Chapter 3: End-of-Life Dilemmas

Michigan Hose

-1992 temporary ban on assisted suicide -Senate approved the temporary ban after Keverkian helped a 6th terminally ill patient kill herself -December 1992: Engler signed the law just hours before two more committed suicide with Kevorkian's aid -The new law, which became effective on April 1, 1993, made assisting suicide a felony punishable by up to 4 years in prison and a $2,000 fine. Under the new law, assisted suicide was banned for 15 months. During this time, a special commission studied assisted suicide and submitted its recommendations to the Michigan legislature for review and action. The new law apparently raised constitutional questions and was challenged by the Civil Liberties Union of Michigan because of the claim that it failed to recognize that the terminally ill have the right to end their lives painlessly and with dignity.

Right to Self-Determination

-Every human being of adult years has a right to determine what shall be done with his own body; and the surgeon who performs an operation without his patient's consent commits an assault for which he is liable for damages. -case In re Storar, when the court announced that every human being of adult years and sound mind has the right to determine what shall be done with his or her own body -The Quinlan case was the first to address significantly the issue of whether euthanasia should be permitted when a patient is terminally ill or incapable of living without extensive medical announced that the constitutional right to privacy protects a patient's right to self-determination. The court noted that the right to privacy "is broad enough to encompass a patient's decision to decline medical treatment under certain circumstances, in much the same way as it is broad enough to encompass a woman's decision to terminate pregnancy under certain conditions.

Right to Die Without a Living Will

-San Juan-Torregoasa v. Garcia: Garcia suffered a cardiac arrest but resuscitated and suffered oxygen deprivation to her brain and chronic vegetative state and had breast cancer -she did not have a living will -statute and other like it applies to all inviduals and does not distinguish between those who are competent and those who are not -have a right to refuse treatment so long as they are mentally competent to make their own healthcare decisions -When an individual becomes clearly incompetent to make healthcare decisions, the state has a duty to help determine what the wishes of the patient would have been had he been conscious and competent to do so. The initial assumption is that an incompetent patient would prefer lifesaving treatment unless there is clear evidence that the patient would not want extraordinary care to save his life. It is clear from both state statutes and court decisions that artificial nutrition and hydration are to be included in the realm of medical treatment that a patient has a right to refuse.

Assisted Suicide Versus Refusal or Withdrawal of Treatment

-The Supreme Court in Quill v. Vacco [50] found that neither the assisted suicide ban nor the law permitting patients to refuse medical treatment treats anyone differently from anyone else or draws any distinctions between persons. -In its decision, the Supreme Court determined that New York had valid reasons for distinguishing between the refusal of treatment and assisting suicide. Those reasons included prohibiting intentional killing and preserving life, preventing suicide, maintaining the physician's role as his or her patient's healer, and protecting vulnerable people from indifference, prejudice, and psychological and financial pressure to end their lives. All of those reasons, the court decided, constitute valid and important public interests fulfilling the constitutional requirement that a legislative classification bear a rational relation to a legitimate end.

A New Beginning and A Better Ending

-The fears that arise at the end of life can be better handled if both the physician, patient, and family together make the choices and decisions early and then place them away and enjoy the life and the days given to each. The Conversation Project (TCP) "is dedicated to helping people talk about their wishes for end-of-life care."[87] TCP believes that the place to begin a discussion about end-of life decisions should begin figuratively at the kitchen table with family and the people we love and not in the intensive care unit of a hospital. TCP provides the Conversation Starter Kit at its website.[88] The TCP does not promote any specific preference for end-of-life care but does encourage families to work together in making such difficult decisions. The Institute for Healthcare Improvement (IHI) was founded in 1991. Its vision is for everyone to have the best care and health possible and its mission is to improve health and health care worldwide. The IHI supports the mission of the TCP, believing that the successful transformation of the healthcare system requires the engagement of patients, families, and the general public. End-of-life care is something every human will face.[89]

Washington v. Glucksberg

-U.S. Supreme Court held that assisted suicide is not a liberty protected by the Constitution's due process clause. -majority of states NOW ban assisted suicide -do NOT affect the right of patients to refuse treatment -the quality of a patient's life must be improved so that physician-assisted suicide does not become the answer for those who are suffering

People v. Eulo (New York)

-] in rejecting the traditional cardiopulmonary definition of death, announced that the determination of brain death can be made according to acceptable medical standards. The court also repeated its holding in In re Storar [30] that clear and convincing evidence of a person's desire to decline extraordinary medical care may be honored and that a third person may not exercise this judgment on behalf of a person who has not expressed or cannot express the desire to decline treatment. -The family of a patient who is in a persistent vegetative state cannot necessarily order physicians to remove artificial nutrition.

Physician-Assisted Suicide

-action in which a physician voluntarily aids a patient in bringing about his or her death. -1989 Kevorkian developed a device that would end-one's life quickly, painlessly, and humanely -but in 1990 was charged for first degree murder= they were dismissed cause Michigan had no law against assisted-suicide

Surrogate Decision Making

-agent who acts behalf of a patient who lacks the capacity to participate in a particular decision. -rights are no greater than those of a competent patient -limited to any specific instructions included in the proxy document -take priority over those of any other person expect the patient -right to consent or refuse to consent to any service or treatment, routine or otherwise, to refuse life-sustaining treatment, and to access all of the patient's medical information to make informed decisions -decisions based on the patient's moral and religious beliefs -If a patient's wishes are not known, decisions must be based on a good-faith judgment of what the patient would have wanted.

Healthcare Proxy

-allows a person to appoint a healthcare agent to make treatment decisions in the event he or she becomes incompetent and is unable to make decisions for him- or herself. -agent must be made aware of the patient's wishes regarding nutrition and hydration in order to be allowed to make a decision concerning withholding or withdrawing them. -In contrast to a living will, a healthcare proxy does not require a person to know about and consider in advance all situations and decisions that could arise. Rather, the appointed agent would know about and interpret the expressed wishes of the patient and then -The Cruzan decision indicates that the Supreme Court views advance directives as clear and convincing evidence of a patient's wishes regarding life-sustaining treatment. -Quinlan and Saikewicz created a constitutionally protected obligation to terminate the incurable incompetent patient's life when guardians use the doctrine of substituted judgment. Furthermore, some states provide for proxy consent in the form of durable power of attorney statutes. Generally, these involve designation of a proxy to speak on the incurable incompetent person's behalf. They represent a combination of the intimate wishes of the patient and the medical recommendations of the physicians.

