Death: Natural or assisted?PATRICK PULLICINO
Here is an explanation of common terms used during end-of-life discussions.
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Euthanasia is the intentional causing or hastening of death in a person with a medical condition that is judged to be serious. The patient may either be (a) alert and (b) aware and (c) competent to make their own decisions and (d) able to communicate or the patient may have (a) decreased alertness (due to encephalopathy or coma), (b) diminished awareness (retardation, dementia, vegetative state) and (c) be incompetent to make their own decisions or (d) be unable to communicate due to aphasia, or inability to speak.
Euthanasia is voluntary, when an alert, aware, competent patient agrees to it being performed, and euthanasia is involuntary when it is performed on a patient without the patient's clear understanding and agreement. Euthanasia may be an obvious, clear-cut act acknowledged as such by both the medical staff and patient or may be an action or series of actions that are put forward as being "standard" medical treatment. An example of a clear act is when a patient is given a lethal intravenous dose of potassium or insulin or an oral fatal dose of sedatives. However, a patient may be given gradually escalating doses of morphine or other narcotics for sedation or analgesia, in the knowledge that the morphine will hasten death.
If the drug is being used primarily to treat severe pain not responsive to other analgesics, in a painful terminal condition, (such as advanced widespread cancer), it may be given in the knowledge that a side-effect of the treatment may be a hastening of death. This cannot be considered euthanasia. However, if excessive and repeated doses of morphine are given to a sick patient who is not in pain, for the purpose of "comforting the patient" or to "relieve air hunger" or to relieve "labored breathing" this may really be euthanasia under the guise of "standard" medical treatment.
Another form of euthanasia that is frequently practiced is to switch off a ventilator (mechanical respirator) that is assisting breathing in a patient who is unable to breathe on their own. Some patients are put on a ventilator because they have lung disease and need the extra oxygen — these patients may be alert and be able to communicate. Some patients cannot breathe on their own because of brain disease. This may be reversible as in encephalopathy, or may be severe and irreversible such as in the persistent vegetative state.
It is frequently difficult to determine early in the course of an illness whether the condition is reversible or not and this usually only becomes clear with passage of time. Patients on ventilators are frequently in a deep coma and they may deteriorate and die. It is often difficult to know without a full neurological examination whether a patient is in deep coma or if they are dead. A series of tests has been drawn up to determine the presence of brain death (see section 5: How is death determined) and these are usually administered by a neurologist or neurosurgeon.
If these tests determine that brain death has occurred, it is legitimate to switch off a ventilator even though the heart may still be beating, because in this situation the ventilator is not keeping the patient alive. There is however, an increasing tendency in intensive care units to discontinue ventilator support in patients who have either severe irreversible brain damage who are not dead (see persistent vegetative state), or in patients with potentially reversible encephalopathy. The stated reason for discontinuing ventilator support is often because the patient's prognosis for recovery to their previous state of functioning is judged to be poor.
There is also an increasing tendency to discontinue ventilator support in patients with severe respiratory disease when it is judged that they have become ventilator-dependent and might need to have ventilator support for the rest of their lives. Mechanical ventilation is clearly an artificial method of life support. Ventilation can be life-saving in an acute illness and patients are usually put on a ventilator as a temporary measure. Difficulty breathing is part of the terminal stages of several illnesses such as large strokes or severe longstanding lung disease. Mechanical ventilation is not part of the recommended treatment of such illnesses because there is little chance that it will help and a high chance the patient will die despite being put on a ventilator or that they will become ventilator-dependent. When a poor outcome to ventilation is predicted, patients or relatives are usually advised to sign a do-not-resuscitate (DNR) order
This will ensure that a ventilator will not be used as part of the patient's treatment and the difficult situation of ventilator-dependency will not arise. Clearly, there is a big difference between a person dying because a ventilator was not used for an inappropriate indication and a patient dying because a ventilator that was keeping a patient alive, was switched off. If a patient needs a ventilator to survive, death is a direct consequence of switching off the machine and this makes this a form of euthanasia. Table of Contents
2. Physician assisted suicide
Physician assisted suicide is when a physician assists a person to commit suicide by providing them with the means to kill themselves. This may be by prescribing a lethal dose of oral medications for a person which the patient then takes at some later time. Alternatively the physician may play a more active role by providing a person with a machine that once set in action, automatically delivers a large intravenous dose of a sedative, such as a barbiturate, followed by a drug such as a large dose of potassium, that stops the heart or a paralyzing agent that stops breathing. The first drug puts the person to sleep, the second kills them. The physician is more directly involved in this type of assisted suicide because apart from prescribing lethal drugs, he/she provides the machine and presumably must also set up the intravenous infusion for the person. A physician may also assist suicide by withdrawing food and water from a patient at the patient's request. The law in many countries does not interfere if a person stops taking food and water of their own volition, but if this occurs in a hospital, the physician in charge, by acquiescing, assists in the suicide. able of Contents
