Death • Inevitable • No, you are not invincible • Yes, even at your age, people die • Example Binge drinking and alcohol poisoning • Obligation to Extend life • Define death
Definitions of Death • Technological—process versus event • Medical • Social • Whole brain definition • Higher brain function definition • Cardiac definition
Whole Brain • Neurological/technical definition • Requires MD/coroner • ACLS standard as an aside in acute settings • Not workable in • Settings of futility of treatment AND organ donation situations/settings where vents are present • Integrated functions versus primary organ function
Higher Brain Definition • Solves the donation/futility problems • Requires standards of what higher function IS • Much more social and societal a definition that is socially constructed around the concepts of quality of life—a concept that is very difficult to define and defend • What does personhood Mean?
Policy in Higher Brain Formulations • Who decides • What criteria • Ethics committees • Qualifications to decide • Is it best to allow OUTSIDE decision-makers • Advanced directives • Medical Futility
Cardiac Death • Vital signs have stopped • Required actions by MDs to restart the vital signs • Standards are social and scientific • Death as a process
Modern issues • Suicide • DNRs • Medical benefit/futility • Quality of life • Euthanasia • Death with dignity (Oregon)
Decisional Capacity • Competency exams • Defining competence • Who decides • Decision-relative ideas • Who is competent—communication, reasoning and deliberation • Alcohol, suicide, drugs, mental incapacity
Competence • Depends on the situation and no one standard fits all situations • Related to the concept of consent in medicine • Implied consent • Prior discussion • Evidentiary standard—reasonable man
Advanced Directives • CPR Directives • Surrogate Medical Power of Attorney or POA for medical decisions • Living wills • Terms to be executed should certain criteria be met and the person can no longer legally speak for self/legally binding on the medical and non-medical community IF
Scenario • 47 year old female with terminal cancer in the last stages • Has living will and advanced directives • Found unconscious by home health aid • 911 call • What do you do? • No evidence of documents/call to doctor/suicide?/resuscitate or not/relative and POA indecisive or obstructionist
Proxy Decision Makers • Bound by statute • Bound by person • Must accept responsibility • Only person that can decide when the person in question meets the criteria of lack of decisional capacity • What if this is not done? Who decides?
In re Claire Conroy • Incapacitated person with multiple chronic debilitating illness—bed ridden • Aphasic, minimal movements, smiled (lower brain function) • Not brain dead, comatose or vegetative • Feeding tube at issue
Conroy • Case on the borders • Social and legal issue • Life-sustaining to tube feed her • Quinlan standard—what did the person want, how do we know? / placed in the position of prior competence • Trustworthy evidence that the patient in this situation would have refused treatment
Personal Decision Making • The legal standard is that of personal CONTROL over decisions on care • MUST be fully and clearly stated to be valid • Subjective standard • What if no clear statement?
When Does this Come Up? • Congenital malformations • Mental incapacity • Trauma • Old age/dementia • Parkinsons and age/neurodegenerative disorders (Tuesdays with Maury)
Summary • Personhood and rights • Technology makes the issues harder • Capacity • Prior discussion • Legal implications • Can you in a similar situation plan your own way of dying—even at your age?
You and death • What needs to be done? • Think first, describe circumstances in your own mind that admit your mortality and defend your right to decide • Trust one other person to make that happen • Make a formal written and legally binding document • Inform your social networks of the decision and who can decide for you • Update it frequently as situations change