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Euthanasia : Euthanasia Euthanasia (or euthanazja From game. e??a?as?a, euthanasia - "Good death") - the task of the death of terminally ill person motivated by shortening its suffering. 16 July 2010 2 Slide 3: Euthanasia (from the Greek e??a?as?a meaning "good death": e?-, eu- (well or good) + ???at??, thanatos (death)) refers to the practice of ending a life in a manner which relieves pain and suffering. According to the House of Lords Select Committee on Medical Ethics, the precise definition of euthanasia is "a deliberate intervention undertaken with the express intention of ending a life, to relieve intractable suffering."[1] 16 July 2010 3 The etymology of the term : The etymology of the term The concept of "euthanasia" for the first time appeared likely to Fifth century BC in comedy Cratinus of undetermined title. Described it this way "a person having a good death" without explaining the term. Once again, this concept has been used at the end The fourth century BC by another Greek poet -- Meander. The second meaning given the term "euthanatos"Define" easy death "which is having the effect of distance to their own lives. 16 July 2010 4 The etymology of the term : The etymology of the term Also in culture Ancient Rome the term "euthanasia" was present. Suetonius in Lives of the Caesars, Has a description of his death Octavian Augustus Who wanted to die peacefully, painlessly, quickly and above all, consciously, so as to be able to organize his affairs as he got. 16 July 2010 5 Definition of Euthanasia : Definition of Euthanasia The intentional killing by act or omission of a dependent human being for his or her alleged benefit. The key word here is "intentional". If death is not intended, it is not an act of euthanasia. 16 July 2010 6 Definitions : Definitions Voluntary euthanasia: When the person who is killed has requested to be killed. . 16 July 2010 7 Definitions : Definitions Non-voluntary euthanasia: When the person who is killed made no request and gave no consent. 16 July 2010 8 Definitions : Definitions Involuntary euthanasia: When the person who is killed made an expressed wish to the contrary. 16 July 2010 9 Definitions : Definitions Assisted suicide: Someone provides an individual with the information, guidance, and means to take his or her own life with the intention that they will be used for this purpose. 16 July 2010 10 Definitions : Definitions Physician Assisted Suicide: When it is a doctor who helps another person to kill themselves. 16 July 2010 11 Definitions : Definitions Euthanasia By Action: Intentionally causing a person's death by performing an action such as by giving a lethal injection. 16 July 2010 12 Definitions : Definitions Euthanasia By Omission: Intentionally causing death by not providing necessary and ordinary (usual and customary) care or food and water. 16 July 2010 13 What Euthanasia is NOT : What Euthanasia is NOT There is no euthanasia unless the death is intentionally caused by what was done or not done. Thus, some medical actions that are often labeled "passive euthanasia" are no form of euthanasia, since the intention to take life is lacking. 16 July 2010 14 These are NOT euthanasia: : These are NOT euthanasia: Not commencing treatment that would not provide a benefit to the patient. Withdrawing treatment that has been shown to be ineffective, too burdensome or is unwanted. The giving of high doses of pain-killers that may endanger life, when they have been shown to be necessary. 16 July 2010 15 Slide 16: WHY THE QUESTION OF EUTHANASIA ARISES ? 16 July 2010 16 Slide 17: BRAIN DEATH 16 July 2010 17 “Harvard Criteria”Report of the Ad Hoc Committee of the Harvard Medical School to Examine the Definition of Brain Death. A definition of irreversible coma. JAMA 1968;205:337-340 : “Harvard Criteria”Report of the Ad Hoc Committee of the Harvard Medical School to Examine the Definition of Brain Death. A definition of irreversible coma. JAMA 1968;205:337-340 Driving forces: advances in care mechanical ventilation and ICU’s Organ transplantation: cadaver (non-heart-beating) donors but some surgeons harvesting from patients with neurologic catastrophes: patients died after transplantation Many surgeons uncomfortable with this but “live donors” improved transplant outcomes When has irreversible loss of full brain function occurred? --premise: not idea that brain, therefore person, is dead; rather: coma irreversible and care futile 16 July 2010 18 Harvard CriteriaReport of the Ad Hoc Committee of the Harvard Medical School to Examine the Definition of Brain Death. A definition of irreversible coma. JAMA 1968;205:337-340 : Harvard CriteriaReport of the Ad Hoc Committee of the Harvard Medical School to Examine the Definition of Brain Death. A definition of irreversible coma. JAMA 1968;205:337-340 Purpose: “…to define irreversible coma as a new criterion for death.” “There are two reasons why there is need for a definition: 1) improvements in resuscitative and supportive measures…sometimes…only partial success…result is an individual whose heart continues to beat but whose brain is irreversibly damaged. The burden is great on patients who suffer permanent loss of intellect, on their families, on the hospitals, and those in need of hospital beds already occupied by those comatose patients.” 16 July 2010 19 Harvard CriteriaReport of the Ad Hoc Committee of the Harvard Medical School to Examine the Definition of Brain Death. A definition of irreversible coma. JAMA 1968;205:337-340 : Harvard CriteriaReport of the Ad Hoc Committee of the Harvard Medical School to Examine the Definition of Brain Death. A definition of irreversible coma. JAMA 1968;205:337-340 Note: presented in narrative rather than algorithmic form; stricter than ever before, but not strict enough (e.g. EEG duration criteria) Purpose: “…to define irreversible coma as a new criterion for death.” “There are two reasons why there is need for a definition: 2) Obsolete criteria for the definition of death can lead to controversy in obtaining organs for transplantation.” 16 July 2010 20 Harvard CriteriaReport of the Ad Hoc Committee of the Harvard Medical School to Examine the Definition of Brain Death. A definition of irreversible coma. JAMA 1968;205:337-340 : Harvard CriteriaReport of the Ad Hoc Committee of the Harvard Medical School to Examine the Definition of Brain Death. A definition of irreversible coma. JAMA 1968;205:337-340 “An organ, brain or other, that no longer functions and has no possibility of functioning again is for all practical purposes dead.” A. determine presence of “a permanently nonfunctioning brain.” 1. Unreceptivity and Unresponsitivity: “total unawareness to externally applied stimuli…even the most intensely painful stimuli evoke no vocal or other response, not even a groan, withdrawal of a limb, or quickening of respiration.” 2. No Movements or Breathing: no spontaneous movements or spontaneous respiration (turn off respirator for 3 minutes; prior to trial breathing room air for =10 minutes and pCO2 normal) or response to pain, touch, sound or light for an hour. 16 July 2010 21 Harvard CriteriaReport of the Ad Hoc Committee of the Harvard Medical School to Examine the Definition of Brain Death. A definition of irreversible coma. JAMA 1968;205:337-340 : Harvard CriteriaReport of the Ad Hoc Committee of the Harvard Medical School to Examine the Definition of Brain Death. A definition of irreversible coma. JAMA 1968;205:337-340 A. determine presence of “a permanently nonfunctioning brain.” 3. No reflexes: pupils fixed, dilated and absence of: Pupillary response to bright light ocular movement to head turning and ice water irrigation of ears blinking postural activity (decerebrate or other) Swallowing, yawning, vocalization Corneal reflexes Pharyngeal reflexes Deep tendon reflexes Response to plantar or noxious stimuli 16 July 2010 22 Harvard CriteriaReport of the Ad Hoc Committee of the Harvard Medical School to Examine the Definition of Brain Death. A definition of irreversible coma. JAMA 1968;205:337-340 : Harvard CriteriaReport of the Ad Hoc Committee of the Harvard Medical School to Examine the Definition of Brain Death. A definition of irreversible coma. JAMA 1968;205:337-340 B. confirmatory data 4. isoelectric EEG (specifies technique; have EKG and noncephalic leads to r/o confounders “At least 10 full minutes of recording are desirable, but twice that would be better.” [!]) EEG: “when available it should be utilized” If EEG unavailable, “the absence of cerebral function has to be determined by purely clinical signs…or by absence of circulation as judged by standstill of blood in the retinal vessels, or by absence of cardiac activity.” A and B all need to be repeated 24 hours later with no ? AND in the absence of hypothermia (<90°F [32.2°C]) or CNS depressants, such as barbiturates, and determined only by a physician 16 July 2010 23 Harvard CriteriaReport of the Ad Hoc Committee of the Harvard Medical School to Examine the Definition of Brain Death. A definition of irreversible coma. JAMA 1968;205:337-340 : Harvard CriteriaReport of the Ad Hoc Committee of the Harvard Medical School to Examine the Definition of Brain Death. A definition of irreversible coma. JAMA 1968;205:337-340 If criteria are met, “Death is to be declared and then the respirator turned off. The decision to do this and the responsibility for it are to be taken by the physician-in-charge, in consultation with one or more physicians who have been directly involved in the case. It is unsound and undesirable to force the family to make the decision.” 16 July 2010 24 Guidelines for the Determination of Death JAMA 11/13/1981;246(19),2184-2186 : Guidelines for the Determination of Death JAMA 11/13/1981;246(19),2184-2186 Report of the Medical Consultants on the Diagnosis of Death to the President’s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research Developed as an aid to implementation of the proposed “Uniform Determination of Death Act” (endorsed by: ABA, AMA, Nat’l Conference of Commissioners on Uniform State Laws, President’s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research, AAN, AES 16 July 2010 25 Guidelines for the Determination of Death JAMA 11/13/1981;246(19),2184-2186 : Guidelines for the Determination of Death JAMA 11/13/1981;246(19),2184-2186 “Uniform Determination of Death Act” “An individual who has sustained either (1) irreversible cessation of circulatory and respiratory functions, or (2) irreversible cessation of all functions of the entire brain, including the brain stem, is dead. A determination of death must be made in accordance with accepted medical standards.” 