The Quinlan Court

-applied a test balancing the state's interest in preserving and maintaining the sanctity of human life against Karen Quinlan's privacy interest -It decided that, especially in light of the prognosis (physicians determined that Quinlan was in an irreversible coma), the state's interest did not justify interference with her right to refuse treatment. Thus, Karen Quinlan's father was appointed her legal guardian, and her respirator was shut off.

Voluntary or Involuntary Euthanasia

-both active and passive euthanasia may be either voluntary or involuntary

Introduction

-human struggle to survive and dreams of immortality have been instrumental throughout history in the search for ways to help alleviate pain and human suffering -want longer and happier life -McMath: -physicians now can implant artificial body organs. Rather than watching hopelessly as a disease destroys a person or as a body part malfunctions, causing death to a patient, physicians now can implant artificial body organs. convergence of shifting payment models, an aging population, and the moral imperative to determine what matters most to patients at the end of life is affecting a sea of change among healthcare providers accustomed to practicing curative medicine. -Medical Technology: pushed the boundaries of what can be done to treat illness, turns out not to be the guide because given a choice, many patients do not want aggressive intervention

Durable Power of Attorney

-legal device that permits one individual, known as the "principal," to give to another person, called the "attorney-in-fact," the authority to act on his or her behalf. -ttorney-in-fact is authorized to handle banking and real estate affairs, incur expenses, pay bills, and handle a wide variety of legal affairs for a specified period of time. -power of attorney may continue indefinitely during the lifetime of the principal so long as that person is competent and capable of granting power of attorney. -If the principal becomes comatose or mentally incompetent, the power of attorney automatically expires, just as it would if the principal dies -Because a power of attorney is limited by the competency of the principal, some states have authorized a special legal device for the principal to express intent concerning the durability of the power of attorney, to allow it to survive disability or incompetency. The durable power of attorney is more general in scope and applies to a wider range of situations than those involving a patient in imminent danger of death, as is necessary for a living will to apply. Although it need not delineate desired medical treatment specifically, it must indicate the identity of the principal's attorney-in-fact and that the principal has communicated his or her healthcare wishes to the attorney-in-fact. Although the laws vary from state to state, all 50 states and the District of Columbia have durable power of attorney statutes. This legal device is an important alternative to guardianship, conservatorship, or trusteeship. Because a durable power of attorney places a considerable amount of power in the hands of the attorney-in-fact, an attorney in the state where the client resides should draw up the power of attorney. In the healthcare setting, a durable power of attorney for health care (e.g., FIGURE 3-3) is a legal instrument that designates and grants authority to an agent to, for example, make healthcare decisions for another.

Guardianship

-legal mechanism by which the court declares a person incompetent and appoints a guardian -The court transfers the responsibility for managing financial affairs, living arrangements, and medical care decisions to the guardian. -The right to refuse medical treatment on behalf of an incompetent person is not limited to legally appointed guardians but may be exercised by healthcare proxies or surrogates, such as close family members or friends. -When a patient has not expressed instructions concerning his or her future health care in the event of later incapacity but has merely delegated full responsibility to a proxy, designation of a proxy must have been made in writing.

Voluntary Euthanasia

-occurs when a person suffering an incurable illness makes the decision to die. -To be considered voluntary, the request or consent must be made by a legally competent adult and be based on material information concerning the possible ramifications and alternatives available. A patient's lack of consent can be due to mental impairment or a comatose state. Important value questions face courts struggling with the boundaries for making voluntary euthanasia decisions: Who should decide to withhold or withdraw treatment? On what factors should the decision be based? Are there viable standards to guide the courts? Should criminal sanctions be imposed on a person assisting in ending a life? When does death occur?

Advance Directives

-patients have a right to make decisions about their health care with their physician -proposed treatment, choose among alternative treatments, or refuse a treatment -in a form of a living will or durable power of attorney, allow the patient to state in advance the kinds of medical care that he or she considers acceptable or not acceptable -patient can apppint an agent, a surrogate decision maker, to make those decisions on his or her behalf -patient should be asked at the time of admission if he or she has an advance directive -if a patient does not have an advance directive, the healthcare facility should provide the patient with information about an advance directive and the opportunity to execute a directive -A patient should clearly understand that an advance directive is a guideline for caregivers describing his or her wishes for medical care—what he or she would and would not want—in the event of incapacitate and inability to make decisions. -interaction should be documented in the patient's medical record -if a patient has an advance directive, a copy should be requested for insertion, into the patient's record -patient does not have a copy of the advance directive with him or her, the substance thereof should be documented and flagged in the patient's medical record -documentations should include the location of the advance directive, the name and telephone nnumber of the designated healthcare agent, and any information that might be helpful in the immediate care situation (patient's desire for food and hydration) -execute a new directive at any time if desire -patient and family education should be provided regarding the existence of the directive and its contents -patient should be periodically queried about whether he or she wishes to make any changes with regard to an advance directive

Do-Not-Resuscitate Orders

-physician orders not to resuscitate a patient in the event of cardiac or respiratory arrest. -Determination as to futility of medical care is a medical decision based on scientific evidence that further treatment is futile and one's quality of life has been so diminished that "heroic" rescue methods are no longer in the patient's best interests. -DNR orders must be written, signed, and dated by the physician -If a patient lacks the ability to make a decision regarding a DNR order, the patient's legally appointed decision maker can make such decisions provided it can be demonstrated that the decision maker is following the patient's wishes. Advance directives, such as living wills, are help -DNR orders must comply with statutory requirements, be of short duration, and be reviewed periodically to determine whether the patient's condition or other circumstances (e.g., change of mind by the patient or family) surrounding the "no code" orders have changed. Currently, it is generally accepted that if a patient is competent, the DNR order is considered to be the same as other medical decisions in which a patient may choose to reject life-sustaining treatment. In the case of an incompetent patient, absent any advance written directives, the best interests of the patient would be considered. Do-not-resuscitate orders are physician orders not to resuscitate a patient in the event of a cardiac or respiratory arrest. Generally written as the result of a patient's wishes or at the family's request Orders must be in written form, signed and dated by the physician.

Assisted Suicide

-presents profound questions of ethics, religious beliefs, and public policy issues. These are precisely the kinds of issues in which public input is vital, and courts are simply not equipped to conduct the type of comprehensive review required.

