Mariano Marcos State University

College of Health Sciences

DEPARTMENT OF NURSING
Batac, Ilocos Norte
Telefax: +6377 7923882; E-mail address: mmsu_chs_2009@yahoo.com
Website: www.mmsu.edu.ph

ETHICAL ISSUES:
DETERMINATION OF BILOGICAL AND CLINICAL
DEATH &
WITHDRAWAL OF LIFE-SUSTAINING TREATMENT

Prepared by:

Javene Joseph P. Pedro

Imee F. Rabang
Kevin June C. Rasco
Mary Kathe G. Rebucal
Marie Ashley R. Rico
Zara Krizcia A. Ruiz
Marie Prezell B. Sabuco
Florlynne P. Salmasan
Ma. Teresa S. Talioaga
Kristin S. Tarampi
Carl Elgen S. Vizcarra

GROUP IV
BSN III-A

Submitted to:

Mr. Ruben M. Asis, Jr.

Instructor, NSG 150
 March, 2011
DETERMINATION OF BIOLOGICAL AND CLINICAL DEATH

Brain Death/ Biological Death is the final cessation of bodily activity, used to determine
when death actually occurs; circulatory and respiratory functions have irreversibly cease, and
the entire brain (including the brainstem) has irreversibly cease to function.
Biological death is much more severe. It is when brain cells die because of lack of
oxygen (hypoxia). Biological death follows clinical death. As such, responding to clinical death
early enough and performing proper rescue techniques render the best chance of preventing
biological death from taking place. Of course, getting advanced medical help as quickly as
possible is also important.
Determination of Death
 Circulatory and respiratory functions have irreversibly ceased.
 The entire brain, including the brain stem, has irreversibly ceased to function.

Death is indicated if the following signs are present:

 Cannot breathe with assistance.
 Has no coughing or gagging reflex.
 Has no pupil response to light.
 Has no blinking reflex when the cornea is touched.
 Has no grimace reflex when the head is rotated or ears are flushed with ice water.
 Has no response to pain.
Clinical death is simply when a casualty has stopped breathing. This results in oxygen
not entering the body, which eventually results in death of body tissues and cardiac arrest.
There are many causes of clinical death such as suffocation, asphyxiation, drowning, injuries,
poisoning, and anaphylaxis.

BIOLOGICAL AND BIOGRAPHICAL LIFE

Of all the problems that can be considered life and death ethics, man has caused the
same level of moral anguish as that of withholding and withdrawing life support systems.
Today, however, the practitioner is faced with the frustrating problem of available technology
that allows for life extension but cannot restore the patient to a life free of pain and misery – or
even, in some cases, to an awareness of the environment. The practitioners duty to respect life
and preserved it where possible may at times come in to direct conflict with the duty to
alleviate pain and suffering. Brain death cases are often very problematic to families, as the
patient appears to have natural warmth and color, the EKG may be in sinus rhythm and the
chest rises and falls with each cycle of the ventilator. Families view these signs of life and need
time to be to an understanding of the true condition. During this period of counseling, the
practitioner will broach the question of consent in order to arrange for the harvest of valuable
organs for transplantation.
At these times, a natural shift occurs, nothing more can be done for the brain dead
patient, who is deceased. The support of the family in this time of personal loss becomes the
major concern of the health care practitioner. In a real sense the family become the patients
with whom the health care practitioners are involved. Great care and sensitivity must be taken
as equipment is removed. Often the devices are turned down slowly so that cardiac failure
takes place to stimulate death. The removal of the equipment, however, is not an act of
“allowing to die”, as infact, a corpse cannot be thought to die. Out of respect to the families, or
out of fear of legal issues, practitioners may delay the removal of life sustaining equipment, but
no consent is required for unhooking a ventilator from a dead body.
There are three concentric circle according to Thomas Furlow with regard to the process
of dying. The outermost ring is made up of interpersonal relationship and is called the social
life. This is the most vulnerable aspects of the human being and usually is the first to die. The
second circle is the intellectual circle, this is the part of ourselves that separates us from the
rest of the biological world. Once dying has claimed this region, biographical death has occurred
and only the innermost ring is left which is the biological life. Loss of function of this region
constitutes biological death.

WITHDRAWAL OF LIFE-SUSTAINING TREATMENT

Health care providers have a long tradition of ethical reasoning, which is evolving
continuously alongside the development of modern medicine. The overall assumption is that
the primary task of health care providers is to promote health and, whenever possible, to save
lives and alleviate suffering. Health care providers are also supposed to avoid harming patients
when they provide treatment. Finally, they are expected to respect a patient's autonomy and
integrity as well as the principle of justice, which requires all to be treated equally.

Making decisions about life-sustaining therapy is a complex process for patients’ family
members that occurs in phases and involves multiple family members. Important factors that
influence the decisions made about withdrawal of life-sustaining therapy include poor expected
quality of life, poor overall prognosis, the patient’s current level of suffering, and previously
discussed advance directives.