16 July 2010 26 Guidelines for the Determination of Death JAMA 11/13/1981;246(19),2184-2186: Criteria : Guidelines for the Determination of Death JAMA 11/13/1981;246(19),2184-2186: Criteria Note: presented in somewhat narrative and somewhat algorithmic form; improvement from Harvard criteria but still room for interpretation of what to do and when. “An individual presenting the findings in either section A (Cardiopulmonary) or section B (neurological) is dead….a diagnosis of death requires that both cessation of functions and irreversibility…be demonstrated.” 16 July 2010 27 Guidelines for the Determination of Death JAMA 11/13/1981;246(19),2184-2186: Criteria : Guidelines for the Determination of Death JAMA 11/13/1981;246(19),2184-2186: Criteria “A. An individual with irreversible cessation of circulatory and respiratory functions is dead. 1. Cessation is recognized by an appropriate clinical examination….at least absence of responsiveness, heartbeat, and respiratory effort….may require the use of…ECG.” 2. Irreversibility is recognized by persistent cessation of functions during an appropriate period of observation and/or trial of therapy.” [duration of observation period dependent on whether is expected vs. unexpected, whether resuscitation attempted, or moment of possible death is witnessed or not] 16 July 2010 28 Guidelines for the Determination of Death JAMA 11/13/1981;246(19),2184-2186: Criteria : Guidelines for the Determination of Death JAMA 11/13/1981;246(19),2184-2186: Criteria “B. An individual with irreversible cessation of all functions of the entire brain, including the brain stem, is dead….” “1. Cessation is recognized when evaluation discloses findings of a and b: a. Cerebral functions are absent, and…” Deep coma (unreceptivity and unresponsivity) “Medical circumstances may require the use of confirmatory studies such as an EEG or blood-flow study.” [??Those circumstances not specified!] b. “Brainstem functions are absent” determined by testing pupillary light, corneal, oculocephalic, oculovestibular, oropharyngeal, and respiratory (apnea) reflexes; 16 July 2010 29 Guidelines for the Determination of Death JAMA 11/13/1981;246(19),2184-2186: Criteria : Guidelines for the Determination of Death JAMA 11/13/1981;246(19),2184-2186: Criteria “B. An individual with irreversible cessation of all functions of the entire brain, including the brain stem, is dead….” “1. Cessation is recognized when evaluation discloses findings of a and b: b. “Brainstem functions are absent” determined by testing pupillary light, corneal, oculocephalic, oculovestibular, oropharyngeal, and respiratory (apnea) reflexes; “When these reflexes cannot be adequately assessed, confirmatory tests are recommended.” Apnea testing specified: O2 ventilation x 10 minutes then w/d ventilator with passive flow of O2,, confirm pCO2=60 by ABG; “spontaneous breathing efforts indicate that part of the brain stem is functioning.” 16 July 2010 30 Guidelines for the Determination of Death JAMA 11/13/1981;246(19),2184-2186: Criteria : Guidelines for the Determination of Death JAMA 11/13/1981;246(19),2184-2186: Criteria “B. An individual with irreversible cessation of all functions of the entire brain, including the brain stem, is dead….” “1. Cessation is recognized when evaluation discloses findings of a and b: “Peripheral nervous system activity and spinal cord reflexes may persist after death. True decerebrate or decorticate posturing or seizures are inconsistent with the diagnosis of death.” 16 July 2010 31 Guidelines for the Determination of Death JAMA 11/13/1981;246(19),2184-2186: Criteria : Guidelines for the Determination of Death JAMA 11/13/1981;246(19),2184-2186: Criteria “B. An individual with irreversible cessation of all functions of the entire brain, including the brain stem, is dead….” “2. Irreversibility is recognized when evaluation discloses findings of a and b and c” or by absence of blood flow to the brain =10 minutes, shown by angiography : a. The cause of coma is established and is sufficient to account for the loss of brain functions, and… b. the possibility of recovery of any brain functions is excluded, and…” (i.e. rule out sedation, hypothermia <32.2°C core temp, neuromuscular blockade, and shock) “c. the cessation of all brain functions persists for an appropriate period of observation and/or trial or therapy” (6 hours; 12 hours if no confirmatory tests; 24 hours if anoxic injury) 16 July 2010 32 Practice parameters for determining brain death in adults: (summary statement) NEUROLOGY 1995;45:1012-1014: V. Medical record documentation (Standard) : Practice parameters for determining brain death in adults: (summary statement) NEUROLOGY 1995;45:1012-1014: V. Medical record documentation (Standard) A. Etiology and irreversibility of condition B. Absence of brainstem reflexes C. Absence of motor response to pain D. Absence of respiration with PCO2=60 mm Hg E. Justification for confirmatory test and result of confirmatory test F. Repeat neurologic examination Option: the interval is arbitrary, but a 6-hour period is reasonable 16 July 2010 33 Practice parameters for determining brain death in adults (summary statement) NEUROLOGY 1995;45:1012-1014 : Practice parameters for determining brain death in adults (summary statement) NEUROLOGY 1995;45:1012-1014 Report of the Quality Standards Subcommittee of the American Academy of Neurology Brain Death Definition: “the irreversible loss of function of the brain, including the brainstem.” Justification: “…need for standardization of the neurologic examination criteria for the diagnosis of brain death.” Process: based on review of literature 1976-1994; are GUIDELINES (class II evidence or strong consensus of class III evidence) Format: algorithm with precise definitions and precisely specified exam methods 16 July 2010 34 Practice parameters for determining brain death in adults: (summary statement) NEUROLOGY 1995;45:1012-1014: I. Diagnostic Criteria : Practice parameters for determining brain death in adults: (summary statement) NEUROLOGY 1995;45:1012-1014: I. Diagnostic Criteria A. “Prerequisites 1.Clinical or neuroimaging evidence of an acute CNS catastrophe that is compatible with the clinical diagnosis of brain death 2. Exclusion of complicating medical conditions” (electrolyte, acid-base, endocrine) “3.No drug intoxication or poisoning 4. Core temperature =32°C(90°F)” 16 July 2010 35 Practice parameters for determining brain death in adults: (summary statement) NEUROLOGY 1995;45:1012-1014: I. Diagnostic Criteria : Practice parameters for determining brain death in adults: (summary statement) NEUROLOGY 1995;45:1012-1014: I. Diagnostic Criteria B. Coma, lack of brainstem reflexes, and apnea 1.Coma or unresponsiveness… (defined specifically) 2. Absence of brainstem reflexes (defined specifically): Pupils Ocular movement Facial sensation and facial motor response Pharyngeal and tracheal reflexes 16 July 2010 36 Practice parameters for determining brain death in adults: (summary statement) NEUROLOGY 1995;45:1012-1014: I. Diagnostic Criteria : Practice parameters for determining brain death in adults: (summary statement) NEUROLOGY 1995;45:1012-1014: I. Diagnostic Criteria B. Coma, lack of brainstem reflexes, and apnea 3. Apnea: very specific description of apnea testing protocol e.g. core temp = 36.5°C; BP, volume, baseline PO2 and PCO2 16 July 2010 37 Slide 38: Apnea Test Generally, the apnea test is performed after the second examination of brainstem reflexes. The apnea test need only be performed once when its results are conclusive. Before performing the apnea test, the physician must determine that the patient meets the following conditions: • Core temperature = 36.5°C or 97.7°F • Euvolemia. Option: positive fluid balance in the previous 6 hours • Normal PCO2. Option: arterial PCO2 = 40 mm Hg • Normal PO2. Option: pre-oxygenation to arterial PO2 = 200 mm Hg After determining that the patient meets the prerequisites above, the physician should conduct the apnea test as follows: • Connect a pulse oximeter and disconnect the ventilator. • Deliver 100% O2, 6 l/min, into the trachea. Option: place a cannula at the level of the carina. 16 July 2010 38 Slide 39: • Look closely for respiratory movements (abdominal or chest excursions that produce adequate tidal volumes). • Measure arterial PO2, PCO2, and pH after approximately 8 minutes and reconnect the ventilator. • If respiratory movements are absent and arterial PCO2 is = 60 mm Hg (option: 20 mm Hg increase in PCO2 over a baseline normal PCO2), the apnea test result is positive (i.e. it supports the diagnosis of brain death). • If respiratory movements are observed, the apnea test result is negative (i.e. it does not support the clinical diagnosis of brain death). • Connect the ventilator if, during testing, the systolic blood pressure becomes < 90 mm Hg (or below age appropriate thresholds in children less than 18 years of age) or the pulse oximeter indicates significant oxygen desaturation, or cardiac arrhythmias develop;immediately draw an arterial blood sample and analyse arterial blood gas. If PCO2 is = 60 mm Hg or PCO2 increase is = 20 mm Hg over baseline normal PCO2, the apnea test result is positive (it supports the clinical diagnosis of brain death); if PCO2 is < 60 mm Hg and PCO2 increase is < 20 mm Hg over baseline normal PCO2, the result is indeterminate and a confirmatory test can be considered. 