3. What is withdrawal of nutrition or hydration (food or water)?
Discontinuation of food and water is a form of euthanasia that is increasingly practiced. The most frequent targets are patients who are in coma and are unable to swallow, or patients with advanced dementia who cannot feed themselves. These patients have to be temporarily fed by a feeding tube through the nose or permanently fed by a tube inserted into the stomach through the skin. Most patients in whom withdrawal of food and water is considered are not competent to be involved in the immediate decision to discontinue food or water but may have made an advance directive that they do not want life support measures taken if they become terminally ill. Many physicians who withdraw food and water in response to advance directives state that a feeding tube is a form of artificial life support that is similar to a ventilator. Provision of food and water is however, the most fundamental of nursing duties. Food and water are necessary to maintain life and their withdrawal with the intent to hasten death is euthanasia. Table of Contents
4. What is unassisted death?
To die naturally a patient should die from the consequences of old age or disease. The patient's death may be at least partly due to surgery, to a treatment or to a medication (or to their complications), that is given in an appropriate dose and for an appropriate indication, with the intent of treating a disease or relieving pain. When giving a potentially lethal medication, there must be no intent to hasten death. Treatment may be withdrawn from a patient and this may indirectly result in their death. Patients do not have any obligation to use medical treatments and may opt to allow a disease condition to take its natural course. This becomes morally questionable when the patient is young and the treatment is easy and life-saving, such as a blood transfusion for a sudden severe loss of blood. A physician is under an obligation to use available treatments to attempt to prolong life or relieve suffering. If treatments to prolong life are likely to result in suffering a physician may, in consultation with patients or relatives, decide to withhold treatment. Treatment that has already been instituted may also be withdrawn if the prolongation of life they result in causes suffering, in a patient who is terminally ill. If withdrawal of a treatment has a high likelihood of directly resulting in the death of a patient, it should not be withdrawn, even at the patient's or relatives' request, because this constitutes an intent to cause or hasten death. (For example switching off a ventilator in a patient unable to breathe will result in immediate death).Table of Contents
5. How is death determined?
Death is normally determined by the cessation of the pulse and breathing. Determination of death in a patient who is connected to a ventilator is more difficult, because the heart often continues to beat after death. The main problem in the determination of death is that the ventilator continues to breathe for the patient, and it is not possible to test whether the patient is able to breathe without the machine unless it is switched off. Switching off the ventilator however, may result in brain injury if the patient is not dead. It is generally accepted that if there is irreversible complete loss of function of the brainstem (the part of the brain in charge of consciousness, breathing and regulation of the heart) this means death of the whole brain.
A series of tests has been drawn up to determine the presence of brainstem death and these are usually administered by a neurologist or neurosurgeon. The tests performed are: a) looking for eye movements in response to turning the patient's head, or in response to putting cold water in the ears, b) looking for an eyeblink in response to touching the eye, c) looking for any movement in response to a mechanical stimulus to the head or limbs, d) looking for a constriction of the pupils in response to a light e) checking to see if the patients gags with stimulation of the throat. f) to ascertain the absence of all brain activity two electroencephalograms (brain wave tests) at least six hours apart should be performed.
