Module 2

Dignity in Death and Dying

Introduction

 Death is not just a biological end but a human experience that involves ethical, spiritual,
legal, and cultural dimensions.

 Nursing plays a central role in helping patients and families navigate the dying process
with compassion and dignity.

 Central questions:

o When is it morally acceptable to prolong life?

o When does treatment become futile or inhumane?

o How do nurses respect life while relieving suffering?

This major ethical concepts and practices related to dying, with legal references in the
Philippines and international frameworks.

1. Euthanasia and Prolongation of Life

 Euthanasia (Greek: eu = good, thanatos = death): the deliberate act of ending life to
relieve suffering. “Mercy killing.”

o Active euthanasia: Direct action to end life (e.g., lethal injection).

o Passive euthanasia: Withholding or withdrawing life-sustaining measures.

 Prolongation of life: using medical technology (ventilators, dialysis, aggressive

chemotherapy, CPR) to keep patients alive even when there is little or no chance of
recovery.

Ethical Tension:

 Autonomy: patient’s right to choose how and when to die.

 Beneficence: duty to relieve suffering.

 Non-maleficence: duty to “do no harm” (question: is prolonging suffering a form of

harm?).

 Sanctity of life: life has inherent value, independent of quality.

Nursing Role:

 Nurses are often the first witnesses to a patient’s suffering. They must:

o Assess patient’s physical and emotional distress.

o Advocate for palliative care rather than futile aggressive treatments.

o Support informed decision-making.

Legal Basis (Philippines):

 Euthanasia is illegal.

o Revised Penal Code, Article 253: criminalizes assistance in suicide.

o Article 256: penalizes acts that shorten life.

 However, withholding extraordinary means (e.g., ventilator in a terminal case) may be

ethically justified if it aligns with patient’s wishes.

2. Inviolability of Human Life

 The principle: Life is sacred, inherent, and must not be intentionally destroyed.

 Rooted in natural law and religious tradition (Catholic moral theology strongly influences
Philippine ethics).

Legal Basis:

 Philippine Constitution, Article II, Sec. 12: “The State shall equally protect the life of the
mother and the life of the unborn from conception.”

 This principle underpins the prohibition of euthanasia in the country.

Nursing Implication:

 Nurses must:

o Avoid participating in direct life-ending interventions.

o Provide care that upholds the dignity of life, even in dying.

o Recognize limits of technology while respecting ethical and legal boundaries.

3. Euthanasia and Suicide

 Suicide: deliberate act of ending one’s own life.

 Assisted suicide: helping a person to end their life (e.g., providing lethal drugs).

Ethical Issues:

 Autonomy vs. social responsibility: Individuals may claim a right to end life, but society
and healthcare providers have a duty to preserve it.

 Compassion vs. professional ethics: Is helping someone die an act of mercy or a betrayal
of nursing values?

Legal Basis (Philippines):

 Assisting in suicide is punishable under Article 253 of the Revised Penal Code.

 Nurses are bound by the Code of Ethics for Nurses (2011), which requires preservation
of life.

Nursing Role:

 Suicide ideation should trigger mental health interventions, not facilitation of death.

 Nurses should provide psychosocial support, counseling referral, and suicide

prevention measures.

4. Dysthanasia (“bad death”)

 Definition: the futile and burdensome prolongation of dying through aggressive

medical interventions.

 Example: keeping a terminal patient with multi-organ failure on life support with no
chance of recovery.

Ethical Concerns:

 Leads to unnecessary suffering, high costs, and poor quality of life.

 Violates beneficence (relieving suffering) and non-maleficence (avoiding harm).

Nursing Implication:

 Nurses must advocate against futile care and promote orthothanasia and palliative
care.
  Support family understanding that “prolonging life is not always preserving life.”

5. Orthothanasia (“right death”)

 Definition: allowing death to occur naturally, without extraordinary or disproportionate

medical interventions.

 Centered on comfort, peace, and dignity rather than cure.

Ethical Basis:

 Respects the natural process of dying.

 Upholds patient autonomy by honoring their wishes.

 Supported by the principle of proportionality: treatment must match patient’s condition.