16 July 2010 39 Practice parameters for determining brain death in adults: (summary statement) NEUROLOGY 1995;45:1012-1014: II. Pitfalls in the diagnosis of brain death : Practice parameters for determining brain death in adults: (summary statement) NEUROLOGY 1995;45:1012-1014: II. Pitfalls in the diagnosis of brain death A. Severe facial trauma B. Preexisting pupillary abnormalities C. Toxic levels of any: sedatives, aminoglycosides, TCA’s, anticholinergic, AED’s, chemotherapeutic agents, or NM blocking agents D. Chronic CO2 retention 16 July 2010 40 Practice parameters for determining brain death in adults: (summary statement) NEUROLOGY 1995;45:1012-1014: III. Clinical observations compatible with the diagnosis of brain death : Practice parameters for determining brain death in adults: (summary statement) NEUROLOGY 1995;45:1012-1014: III. Clinical observations compatible with the diagnosis of brain death A. Spontaneous movements B. Respiratory-like movements C. Sweating, blushing, tachycardia D. Normal BP without pressors E. Absence of diabetes insipidus F. DTR’s, superficial abdominal reflexes, triple flexion response G. Babinski reflex 16 July 2010 41 Practice parameters for determining brain death in adults: (summary statement) NEUROLOGY 1995;45:1012-1014: IV. Confirmatory laboratory tests (Options) : Practice parameters for determining brain death in adults: (summary statement) NEUROLOGY 1995;45:1012-1014: IV. Confirmatory laboratory tests (Options) “Brain death is a clinical diagnosis. A repeat clinical evaluation 6 hours later is recommended, but this interval is arbitrary. A confirmatory test is not mandatory but is desirable in patients in whom specific components of clinical testing cannot be reliably performed or evaluated….most sensitive test [is listed] first: 16 July 2010 42 Practice parameters for determining brain death in adults: (summary statement) NEUROLOGY 1995;45:1012-1014: IV. Confirmatory laboratory tests (Options)(specific criteria described for all) : Practice parameters for determining brain death in adults: (summary statement) NEUROLOGY 1995;45:1012-1014: IV. Confirmatory laboratory tests (Options)(specific criteria described for all) A. Conventional Angiography B. EEG: no electrical activity over =30’ C. Transcranial Doppler U/S D. Technetium-99m HMPA brain scan E. Somatosensory evoked potentials 16 July 2010 43 Slide 44: • Fifty-six consecutive patients clinically diagnosed as brain dead were seen at Loyola University Medical Centre, May-wood, III, from January 1984 through May 1986. Eleven (19.6%) of the 56 patients had (EEG) activity following the diagnosis of brain death. The mean duration of the observed EEG activity was 36.6 hours (range, two to 168 hours). Three patterns of EEG activity were observed: (1) low-voltage (4 to 20 µV) theta or beta activity was recorded in nine (16.1%) patients as long as 72 hours following brain death. Neuropathologic studies in one patient showed hypoxicischemic neuronal changes involving all cell layers of the cerebral cortex, basal ganglia, brain stem, and cerebellum; (2) sleep-like activity (a mixture of synchronous 30 to 40 µV theta and delta activity and 60 to 80 µV, 10 to 12 Hz spindle-like potentials) was noted in two (3.6%) patients for as long as 168 hours following brain death. Pathologic studies in both cases demonstrated ischemic necrosis of the brain stem with relative preservation of the cerebral cortex; and 16 July 2010 44 Slide 45: (3) alpha-like activity (monotonous, unreactive, anteriorly predominant, 25 to 40 µV, 9 to 12 Hz activity) was observed in one (1.8%) patient three hours following brain death. Regardless of activity on the EEG, none of the patients recovered. The occurrence of EEG activity following brain death would suggest reliance on the EEG to confirm brain death may be unwarranted. The use of the EEG as a confirmatory test of brain death may be of questionable value. 16 July 2010 45 Slide 46: EEG and brain death determination in children L. A. Alvarez, MD, S. L. Moshé, MD, A. L. Belman, MD, J. Maytal, MD, T. J. Resnick, MD and M. Keilson, MD In a retrospective study involving several medical centers we identified 52 patients under age 5 years who met the adult clinical criteria for brain death and had at least one EEG with electrocerebral silence. Of the 52 patients, 31 died spontaneously and 21 were disconnected from the respirator. Repeat EEGs were obtained in 28 patients, and in all electrocerebral silence persisted. The study suggests that clinical criteria similar to those used for adults in the determination of brain death can also be applied to children above age 3 months and that a single EEG with electrocerebral silence is sufficient to confirm brain death in this age group. 16 July 2010 46 Slide 47: 16 July 2010 47 The image in patients with brain death shows a clear-cut ‘hollow-skull sign’, which is tantamount to a ‘functional decapitation’. This is markedly different from the situation seen in patients in a vegetative state, in whom cerebral metabolism is massively and globally decreased (to 50% of normal value) but not absent. The colour scale shows the amount of glucose metabolized per 100 g of brain tissue per minute. NATUREREVIEWS Neuroscience, Volume 6, November 2005, 903 What is euthanasia? : What is euthanasia? “Euthanasia” literally means “a gentle, easy death.” 16 July 2010 48 1973 Policy Statement of American Medical Association (AMA; Steinbock, 155) : 1973 Policy Statement of American Medical Association (AMA; Steinbock, 155) The intentional termination of the life of one human being by another—mercy killing—is contrary to that for which the medical profession stands and is contrary to the policy of the American Medical Association. . . . 16 July 2010 49 The Changing Medical Situation : The Changing Medical Situation Until the 1940’s, medical care was often just comfort care, alleviating pain when possible During the last 50+ years, medicine has become increasingly capable of postponing death Increasingly, we are forced to choose whether to allow ourselves to die. 16 July 2010 50 What are we striving for? : What are we striving for? Euthanasia means “a good death,” “dying well.” What is a good death? Peaceful Painless Lucid With loved ones gathered around 16 July 2010 51 The Independence of the Distinctions: Euthanasia : The Independence of the Distinctions: Euthanasia 16 July 2010 52 1973 AMA Policy Statement (cont’d.) : 1973 AMA Policy Statement (cont’d.) The cessation of the employment of extraordinary means to prolong the life of the body when there is irrefutable evidence that biological death is imminent is the decision of the patient and/or his immediate family. The advice and judgment of the physician should be freely available to the patient and/or his immediate family. 16 July 2010 53 Slide 54: What to do? DNR Orders Increased dosages of pain-killers such as morphine Advance Directives 1991 Patient Self-Determination Act requires health-care providers to offer written information about “living wills” About 15% of patients sign a living will 16 July 2010 54 Active Euthanasia : Active Euthanasia Typical case for active euthanasia there is no doubt that the patient will die soon the option of passive euthanasia causes significantly more pain for the patient (and often the family as well) than active euthanasia and does nothing to enhance the remaining life of the patient, and passive measures will not bring about the death of the patient. 16 July 2010 55 Compassion for Suffering : Compassion for Suffering The larger question in many of these situations is: how do we respond to suffering? Hospice and palliative care Aggressive pain-killing medications Sitting with the dying Euthanasia 16 July 2010 56 The Right to Die : The Right to Die Do we have a right to die? Negative right (others may not interfere) Positive right (others must help) Do we own our own bodies and our lives? If we do own our own bodies, does that give us the right to do whatever we want with them? Isn’t it cruel to let people suffer pointlessly? 16 July 2010 57 The Slippery Slope : The Slippery Slope Worrisome examples from history: Nazi eugenics program California eugenics program Chinese orphanages Special danger to undervalued groups in our society The elderly Minorities Persons with disabilities Groups that are typically discriminated against 16 July 2010 58 How much care should be given at the end of life? : How much care should be given at the end of life? Health care providers are increasingly concerned, not just about how much money is spent on patients, but about how effectively it is spent. Disproportionate amount of money spent in final months of life. 40 percent of Medicare dollars cover care for people in the last month. Nearly one third of terminally ill patients with insurance used up most or all of their savings to cover uninsured medical expenses such as home care. Concept of medical futility is utilitarian in character. 16 July 2010 59 The Kantian Model : The Kantian Model Central insight: people cannot be treated like mere things. Key notions: Autonomy & Dignity Respect Rights 16 July 2010 60 Conclusion : Conclusion Many of the ethical disagreements about end-of-life decisions can be seen as resulting from differing ethical frameworks, esp. Kantian vs. utilitarian. Use these models to understand where you stand, where your patients stand, and where your organization stands in regard to end-of-life issues. 16 July 2010 61 Disciplines Considering End-of-Life Issues : Disciplines Considering End-of-Life Issues Philosophy Religious Studies & Theology Literature Psychology Sociology Biology Economics Political Science Media Studies Medicine Art Theater 16 July 2010 62 End-of-Life Decisions : End-of-Life Decisions Until recently, end-of-life decisions for most people were easy: You tried to stay alive as long as you could, and then you just died. Today, we are lucky if we are able to “just die.” In most cases, difficult decisions have to be made about when to stop medical treatment. 16 July 2010 63 The Biology of Aging and Dying : The Biology of Aging and Dying Biologists and researchers in related fields are continually probing into questions central to our understanding of the biological dimensions of aging and dying, including: Can the aging process be slowed down? On the biology of dying, see Sherwin Nuland’s How We Die. 16 July 2010 64 Psychology : Psychology The psychological dimensions of end-of-life decisions Classic source: Elizabeth Kübler-Ross, On Death and Dying Stage 1- Shock and denial Stage 2- Anger Stage 3- Bargaining Stage 4- Depression Stage 5- Acceptance Typically no clear demarcation b/w stages and some may occur in different order 16 July 2010 65 Art : Art Throughout the ages, we have sought to understand death through art. 16 July 2010 66 Art : Art Throughout the ages, we have sought to understand death through art. Dürer, “The Four Horsemen of the Apocalypse” 16 July 2010 67 Art--2 : Art--2 16 July 2010 68 Jack KevorkianNearer My God to Thee Music : Music Whether through requiems or ragas, we have always expressed our feelings about death and end-of-life decisions through music. Mahler’s Kindestotenlieder 16 July 2010 69 Literature : Literature Leo Tolstoy, “The Death of Ivan Illych” See The Oxford Book of Deathby D. J. Enright 16 July 2010 70 Slide 71: ARGUMENTS AGAINST EUTANASIA 16 July 2010 71 1: Some terminally ill people recover and get well.2: Doctors make mistakes in medical care.3:Assisted suicide laws give societal approval to suicide. 4:No one, not even incapacitated people, needs assisted suicide. 5: You already have control over your final illness. : 1: Some terminally ill people recover and get well.2: Doctors make mistakes in medical care.3:Assisted suicide laws give societal approval to suicide. 4:No one, not even incapacitated people, needs assisted suicide. 5: You already have control over your final illness. 16 July 2010 72 6: We can come up with better ways of helping the dying besides assisted suicide..7 : Assisted suicide laws give more power to the government, not the individual.8 : Assisted suicide laws removes incentive to do medical research. : 6: We can come up with better ways of helping the dying besides assisted suicide..7 : Assisted suicide laws give more power to the government, not the individual.8 : Assisted suicide laws removes incentive to do medical research. 