If all these tests are negative and certain baseline conditions such as adquate body temperature and lack of recent sedative drug ingestion, the physician will perform a breathing test. This is the final crucial test and it is done under carefully controlled conditiions. The patient may have to remain off the breathing machine for several minutes to allow carbondioxide to accumulate in the blood, because this is a strong stimulus for breathing. There is a risk that the high levels of carbondioxide may affect the heart and the heart may stop beating during this test. If the patient is not seen to breathe over a period of observation of about three minutes without the breathing machine but with 100% oxygen, then the patient is determined to be brain dead. The patient is usually temporarily put back on the machine and it may be necessary to repeat all the tests again after a few hours. When brain death has been ascertained the breathing machine can be switched off. Table of Contents
6. What is "persistent vegetative state (pvs)"?
This is a permanent condition in which severe brain damage causes the patient to have reduced awareness and an inability to respond meaningfully to the environment. The patient with PVS is typically one who suffers a severe head injury, a prolonged cardiac arrest or multiple strokes. The patient with PVS is able to open their eyes and look like they are awake, but seems to be totally unresponsive to their surroundings. The patient may be able to breathe on their own or need a ventilator. The patient is usually unable to swallow and needs a feeding tube. When PVS is established it is usually permanent. There are several problems about the diagnosis of persistent vegetative state:
7. What is a "ventilator-dependent" patient?
Patients are not normally put on a ventilator unless there is a strong chance that they will get better and be able to breathe again without the machine. Patients with acute reversible respiratory or brain conditions are most likely to benefit from a ventilator. Often a ventilator is the only treatment that will save a patient's life and there is pressure from relatives to use this treatment. Patients with long standing or with severe irreversible brain or lung disease are however unlikely to benefit from a ventilator. The severe brain or lung disease is not cured by the machine but the patient may be kept alive by being on the machine but not be able to breathe sufficiently by themselves to be taken off the ventilator. This is called a ventilator-dependent patient. A patient can breathe using a ventilator for an unlimited period of time, and there are many portable types of ventilator and many people live at home with the aid of a ventilator.
The cost of being maintained on a ventilator in an intensive care unit is high and this is one reason that there is increasing pressure to switch off the ventilator if a patient is unable to breathe without it after a trial of several days on the ventilator. This is clearly a form of euthanasia since the action of switching off the ventilator directly results in the death of the patient. Not all cases are clear-cut however, some patients are able to breathe on their own for a period of a few hours, when the ventilator is first disconnected but then they get tired and breathing deteriorates and the patient dies if not put back on the ventilator. Is it ever ethically justifiable to permanently discontinue ventilator support in this situation? If there is a reasonable chance that the patient may be able to breathe on their own, and they are in fact able to so for at least a couple of hours, it is probably reasonable to discontinue the ventilator if the patient or surrogate know and accept the risk of death.
If the patient subsequently dies, death can reasonably be ascribed to the underlying disease rather than to the discontinuation of the ventilator. This is an area fraught with dangers because a surrogate may not always act in the patient's best interest. The patient must be given every chance for their lung function to return to baseline before an attempt is made to discontinue the ventilator. Premature withdrawal of ventilation is likely to fail. If, on discontinuing the ventilator, it is immediately clear that the patient is unable to breathe sufficiently, the ventilator should be re-instituted, rather than giving the patient narcotics. Once the patient is removed from a ventilator, narcotics should only be given, if after a period of time the patient starts to be unduly distressed and it becomes obvious that they are not going to survive. Excessive haste in removing ventilator support or in giving narcotics with the intent to hasten death is euthanasia. Table of Contents
8. What is a do-not-resusciate order?
A do-not-resuscitate (DNR) order is an order placed in a patient's hospital chart telling the doctor not to attempt to resuscitate a patient if the patient is in imminent danger of death. When signing a DNR order a patient is usually concerned about being connected to a ventilator. The decision to sign a DNR order usually means that the patient or surrogate has decided that resuscitation would cause the patient unnecessary suffering and would not alleviate the underlying illness. DNR orders are important for protecting a patient against excessive medical interventions which often cause needless suffering in the terminally sick and elderly. Institution of a DNR order should not be a pretext for reducing the level of nursing and medical care a patient gets. Table of Contents
9. What is an advance directive?
An advance directive is a legal document drawn up by a person stipulating their preferences with regard to end-of-life care should they become sick and unable to express these preferences themselves. The advance directive usually states that if the person has a terminal illness that they do not wish extraordinary resuscitative measures to be taken. The problem is that it is difficult for an advance directive to cover all the possible situations that may occur and there is a wide range of interpretation left up to the surrogate. Individuals may take "resuscitative measures" to mean either mechanical ventilation or even just placing a feeding tube or intravenous infusion. Also a severe disabling stroke may be interpreted as "fatal" illness. An advance directive may in this way be used by a surrogate as a reason for not giving food and water to a patient with a severe but notn-fatal medical condition. Table of Contents
