Death and Dying



Death and Dying




Learning Objectives


After completing the chapter, the reader will be able to perform the following:


• Provide definitions of life and death.


• Differentiate between the patient’s and the imaging professional’s role in death and dying.


• Identify the physical and ethical differences between active and passive suicide.


• State a perceived need for euthanasia.


• Develop arguments for and against the right to die.


• Define the meaning of quality of life and explain what affects it.


• List reasons for ethics committees.


• Cite the basis for the patient’s right to forgo life-sustaining treatment.


• Define and understand differences between a persistent vegetative state and a minimally conscious state.


• Define how death is determined.


• Define life-sustaining treatment and its exclusions.


• Explain the difference between living wills and durable powers of attorney.


• Identify the limitations of living wills.


• Define the advantages of durable powers of attorney.


• Compare the ways in which powers of attorney influence the decision-making process of ancillary people such as physicians, ministers, and specified family members and friends.


• Identify the differences between persons in a persistent vegetative state and those in a minimally conscious state.


• Explain the difference between competency and decisional capacity.


• Contrast the treatment of persons who have never been competent and competent persons who have become incompetent.



Key Terms




Professional Profile



I recall my first experience with death and dying when I was a student radiologic technologist. The image is still quite clear although it happened more than 30 years ago. The department was closed, and I was called in from home around 2:30 am. A second-year student and staff technologist had also been called in. I was a first-year student.


We wheeled the stretcher with a young man who appeared to be about my age from the emergency department to the radiology department. He had been in a motor vehicle accident, and the gearshift lever from his car was sticking out of his chest. We moved him onto the table and began taking films. His breathing became erratic, and the staff technologist called the emergency room staff. Soon the entire room was filled with people and equipment. The scene was frantic, with everyone working to try to keep this young man alive. Unfortunately, they were unsuccessful, and he died on the x-ray table.


After all the paperwork was completed and the appropriate procedures were followed, he had to be moved from the x-ray table to the morgue cart. Because staff was sparse at that time of night, the three radiology personnel who were present had to help the night supervisor with the actual transporting of the body. I will never forget the way that young man’s body felt. It was cold and hard, almost like stone.


That night was the first time I experienced death. That night was the first time I really thought about death. That young man had been alive when we started the examination. He was warm, he had feelings, aspirations, hopes, dreams, and fears. Then he was cold and hard. I thought about what he had experienced. Was he afraid, was he angry, did he see his short life flashing before his eyes? Was it just his body that was dead and did his soul live on to go to heaven or hell as I was taught in grade school, or is this life all there is? This experience bothered me for a very long time. I would wake up in the middle of the night and think of the way this young man’s body felt. I would dwell on whether he knew he was going to die, whether he was prepared, what exactly it meant to die.


I now realize that each person must form his or her own answers to these questions. I also believe that some guidance on the ethical and legal issues of death and dying for the imaging student is appropriate. I was not prepared to deal with these issues as a first-year student, and I wish that I had been.




ETHICAL ISSUES


Imaging professionals often have contact with patients who have critical or terminal conditions. Most of the imaging modalities (except radiation therapy) do not involve lengthy contact with patients. Nevertheless, regardless of the length of the therapeutic relationship, the imaging professional will encounter death and dying.


To help the imaging professional deal with questions regarding patients’ rights, refusal of treatment, and quality of life, this portion of Chapter 6 discusses ethical concerns surrounding death and dying. The ethical dilemmas of patients and imaging professionals are emphasized.



VALUE OF LIFE


Before imaging professionals consider questions of death and dying, they should understand the ethical issues surrounding life. Life may be considered as an element of human autonomy through which a person experiences a sense of self. It is defined as the entire state of the living thing; it encompasses the value of the self and is a determining factor in a person’s “preconscious” standard of judgment. Thought, analysis, and action come from this fundamental sense of the value of life.





IMAGING SCENARIO


The portable and trauma team imaging professionals are called to the morgue to perform a radiographic examination on a young man with a gunshot wound. The bullet entered the right temple and is lodged in the brain. The images corroborate forensic analysis that indicates suicide. Before the fatal wound the young man appeared to have been muscular, handsome, and healthy. The youngest imaging professional questions why such a young man who had his whole life to look forward to would choose such a tragic ending.


The next day another staff imaging professional notes that the young man had recently been diagnosed with an incurable and inoperable brain tumor. This information leads to a discussion about the choices people make when they know they will die, perhaps painfully. Did this man have the right to end his life? In what way did the suicide affect his family and friends? Did his situation excuse his suicide? In what ways were the family dealing with not being able to say their final good-byes?


The young trauma imaging specialist wonders what she would do in such a situation. Would she choose to die a slow, painful death or end her life quickly? Does she have the right to determine the quality of her life and choose suicide or euthanasia even if both are illegal or considered immoral by many? How would she respond to a healthy young patient faced with the prospect of an early and painful death? Was there an obligation to counsel about possible treatments and pain control modalities that was not met or could have been handled better?