16 July 2010 73 9 : Big financial interests are often behind assisted suicide laws.10 : Christopher Reeve considered assisted suicide.11 : Assisted suicide laws put poor people at risk.12 : Suicide interrupts a natural path to wisdom.13 : The first Nazi victims were terminally ill people. : 9 : Big financial interests are often behind assisted suicide laws.10 : Christopher Reeve considered assisted suicide.11 : Assisted suicide laws put poor people at risk.12 : Suicide interrupts a natural path to wisdom.13 : The first Nazi victims were terminally ill people. 16 July 2010 74 14 : Dying people can be treated for depression.15 : Insurance companies love assisted suicide.16 : Skilled hospice caregivers can control physical pain.17 : All humans have dignity, even the sick and dying.18 : Suicidal people have a diminished capacity to make the decision to end their lives. : 14 : Dying people can be treated for depression.15 : Insurance companies love assisted suicide.16 : Skilled hospice caregivers can control physical pain.17 : All humans have dignity, even the sick and dying.18 : Suicidal people have a diminished capacity to make the decision to end their lives. 16 July 2010 75 19 : Assisted suicide makes doctors accessories of fact to homicide.20 : Assisted suicide creates a world without love. : 19 : Assisted suicide makes doctors accessories of fact to homicide.20 : Assisted suicide creates a world without love. 16 July 2010 76 Slide 77: 16 July 2010 77 Patented and marketed by Count Karnice-Karnicki, chamberlain to the Tsar of Russia, in 1896. The apparatus allowed the buried to signal that he or she was still alive by activating a flag and ringing a bell. It could be rented for a small amount of money and, after a length of time, when there was no chance of revival, the tube could be pulled up and used in another coffin. Slide 78: The current legal position on euthanasia and assisted suicide in India In India, euthanasia is undoubtedly illegal. Since in cases of euthanasia or mercy killing there is an intention on the part of the doctor to kill the patient, such cases would clearly fall under clause first of Section 300 of the Indian Penal Code, 1860. However, as in such cases there is the valid consent of the deceased Exception 5 to the said Section would be attracted and the doctor or mercy killer would be punishable under Section 304 for culpable homicide not amounting to murder. Cases of non-voluntary and involuntary euthanasia would be struck by proviso one to Section 92 of the IPC and thus be rendered illegal. Euthanasia and suicide are different, distinguishing euthanasia from suicide, Lodha J. in Naresh Marotrao Sakhre v. Union of India, observed: 16 July 2010 78 Slide 79: “Suicide by its very nature is an act of self-killing or self-destruction, an act of terminating one’s own act and without the aid or assistance of any other human agency. Euthanasia or mercy killing on the other hand means and implies the intervention of other human agency to end the life. Mercy killing thus is not suicide and an attempt at mercy killing is not covered by the provisions of Section 309. The two concepts are both factually and legally distinct. Euthanasia or mercy killing is nothing but homicide whatever the circumstances in which it is effected.” 16 July 2010 79 Slide 80: The law in India is also very clear on the aspect of assisted suicide. Abetment of suicide is an offence expressly punishable under Sections 305 and 306 of the IPC. Moreover, after the decision of a five judge bench of the Supreme Court in Gian Kaur v. State of Punjab it is well settled that the “right to life” guaranteed by Article 21 of the Constitution does not include the “right to die”. The Court held that Article 21 is a provision guaranteeing “protection of life and personal liberty” and by no stretch of the imagination can extinction of life be read into it. 16 July 2010 80 Slide 81: Gandhiji observed ,in NAVJIVAN, in 1929 "Would I apply to human beings the principle that I have enunciated in connection with the calf? Would I like it to be applied in my own case? My reply is yes. Just as a surgeon does not commit himsa when he wields his knife on his patient's body for the latter's benefit, similarly one may find it necessary under certain imperative circumstances to go a step further and sever life from the body in the interest of the sufferer". 16 July 2010 81 Regulations in the world : Regulations in the world Euthanasia is legalized in Netherlands (2002), Belgium, Luxembourg (including sick children), Albania, Japan and the U.S. states Texas and Oregon And until recently also in Australia Northern Territory (which is however overruled later, due to federal nature of the subject). Special form of euthanasia is allowed in Switzerland Where one can prescribe a lethal dose of sleeping pills, but the patient must accept it yourself. In other countries, euthanasia is not allowed and punishable as murder or simpler punishments 16 July 2010 82 Euthanasia in the Netherlands : Euthanasia in the Netherlands The Dutch law allows euthanasia only if all are met the following conditions: patient's suffering is unbearable with no prospect of improvement in the status of the patient request by the patient euthanasia must be voluntary and should be kept to a predetermined time, can not be met if the person is under the influence of drugs, suffering from a mental illness or have been influenced by other people the patient must be fully aware of their health status, prognosis and asserting their rights 16 July 2010 83 Euthanasia in the Netherlands : Euthanasia in the Netherlands to be consulted with at least one independent doctor, who must confirm the patient's health status and conditions referred to above Euthanasia must be carried out in a medically appropriate way by the doctor or patient in the presence of a physician you must be at least 12 years (patients aged 12 to 16 years old must obtain parental consent) Dutch legislation recognizes the validity of the will of the patient's written statement. Such declaration may be used when the patient will be in a coma or in another state, which makes it impossible to agree to euthanasia. 16 July 2010 84 Euthanasia in Luxembourg : Euthanasia in Luxembourg In Luxembourg February 20 2008 Luxembourg, the Parliament adopted by a majority of 30 of the 59 votes in a law legalizing shortening life seriously ill persons upon request. It entered into force after the second ballot in March 2009 . The bill was strongly criticized by the Catholic Church (which have a large impact on society Luxembourg), most of the medical and the ruling Christian Social Party. According to the draft decision on euthanasia can only be taken provided that the patient is seriously and terminally ill. Decide on euthanasia can be taken include writing down a will 16 July 2010 85 Euthanasia in Belgium : Euthanasia in Belgium The Belgian parliament Belgium passed a law legalizing euthanasia in September 2002 year. 16 July 2010 86 Euthanasia in Albania : Euthanasia in Albania Albania was the first country Europe that legalized euthanasia - has been the case in 1999 year under amendments to the Law on the Rights of the terminally ill. It legalizes any form of active euthanasia, with the consent of the patient. Passive euthanasia is permissible with the consent of three members of the family of the sick person. 16 July 2010 87 Slide 88: RELIGION AND EUTHANASIA 16 July 2010 88 Hinduism : Hinduism Euthanasia is seen as the death of the elected and approved as an escape from attachment to the self that suffers (e.g. due to old age) makes it possible to free oneself from uncomfortable forms of life and move to the next life (reincarnation). Those who take the decision of suicide, and those make euthanasia, should be freed from the evil intentions, passions and selfishness. 16 July 2010 89 Judaism : Judaism Jewish the right to reject any measures that seek to reduce human life. Nevertheless, discussing over a few exceptions, for example when people are terminally ill and thus can be euthanized to prevent excessive suffering. Midrash refers to the story of King Saul, who threw himself on his sword to avoid torture. Modern rabbinical authorities permit the administration of palliatives of pain, although significantly shorten the life terminally ill. However, prohibit injection whether the administration of the measures to accelerate death. Likewise, reject medical interventions that artificially extend life. 16 July 2010 90 Christianity : Christianity Ethics Catholic rejects direct euthanasia . Similar considerations are taken under the ethics Orthodox and Protestant. 16 July 2010 91 Islam : Islam First International Conference on Medicine Muslim (Kuwait, 1981) were condemned suicide and euthanasia. The meeting also voted for the resignation of the method used to artificially prolonging life. 16 July 2010 92 Buddhism : Buddhism Buddhism does not approve of euthanasia due to its doctrine of karma nor from a psychological perspective. Bad Karman That determines human suffering (patient), it should take so long until he is exhausted and no longer affect the subsequent birth. If we stop suffering, start afresh in the next incarnation, until exhaustion. If, however, eliminate suffering as a result of bad, negative karma You can be reborn again in a better existence. Buddhist psychology comes from the fact that the death of the preset is filled with compassion, hatred and negative feelings for the suffering patient. Even if the primary motive is to relieve temporary suffering, a good intention turns into action when the decision marked aversion. Although the doctor believes that kill out of compassion, but in fact work with the aversion to suffering. Thus, he raises for himself and for his patient's negative karmic energy. 16 July 2010 93 Buddhism : Buddhism Buddhist doctors also discuss about the exact moment of death, i.e. when you turn off the apparatus, which is only artificially prolongs life, whereas it is necessary to other patients. It is very important in this context prana (washed - Breath of life). It appears already in the Upanishads, and means "life force" of man, inherent in the heart. When you disappear, the doctor must abandon its efforts. 16 July 2010 94 Slide 95: Question 1: if your loved one is in intense pain, will you do it ???? Question 2 : should you do it ????? Question 3 : if yes, how? If no, then how will you alleviate his/her suffering ? 16 July 2010 95 Slide 96: Thank you 16 July 2010 96 Slide 97: References : www. British medical journal Newspapers (the Hindu , the times of India ) Harvard medical review Springerlink Journal of American academy of neurology. 16 July 2010 97 You do not have the permission to view this presentation. In order to view it, please contact the author of the presentation.