Patient Self-Determination Act of 1990

-provides that patients have a right to formulate advance directives and to make decisions regarding their health care -self-determination includes the right to accept or refuse medical treatment -Healthcare providers (including hospitals, nursing homes, home health agencies, health maintenance organizations, and hospices) receiving federal funds under Medicare are required to comply with the new regulations. 1. Provide individuals written information concerning their rights under state law (whether statutory or recognized by courts of the state) to make decisions including the right to accept or refuse medical or surgical treatment and the right to formulate advance directives. 2. Document in the individual's medical record whether the individual has executed an advance directive. 3. Not condition the provision of care or otherwise discriminate against an individual based on whether the individual has executed an advance directive. 4.Ensure compliance with requirements of state law (whether statutory or recognized by the courts of the state) regarding advance directives. The provider must inform individuals that complaints concerning the advance directive requirements may be filed with the state survey and certification agency. 5. Provide education for staff concerning its policies and procedures on advance directives. 6. Provide for community education regarding issues concerning advance directives by defining what constitutes an advance directive, emphasizing that an advance directive is designed to enhance an incapacitated individual's control over medical treatment and describe applicable state law concerning advance directives. A provider must be able to document its community education efforts

United States Supreme Court 1967

-ruled that state laws prohibiting assisted suicide are constitutional -ruled that state can allow physicians to assist in the suicide of TERMINALLY ill patients

Cruzan and Court

-they wanted her to be taken off machines but court refused -Missouri Supreme Court: Because Missouri recognizes living wills, the court held that Cruzan's parents were not entitled to order the termination of her treatment because "no person can assume that choice for an incompetent person in the absence of the formalities required under Missouri's Living Will statutes or the clear and convincing, inherently reliable evidence absent here."[31] The court found that Cruzan's statements to her roommate did not rise to the level of clear and convincing evidence of her desire to end nutrition and hydration. June 1990: 1. The U.S. Constitution does not forbid Missouri from requiring that there be clear and convincing evidence of an incompetent person's wishes as to the withdrawal of life-sustaining treatment. 2. The Missouri Supreme Court did not commit constitutional error in concluding that evidence adduced at trial did not amount to clear and convincing evidence of Cruzan's desire to cease hydration and nutrition. 3. Due process did not require the state to accept the substituted judgment of close family members, absent substantial proof that their views reflected those of the patient. -After the Supreme Court rendered its decision, the Cruzans returned to Missouri probate court, where, on November 14, 1990, Judge Charles Teel authorized physicians to remove the feeding tubes from Cruzan. The judge determined that testimony presented to him early in November demonstrated clear and convincing evidence that Nancy would not have wanted to live in a persistent vegetative state. Several of her coworkers had testified that she told them before her accident that she would not want to live "like a vegetable." On December 26, 1990, 2 weeks after her feeding tubes were removed, Nancy Cruzan died.

Some courts hold that artificial nutrition can be withheld from a patient who is unable to converse or feed oneself. Unequivocal proof of a patient's wishes will suffice when the decision to terminate life support is at issue. Factors for determining the existence of clear and convincing evidence of a patient's intention to reject the prolongation of life by artificial means include the:

1. Persistence of statements regarding an individual's beliefs 2. Desirability of the commitment to those beliefs 3. Seriousness with which such statements were made 4. Inferences that may be drawn from the surrounding circumstances

Cruzan v. Director, Missouri Department of Health

1990; competent persons can refuse medical treatment; right to die. An incompetent person is not able to make an informed and voluntary choice to exercise a hypothetical right to refuse treatment, or any other right. Such a 'right' must be exercised for her, if at all, by some sort of surrogate." -incompetent people should have the same right

Oregon's Death with Dignity Act 1994

1997: Physician-assisted suicide became a legal medical option for terminally ill residents of Oregon -first law to legalize assisted suicide, allowing terminally ill Oregon residents to obtain prescriptions from their physician for self-administered, lethal doses of medications -act legalizes physician-assisted suicide but SPECIFICALLY prohibits euthanasia, where a physician or other person directly adminsters a medication to end another's life -Terminal Disease: incurable and irreversible disease that has been medically confirmed and will, within reasonable medical judgement, produce death within 6 months Inform the patient of: His or her medical diagnosis; His or her prognosis; The potential risks associated with taking the medication to be prescribed; The probable result of taking the medication to be prescribed; and The feasible alternatives, including, but not limited to, comfort care, hospice care, and pain control. -written and oral requests, waiting periods, form of a request

Adequate Safeguards

A cogent reply to any particular slippery slope argument is that we will not slide to the bottom; we will institute adequate safeguards to prevent abuses. The question of safeguards has been hotly contested in the debate over physician-assisted suicide. Yale Kamisar, professor of law at the University of Michigan and an important, longstanding opponent of legalizing euthanasia, has remarked, "If assisted suicide went through, we'd be providing more safeguards for criminals picked up on the street than we would for the dying." This point is, at the same time, misleading and important. On the misleading side, the analogy is simply not as strong as Kamisar suggests. Any decent society sets an appropriately high level of safeguards for criminals, faced as they are with the overwhelming power of the state. Yet, in the matter of safeguards, few cases can be usefully compared with the plight of criminals. For example, we provide more explicit constitutional safeguards for criminals than we do for schoolchildren. We do not thereby degrade the status or the safety of schoolchildren. Adequate safeguards against abuses of power are not defined solely by what we do for criminals. This point having been made, we must take seriously Kamisar's general worry about safeguards for legalized physician-assisted suicide. It is far from obvious that a society as large, diverse, and unequal as ours can implement adequate safeguards. In a nation with great — and ever-increasing — disparities of wealth and education and ever-growing numbers of uninsured and underinsured citizens, the problem that people who cannot pay for health care might regularly be coerced to die may be genuinely unmanageable. Add to these already large and systemic forces the fact that for-profit HMOs are increasingly taking over our health-care system, and the problem of adequate safeguards may very well be intractable.

Patient Not in a Persistent Vegetative State

A guardian may direct the withdrawal of life-sustaining medical treatment, including nutrition and hydration, only if the incompetent ward is in a persistent vegetative state and the decision to withdraw is in the best interests of the ward. -Span v. Eisenberg: sought permission to direct the withholding of edn'as nutrution, claiming that her sister would not have want this condition -only testimony presented at trial -Edna's views on the use of life-sustaining medical treatment involved a statement made 30 years earlier. -. The committee approved withholding nutrition if no family member objected; however, one of Edna's nieces refused to sign a statement approving the withdrawal of nutrition.

Confidentiality

A more recent principle in medicine has been confidentiality. All patients have the right to expect their records and any communication pertaining to their care is kept confidential. As we work with a variety of family members, well meaning friends, and providers, it can be a challenge to maintain confidentiality.