10. What is palliative care?
Palliative care refers to the treatment of patient with a terminal condition such as cancer with a therapy that will not cure the patient but will make what remains of their life easier. Palliative care is very important in the management of any incurable illness, particularly if the patient is distressed or in pain. Physicians are learning anew that they have to be very aggressive in treating pain and suffering in these patients. Relief from psychological and financial stresses are also important but often harder to achieve. The commitment of physicians to palliative care is undergoing renewed scrutiny in the light of the rise of assisted suicide and euthanasia, and many feel that current interest in euthanasia and assisted suicide is the result of inadequate palliative care. Unfortunately, since the goal of palliative care is primarily to "reduce suffering" many people now consider palliative care to include the hastening of death in order to reduce suffering. Withdrawal of nutrition and hydration are considered by some to be part of palliative care. In addition, the use of strong narcotics which was once restricted to pain management, is becoming accepted for a range of indications such as anxiety, shortness of breath and to suppress feelings of hunger when feeding is withdrawn. In this way palliative care is quickly becoming a euphemism for euthanasia. Table of Contents
11. What are the views of physicians regarding euthanasia and assisted suicide?
It is difficult to get a true picture of physicians views from articles in newspapers or from journal review articles. Since euthanasia and assisted suicide are new and a challenge to established values, a report about a single physician practicing assisted suicide is more likely to get published than a report that members of a large physicians' organization reaffirms traditional values. Physicians that practice euthanasia and assisted suicide have been more outspoken and vociferous since many consider themselves as pioneers. Whereas many physicians who continue to practice with traditional ethics, see no need to advertise this fact. Even if one reads consensus statements from medical ethics groups one may get a biased idea of the mainstream views of physicians. These statements are usually written by a small group of physicians, many of whom are active in ethics groups because they want to see change. Several articles have been published that poll doctors' views on the euthanasia and assisted suicide, and these are likely to get closer to the real views of doctors. In a survey of British doctors on management of the persistent vegetative state, 35% of doctors would never withdraw feeding or nutrition and 28% would always treat an acute infection or other life-threatening condition (see reference 26).
In a survey of 355 oncologists, the majority found euthanasia or assisted suicide unacceptable. However one in seven oncologists had actually carried out euthanasia or assisted suicide (see reference 10). 37% of physicians who look after AIDS patients would be unlikely assist a patient with established AIDS to commit suicide but 48% said they would be likely to do so (see reference 40). 48% of 1355 physicians in Washington state agree that euthanasia is never ethically justified but 33% said they would be willing to perform euthanasia (see reference 8). 40% of 1119 Michigan physicians involved in the care of terminally ill patients were in favor of legalization of assisted suicide and 17% favored prohibition of assisted suicide. 22% of physicians would participate in either assisted suicide or euthanasia (see reference 7). Table of Contents
12. What are the views of the general public regarding euthanasia and assisted suicide?
Two-thirds of oncology patients and of the public consider euthanasia and assisted suicide acceptable for cancer patients with unremitting pain (see reference 10). 66% of a sample of 998 adults in Michigan would chose legalization of assisted suicide over banning of it. (see reference 7). A poll of 1022 adults published in the January 7 1997 issue of USA Today states that 58% of the individuals polled said that doctors ought to be allowed to assist the suicide of terminally ill patients in severe pain.
13. What is the Hippocratic view or the view traditionally taught in medical schools?
"You will exercise your art solely for the cure of your patients, and will give no drug, perform no operation for a criminal purpose, even if solicited, far less suggest it". "You will not give to a woman a pessary to produce abortion" Table of Contents
References from medical journals on euthanasia and related topics.
Several of these articles have pro-euthanasia or pro-assisted suicide views or content. They are listed here in order to provide anyone who wants to research into these topics access to all view points.
Pullicino, MD, PhD., Patrick "Death: Natural or assisted?: A patient's guide to medical end-of-life issues." Unpublished paper.
Published with permission of the author, Patrick Pullicino MD, PhD.
Copyright © 2000 Patrick Pullicino MD, PhD.
Not all articles published on CERC are the objects of official Church teaching, but these are supplied to provide supplementary information.