Traditional religious and secular beliefs celebrate the uniqueness of life, but when life begins and the way it ends remain points of contention. The imaging professional should consider the following aspects of life when making determinations in ethical dilemmas1:







SUICIDE


Suicide is the act of knowingly ending one’s own life. It may be accomplished either actively or by omitting treatment, which is a passive form of suicide. The individual must also have the intention to die.




Several arguments may be made against suicide (Box 6-1). Some find it unacceptable for religious reasons—God has lent life to the individual, and therefore that life is not the individual’s to end. Others believe that human life is the greatest of goods and consider it precious. However, what if the patient has tremendous pain and therapy has caused such nausea and weakness that the patient cannot move from bed? Is life “good” at this level of pain and loss of dignity? Harm to the community is another argument against suicide. If one suicide leads to another (as has been observed with teenage suicides), does this not harm the community? A further argument against suicide is the harm it inflicts on family and friends. Suicide denies them time with their loved ones to plan, share, make amends, and say good-bye.



BOX 6-1   ARGUMENTS AGAINST SUICIDE




All these arguments have some logic, and laws to control and discourage suicide are based on such arguments. If suicide were declared legal, would more untimely deaths be associated with emotional problems and not just physical problems? Would the broken heart be cured more often with a bullet than with therapy and understanding?




Active Suicide


Some people can accept the idea of passive suicide because refusing treatment is a person’s right and refusal of treatment does not seem to be an act of violence toward the self. However, when the young man in the imaging scenario on p. 118 shot himself to end his life quickly rather than die a painful and slow death, would some consider this active suicide wrong? Those who oppose suicide do so for various reasons. Some believe that life is sacred and must be cherished. Others believe that only God or some supreme being gives life and only that being should decide when it should end.




Suicide proponents also have their rationale. Many believe suicide is an individual right, analogous to a woman’s right to an abortion. If a woman has the right to choose what will happen to her body, shouldn’t an individual have the right to choose life or death? Some also argue that it is not only the supreme being that gives us life, that technology also allows humanity to produce life, and if humanity can produce life, why shouldn’t it be allowed to decide when it should end? The technology that has been developed to prolong life also is used as an argument against the “God brought life, God should take it away” theory.



IMAGING SCENARIO


Pancreatic cancer is diagnosed in two patients, and the computed tomography scan indicates that the cancer has invaded many other organs. One patient has elected to discontinue nourishment to hurry death; the other patient elects to continue all treatment to sustain his life as long as possible.



Discussion question




• How do personal values, as discussed in Chapter 1, influence the weighing of reasons for refusing treatment as compared with continuing it?



IMAGING PROFESSIONALS AND SUICIDE


Many imaging professionals have encountered patients who have no hope of becoming well and whose pain can no longer be controlled with drugs. Their lives are full of pain and suffering, and their desire to end their lives may be reasonable. If these patients discontinue treatment, they will suffer but die sooner. They could also overdose and end their suffering quickly. Whether the suicide is active or passive, imaging professionals should be careful not to make judgments. What should be the response of an imaging professional asked to interact with a patient determined to commit suicide (Box 6-2)? In what way should an imaging professional respond when approached by a patient who wishes to end life either actively or passively? These may be rare situations for imaging specialists, but they must be considered because of imaging professionals’ changing interactions with patients and their families. Imaging professionals must recognize that each case is different. They may be required to participate in procedures involving patients who have elected to end nourishment and hydration. The imaging professional must remember that it is the value system of the patient that is important in such situations, not the value system of the imaging professional.



BOX 6-2   REASONS FOR THE IMAGING PROFESSIONAL’S DUTY NOT TO COOPERATE WITH SUICIDE





EUTHANASIA


Suicide is taken one step further when another person becomes involved. Euthanasia is the act of painlessly putting to death a person suffering from an incurable and painful disease or condition. Physician participation in euthanasia, or assisted suicide, has stirred great controversy recently (Box 6-3). The legal issues surrounding physician-assisted suicide are discussed in the legal section of this chapter.



BOX 6-3


PHYSICIAN-ASSISTED SUICIDE


The physician who has drawn the most attention to the controversy over physician-assisted suicide is Dr. Jack Kevorkian. Dr. Kevorkian is a pathologist by training, although he has not held a position on a hospital staff since 1982 and he lost his medical license in Michigan in 1991.


Beginning in 1990 and ending in 1998, Kevorkian assisted in over 100 suicides. In all but the last case he gave the patient the means to commit suicide, but the patient carried out the final act using a device designed so that the patient could pull the trigger. On November 22, 1998, CBS’s 60 Minutes aired a videotape showing Kevorkian giving a lethal injection to Thomas Youk, a terminally ill 52-year-old man with amyotrophic lateral sclerosis (ALS). During the taping, Kevorkian asked Youk to sign a consent form, after which Kevorkian gave him a lethal injection. Kevorkian was convicted of second-degree murder and delivery of a controlled substance.


A Michigan judge sentenced Kevorkian to 10 to 25 years in prison. Having been repeatedly denied parole, Kevorkian remains in prison at this writing. He will next be eligible for parole in June 2007. Kevorkian has said that while he still believes in assisted suicide where it is legal, he regrets flouting the law and should have worked toward legalization of assisted suicide. He also says that if released, he will no longer assist suicides.