Where Do Americans Die?

According to Stanford School of Medicine's Palliative Care: Studies show that 80% of Americans would prefer to die at home, if possible. Despite this, 60% of Americans die in acute care hospitals, 20% in nursing homes, and only 20% at home. A minority of dying patients use hospice care, even those patients (who) are often referred to hospice, only in the last 3 to 4 years of life. However, not every patient will want to die at home. Dying at home is not favored in certain cultures (due to cultural taboos) and some patients may wish to die at home, out of concern that they might be a burden to the family. -fewer patients are dying at home than want to do so There comes a point in life where some patients wish to halt the aggressive approach to hold on to life when it appears futile. At that point in time, the physician may suggest palliative care in the home by family and/or hospice. Even as one nears the end of life, hospice care may even be rejected by the patient. This chapter reviews a variety of the issues that inevitably arise as one approaches the end of life.

Active or Passive Euthanasia

Active Euthanasia: understood to be the intentional commission of an act, such as providing a patient a lethal dose of a medication that results in death. -The act, if committed by the patient, is thought of as suicide. Moreover, because in most states the patient cannot take his or her own life, any person who assists in the causing of the death could be subject to criminal sanction for aiding and abetting suicide. Passive Euthanasia: occurs when lifesaving treatment (such as a respirator) is withdrawn or withheld, allowing the terminally ill patient to die a natural death. -accepted pursuant to legislative acts and judicial decisions, based on the facts of a particular case -The distinctions are important when considering the duty and liability of a physician who must decide whether to continue or initiate treatment of a comatose or terminally ill patient. Physicians are obligated to use reasonable care to preserve health and to save lives, and, thus, unless fully protected by the law, they will be reluctant, for example, to abide by a patient's or family's wishes to terminate life-support devices.

Legislative Response

After the Cruzan decision, states began to draft new legislation in the areas of living wills, durable powers of attorney, healthcare proxies, and surrogate decision making -Because of continuing litigation involving the right to die, it is clear that the public must be educated as to the importance of expressing their wishes concerning medical treatment while they are competent. Uniformity with regard to the legal instruments available for demonstrating what a patient wants should be a common goal of legislators, courts, and the medical profession. If living wills, surrogates, and durable powers of attorney were to be enacted pursuant to national rather than individual state guidelines, the process of resolving end-of-life issues might be less complicated. Some states have addressed the problem by statutorily providing for these instruments, thereby enabling individuals to have a say in the medical care they would like to receive should they become unable to speak for themselves.

Withholding and Withdrawal of Treatment

Although the courts have accepted decisions to withhold or withdraw extraordinary care, especially the respirator, from those who are comatose or in a persistent vegetative state with no possibility of emerging, they have been unwilling until recent years to discontinue feeding, which they have considered to be ordinary care. For example, the Illinois Supreme Court, in In re Estate of Longeway,[67] found that the authorized guardian of a terminally ill patient in an irreversible coma or persistent vegetative state has a common-law right to refuse artificial nutrition and hydration. The court found that there must be clear and convincing evidence that the refusal is consistent with the patient's interest. The court also required the concurrence of the patient's attending physician and two other physicians. Court intervention is also necessary to guard against the possibility that greed may taint the judgment of the surrogate decision maker. Although there may be a duty to provide life-sustaining equipment in the immediate aftermath of cardiopulmonary arrest, there is no duty to continue its use when it has become futile and ineffective to do so in the opinion of qualified medical personnel.

Removal of Life-Support Equipment

Although there may be a duty to provide life-sustaining equipment in the immediate aftermath of cardiopulmonary arrest, there is no duty to continue its use after it has become futile and ineffective to do so in the opinion of qualified medical personnel -. The charges were based on their acceding to requests of the patient's family to discontinue life-support equipment and intravenous tubes. -

continuing

An advance directive, such as a living will, is persuasive evidence of an incompetent person's wishes. An incompetent patient can act as a guardian and in accordance with the terms of a living will. An agent can substitute his or her judgment for that of the patient. -A court may require the attending physician to certify that a patient is in a permanent vegetative state, with no reasonable chance for recovery, before a family member or guardian can request termination of extraordinary means of medical treatment. -The decision maker would attempt to ascertain the incompetent patient's actual interests and preferences. A court can appoint a guardian if:[24] Family members disagree as to the incompetent person's wishes. Physicians disagree on the prognosis. The patient's wishes cannot be known because he or she has always been incompetent. Evidence exists of wrongful motives or malpractice. No family member can serve as a guardian.

informed consent example

An example of an informed consent ethical issue may involve a patient who is competent, but heavily sedated secondary to appropriate pain management treatment. It would be important for the nurse, or other care provider, to explore options before the patient is asked to make a decision. It may be appropriate to back off on some pain medication or it may be a better choice to involve family at this stage. Every situation needs to be dealt with on an individual basis. Whenever possible it is best to discuss patient values and goals of care as early as possible. These discussions will help guide the treatment plan as the patient status deteriorates.

Autonomy

An important principle to most Americans is autonomy. In health care, individuals have the personal liberty to make decisions based on options given by their health care provider. Given intellectual competence and adequate information, an individual has the power to make their own decisions

Veracity

An important principle to most Americans is autonomy. In health care, individuals have the personal liberty to make decisions based on options given by their health care provider. Given intellectual competence and adequate information, an individual has the power to make their own decisions

Informed Consent

As the culture of our healthcare model moves from paternalism to autonomy, the concept of "informed consent" has gained significance. To make decisions, patients must have information, understand the information, know their options without feeling coercion, and be competent to make the decision. Healthcare providers have the added challenges of assessing competency, knowing within reason all options available, and providing this information in a language the patient and /or family can understand.