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Euthanasia : Euthanasia Euthanasia (or euthanazja From game. e??a?as?a, euthanasia - "Good death") - the task of the death of terminally ill person motivated by shortening its suffering. 16 July 2010 2 Slide 3: Euthanasia (from the Greek e??a?as?a meaning "good death": e?-, eu- (well or good) + ???at??, thanatos (death)) refers to the practice of ending a life in a manner which relieves pain and suffering. According to the House of Lords Select Committee on Medical Ethics, the precise definition of euthanasia is "a deliberate intervention undertaken with the express intention of ending a life, to relieve intractable suffering."[1] 16 July 2010 3 The etymology of the term : The etymology of the term The concept of "euthanasia" for the first time appeared likely to Fifth century BC in comedy Cratinus of undetermined title. Described it this way "a person having a good death" without explaining the term. Once again, this concept has been used at the end The fourth century BC by another Greek poet -- Meander. The second meaning given the term "euthanatos"Define" easy death "which is having the effect of distance to their own lives. 16 July 2010 4 The etymology of the term : The etymology of the term Also in culture Ancient Rome the term "euthanasia" was present. Suetonius in Lives of the Caesars, Has a description of his death Octavian Augustus Who wanted to die peacefully, painlessly, quickly and above all, consciously, so as to be able to organize his affairs as he got. 16 July 2010 5 Definition of Euthanasia : Definition of Euthanasia The intentional killing by act or omission of a dependent human being for his or her alleged benefit. The key word here is "intentional". If death is not intended, it is not an act of euthanasia. 16 July 2010 6 Definitions : Definitions Voluntary euthanasia: When the person who is killed has requested to be killed. . 16 July 2010 7 Definitions : Definitions Non-voluntary euthanasia: When the person who is killed made no request and gave no consent. 16 July 2010 8 Definitions : Definitions Involuntary euthanasia: When the person who is killed made an expressed wish to the contrary. 16 July 2010 9 Definitions : Definitions Assisted suicide: Someone provides an individual with the information, guidance, and means to take his or her own life with the intention that they will be used for this purpose. 16 July 2010 10 Definitions : Definitions Physician Assisted Suicide: When it is a doctor who helps another person to kill themselves. 16 July 2010 11 Definitions : Definitions Euthanasia By Action: Intentionally causing a person's death by performing an action such as by giving a lethal injection. 16 July 2010 12 Definitions : Definitions Euthanasia By Omission: Intentionally causing death by not providing necessary and ordinary (usual and customary) care or food and water. 16 July 2010 13 What Euthanasia is NOT : What Euthanasia is NOT There is no euthanasia unless the death is intentionally caused by what was done or not done. Thus, some medical actions that are often labeled "passive euthanasia" are no form of euthanasia, since the intention to take life is lacking. 16 July 2010 14 These are NOT euthanasia: : These are NOT euthanasia: Not commencing treatment that would not provide a benefit to the patient. Withdrawing treatment that has been shown to be ineffective, too burdensome or is unwanted. The giving of high doses of pain-killers that may endanger life, when they have been shown to be necessary. 16 July 2010 15 Slide 16: WHY THE QUESTION OF EUTHANASIA ARISES ? 16 July 2010 16 Slide 17: BRAIN DEATH 16 July 2010 17 “Harvard Criteria”Report of the Ad Hoc Committee of the Harvard Medical School to Examine the Definition of Brain Death. A definition of irreversible coma. JAMA 1968;205:337-340 : “Harvard Criteria”Report of the Ad Hoc Committee of the Harvard Medical School to Examine the Definition of Brain Death. A definition of irreversible coma. JAMA 1968;205:337-340 Driving forces: advances in care mechanical ventilation and ICU’s Organ transplantation: cadaver (non-heart-beating) donors but some surgeons harvesting from patients with neurologic catastrophes: patients died after transplantation Many surgeons uncomfortable with this but “live donors” improved transplant outcomes When has irreversible loss of full brain function occurred? --premise: not idea that brain, therefore person, is dead; rather: coma irreversible and care futile 16 July 2010 18 Harvard CriteriaReport of the Ad Hoc Committee of the Harvard Medical School to Examine the Definition of Brain Death. A definition of irreversible coma. JAMA 1968;205:337-340 : Harvard CriteriaReport of the Ad Hoc Committee of the Harvard Medical School to Examine the Definition of Brain Death. A definition of irreversible coma. JAMA 1968;205:337-340 Purpose: “…to define irreversible coma as a new criterion for death.” “There are two reasons why there is need for a definition: 1) improvements in resuscitative and supportive measures…sometimes…only partial success…result is an individual whose heart continues to beat but whose brain is irreversibly damaged. The burden is great on patients who suffer permanent loss of intellect, on their families, on the hospitals, and those in need of hospital beds already occupied by those comatose patients.” 16 July 2010 19 Harvard CriteriaReport of the Ad Hoc Committee of the Harvard Medical School to Examine the Definition of Brain Death. A definition of irreversible coma. JAMA 1968;205:337-340 : Harvard CriteriaReport of the Ad Hoc Committee of the Harvard Medical School to Examine the Definition of Brain Death. A definition of irreversible coma. JAMA 1968;205:337-340 Note: presented in narrative rather than algorithmic form; stricter than ever before, but not strict enough (e.g. EEG duration criteria) Purpose: “…to define irreversible coma as a new criterion for death.” “There are two reasons why there is need for a definition: 2) Obsolete criteria for the definition of death can lead to controversy in obtaining organs for transplantation.” 16 July 2010 20 Harvard CriteriaReport of the Ad Hoc Committee of the Harvard Medical School to Examine the Definition of Brain Death. A definition of irreversible coma. JAMA 1968;205:337-340 : Harvard CriteriaReport of the Ad Hoc Committee of the Harvard Medical School to Examine the Definition of Brain Death. A definition of irreversible coma. JAMA 1968;205:337-340 “An organ, brain or other, that no longer functions and has no possibility of functioning again is for all practical purposes dead.” A. determine presence of “a permanently nonfunctioning brain.” 1. Unreceptivity and Unresponsitivity: “total unawareness to externally applied stimuli…even the most intensely painful stimuli evoke no vocal or other response, not even a groan, withdrawal of a limb, or quickening of respiration.” 2. No Movements or Breathing: no spontaneous movements or spontaneous respiration (turn off respirator for 3 minutes; prior to trial breathing room air for =10 minutes and pCO2 normal) or response to pain, touch, sound or light for an hour. 16 July 2010 21 Harvard CriteriaReport of the Ad Hoc Committee of the Harvard Medical School to Examine the Definition of Brain Death. A definition of irreversible coma. JAMA 1968;205:337-340 : Harvard CriteriaReport of the Ad Hoc Committee of the Harvard Medical School to Examine the Definition of Brain Death. A definition of irreversible coma. JAMA 1968;205:337-340 A. determine presence of “a permanently nonfunctioning brain.” 3. No reflexes: pupils fixed, dilated and absence of: Pupillary response to bright light ocular movement to head turning and ice water irrigation of ears blinking postural activity (decerebrate or other) Swallowing, yawning, vocalization Corneal reflexes Pharyngeal reflexes Deep tendon reflexes Response to plantar or noxious stimuli 16 July 2010 22 Harvard CriteriaReport of the Ad Hoc Committee of the Harvard Medical School to Examine the Definition of Brain Death. A definition of irreversible coma. JAMA 1968;205:337-340 : Harvard CriteriaReport of the Ad Hoc Committee of the Harvard Medical School to Examine the Definition of Brain Death. A definition of irreversible coma. JAMA 1968;205:337-340 B. confirmatory data 4. isoelectric EEG (specifies technique; have EKG and noncephalic leads to r/o confounders “At least 10 full minutes of recording are desirable, but twice that would be better.” [!]) EEG: “when available it should be utilized” If EEG unavailable, “the absence of cerebral function has to be determined by purely clinical signs…or by absence of circulation as judged by standstill of blood in the retinal vessels, or by absence of cardiac activity.” A and B all need to be repeated 24 hours later with no ? AND in the absence of hypothermia (<90°F [32.2°C]) or CNS depressants, such as barbiturates, and determined only by a physician 16 July 2010 23 Harvard CriteriaReport of the Ad Hoc Committee of the Harvard Medical School to Examine the Definition of Brain Death. A definition of irreversible coma. JAMA 1968;205:337-340 : Harvard CriteriaReport of the Ad Hoc Committee of the Harvard Medical School to Examine the Definition of Brain Death. A definition of irreversible coma. JAMA 1968;205:337-340 If criteria are met, “Death is to be declared and then the respirator turned off. The decision to do this and the responsibility for it are to be taken by the physician-in-charge, in consultation with one or more physicians who have been directly involved in the case. It is unsound and undesirable to force the family to make the decision.” 16 July 2010 24 Guidelines for the Determination of Death JAMA 11/13/1981;246(19),2184-2186 : Guidelines for the Determination of Death JAMA 11/13/1981;246(19),2184-2186 Report of the Medical Consultants on the Diagnosis of Death to the President’s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research Developed as an aid to implementation of the proposed “Uniform Determination of Death Act” (endorsed by: ABA, AMA, Nat’l Conference of Commissioners on Uniform State Laws, President’s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research, AAN, AES 16 July 2010 25 Guidelines for the Determination of Death JAMA 11/13/1981;246(19),2184-2186 : Guidelines for the Determination of Death JAMA 11/13/1981;246(19),2184-2186 “Uniform Determination of Death Act” “An individual who has sustained either (1) irreversible cessation of circulatory and respiratory functions, or (2) irreversible cessation of all functions of the entire brain, including the brain stem, is dead. A determination of death must be made in accordance with accepted medical standards.” 