Nursing Role:

 Implement palliative care and hospice measures: pain management, emotional

support, family counseling.

 Respect spiritual needs of the patient.

6. Administration of Drugs to the Dying

 Goal: relieve pain, not hasten death.

 Doctrine of Double Effect:

o An action with both good and bad effects is ethically acceptable if the intention is
good (e.g., giving morphine to relieve pain even if it unintentionally hastens
death).

Legal Basis:

 RA 9165 (Comprehensive Dangerous Drugs Act of 2002): regulates controlled

substances (opioids, sedatives).

 Nurses may administer only with physician’s prescription, following strict

documentation.

Nursing Implication:

 Ensure correct dosing, monitoring, and documentation.

 Communicate openly with patients and families about goals of pain management.
7. Advanced Directives

 Definition: Written statements made by competent patients regarding future medical

care.

 Examples:

o Living Will: instructions to withhold certain treatments.

o Health Care Proxy: appoints someone to make decisions on their behalf.

Legal Basis (Philippines):

 No comprehensive national law, but Senate Bill 1886 (Advance Directives Act) was
proposed.

 Some hospitals practice institutional policies allowing advance directives.

Nursing Role:

 Educate patients about advance directives.

 Respect and uphold patient’s documented wishes.

 Serve as advocates in ethical committees.

8. DNR (Do Not Resuscitate) and End-of-Life Care Plan

 DNR Order: A medical directive that no CPR will be performed if the patient’s heart or
breathing stops.

 End-of-Life Care Plan: broader; includes pain management, spiritual care, comfort
measures, family support, and withdrawal of futile treatments.

Ethical Basis:

 Respects patient autonomy.

 Prevents dysthanasia and unnecessary suffering.

Legal Basis (Philippines):

 No national law, but hospitals implement DNR policies.

 Philippine Nurses Association Code of Ethics (2011): “The nurse respects the patient’s
right to a peaceful death.”

Nursing Role:
  Explain DNR to patients and families.

 Provide comfort care and ensure patient dignity.

 Support family through the grieving process.

9. Ethical Decision-Making Process in End-of-Life Care

Framework for nurses and healthcare teams:

1. Identify the problem – e.g., Should life support continue in a terminal case?

2. Collect facts – medical condition, prognosis, patient’s wishes, cultural/religious values.

3. Identify stakeholders – patient, family, medical team, institution.

4. Clarify ethical principles – autonomy, beneficence, non-maleficence, justice.

5. Explore options – continue life support, withdraw, shift to palliative care.

6. Consult legal and institutional guidelines – check hospital ethics committee.

7. Decide and implement – collaboratively with team and family.

8. Evaluate and reflect – ensure decision upheld dignity and minimized suffering.

Reference Frameworks:

 Philippine Code of Ethics for Nurses (2011).

 International Council of Nurses (ICN) Code of Ethics.

 WHO Guidelines on Palliative Care.

Key Points:

 Nursing’s moral responsibility is not just to preserve life, but to ensure that patients die
with dignity, comfort, and peace.

 Euthanasia and assisted suicide are prohibited by law in the Philippines, but
orthothanasia, palliative care, DNR, and pain management are ethically and
professionally accepted.

 Nurses must apply ethical decision-making, advocate for patients’ wishes, and balance
legal frameworks with compassionate care.
END OF TOPIC ACTIVITIES: CASE ANALYSIS

Case 1 – The Terminal Cancer Patient

Mr. Dela Cruz, a 65-year-old man with stage IV lung cancer, is in severe pain despite aggressive
treatment. His daughter asks the nurse:

“Can you give my father a stronger dose to end his suffering quickly, even if it means he might
not wake up again?”

Guided Questions

1. What ethical principles are at stake in this situation?

2. How does the Doctrine of Double Effect apply here?

3. What should be the nurse’s response to the daughter’s request?

4. Cite the legal basis in the Philippines regarding drug administration to the dying.

Case 2 – The Request for Euthanasia

Maria, a 45-year-old with advanced ALS (amyotrophic lateral sclerosis), is fully conscious but
completely dependent on machines. She whispers to the nurse:

“Please, end my life. I don’t want to be a burden anymore.”