The Value of Life

Beyond death with dignity is another issue: basic respect for life, a fundamentally important value in any civilized society. Some parties to this debate will contend that the very decision to legalize physician assisted suicide is a serious violation of this fundamental value. One seemingly cogent rebuttal is that, at the end of life, the best way to respect it is to honor the liberty of those who have no reasonable way to end their suffering other than ending their life. But how will legally sanctioned suicide in these cases affect our view of those who suffer? As a society, we already tend to put higher value on happy and productive lives and to devalue those that are, in various ways, "substandard" or "dysfunctional." We have a particular fear of dependence. If physician-assisted suicide is deemed a constitutional right, will this further erode the value we place — both publicly and personally — on those who are dependent on us? This question, of course, points toward some worrisome "slippery slopes," all of which suggest that any implementation of physician assisted suicide is only the beginning of a social movement, the end of which may appall even those who

summary

Ethical issues at the end of life are best addressed in an open discussion with the patient, family and /or significant others. Home care providers should be prepared to communicate all information truthfully in a language and at a level understood by everyone involved in the discussion. When the home care provider is faced with a difficult ethical problem, it would be ideal to involve an ethics committee. Unfortunately, most agencies do not have access to this resource. An alternative would be the agency's interdisciplinary team, including the medical director. This team could support decision making by providing a broad knowledge base with the added value of personal experience. Patient, families, and healthcare providers want to "do the right thing" at the end of life. Making these decisions requires identification of the issue, understanding relevant facts, exploration of patient and family values, listing the options, and making the best possible choice. Patients and families place their trust in their healthcare providers throughout their lives. Learning how to effectively lead an ethical discussion at the end of life is an important skill for all home care providers.

Nutritional and IV Fluids Support

Family members frequently struggle with whether or not to provide nutrition or fluids at the end of life. Seen as a basic human need, it is difficult to make the decision to not give this support. Health care providers can help by giving clinical information. If the patient is near death, it might be inappropriate to provide this intervention as major body organs have most likely started to shut down and will not be able to utilize the nutrition or fluid (Casarett, Kapo, & Caplan, 2005). Explaining the dying process as a natural process where patients no longer want or need nutrition may relieve some of the concerns family members have when making this decision. Focusing on quality of life and what is best for the patient may help guide this discussion.

Legalized physician assisted suicide

For the partial year ending December 31, 2016, 191 individuals received prescriptions under EOLA. 111 individuals died following their ingestion of the prescribed aid-in-dying drug(s). Of the 111 individuals, 87.4 percent were 60 years of age or older, 96.4 percent had health insurance, and 83.8 percent were receiving hospice and/or palliative care. As this report covers only six-months of data, caution should be exercised in drawing conclusions based on the numbers reported.[42]

4. Patient Self-Determination Act of 1990

Healthcare organizations have a responsibility to explain to patients, staff, and families that patients have legal rights to direct their medical and nursing care as it corresponds to existing state law.

Skills and Knowledge

Inexperienced providers need to gain skills and knowledge by observing successful ethical discussions and practicing with the health care team. As questions arise within the team, it is beneficial to bring these concerns out in the open for discussion. Examples of questions might be, "Are we giving too much pain medication?" or "Should we be offering antibiotics (or nutrition, or IV fluids)?" By discussing these issues among team members, the entire team has the opportunity to work through the ethical concerns in a "safe" environment. It is important for all members of the team to have a clear understanding of the goals of care. With this information, everyone on the team is able to reinforce the plan of care with the patient and family. Many family members have never been confronted with the issues frequently seen at the end of life and will want and need the time to discuss concerns with team members. Any member of the team (physician, nurse, social worker, chaplain, etc) may find themselves faced with facilitating an unplanned ethical discussion. Careful exploration of the issue at hand, providing any additional clinical knowledge, and reinforcing decisions with an ethical basis may provide comfort to family concerned about "doing the right thing" for their dying family member.

Superintendent of Belchertown State School v. Saikewicz

Joseph Saikewicz was a 67-year-old intellectually disabled patient with leukemia he court found from the evidence that the prognosis was dim, and even though a "normal" person would probably have chosen chemotherapy, it allowed Saikewicz to die without treatment to spare him the suffering. -approved the recommendation of a court appointed guardian ad litem that it would be in Saikewics's best interest to end chemotherapy treatment -Saikewicz had always been incompetent, -It rejected the Quinlan approach of entrusting a decision concerning the continuance of artificial life support to the patient's guardian, family, attending physicians, and a hospital ethics committee. The Saikewicz court asserted that even though a judge might find the opinions of physicians, medical experts, or hospital ethics committees helpful in reaching a decision, there should be no requirement to seek out the advice. This main point of difference between the Saikewicz and Quinlan cases marked the emergence of two different policies on the incompetent person's right to refuse treatment. One line of cases has followed Saikewicz and supports court approval before physicians are allowed to withhold or withdraw life support. Advocates of this view argue that it makes more sense to leave the decision to an objective tribunal than to extend the right of a patient's privacy to a number of interested parties, as was done in Quinlan. They also attack the Quinlan method as being a privacy decision effectuated by popular vote.[21]

5. Advance directives, in the form of a "living will" or "durable power of attorney," allow the patient to make end-of-life choices.

Living will is the instrument or legal document that describes those treatments an individual wishes or does not wish to receive should he or she become incapacitated and unable to communicate treatment decisions. Durable power of attorney is a legal device that permits one individual, known as the "principal," to give to another person, called the "attorney-in-fact," the authority to act on his or her behalf. Guardianship is a legal mechanism by which the court declares a person incompetent and appoints a guardian. The court transfers the responsibility for managing financial affairs, living arrangements, and medical care decisions to the guardian. Healthcare proxy allows a person to appoint a healthcare agent to make treatment decisions in the event that he or she becomes incompetent and is unable to make decisions for him- or herself. Surrogate decision maker is an agent who acts on behalf of a patient who lacks the capacity to participate in a particular decision. Substituted judgment is a form of surrogate decision making where the surrogate attempts to establish what decision the patient would have made if that patient were competent to do so.

Principles of Double Effect

Many procedures are uncomfortable or painful, but in the big picture do good for the patient. That's when we describe our actions through the principle of double effect. In this case, the good must outweigh the harm being done. Harm must never be intended, but simply tolerated as a result of achieving good.

Euthanasia

Mercy killing of the hopelessly ill, injured, or incapacitated. Debate over euthanasia is complex. Legal system must maintain a balance between ensuring the patient's constitutional rights are protected and protecting society's interests in preserving life, preventing suicide, and maintaining the integrity of the medical profession. When there is uncertainty regarding a patient's wishes in an emergency The situation should be resolved in a way that favors the preservation of life. Protect the patient's right to freedom of religion and self-determination. Active euthanasia is the intentional commission of an act that will result in death. Passive euthanasia is when a potentially lifesaving treatment is withdrawn or withheld. Voluntary euthanasia When a competent adult patient with an incurable condition who has been informed of the possible ramifications and alternatives available gives consent. Involuntary euthanasia When the decision to terminate the life of an incurable person is made by someone other than the incurable person. Supreme Court ruled there is no constitutional right to assisted suicide. Decision allowed the state of Michigan to prosecute Dr. Jack Kevorkian for assisting patients in committing suicide.