Data from http://medicine.creighton.edu/idc135/2004/group4a/index.htm; www.pbs.org/wgbh/pages/frontline/kevorkian/chronology.html; Martindale M: Dying Kevorkian wouldn’t pick suicide, Detroit News, June 13, 2006; and http://www.cnn.com/US/9812/09/kevorkian.02/index.html.




Euthanasia may be either passive or active. The difference between the two lies in the methods, not the consequences. Passive euthanasia may be committed through the withholding of nourishment or through a decision not to perform cardiopulmonary resuscitation (CPR) on a patient who has stopped breathing. It is considered legal in certain instances because no one delivers a method of death. “Nothing” is done and that “nothing” leads to death. Active euthanasia is the performance of a specific act on the request or behalf of the patient to end life.






Professionals in the medical imaging services may see patients with terminal diseases, patients in horrible pain, or those in a persistent vegetative state (PVS) (the medicolegal definition of PVS is discussed in the legal section of the chapter). These imaging professionals may struggle with whether they should perform procedures that will add to the patient’s pain and loss of dignity and autonomy (e.g., barium enemas). They may imagine themselves in the patient’s position and hope that someone who cares about them would help hasten their death. At the same time, they should consider the consequences for the person “helping” to carry out a suicide. Imaging professionals should also remember that they should not base their decisions on their personal values. The patient’s values and needs are the important issues in these decisions.


The legal ramifications of euthanasia, especially active euthanasia, are tied to the act of murder. Indeed, many people believe that they are the same, and for this reason euthanasia is generally illegal in the United States. In Holland, where euthanasia has become an accepted procedure, some health care professionals and ethicists wonder whether this acceptance will become a slippery slope leading to the overuse and misuse of euthanasia. For example, will the euthanasia of a patient suffering from acquired immunodeficiency syndrome (AIDS) lead to the deaths of unwanted types of individuals and ethnic cleansing? No policies are currently in place regarding who makes these decisions, and the ways in which controls should be established remain controversial.





IMAGING SCENARIO


An imaging professional’s father is dying from an aggressive cancer with no hope for recovery. The father has an advance directive explaining that he does not want the use of life-sustaining equipment. He becomes nonresponsive, and a family conflict develops concerning withdrawal of nourishment and hydration. Part of the family believes this is in the best interest of the parent—to hasten his death and end his suffering—and the other family members view this as killing him. They ask the imaging professional about the pain and suffering, the issues of active and passive euthanasia, and whether not using life-sustaining machines is equal to starving the man to death.



The moral and legal questions regarding passive euthanasia are more complex. The passive withdrawal of nourishment from a patient in a PVS seems less awful than the active euthanasia of a patient who is conscious and aware. However, after health care professionals and family members start making judgments for handicapped neonates or patients who are incompetent, in a PVS, old, or senile, the implications for patient autonomy become serious. Who decides who is fit to live? Does a person have to have consciousness and decision-making ability to be worthy of life? The potential for development and quality of life must be considered. If a neonate has a chance to develop and live (not necessarily by traditional standards), should that chance be given? Should cost and distribution of resources issues play a role in such decisions?




The controversies surrounding the euthanasia of neonates are often related to the issues in the abortion debate. Questions regarding when the fetus has a right to life, self-determination, and dignity have yet to be resolved. When aborting a fetus that can wave its arms and legs and suck its thumb is legal, but the legality of letting an anencephalic neonate be an organ donor is still in question, do such perceptions confuse the issues surrounding the processes of life and death? Ultrasonographers required to participate in fetal ultrasound examinations that may lead to abortive procedures must learn to deal with these dilemmas based on professional standards and personal conscience.




Euthanasia of patients at the beginning of life raises serious ethical questions. So too does the active or passive euthanasia of elderly people. Elderly patients should be evaluated by imaging professionals as individuals with value, not as “old people” who have lived long lives and are somehow expendable. The intellectual capacity and strength of elderly people may be failing (although many elderly people retain a high degree of intellectual capability), but a human being does not have to be a perfect specimen to have a reason for living. The fear of pain and loss associated with death may be as great to an 85-year-old as it is to a 35-year-old. The age of the patient should never prevent the imaging professional from granting the best care possible.



Patients’ Rights Regarding Euthanasia


The ethical questions surrounding the possibility that patients have a right to active euthanasia are complex. Consider the patient in hospice care with pain control who has been diagnosed with invasive liver and pancreatic cancer by a CT scan and has undergone radiation therapy for pain. Does this patient have the right to self-determination and a “good death” through euthanasia if all of these procedures have not lessened the pain, or must the patient continue to be in pain?


The exercise of rights requires a self; proponents of patient-chosen euthanasia consider it an act of self-determination. Therefore the person seeking euthanasia must completely understand the nature and consequences of the request. The person must be competent and as informed as possible. Ideally the person should have experienced the five stages of coming to terms with death:



In a scenario of legalized euthanasia, only after going through these phases would the patient be considered ready to make the decision regarding the commission of euthanasia.


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Feb 27, 2016 | Posted by in GENERAL RADIOLOGY | Comments Off on Death and Dying

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