Guided Questions

1. How should the nurse respond to Maria’s request?

2. Is euthanasia legal in the Philippines? Cite the law.

3. What alternative care options (orthothanasia, palliative care, psychosocial support) can
be offered?

4. How can the nurse respect Maria’s autonomy while upholding professional ethics?

Case 3 – The DNR Dilemma

A patient with end-stage kidney disease signed a Do Not Resuscitate (DNR) order. During the
night shift, he went into cardiac arrest. The patient’s son, who just arrived, begs:
“Please save my father! Do CPR!”

Guided Questions

1. As the attending nurse, what should you do first?

2. How should the nurse handle the conflict between the DNR order and the son’s request?

3. What ethical principles are involved (autonomy, beneficence, fidelity, justice)?

4. What is the legal and institutional basis of honoring DNR orders in the Philippines?

Case 4 – Dysthanasia in the ICU

A 78-year-old patient with multi-organ failure has been on a ventilator for three weeks. He is
unresponsive, and the doctors admit there is no chance of recovery. The family insists:

“Do everything possible. Don’t remove the machines. We want him alive at all costs.”

Guided Questions

1. Define dysthanasia. Is this situation an example of it?

2. What ethical issues arise when families request futile treatment?

3. How should the nurse advocate for orthothanasia and dignity in dying?

4. If the family refuses withdrawal of life support, what should the nurse’s role be?

Case 5 – Advance Directive Conflict

Mrs. Santos, a 72-year-old woman, signed an advance directive refusing intubation. Now
unconscious, she is rushed to the ER in respiratory distress. Her eldest son insists:

“Ignore that document. Intubate her! I am her son, I decide now.”

Guided Questions

1. What is the purpose of an advance directive?

2. Should the nurse and medical team honor the son’s demand or the patient’s
documented wishes? Why?

3. What legal protection exists in the Philippines regarding advance directives?

4. How can the nurse mediate between the patient’s autonomy and family pressure?
Activity Instructions

1. Divide students into groups.

2. Assign one case to each group.

3. Each group will:

o Identify the ethical principles involved.

o State the legal basis (Philippine law or Code of Ethics).

o Propose the nursing interventions/decisions.

4. Groups present their conclusions in class for open discussion.

Module 4
Bioethics and Research in Nursing

Introduction
Research is essential to advance nursing knowledge, improve patient outcomes, and support
evidence-based practice. However, history shows that research has also caused harm,
exploitation, and abuse when ethics were ignored. Thus, bioethics provides guiding principles to
ensure that research protects human dignity, rights, and welfare.

A. Principles of Ethics in Research

1. Nuremberg Code (1947)

 Historical Background:

o Developed after World War II during the Nuremberg Trials, where Nazi
physicians were prosecuted for conducting brutal experiments on prisoners
without consent.

o These included exposure to extreme cold, high altitudes, infectious diseases, and
toxic substances—all without concern for human life.

 Core Principles:

1. Voluntary informed consent is absolutely essential. Subjects must freely agree without
coercion.

2. Research must aim to benefit society and be scientifically valid.

3. Experiments should avoid unnecessary physical and mental suffering.

4. No study should be conducted if there is a prior expectation of death or disabling

injury.

5. Subjects must have the right to withdraw from participation at any point.

Researchers must be prepared to terminate the study if it poses risks to participants

• Significance:

o First international set of principles for human research ethics.

o Foundation for later documents like the Declaration of Helsinki and Belmont Report.
o For nurses: emphasizes the duty to protect patient rights and autonomy in any research
setting.

 Key Principles:

1. Voluntary informed consent is essential.

2. Research must aim for the good of society.

3. Avoid unnecessary physical and mental suffering.

4. No experiment should be conducted if death or disabling injury is expected.

5. Subjects must have the right to withdraw at any time.

 Nursing Implication:
Nurses involved in research must ensure patients/subjects understand what they
consent to and are free from coercion.

2. Declaration of Helsinki (1964, updated)

 Historical Background:

o Drafted by the World Medical Association (WMA) to guide physicians in clinical

research.

o Built on the Nuremberg Code but more detailed, addressing medical research
involving patients and modern science.

o Continuously updated to respond to advances in research and bioethics (latest

revision: 2013).

