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63 Cards in this Set
- Front
- Back
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withdraw treatment, withold treatment.
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forgoing medical treatment
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treatment produces more benefit that burdon therefore morally required
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morally ordinary treatment.
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treatment produces more burdon than benefit therefore optional
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morally extraordinary
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life is of ultimate value must be perserved at all cost
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vitalism
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only imp. if you think its vaulable (life only has value if you give it value) burden or benefit defined by patient there view.
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subjectivism
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degree of success
how invasive how painful anxiety |
weighing burden and benefits
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any treatment can be ordinary or extraordinary.
depends on patients perspective. |
treatment exceptions
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- when the treatment is morally extraordinary
- competent patient refuses treatment |
allowing patient to die morally acceptable.
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comfort care- paint management- morphine given to relieve pain although may cause other issues
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palliative
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can give necessary dossages of morphine that may hasten death as long as the intent is to relieve pain.
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double effect principle
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any competent adult can accept/ reject any / all treatment
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legal pillar
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1. preservation of life
2. protection of innocent life/ 3rd parties 3. prevention of suicide 4. protection of medical standards. |
4 essential state interests
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executive funstion higher thinking
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frontal
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vision
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occipital
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touch pressure sensation
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pariatal
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hearing sounds smell short term memory
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temporal
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swelling- increased intercranial pressure- craniactomy- bore hole to let brain swell- burr hole better to have
6 months in a before diagnosis of PVS |
traumatic brain injury
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cardiac arrest 3 monts diagnosis changes to PVS
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nontraumatic brain injury
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eyes closed unconsciousness injury to brain trying to heal itself. transient state not fixed diagnosis
- prognosis- is unknown 2 options= come out of it (baseline and neurological defecits) and presist ( PVS (VEGGIE) MCS (mininammly conscious state). |
coma
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eyes open unconsciousness, ventilate spontaneously arousal no awareness noncognitive bio exsistence prognisis is catastrophic & articicial nutrition and hydration.
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pvs
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some episodic awareness prognosis- not going to change unchanginng
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mcs
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cesation of integrated functioning of the organisms as a whole (irreversible) 2 criteria to determiine death
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TBF and cardio respiratory failure
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irreversible cesation of the entire brain inculding the brainstem best organ donors heart beating cadavir
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tbf
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-no response to painful stimuli
- no posture- decerebrate and decorticate - no pupillary reaction - no oculocephallic reflex (dolls eyes) -no vestibulocular reflex -apnea -gag reflex -eeg -cerebral blood flow studies CBC -4-6hrs |
TBF
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allow for a legal exemption of TBF ___ ___ --____
and in what states ? |
religious objection, jewish
new york and new jersey |
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Document that specifies type of healthcare pt. would want if unable to communicate wishes only under CERTAIN CIRCUMSTANCES:
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living will
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If pt is incompetent AND EITHER
Terminally ill PVS |
living will becomes effective
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takes precedence over a__n Ohio
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LW ,DPA
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Document that appoints a surrogate decision maker
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durable power of attorney
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Become effective when pt. loses decisional capacity
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durable power of attorney
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Foster dialogue
COMMUNICATION Enacting _is a process Revisited over time |
advanced directives
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Competent adult over 18
Signed by patient AND EITHER Two adults not related to pt. by blood, marriage, or adoption; nor attending MD, administrator of a nursing home OR Notary Public |
procedure to making a living will
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CANNOT forgo LST unless pt is terminal OR in PVS…. (?)
CANNOT forgo palliative care CANNOT forgo ANH unless pt terminally ill… (?) CANNOT forgo ANH if pt in PVS unless pt has documented wishes re ANH CANNOT forgo tx pt previously authorized unless pt condition has changed so significantly so as to no longer be in the pt’s Best Interest |
5 limitations on DPA
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Don’t choose a surrogate who can’t enact your stated wishes!