16 July 2010 26 Guidelines for the Determination of Death JAMA 11/13/1981;246(19),2184-2186: Criteria : Guidelines for the Determination of Death JAMA 11/13/1981;246(19),2184-2186: Criteria Note: presented in somewhat narrative and somewhat algorithmic form; improvement from Harvard criteria but still room for interpretation of what to do and when. “An individual presenting the findings in either section A (Cardiopulmonary) or section B (neurological) is dead….a diagnosis of death requires that both cessation of functions and irreversibility…be demonstrated.” 16 July 2010 27 Guidelines for the Determination of Death JAMA 11/13/1981;246(19),2184-2186: Criteria : Guidelines for the Determination of Death JAMA 11/13/1981;246(19),2184-2186: Criteria “A. An individual with irreversible cessation of circulatory and respiratory functions is dead. 1. Cessation is recognized by an appropriate clinical examination….at least absence of responsiveness, heartbeat, and respiratory effort….may require the use of…ECG.” 2. Irreversibility is recognized by persistent cessation of functions during an appropriate period of observation and/or trial of therapy.” [duration of observation period dependent on whether is expected vs. unexpected, whether resuscitation attempted, or moment of possible death is witnessed or not] 16 July 2010 28 Guidelines for the Determination of Death JAMA 11/13/1981;246(19),2184-2186: Criteria : Guidelines for the Determination of Death JAMA 11/13/1981;246(19),2184-2186: Criteria “B. An individual with irreversible cessation of all functions of the entire brain, including the brain stem, is dead….” “1. Cessation is recognized when evaluation discloses findings of a and b: a. Cerebral functions are absent, and…” Deep coma (unreceptivity and unresponsivity) “Medical circumstances may require the use of confirmatory studies such as an EEG or blood-flow study.” [??Those circumstances not specified!] b. “Brainstem functions are absent” determined by testing pupillary light, corneal, oculocephalic, oculovestibular, oropharyngeal, and respiratory (apnea) reflexes; 16 July 2010 29 Guidelines for the Determination of Death JAMA 11/13/1981;246(19),2184-2186: Criteria : Guidelines for the Determination of Death JAMA 11/13/1981;246(19),2184-2186: Criteria “B. An individual with irreversible cessation of all functions of the entire brain, including the brain stem, is dead….” “1. Cessation is recognized when evaluation discloses findings of a and b: b. “Brainstem functions are absent” determined by testing pupillary light, corneal, oculocephalic, oculovestibular, oropharyngeal, and respiratory (apnea) reflexes; “When these reflexes cannot be adequately assessed, confirmatory tests are recommended.” Apnea testing specified: O2 ventilation x 10 minutes then w/d ventilator with passive flow of O2,, confirm pCO2=60 by ABG; “spontaneous breathing efforts indicate that part of the brain stem is functioning.” 16 July 2010 30 Guidelines for the Determination of Death JAMA 11/13/1981;246(19),2184-2186: Criteria : Guidelines for the Determination of Death JAMA 11/13/1981;246(19),2184-2186: Criteria “B. An individual with irreversible cessation of all functions of the entire brain, including the brain stem, is dead….” “1. Cessation is recognized when evaluation discloses findings of a and b: “Peripheral nervous system activity and spinal cord reflexes may persist after death. True decerebrate or decorticate posturing or seizures are inconsistent with the diagnosis of death.” 16 July 2010 31 Guidelines for the Determination of Death JAMA 11/13/1981;246(19),2184-2186: Criteria : Guidelines for the Determination of Death JAMA 11/13/1981;246(19),2184-2186: Criteria “B. An individual with irreversible cessation of all functions of the entire brain, including the brain stem, is dead….” “2. Irreversibility is recognized when evaluation discloses findings of a and b and c” or by absence of blood flow to the brain =10 minutes, shown by angiography : a. The cause of coma is established and is sufficient to account for the loss of brain functions, and… b. the possibility of recovery of any brain functions is excluded, and…” (i.e. rule out sedation, hypothermia <32.2°C core temp, neuromuscular blockade, and shock) “c. the cessation of all brain functions persists for an appropriate period of observation and/or trial or therapy” (6 hours; 12 hours if no confirmatory tests; 24 hours if anoxic injury) 16 July 2010 32 Practice parameters for determining brain death in adults: (summary statement) NEUROLOGY 1995;45:1012-1014: V. Medical record documentation (Standard) : Practice parameters for determining brain death in adults: (summary statement) NEUROLOGY 1995;45:1012-1014: V. Medical record documentation (Standard) A. Etiology and irreversibility of condition B. Absence of brainstem reflexes C. Absence of motor response to pain D. Absence of respiration with PCO2=60 mm Hg E. Justification for confirmatory test and result of confirmatory test F. Repeat neurologic examination Option: the interval is arbitrary, but a 6-hour period is reasonable 16 July 2010 33 Practice parameters for determining brain death in adults (summary statement) NEUROLOGY 1995;45:1012-1014 : Practice parameters for determining brain death in adults (summary statement) NEUROLOGY 1995;45:1012-1014 Report of the Quality Standards Subcommittee of the American Academy of Neurology Brain Death Definition: “the irreversible loss of function of the brain, including the brainstem.” Justification: “…need for standardization of the neurologic examination criteria for the diagnosis of brain death.” Process: based on review of literature 1976-1994; are GUIDELINES (class II evidence or strong consensus of class III evidence) Format: algorithm with precise definitions and precisely specified exam methods 16 July 2010 34 Practice parameters for determining brain death in adults: (summary statement) NEUROLOGY 1995;45:1012-1014: I. Diagnostic Criteria : Practice parameters for determining brain death in adults: (summary statement) NEUROLOGY 1995;45:1012-1014: I. Diagnostic Criteria A. “Prerequisites 1.Clinical or neuroimaging evidence of an acute CNS catastrophe that is compatible with the clinical diagnosis of brain death 2. Exclusion of complicating medical conditions” (electrolyte, acid-base, endocrine) “3.No drug intoxication or poisoning 4. Core temperature =32°C(90°F)” 16 July 2010 35 Practice parameters for determining brain death in adults: (summary statement) NEUROLOGY 1995;45:1012-1014: I. Diagnostic Criteria : Practice parameters for determining brain death in adults: (summary statement) NEUROLOGY 1995;45:1012-1014: I. Diagnostic Criteria B. Coma, lack of brainstem reflexes, and apnea 1.Coma or unresponsiveness… (defined specifically) 2. Absence of brainstem reflexes (defined specifically): Pupils Ocular movement Facial sensation and facial motor response Pharyngeal and tracheal reflexes 16 July 2010 36 Practice parameters for determining brain death in adults: (summary statement) NEUROLOGY 1995;45:1012-1014: I. Diagnostic Criteria : Practice parameters for determining brain death in adults: (summary statement) NEUROLOGY 1995;45:1012-1014: I. Diagnostic Criteria B. Coma, lack of brainstem reflexes, and apnea 3. Apnea: very specific description of apnea testing protocol e.g. core temp = 36.5°C; BP, volume, baseline PO2 and PCO2 16 July 2010 37 Slide 38: Apnea Test Generally, the apnea test is performed after the second examination of brainstem reflexes. The apnea test need only be performed once when its results are conclusive. Before performing the apnea test, the physician must determine that the patient meets the following conditions: • Core temperature = 36.5°C or 97.7°F • Euvolemia. Option: positive fluid balance in the previous 6 hours • Normal PCO2. Option: arterial PCO2 = 40 mm Hg • Normal PO2. Option: pre-oxygenation to arterial PO2 = 200 mm Hg After determining that the patient meets the prerequisites above, the physician should conduct the apnea test as follows: • Connect a pulse oximeter and disconnect the ventilator. • Deliver 100% O2, 6 l/min, into the trachea. Option: place a cannula at the level of the carina. 16 July 2010 38 Slide 39: • Look closely for respiratory movements (abdominal or chest excursions that produce adequate tidal volumes). • Measure arterial PO2, PCO2, and pH after approximately 8 minutes and reconnect the ventilator. • If respiratory movements are absent and arterial PCO2 is = 60 mm Hg (option: 20 mm Hg increase in PCO2 over a baseline normal PCO2), the apnea test result is positive (i.e. it supports the diagnosis of brain death). • If respiratory movements are observed, the apnea test result is negative (i.e. it does not support the clinical diagnosis of brain death). • Connect the ventilator if, during testing, the systolic blood pressure becomes < 90 mm Hg (or below age appropriate thresholds in children less than 18 years of age) or the pulse oximeter indicates significant oxygen desaturation, or cardiac arrhythmias develop;immediately draw an arterial blood sample and analyse arterial blood gas. If PCO2 is = 60 mm Hg or PCO2 increase is = 20 mm Hg over baseline normal PCO2, the apnea test result is positive (it supports the clinical diagnosis of brain death); if PCO2 is < 60 mm Hg and PCO2 increase is < 20 mm Hg over baseline normal PCO2, the result is indeterminate and a confirmatory test can be considered. 