 Core Principles:

1. Research must be based on sound scientific evidence and comply with ethical
standards.

2. Risks must be carefully assessed—benefits should outweigh risks.

3. Research protocols must be reviewed by an Independent Research Ethics

Committee (IRB/REC) before starting.

4. Informed consent is required, and participants must be informed of risks,

benefits, and rights.

5. Vulnerable populations (children, disabled, economically disadvantaged) require

special protection.
 6. Research participants’ well-being takes priority over scientific or societal
interests.

 Significance:

o The most widely recognized international guideline for medical and clinical
research.

o Institutional Review Boards (IRBs) and Ethics Committees are based on its
provisions.

Nursing Implication:

1. Nurses as researchers must submit proposals to an ethics review board.

2. In clinical practice, nurses should protect vulnerable patients from being exploited in
research.

3. Belmont Report (1979)

 Historical Background:

o Written by the U.S. National Commission for the Protection of Human Subjects of
Biomedical and Behavioral Research.

o Developed in response to ethical abuses like the Tuskegee Syphilis Study (1932–
1972) where African American men were denied treatment for syphilis, even
after penicillin was available, just to observe disease progression.

 Core Principles:

1. Respect for Persons (Autonomy):

 Individuals must be treated as autonomous agents.

 Vulnerable populations (children, mentally ill, prisoners) deserve special

protection.

 Requires informed consent as a safeguard.

2. Beneficence:

 Obligation to maximize benefits and minimize possible harm.

 Researchers must perform risk-benefit analysis before conducting studies.

 3. Justice:

 Fair distribution of research benefits and burdens.

 Participants must not be selected simply because they are vulnerable,

poor, or easily exploited.

 Significance:

o Became the foundation of modern research ethics guidelines and IRB

regulations.

o Core principles (Respect, Beneficence, Justice) remain the gold standard in

nursing research and evidence-based practice.

o For nurses: guides their role in protecting subjects, ensuring fairness, and
practicing evidence-based care ethically.

Nursing Implication:

1.Nurses must ensure that research participants are respected, protected, and treated fairly.

2. Recruitment must be ethical and inclusive, not discriminatory.

The Nuremberg Code, Declaration of Helsinki, and Belmont Report form the ethical backbone
of research involving humans.

📌 In short:

• Nuremberg Code – birth of research ethics, focus on voluntary consent.

• Declaration of Helsinki – expanded to clinical and medical research, requires ethics

committees.

• Belmont Report – established the three fundamental principles guiding modern research
ethics: respect, beneficence, and justice.

B. Ethical Issues in Evidence-Based Practice (EBP)

Evidence-Based Practice (EBP): the integration of best current evidence, clinical expertise, and
patient preferences in decision-making.
Ethical Issues:

1. Informed Consent in EBP: Patients must understand treatment decisions based on best
evidence.

2. Patient Autonomy: Respecting patients’ choices, even if they differ from evidence-based
recommendations.

3. Justice and Equity: Ensuring all patients have access to evidence-based care, regardless of
socioeconomic status.

4. Confidentiality: Using patient data in research or practice must comply with privacy laws
(Philippines: Data Privacy Act of 2012, RA 10173).

5. Conflicts of Interest: Pharmaceutical funding or institutional bias may distort evidence.

Nurses must be vigilant against unethical influence.

C. Ethico-Moral Obligations of the Nurse in Evidence-Based Practice

Nurses, as both care providers and knowledge users, have specific moral duties:

A. Advocate for Patient Rights

B. Ensure patients understand treatment options, including risks and benefits.

C. Uphold autonomy in decision-making.

D. Commitment to Integrity and Honesty

E. Report accurate data in research and practice.

F. Avoid fabrication, falsification, and plagiarism.

Professional Accountability

A. Adhere to Philippine Code of Ethics for Nurses (2011): “The nurse values the worth
and dignity of each person.”

B. Uphold standards of practice when applying evidence in patient care.

C. Apply evidence in ways that maximize patient benefit and minimize harm.

D. Question outdated or unsafe practices.

E. Respect for Cultural and Individual Differences