Theoretically DPA are better than LW because the healthcare team has a person they can talk to rather than a document |
DPA
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Most states don’t allow LST to be removed from pg. female unless continued LST causes more burden than benefit for pt OR if continued LST would not result in live birth
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pregnancy DPA
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1976 nj20s diagnosis: PVS
treament: ANH MV parents request to discontinue mechanical ventilation- hosp refuses to comply they are not in the bisness of murdering there patients |
Quinlan
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- patient still has privacy court appoints father as legal guardian.
- the states interests in the preservation of life weakens and the patients right to privacy grows as the degree of bodily invasion increases and the prognisis decreases -end of life decisions should be made at the bedside they d/c mechinical ventilation breaths spontaneouslt for 9 years |
quinlan
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judge does not allow surrogate decision making
we say withholding and withdrawling are the same thing killing versus allowing to die |
brophy case 3 key mistakes with court ruling
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first ethics case to reach the supreme court was ?
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cruzan
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1983 missuori 25 motor vehicle accident diagnosis: PVS treatment: ANH
parents request discontinueing ANH- hosp refuses to comply- starvation |
cruzan
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highest evidentiary standard in civil case- advanced directives - mo, fl, ny
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clear and convincing evidence
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which states require clear and convicing evidence
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mo, fl, ny
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more likely then not the patient would have refused treatment
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preponderance of the evidence
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for of the six points supreme court handed down from the cruzan case
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1. anh is a medical treatment like any other and may be forgone.
2. withholding treatment is same as withdrawing treatment 3. established a nationwide right to refuse treament 4. competent patients may make advanced directives and must be followed |
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criteria to assess if latient has capacity is relative to the task at hand
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sliding scale
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affect ____ = meds, dementia, psych, pain, stress, culture, language
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capacity
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elements of decisional making capacity- patient can understand material given to them
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person
place time a&o x3 |
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only a ___ incompetence
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judge
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clinician overrides a patients autonomous decision- doctor knows best
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strong paternalism
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clinician interveins with patients nonautonomous decision- protect the patient
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weak paternalism
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chain of command for surrogacy
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Guardain, Spouse, Adultchild, Parents, Siblings
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1985 nj 83 female
skilld nursing facility -contracted semi-fetal position -bed ridden unale to speak -advanced dementia - diabetes -gangrene on leg -on ocassion tract with eyes -NG-tube |
conroy
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nephew request D/C NG tube
docters refuse-vialation of medical ethics. ruling treatment can be forgone from an incapacitated patient under certain circumstances |
conroy
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1976 ma 67 male
severe mental retardation instituitionalized > 40 years IQ=10 no family diagnosed with leukemia (fatal) 30-50% have remission up to 13 months with aggressive chemo burdens worse then benefit. |
saikewicz
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1. substitutional judgement- speaks as patients mouthpiece
2. best interests- use for patients who have never been autonomous 3. mix standard- see most interperit patiesnts wishes hybrid approach |
3 standards of surogacy
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1988 ny 77 female mulitiple strokes- brain damage
doctors seek to insert ANH loss of gag reflex- 2 daughters oppose it. no articifial life support per mothers verbal wishes. -ethics committee agrees with doctor |
o'connor
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MD #1- patient alert and conscious. death via starvation/ dehydration painful
MD#2- regardless of mental status palliative care would be given ny clear and convincing evidence before life support can be distaines still given despite the wishes of the daughters |
o'connor
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1990 MN 85 femal
diagnosis: PVS, MV, ANH, Antibiotics MDS want to stop treatment feel it is futile (not going to help) family makes DNR wants life supprt continued. court states husband would know patients best wishes |
wanglie
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all should be held being equal unless they conflict an equal greater value
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principilism
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self rule- independence
self governance- live or lives as we go so long as we dont impinge on the rights of others |
autonomy
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promote welfare, remove harm, active obligation
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beneficence
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do no harm
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nonmaleficence
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fair, equitable
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justice
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