Nonmaleficence

Most professional codes also echo the opposite of doing good. The principle of nonmaleficence implies that providers should do no harm. This can be a difficult principle to follow, since many of our treatments cause secondary side effects that harm the body

oral declaration

ONLY after the patient has been declared terminally ill -declaration bears the responsibility of informing the physician to ensure that the document becomes a part of the medical record Most states allow the document to be effective until revoked by the individual. To revoke, the patient must sign and date a new writing, destroy the first document himself or herself, direct another to destroy the first document in his or her presence, or orally state to the physician an intent to revoke. Before exercising an incompetent patient's right to forgo medical treatment, the surrogate decision maker must satisfy the following conditions: -The surrogate must be satisfied that the patient executed a document (e.g., Durable Power of Attorney for Health Care and Health Care Proxy) knowingly, willingly, and without undue influence and that the evidence of the patient's oral declaration is reliable. -The patient must not have reasonable probability of recovering competency so that the patient could exercise the right. -The surrogate must take care to ensure that any limitations or conditions expressed either orally or in written declarations have been considered carefully and satisfied.

Role Fidelity

One final principle is called role fidelity. As most health care is provided by teams, and this is certainly true for home care, team members have a duty to practice within the constraints of their role also referred to as their "scope of practice."

3. Assisted suicide

Oregon legislates physician-assisted suicide

Pain management

Patients frequently list their biggest fear at the end of life as pain. It is critical that providers address pain issues with respect, concern for patient dignity, and careful attention to emotional suffering. All the pain medication you can give, in any kind of route is not going to help if your patient is suffering emotionally or spiritually. Addressing these concerns is just as important as finding the right mix of medications and complementary treatments. The principle of double effect is frequently used when concerns arise related to high doses of medication and sedation. There are times when, in order to provide adequate pain relief, the unintended side effect is respiratory depression. The greater good is providing pain relief and the respiratory depression becomes an unintended consequence (Fohr, 1998)

Beneficence

That providers have a duty to do what is good and beneficial to the patient and family is called beneficence. The Hippocratic Oath and other professional pledges are based on doing what is good for the patient.

Feeding Tubes

The New Jersey Supreme Court in 1985 heard the case of In re Claire C. Conroy. [71] The case involved an 84-year-old nursing home patient whose nephew petitioned the court for authority to remove the nasogastric tube that was feeding her. The court overturned the appellate division decision and held that life-sustaining treatment, including nasogastric feeding, could be withheld or withdrawn from incompetent nursing home patients who will, according to physicians, die within 1 year, in three specific circumstances. These are as follows: 1. When it is clear that the particular patient would have refused the treatment under the circumstances involved (the subjective test) 2. When there is some indication of the patient's wishes (but he or she has not "unequivocally expressed" his or her desires before becoming incompetent) and the treatment "would only prolong suffering" (the limited objective test) 3. When there is no evidence at all of the patient's wishes, but the treatment "clearly and markedly outweighs the benefits the patient derives from life" (the pure objective test, based on pain) Those quality-of-life judgments would be most dangerous for nursing home patients whose age would be a factor in the decision-making process. "Advocates of 'the right to life' fear that the 'right to die' for the elderly and handicapped will become a 'duty to die.'"[73] In both the Saikewicz and Spring cases, age was a determining factor weighing against life-sustaining treatment. Furthermore, in In re Hier, [74] the court found that Mrs. Hier's age of 92 years made the "proposed gastrostomy substantially more onerous or burdensome ... than it would be for a younger, healthier person." Moreover, a New York Superior Court held that the burdens of an emergency amputation for an elderly patient outweighed the benefit of continued life.[75] Finding that prolonging her life would be cruel, the court stated that life had no meaning for her. Although some courts have recognized the difference, other courts must still address the difference between Quinlan-type patients and older, confined, and conscious patients who can interact but whose mental or physical functioning is impaired.

Deactivating Implantable Cardiovascular Defibrillators (ICD)

The implantable cardioverter defibrillators (ICD) have been a life saving technology for patients with impaired left ventricular ejection fraction, malignant arrhythmias and other cardiac conditions. As more patients elect to utilize this technology, homecare agencies will increasingly be faced with helping patients decide when it is appropriate to have them deactivated. Patients with serious co-morbidities may eventually experience progressive physiologic and functional decline resulting in a terminal condition with significant decrease in quality of life. When a patient no longer values continued survival, the ICD can no longer offer increased survival, and /or if the ICD impedes active dying it is appropriate to discuss disabling this device (Berger, 2005). Deactivating this device is a noninvasive procedure involving a magnet. It is critical that this issue be addressed with the actively dying patient. Having this device continually provide a shock to the heart when the patient is ready to die would not contribute to a "peaceful" death.

Justice

The principle of justice relates to fairness. Most often this principle is used when making the decision about how to distribute scarce resources.

Death With Dignity (pdf)

Those who support the legalization of suicide often argue that individuals have a basic (constitutional) right to die with dignity, but this rhetoric is worth unveiling. Establishing a right to physician-assisted suicide doesn't guarantee a dignified death. Some might argue that having the liberty to choose how we die is synonymous with dignity. But unless we are willing to stipulate that a dignified death is any death under the auspices of a legal right to die, then all the legal right provides is an opportunity for a dignified death. A truly dignified death is presumably an extension of a dignified life. Meeting death with dignity, like meeting it with courage, is likely to be the result of a life in pursuit of these characteristics. As philosopher Ronald Dworkin notes, "It is a platitude that we live our whole lives in the shadow of death; it is also true that we die in the shadow of our whole lives." All parties to the debate should admit that a dignified death cannot be secured by a simple expansion of rights; such a death will require further personal and communal courage, compassion, fortitude, and faith.

Overconfidence

Those with confident answers to these and other hard questions will step forward as the Supreme Court deliberates assisted suicide. Yet, we are well advised to avoid overconfidence on such issues. In many ways, those with certain answers regarding physician-assisted suicide are like Miranda in Shakespeare's Tempest, regarding the brave new world she sees with innocent wonder. As we confront our own brave new world of high-technology health care and aid in dying, we might do well to remember the sober reply of Miranda's father, Prospero, who has seen something of the perils in the brave new world his daughter wants to embrace. Her father's reply: "'Tis new to thee." Michael J. Meyer, associate professor of philosophy at Santa Clara University, is on the Markkula Center for Applied Ethics Steering Committee. His current work is on the idea of human dignity as well as liberal virtues like tolerance and civility. A version of this article appeared in the San Jose Mercury News.