16 July 2010 39 Practice parameters for determining brain death in adults: (summary statement) NEUROLOGY 1995;45:1012-1014: II. Pitfalls in the diagnosis of brain death : Practice parameters for determining brain death in adults: (summary statement) NEUROLOGY 1995;45:1012-1014: II. Pitfalls in the diagnosis of brain death A. Severe facial trauma B. Preexisting pupillary abnormalities C. Toxic levels of any: sedatives, aminoglycosides, TCA’s, anticholinergic, AED’s, chemotherapeutic agents, or NM blocking agents D. Chronic CO2 retention 16 July 2010 40 Practice parameters for determining brain death in adults: (summary statement) NEUROLOGY 1995;45:1012-1014: III. Clinical observations compatible with the diagnosis of brain death : Practice parameters for determining brain death in adults: (summary statement) NEUROLOGY 1995;45:1012-1014: III. Clinical observations compatible with the diagnosis of brain death A. Spontaneous movements B. Respiratory-like movements C. Sweating, blushing, tachycardia D. Normal BP without pressors E. Absence of diabetes insipidus F. DTR’s, superficial abdominal reflexes, triple flexion response G. Babinski reflex 16 July 2010 41 Practice parameters for determining brain death in adults: (summary statement) NEUROLOGY 1995;45:1012-1014: IV. Confirmatory laboratory tests (Options) : Practice parameters for determining brain death in adults: (summary statement) NEUROLOGY 1995;45:1012-1014: IV. Confirmatory laboratory tests (Options) “Brain death is a clinical diagnosis. A repeat clinical evaluation 6 hours later is recommended, but this interval is arbitrary. A confirmatory test is not mandatory but is desirable in patients in whom specific components of clinical testing cannot be reliably performed or evaluated….most sensitive test [is listed] first: 16 July 2010 42 Practice parameters for determining brain death in adults: (summary statement) NEUROLOGY 1995;45:1012-1014: IV. Confirmatory laboratory tests (Options)(specific criteria described for all) : Practice parameters for determining brain death in adults: (summary statement) NEUROLOGY 1995;45:1012-1014: IV. Confirmatory laboratory tests (Options)(specific criteria described for all) A. Conventional Angiography B. EEG: no electrical activity over =30’ C. Transcranial Doppler U/S D. Technetium-99m HMPA brain scan E. Somatosensory evoked potentials 16 July 2010 43 Slide 44: • Fifty-six consecutive patients clinically diagnosed as brain dead were seen at Loyola University Medical Centre, May-wood, III, from January 1984 through May 1986. Eleven (19.6%) of the 56 patients had (EEG) activity following the diagnosis of brain death. The mean duration of the observed EEG activity was 36.6 hours (range, two to 168 hours). Three patterns of EEG activity were observed: (1) low-voltage (4 to 20 µV) theta or beta activity was recorded in nine (16.1%) patients as long as 72 hours following brain death. Neuropathologic studies in one patient showed hypoxicischemic neuronal changes involving all cell layers of the cerebral cortex, basal ganglia, brain stem, and cerebellum; (2) sleep-like activity (a mixture of synchronous 30 to 40 µV theta and delta activity and 60 to 80 µV, 10 to 12 Hz spindle-like potentials) was noted in two (3.6%) patients for as long as 168 hours following brain death. Pathologic studies in both cases demonstrated ischemic necrosis of the brain stem with relative preservation of the cerebral cortex; and 16 July 2010 44 Slide 45: (3) alpha-like activity (monotonous, unreactive, anteriorly predominant, 25 to 40 µV, 9 to 12 Hz activity) was observed in one (1.8%) patient three hours following brain death. Regardless of activity on the EEG, none of the patients recovered. The occurrence of EEG activity following brain death would suggest reliance on the EEG to confirm brain death may be unwarranted. The use of the EEG as a confirmatory test of brain death may be of questionable value. 16 July 2010 45 Slide 46: EEG and brain death determination in children L. A. Alvarez, MD, S. L. Moshé, MD, A. L. Belman, MD, J. Maytal, MD, T. J. Resnick, MD and M. Keilson, MD In a retrospective study involving several medical centers we identified 52 patients under age 5 years who met the adult clinical criteria for brain death and had at least one EEG with electrocerebral silence. Of the 52 patients, 31 died spontaneously and 21 were disconnected from the respirator. Repeat EEGs were obtained in 28 patients, and in all electrocerebral silence persisted. The study suggests that clinical criteria similar to those used for adults in the determination of brain death can also be applied to children above age 3 months and that a single EEG with electrocerebral silence is sufficient to confirm brain death in this age group. 16 July 2010 46 Slide 47: 16 July 2010 47 The image in patients with brain death shows a clear-cut ‘hollow-skull sign’, which is tantamount to a ‘functional decapitation’. This is markedly different from the situation seen in patients in a vegetative state, in whom cerebral metabolism is massively and globally decreased (to 50% of normal value) but not absent. The colour scale shows the amount of glucose metabolized per 100 g of brain tissue per minute. NATUREREVIEWS Neuroscience, Volume 6, November 2005, 903 What is euthanasia? : What is euthanasia? “Euthanasia” literally means “a gentle, easy death.” 16 July 2010 48 1973 Policy Statement of American Medical Association (AMA; Steinbock, 155) : 1973 Policy Statement of American Medical Association (AMA; Steinbock, 155) The intentional termination of the life of one human being by another—mercy killing—is contrary to that for which the medical profession stands and is contrary to the policy of the American Medical Association. . . . 16 July 2010 49 The Changing Medical Situation : The Changing Medical Situation Until the 1940’s, medical care was often just comfort care, alleviating pain when possible During the last 50+ years, medicine has become increasingly capable of postponing death Increasingly, we are forced to choose whether to allow ourselves to die. 16 July 2010 50 What are we striving for? : What are we striving for? Euthanasia means “a good death,” “dying well.” What is a good death? Peaceful Painless Lucid With loved ones gathered around 16 July 2010 51 The Independence of the Distinctions: Euthanasia : The Independence of the Distinctions: Euthanasia 16 July 2010 52 1973 AMA Policy Statement (cont’d.) : 1973 AMA Policy Statement (cont’d.) The cessation of the employment of extraordinary means to prolong the life of the body when there is irrefutable evidence that biological death is imminent is the decision of the patient and/or his immediate family. The advice and judgment of the physician should be freely available to the patient and/or his immediate family. 16 July 2010 53 Slide 54: What to do? DNR Orders Increased dosages of pain-killers such as morphine Advance Directives 1991 Patient Self-Determination Act requires health-care providers to offer written information about “living wills” About 15% of patients sign a living will 16 July 2010 54 Active Euthanasia : Active Euthanasia Typical case for active euthanasia there is no doubt that the patient will die soon the option of passive euthanasia causes significantly more pain for the patient (and often the family as well) than active euthanasia and does nothing to enhance the remaining life of the patient, and passive measures will not bring about the death of the patient. 16 July 2010 55 Compassion for Suffering : Compassion for Suffering The larger question in many of these situations is: how do we respond to suffering? Hospice and palliative care Aggressive pain-killing medications Sitting with the dying Euthanasia 16 July 2010 56 The Right to Die : The Right to Die Do we have a right to die? Negative right (others may not interfere) Positive right (others must help) Do we own our own bodies and our lives? If we do own our own bodies, does that give us the right to do whatever we want with them? Isn’t it cruel to let people suffer pointlessly? 16 July 2010 57 The Slippery Slope : The Slippery Slope Worrisome examples from history: Nazi eugenics program California eugenics program Chinese orphanages Special danger to undervalued groups in our society The elderly Minorities Persons with disabilities Groups that are typically discriminated against 16 July 2010 58 How much care should be given at the end of life? : How much care should be given at the end of life? Health care providers are increasingly concerned, not just about how much money is spent on patients, but about how effectively it is spent. Disproportionate amount of money spent in final months of life. 40 percent of Medicare dollars cover care for people in the last month. Nearly one third of terminally ill patients with insurance used up most or all of their savings to cover uninsured medical expenses such as home care. Concept of medical futility is utilitarian in character. 16 July 2010 59 The Kantian Model : The Kantian Model Central insight: people cannot be treated like mere things. Key notions: Autonomy & Dignity Respect Rights 16 July 2010 60 Conclusion : Conclusion Many of the ethical disagreements about end-of-life decisions can be seen as resulting from differing ethical frameworks, esp. Kantian vs. utilitarian. Use these models to understand where you stand, where your patients stand, and where your organization stands in regard to end-of-life issues. 16 July 2010 61 Disciplines Considering End-of-Life Issues : Disciplines Considering End-of-Life Issues Philosophy Religious Studies & Theology Literature Psychology Sociology Biology Economics Political Science Media Studies Medicine Art Theater 16 July 2010 62 End-of-Life Decisions : End-of-Life Decisions Until recently, end-of-life decisions for most people were easy: You tried to stay alive as long as you could, and then you just died. Today, we are lucky if we are able to “just die.” In most cases, difficult decisions have to be made about when to stop medical treatment. 16 July 2010 63 The Biology of Aging and Dying : The Biology of Aging and Dying Biologists and researchers in related fields are continually probing into questions central to our understanding of the biological dimensions of aging and dying, including: Can the aging process be slowed down? On the biology of dying, see Sherwin Nuland’s How We Die. 16 July 2010 64 Psychology : Psychology The psychological dimensions of end-of-life decisions Classic source: Elizabeth Kübler-Ross, On Death and Dying Stage 1- Shock and denial Stage 2- Anger Stage 3- Bargaining Stage 4- Depression Stage 5- Acceptance Typically no clear demarcation b/w stages and some may occur in different order 16 July 2010 65 Art : Art Throughout the ages, we have sought to understand death through art. 16 July 2010 66 Art : Art Throughout the ages, we have sought to understand death through art. Dürer, “The Four Horsemen of the Apocalypse” 16 July 2010 67 Art--2 : Art--2 16 July 2010 68 Jack KevorkianNearer My God to Thee Music : Music Whether through requiems or ragas, we have always expressed our feelings about death and end-of-life decisions through music. Mahler’s Kindestotenlieder 16 July 2010 69 Literature : Literature Leo Tolstoy, “The Death of Ivan Illych” See The Oxford Book of Deathby D. J. Enright 16 July 2010 70 Slide 71: ARGUMENTS AGAINST EUTANASIA 16 July 2010 71 1: Some terminally ill people recover and get well.2: Doctors make mistakes in medical care.3:Assisted suicide laws give societal approval to suicide. 4:No one, not even incapacitated people, needs assisted suicide. 5: You already have control over your final illness. : 1: Some terminally ill people recover and get well.2: Doctors make mistakes in medical care.3:Assisted suicide laws give societal approval to suicide. 4:No one, not even incapacitated people, needs assisted suicide. 5: You already have control over your final illness. 16 July 2010 72 6: We can come up with better ways of helping the dying besides assisted suicide..7 : Assisted suicide laws give more power to the government, not the individual.8 : Assisted suicide laws removes incentive to do medical research. : 6: We can come up with better ways of helping the dying besides assisted suicide..7 : Assisted suicide laws give more power to the government, not the individual.8 : Assisted suicide laws removes incentive to do medical research. 