1
  acknowledged participation in AS, 4.5 reported
  assistance with patient-requested euthanasia

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Ethical principle of Double Effect

• Grounded in Roman Catholic moral theology
• Distinguishes the primary intention from the
  secondary foreseen, but unintended consequences
• Is the intent to relieve pain suffering or to
  kill?

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Terminal/Palliative Sedation

• Intention of deliberately inducing and
  maintaining deep sleep, but not deliberately
  causing death
• For the relief of one or more intractable
  symptoms
• When all possible interventions have failed
• When pt. perceived to be near death