Defining Death

Traditionally, the definition of death adopted by the courts has been, according to Black's Law Dictionary, "cessation of respiration, heartbeat, and certain indications of central nervous system activity, such as respiration and pulsation." Currently, however, modern science has the capacity to sustain vegetative functions of those in irreversible comas. Although life support equipment can sustain heartbeat and respiration, it is generally accepted that the irreversible cessation of brain function constitutes death. -Ethicists who advocate the prohibition on taking action to shorten life agree "where death is imminent and inevitable, it is permissible to forgo treatments that would only provide a precarious and painful prolongation of life, as long as the normal care due to the sick person in similar cases is not interrupted. -"irreversible cessation of all brain functions including the brain stem.

Euthanasia

When patients and their families perceive a deterioration of the quality of life with no end in sight, conflict often arises within the hearts and minds of both healthcare professionals, who are trained to save lives, and patients and their families, who wish to hold on to their loved ones. -there seems to be an absence of controversy only when a patient who is kept alive by modern technology is still able to appreciate and maintain control over his or her life. -obliges a person to confront humanity's greatest fear—death -evolved into an issue with competing legal, medical, and moral implications that continues to generate debate, confusion, and conflict. Currently, there is a strong movement advocating death with dignity, which excludes machines, monitors, and tubes. -Euthanasia originated from the Greek word euthanatos, meaning good death or easy death, and was accepted in situations where people had what was considered to be incurable diseases. -Euthanasia is defined broadly as "the mercy killing of the hopelessly ill, injured, or incapacitated." -Confucian philosophy and the Buddhist religion: suicide was an acceptable answer to unendurable pain and incurable disease 1870s: the act or practice of painlessly putting to death persons suffering from incurable conditions or diseases," it was considered to be a merciful release from incurable suffering -20th Century: no clear answers or guidelines regarding the use of euthanasia -Some believe euthanasia is meant to allow a painless death when one suffers from an incurable disease yet is not dying. Others, who remain in the majority, perceive euthanasia only as an instrument to aid dying people in ending their lives with as little suffering as possible. To ensure compliance with the law while serving the needs of their patients, it is incumbent on healthcare providers to keep themselves informed of professional guidelines and regulatory requirements in this ever-changing field.

Voices in the Discussion

When patients are unable to speak for themselves, the provider must have a working understanding of the law and who is "next in line" as the decision-maker. This does not mean that the others don't deserve a "voice" during the discussion (Burt, 2005). Homecare providers may want to involve all significant family and friends, taking the lead from the patient or a closest relative. Helping the family review all possible options and outlying risk and benefits of each choice will help clarify the issues. Giving everyone an opportunity to voice their questions, concerns and opinions will in most cases, help the person making the decision feel more comfortable with the decision that is made. Spending this time on the front end usually eliminates the need to revisit the decision with other family members later during treatment.

6. Futility of Treatment

When the physician recognizes further treatment will be of no benefit to the patient. Morally, the physician has a duty to inform the patient when there is little likelihood of success of further treatment. Determination as to futility of medical care is a medical decision based on scientific evidence.

7. Withholding or Withdrawal of Treatment

Withholding of treatment is a decision not to initiate treatment or medical intervention for the patient. Withdrawal of treatment is a decision to discontinue treatment or medical interventions for the patient. Do-not-resuscitate orders are physician orders not to resuscitate a patient in the event of a cardiac or respiratory arrest. Generally written as the result of a patient's wishes or at the family's request Orders must be in written form, signed and dated by the physician.

In re Dinnerstein

by finding that "no code" orders are valid to prevent the use of artificial resuscitative measures on incompetent, terminally ill patients. The court was faced with the case of a 67-year-old woman who was suffering from Alzheimer's disease. It was determined that she was permanently comatose at the time of trial. Furthermore, the court decided that Saikewicz-type judicial proceedings should take place only when medical treatment could offer a reasonable expectation of effecting a permanent or temporary cure of or relief from the illness.

Withholding of Treatment

decision not to initiate treatment or medical intervention for the patient. This is a decision often made when death is imminent and there is no hope of recovery.

Withdrawal of Treatment

decision to discontinue treatment or medical interventions for the patient when death is imminent and cannot be prevented by available treatment. -Withholding or withdrawing treatment should be considered when: -the patient is in a terminal condition and there is a reasonable expectation of imminent death of the patient; -the patient is in a noncognitive state with no reasonable possibility of regaining cognitive function; and/or -restoration of cardiac function will last for a brief period.

Substituted Judgment

form of surrogate decision making where the surrogate attempts to establish what decision the patient would have made if that patient were competent to do so. -This conclusion can be based on the patient's preference expressed in previous statements or the surrogate's knowledge of the patient's beliefs (e.g., religious) and values -The Supreme Court of Rhode Island had a case, In re Jane Doe,[64] come before it pursuant to a motion filed on behalf of the mother of Jane Doe, following a determination by the Family Court authorizing termination of her daughter's pregnancy due to a sexual assault by an unknown person during her residence at a group home. As a result of her pregnancy and overlapping medical concerns, permission was sought to terminate her pregnancy. -unable to understand the pain and travail that would normally attend pregnancy and that it would be in her best interests to terminate the pregnancy without delay. -The only question presented by this litigation was the determination of whether Jane Doe would have chosen an abortion if she were competent to exercise freedom of choice

Living Will

instrument or legal document that describes those treatments an individual wishes or does not wish to receive should he or she become incapacitated and unable to communicate treatment decisions. -enables a person, when competent, to inform caregivers in writing of his or her wishes with regard to withholding and withdrawing life-supporting treatment, including nutrition and hydration -helpful to healthcare professionals because it provides guidance about a patient's wishes for treatment, provides legally valid instructions about treatment, and protects the patients rights and the provider who honors them This right of terminally ill patients should not be lost when they suffer irreversible brain damage, become comatose, and are no longer able to personally express their wishes to discontinue the use of extraordinary artificial support systems -Kentucky's living will: allows a judicially appointed guadian or other designated surrogate to remove a ward's life support -If there was no legal guardian but the physicians, family, and ethics committee all agree with the surrogate's decision—in this case, the state's—there is no need for judicial approval. -should be signed and dated by two witnesses who are not blood relatives or beneficiaries of the patient's property -discussed with the patient's physcisian, and a signed copy whould be placed in the patient's medical record -copy for individual designated to make decisions in the event the patient is unable to do so - person who executes a living will when healthy and mentally competent cannot predict how he or she will feel at the time of a terminal illness; therefore, it should be updated regularly so that it accurately reflects a patient's wishes