16 July 2010 73 9 : Big financial interests are often behind assisted suicide laws.10 : Christopher Reeve considered assisted suicide.11 : Assisted suicide laws put poor people at risk.12 : Suicide interrupts a natural path to wisdom.13 : The first Nazi victims were terminally ill people. : 9 : Big financial interests are often behind assisted suicide laws.10 : Christopher Reeve considered assisted suicide.11 : Assisted suicide laws put poor people at risk.12 : Suicide interrupts a natural path to wisdom.13 : The first Nazi victims were terminally ill people. 16 July 2010 74 14 : Dying people can be treated for depression.15 : Insurance companies love assisted suicide.16 : Skilled hospice caregivers can control physical pain.17 : All humans have dignity, even the sick and dying.18 : Suicidal people have a diminished capacity to make the decision to end their lives. : 14 : Dying people can be treated for depression.15 : Insurance companies love assisted suicide.16 : Skilled hospice caregivers can control physical pain.17 : All humans have dignity, even the sick and dying.18 : Suicidal people have a diminished capacity to make the decision to end their lives. 16 July 2010 75 19 : Assisted suicide makes doctors accessories of fact to homicide.20 : Assisted suicide creates a world without love. : 19 : Assisted suicide makes doctors accessories of fact to homicide.20 : Assisted suicide creates a world without love. 16 July 2010 76 Slide 77: 16 July 2010 77 Patented and marketed by Count Karnice-Karnicki, chamberlain to the Tsar of Russia, in 1896. The apparatus allowed the buried to signal that he or she was still alive by activating a flag and ringing a bell. It could be rented for a small amount of money and, after a length of time, when there was no chance of revival, the tube could be pulled up and used in another coffin. Slide 78: The current legal position on euthanasia and assisted suicide in India In India, euthanasia is undoubtedly illegal. Since in cases of euthanasia or mercy killing there is an intention on the part of the doctor to kill the patient, such cases would clearly fall under clause first of Section 300 of the Indian Penal Code, 1860. However, as in such cases there is the valid consent of the deceased Exception 5 to the said Section would be attracted and the doctor or mercy killer would be punishable under Section 304 for culpable homicide not amounting to murder. Cases of non-voluntary and involuntary euthanasia would be struck by proviso one to Section 92 of the IPC and thus be rendered illegal. Euthanasia and suicide are different, distinguishing euthanasia from suicide, Lodha J. in Naresh Marotrao Sakhre v. Union of India, observed: 16 July 2010 78 Slide 79: “Suicide by its very nature is an act of self-killing or self-destruction, an act of terminating one’s own act and without the aid or assistance of any other human agency. Euthanasia or mercy killing on the other hand means and implies the intervention of other human agency to end the life. Mercy killing thus is not suicide and an attempt at mercy killing is not covered by the provisions of Section 309. The two concepts are both factually and legally distinct. Euthanasia or mercy killing is nothing but homicide whatever the circumstances in which it is effected.” 16 July 2010 79 Slide 80: The law in India is also very clear on the aspect of assisted suicide. Abetment of suicide is an offence expressly punishable under Sections 305 and 306 of the IPC. Moreover, after the decision of a five judge bench of the Supreme Court in Gian Kaur v. State of Punjab it is well settled that the “right to life” guaranteed by Article 21 of the Constitution does not include the “right to die”. The Court held that Article 21 is a provision guaranteeing “protection of life and personal liberty” and by no stretch of the imagination can extinction of life be read into it. 16 July 2010 80 Slide 81: Gandhiji observed ,in NAVJIVAN, in 1929 "Would I apply to human beings the principle that I have enunciated in connection with the calf? Would I like it to be applied in my own case? My reply is yes. Just as a surgeon does not commit himsa when he wields his knife on his patient's body for the latter's benefit, similarly one may find it necessary under certain imperative circumstances to go a step further and sever life from the body in the interest of the sufferer". 16 July 2010 81 Regulations in the world : Regulations in the world Euthanasia is legalized in Netherlands (2002), Belgium, Luxembourg (including sick children), Albania, Japan and the U.S. states Texas and Oregon And until recently also in Australia Northern Territory (which is however overruled later, due to federal nature of the subject). Special form of euthanasia is allowed in Switzerland Where one can prescribe a lethal dose of sleeping pills, but the patient must accept it yourself. In other countries, euthanasia is not allowed and punishable as murder or simpler punishments 16 July 2010 82 Euthanasia in the Netherlands : Euthanasia in the Netherlands The Dutch law allows euthanasia only if all are met the following conditions: patient's suffering is unbearable with no prospect of improvement in the status of the patient request by the patient euthanasia must be voluntary and should be kept to a predetermined time, can not be met if the person is under the influence of drugs, suffering from a mental illness or have been influenced by other people the patient must be fully aware of their health status, prognosis and asserting their rights 16 July 2010 83 Euthanasia in the Netherlands : Euthanasia in the Netherlands to be consulted with at least one independent doctor, who must confirm the patient's health status and conditions referred to above Euthanasia must be carried out in a medically appropriate way by the doctor or patient in the presence of a physician you must be at least 12 years (patients aged 12 to 16 years old must obtain parental consent) Dutch legislation recognizes the validity of the will of the patient's written statement. Such declaration may be used when the patient will be in a coma or in another state, which makes it impossible to agree to euthanasia. 16 July 2010 84 Euthanasia in Luxembourg : Euthanasia in Luxembourg In Luxembourg February 20 2008 Luxembourg, the Parliament adopted by a majority of 30 of the 59 votes in a law legalizing shortening life seriously ill persons upon request. It entered into force after the second ballot in March 2009 . The bill was strongly criticized by the Catholic Church (which have a large impact on society Luxembourg), most of the medical and the ruling Christian Social Party. According to the draft decision on euthanasia can only be taken provided that the patient is seriously and terminally ill. Decide on euthanasia can be taken include writing down a will 16 July 2010 85 Euthanasia in Belgium : Euthanasia in Belgium The Belgian parliament Belgium passed a law legalizing euthanasia in September 2002 year. 16 July 2010 86 Euthanasia in Albania : Euthanasia in Albania Albania was the first country Europe that legalized euthanasia - has been the case in 1999 year under amendments to the Law on the Rights of the terminally ill. It legalizes any form of active euthanasia, with the consent of the patient. Passive euthanasia is permissible with the consent of three members of the family of the sick person. 16 July 2010 87 Slide 88: RELIGION AND EUTHANASIA 16 July 2010 88 Hinduism : Hinduism Euthanasia is seen as the death of the elected and approved as an escape from attachment to the self that suffers (e.g. due to old age) makes it possible to free oneself from uncomfortable forms of life and move to the next life (reincarnation). Those who take the decision of suicide, and those make euthanasia, should be freed from the evil intentions, passions and selfishness. 16 July 2010 89 Judaism : Judaism Jewish the right to reject any measures that seek to reduce human life. Nevertheless, discussing over a few exceptions, for example when people are terminally ill and thus can be euthanized to prevent excessive suffering. Midrash refers to the story of King Saul, who threw himself on his sword to avoid torture. Modern rabbinical authorities permit the administration of palliatives of pain, although significantly shorten the life terminally ill. However, prohibit injection whether the administration of the measures to accelerate death. Likewise, reject medical interventions that artificially extend life. 16 July 2010 90 Christianity : Christianity Ethics Catholic rejects direct euthanasia . Similar considerations are taken under the ethics Orthodox and Protestant. 16 July 2010 91 Islam : Islam First International Conference on Medicine Muslim (Kuwait, 1981) were condemned suicide and euthanasia. The meeting also voted for the resignation of the method used to artificially prolonging life. 16 July 2010 92 Buddhism : Buddhism Buddhism does not approve of euthanasia due to its doctrine of karma nor from a psychological perspective. Bad Karman That determines human suffering (patient), it should take so long until he is exhausted and no longer affect the subsequent birth. If we stop suffering, start afresh in the next incarnation, until exhaustion. If, however, eliminate suffering as a result of bad, negative karma You can be reborn again in a better existence. Buddhist psychology comes from the fact that the death of the preset is filled with compassion, hatred and negative feelings for the suffering patient. Even if the primary motive is to relieve temporary suffering, a good intention turns into action when the decision marked aversion. Although the doctor believes that kill out of compassion, but in fact work with the aversion to suffering. Thus, he raises for himself and for his patient's negative karmic energy. 16 July 2010 93 Buddhism : Buddhism Buddhist doctors also discuss about the exact moment of death, i.e. when you turn off the apparatus, which is only artificially prolongs life, whereas it is necessary to other patients. It is very important in this context prana (washed - Breath of life). It appears already in the Upanishads, and means "life force" of man, inherent in the heart. When you disappear, the doctor must abandon its efforts. 16 July 2010 94 Slide 95: Question 1: if your loved one is in intense pain, will you do it ???? Question 2 : should you do it ????? Question 3 : if yes, how? If no, then how will you alleviate his/her suffering ? 16 July 2010 95 Slide 96: Thank you 16 July 2010 96 Slide 97: References : www. British medical journal Newspapers (the Hindu , the times of India ) Harvard medical review Springerlink Journal of American academy of neurology. 16 July 2010 97