REVIEW OF TERMS ANDS DEFINITIONS

The basic ethical principles

In clinical ethics there a number of basic principles, which identify key ethical values. In the
most general terms, these principles are
• Beneficence – the principle of producing benefit or doing good to the patient
• Non-maleficence – the principle of not causing harm, or allowing harm to occur to the patient
• Autonomy – the principle of respecting the patients’ right to make their own choices about
their own lives. Put into practice via the processes of informed consent and shared decision-
making.
 Confidentiality and privacy
Also grounds the ethical value of confidentiality and privacy, because control of who
knows or sees things about oneself is an important aspect of making choices about
one’s own life.
• Justice – fairness or distributive justice in the allocation of resources, and of benefits and
burdens of health care. Includes non-discrimination.

 Attempt to have these decisions before a crisis: ADVANCE DIRECTIVES

 Living will and durable power of attorney for health care
 Discussing patient preferences rather than just having a piece of paper.
 The crucial point is that the wishes of patient are a central factor in decisions about
instituting, withholding, and withdrawing life sustaining therapy.
 In discussions with patients and/or family contextualize decisions within the clinical realities
and a commitment not to abandon the patient.
 Preserving life is tempered by a recognition of mortality
 Life-sustaining therapies are medical treatments with indications and contraindications.
 Avoid focus on a specific therapy: rather present a plan that will meet achievable patient
goals, limit suffering, and ensure that the person is not abandoned to illness.
 Principles and some rules of thumb
 The obligation to preserve life. This is part of the role of the physician. Life is generally
considered a great good and thus beneficence suggests that doctors normally act to
preserve life and non-maleficence mandates that doctors never directly take life.
 Important distinctions and concepts
a. The right to refuse treatment : competent patients can refuse treatment and their
refusals are to be accepted unless there is serious doubt about competence (for
whatever reason) or fears of coercion.
b. Withholding versus withdrawing therapy : ethically there is not felt to be a
significant distinction between the two, although sentiment and emotion may make
withdrawal far more difficult than withholding therapy.
c. Terminal versus non-terminal illness : the obligation to institute therapy changes
depending on the clinical situation. For example, if death is imminent from
 metatstatic cancer, the ethical obligation to preserve life is tempered, even if there
re_selfs the traditional prohibition against taking life directly.
d. Intention and killing : the intention to cause the death of a patient whether by
omission or commission is generally considered wrong.
e. Killing versus letting die : the difference may occasionally be blurred but that does
not mean there is not a difference.
f. There is no ethical obligation to institute futile treatment : but there may be other
obligations and the notion of what constitutes futility is not always clear.
g. Cost is not to be used by the physician as a criterion for bedside rationing. Cost is a
valid concern on a social level, but without clear standards for limiting treatment in
individual cases, decisions are arbitrary and ill-advised.

LEGAL IMPLICATIONS
Another issue is the perceived legal implications of withdrawing life-sustaining medical
treatment. Although many believe it to be an action of physician-assisted suicide, in reality
withdrawing life-support has been affirmed in court many times (Quinlan, Herbert, Linares, and
the like). If certain conditions are fulfilled, it is a procedure in which the physician (or health
care proxy) is acting within the limits of the law. The conditions required are the following:
* It is virtually certain that further medical intervention will not attain any of the goals of
medicine other than sustaining organic life. (futility)
-Autonomous decision of the patient or proxy decision making (surrogate agent)
* The preferences of the patient are not known and cannot be expressed.
- One of the prerequisites for deciding capacity is the ability to make and communicate
one's preferences. If the case were such that she was fully lacking the capacity to make a
decision about her medical treatment, we are under the obligation to respect the substituted
judgment of her health care proxy. Once again, this is based on the ethical principle that the
autonomy of a competent patient should be the prevailing factor in all decision-making
processes in a medical setting.
* The quality of life clearly falls below minimal.
- It is generally agreed that minimal quality of life can be described as a condition that
has deteriorated beyond recovery and under which the patient appears to suffer discomfort or
pain. The quality of life descends below minimal when the patient suffers extreme debilitation
as well as complete and irreversible loss of sensory and intellectual ability (for example,
patients on opiates for pain).
* Family and members of the staff are in accord.
When is it justifiable to discontinue life-sustaining treatments?

 If the patient has the ability to make decisions, fully understands the consequences of
their decision, and states they no longer want a treatment, it is justifiable to withdraw
the treatment.
 Treatment withdrawal is also justifiable if the treatment no longer offers benefit to the
patient.

CONCLUSION
Refusal of treatment is controversial in terms of the physician's principle of beneficence.
Perhaps a way to avoid this dilemma, however, would be to develop a list of conditions (age,
life expectancy with and without treatment, the level of incapacity with and without treatment,
the degree of pain and suffering, and so forth) that would be used to determine whether the
right to refuse treatment should be respected. The flaw with this view is that the focus shifts to
the patient's physical condition rather than her or his choice. This ultimately leads to decision
making about the patient instead of by the patient, thus violating the most salient feature of
modern ethics and the physician-patient relationship: the patient's autonomy.
Refusal of treatment is not a privilege of terminally ill patients but, rather, a right that all
patients have and is accordingly respected in the courts. The decision of burdens--versus-
benefits as they are reflected in the patient's quality of life is one that can only be made by the
patient in compliance with his or her values. In modern "democratic" medicine, the physicians
are there to serve and advise, and only in extreme situations of incapacity, emergency, lack of
available health care proxy, or patient's waiver of decision making can they decide for a patient.