Involuntary Euthanasia

occurs when the decision to terminate the life of an incurable person (an incompetent or consenting competent person_ is made by someone other than that incurable person

Futility of Treatment

occurs when the physician recognizes that the effect of treatment will be of no benefit to the patient. -physician has a duty to inform the patient when there is little likelihood of success. -The determination as to futility of treatment is based on the physician's assessment and medical judgment. -After a diagnosis has been made that a person is terminally ill with no hope of recovery and is in a chronic vegetative state with no possibility of attaining cognitive function, a state generally has no compelling interest in maintaining life. The decision to forgo or terminate life-support measures is, at this point, simply a decision that the dying process will not be artificially extended. Although the state has an interest in the prolongation of life, it has no interest in the prolongation of dying, and although there is a moral and ethical decision to be made to end the process, that decision can be made only by the surrogate. The decision whether to end the dying process is a personal decision for family members or those who bear a legal responsibility for the patient. -A determination as to the futility of medical care is a decision that must be made by a physician. Even if death is not imminent but a patient's coma is irreversible beyond doubt and there are adequate safeguards to confirm the accuracy of the diagnosis with the concurrence of those responsible for the patient's care, it is not unethical to discontinue all means of life-prolonging medical treatment.

Competent Patients Make Their Own Decisions

physician had issued a no-code status on patient David Payne despite evidence given by a nurse that Payne could communicate up to a few minutes before his death -endering him unable to give informed consent to treatment -Payne left no written directives, the physician relied on one of Payne's relatives, who asked for the DNR order. The court found that there was evidence that Payne was not incompetent and should have been consulted before a DNR order was given. -Furthermore, the court reviewed testimony that one year earlier, Payne had suffered and recovered from the same type of symptoms, leading to the conclusion that there was a possibility that he could have survived if resuscitation had continued. There was no DNR policy in place at the hospital to assist the physician in making his decision. To avoid this type of problem, healthcare providers should adopt an appropriate process with respect to issuing no-code orders.

Massachusetts Supreme Judicial Court

ttempted to clarify its Saikewicz opinion with regard to court orders in In re Spring -different factors such as the patient's mental status and his or her medical prognosis with or without treatment must be considered before judicial approval is necessary to withdraw or withhold treatment from an incompetent patient. -The inconsistencies presented by the Massachusetts cases led courts since 1977 to follow the parameters set by Quinlan, requiring judicial intervention. In cases in which physicians have certified the irreversible nature of a patient's loss of consciousness, an ethics committee (actually a neurologic team) could certify the patient's hopeless neurologic condition. Then a guardian would be free to take the legal steps necessary to remove life-support systems. The main reason for the appointment of a guardian is to ensure that incompetent patients, like all other patients, maintain their right to refuse treatment. Most holdings indicate that because a patient has the constitutional right of self-determination, those acting on the patient's behalf can exercise that right when rendering their best judgment concerning how the patient would assert the right. This substituted judgment doctrine could be argued on standing grounds, whereby a second party has the right to assert the constitutional rights of another when that second party's intervention is necessary to protect the other's constitutional rights. The guardian's decision is sounder if it is based on the known desires of a patient who was competent immediately before becoming comatose.

Powerpoint

•Terry Schiavo 27 year old Terry suffered a cardiac arrest in 1990 & never regained consciousness, lived in nursing homes, & fed & hydrated by tubes. In 1998, Michael, Terry's husband, petitioned the court for guardianship to authorize termination of life-prolonging procedures. Terry's parents, opposed the petition. • •Schiavo II •Michael contended his wife never wanted to be kept alive artificially. •Terry's parents told justices that their son-in-law is trying to rush her death so he can •inherit her estate •be free to marry another woman. • •Schiavo - III •A guardianship court issued an order authorizing discontinuance of artificial life support •trial court found by convincing evidence •Terry was in a persistent vegetative state •she would elect to cease life-prolonging procedures if she were competent to do so •order was affirmed on appeal • •Schiavo - IV On October 21, 2003, the Florida Legislature enacted chapter 2003-418, which the Governor signed into law, & issued executive order No. 03-201 to stay the continued withholding of nutrition & hydration. The nutrition & hydration tube was reinserted pursuant to the Governor's executive order. • •Schiavo - V Florida Law Chapter 2003-418 Section 1. (1) The Governor shall have the authority to issue a one-time stay to prevent the withholding of nutrition . . . : (a) That patient has no written advance directive; (b) The court has found that patient to be in a persistent vegetative state; (c) That patient has had nutrition & hydration withheld; & (d) A member of . . . family has challenged the withholding of nutrition . . . . •Schiavo - VI The circuit court entered a judgment on May 6, 2004, in favor of Michael. The circuit court found that chapter 2003-418 was unconstitutional because it allowed the Governor to encroach upon judicial power & to retroactively abolish Terry's vested right to privacy. • •Schiavo - VII This case is not about the aspirations loving parents have for their children. It is about Terry's right to make her own decision. •Schiavo - VIII •It is unfortunate that when families cannot agree, the best forum for a personal decision •is a public courtroom •the decision-maker is a judge •the law, however, provides no better solution to protect interests of promoting value of life • •Schiavo - IX The court stated we are a nation of laws & we must govern our decisions by the rule of law & not by our emotions. Our hearts comprehend the grief so fully demonstrated by Terry's family members. But our hearts are not the law. What is in the Constitution always must prevail over emotion. Our oaths as judges require that this principle is our polestar, & it alone. •Schiavo - XSeparation of Powers If the Legislature with the assent of the Governor can do what was attempted here, the judicial branch would be subordinated to the final directive of the other branches. Also, subordinated would be the rights of individuals, including the well established privacy right to self determination. Bush v. Schiavo, No. SC04-925 (Fla.App. 2004) •Schiavo - XISeparation of Powers No court judgment could ever be considered truly final & no constitutional right truly secure, because the precedent of this case would hold to the contrary. Vested rights could be stripped away based on popular clamor. Bush v. Schiavo, No. SC04-925 (Fla.App. 2004) •Schiavo - XII U.S. Supreme Court, on January 24, 2005, refused to reinstate the Florida law passed to keep Terry connected to a feeding tube, clearing the way for it to be removed. Discuss the ethical & legal issues. • •Schiavo - XIII •Ethical Issues •Autonomy • •Legal Issues •Guardianship •Right to Self-Determination •