Module 2

Dignity in Death and Dying

Introduc on
• 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 pa ents and families navigate the dying process
with compassion and dignity.
• Central ques ons:

o When is it morally acceptable to prolong life?

o When does treatment become fu le or inhumane?

o How do nurses respect life while relieving su ering?

This major ethical concepts and prac ces related to dying, with legal references in the
Philippines and interna onal frameworks.

1. Euthanasia and Prolonga on of Life

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

o Ac ve euthanasia: Direct ac on to end life (e.g., lethal injec on).

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

• Prolonga on of life: using medical technology (ven lators, dialysis, aggressive
chemotherapy, CPR) to keep pa ents alive even when there is li le or no chance of
recovery.

Ethical Tension:
• Autonomy: pa ent’s right to choose how and when to die.
• Bene cence: duty to relieve su ering.
• Non-male cence: duty to “do no harm” (ques on: is prolonging su ering a form of
harm?).
• Sanc ty of life: life has inherent value, independent of quality.
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 Nursing Role:
• Nurses are o en the rst witnesses to a pa ent’s su ering. They must:

o Assess pa ent’s physical and emo onal distress.

o Advocate for pallia ve care rather than fu le aggressive treatments.

o Support informed decision-making.

Legal Basis (Philippines):

• Euthanasia is illegal.

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

o Ar cle 256: penalizes acts that shorten life.

• However, withholding extraordinary means (e.g., ven lator in a terminal case) may be
ethically jus ed if it aligns with pa ent’s wishes.

2. Inviolability of Human Life

• The principle: Life is sacred, inherent, and must not be inten onally destroyed.
• Rooted in natural law and religious tradi on (Catholic moral theology strongly in uences
Philippine ethics).

Legal Basis:
• Philippine Cons tu on, Ar cle II, Sec. 12: “The State shall equally protect the life of the
mother and the life of the unborn from concep on.”
• This principle underpins the prohibi on of euthanasia in the country.

Nursing Implica on:

• Nurses must:

o Avoid par cipa ng in direct life-ending interven ons.

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

o Recognize limits of technology while respec ng ethical and legal boundaries.

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 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):

• Assis ng in suicide is punishable under Ar cle 253 of the Revised Penal Code.
• Nurses are bound by the Code of Ethics for Nurses (2011), which requires preserva on
of life.

Nursing Role:
• Suicide idea on should trigger mental health interven ons, not facilita on of death.
• Nurses should provide psychosocial support, counseling referral, and suicide
preven on measures.

4. Dysthanasia (“bad death”)

• De ni on: the fu le and burdensome prolonga on of dying through aggressive
medical interven ons.
• Example: keeping a terminal pa ent with mul -organ failure on life support with no
chance of recovery.

Ethical Concerns:
• Leads to unnecessary su ering, high costs, and poor quality of life.
• Violates bene cence (relieving su ering) and non-male cence (avoiding harm).

Nursing Implica on:

• Nurses must advocate against fu le care and promote orthothanasia and pallia ve
care.
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 • Support family understanding that “prolonging life is not always preserving life.”

5. Orthothanasia (“right death”)

• De ni on: allowing death to occur naturally, without extraordinary or dispropor onate
medical interven ons.
• Centered on comfort, peace, and dignity rather than cure.

Ethical Basis:
• Respects the natural process of dying.
• Upholds pa ent autonomy by honoring their wishes.
• Supported by the principle of propor onality: treatment must match pa ent’s condi on.

Nursing Role:
• Implement pallia ve care and hospice measures: pain management, emo onal
support, family counseling.
• Respect spiritual needs of the pa ent.

6. Administra on of Drugs to the Dying

• Goal: relieve pain, not hasten death.
• Doctrine of Double E ect:

o An ac on with both good and bad e ects is ethically acceptable if the inten on is
good (e.g., giving morphine to relieve pain even if it uninten onally hastens
death).

Legal Basis:
• RA 9165 (Comprehensive Dangerous Drugs Act of 2002): regulates controlled
substances (opioids, seda ves).
• Nurses may administer only with physician’s prescrip on, following strict
documenta on.

Nursing Implica on:

• Ensure correct dosing, monitoring, and documenta on.
• Communicate openly with pa ents and families about goals of pain management.
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 7. Advanced Direc ves
• De ni on: Wri en statements made by competent pa ents regarding future medical
care.
• Examples:

o Living Will: instruc ons to withhold certain treatments.

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

Legal Basis (Philippines):

• No comprehensive na onal law, but Senate Bill 1886 (Advance Direc ves Act) was
proposed.
• Some hospitals prac ce ins tu onal policies allowing advance direc ves.

Nursing Role:
• Educate pa ents about advance direc ves.
• Respect and uphold pa ent’s documented wishes.
• Serve as advocates in ethical commi ees.

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

• DNR Order: A medical direc ve that no CPR will be performed if the pa ent’s heart or
breathing stops.
• End-of-Life Care Plan: broader; includes pain management, spiritual care, comfort
measures, family support, and withdrawal of fu le treatments.

Ethical Basis:
• Respects pa ent autonomy.
• Prevents dysthanasia and unnecessary su ering.

Legal Basis (Philippines):

• No na onal law, but hospitals implement DNR policies.
• Philippine Nurses Associa on Code of Ethics (2011): “The nurse respects the pa ent’s
right to a peaceful death.”

Nursing Role:
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 • Explain DNR to pa ents and families.
• Provide comfort care and ensure pa ent dignity.
• Support family through the grieving process.

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

Framework for nurses and healthcare teams:

1. Iden fy the problem – e.g., Should life support con nue in a terminal case?

2. Collect facts – medical condi on, prognosis, pa ent’s wishes, cultural/religious values.

3. Iden fy stakeholders – pa ent, family, medical team, ins tu on.

4. Clarify ethical principles – autonomy, bene cence, non-male cence, jus ce.

5. Explore op ons – con nue life support, withdraw, shi to pallia ve care.

6. Consult legal and ins tu onal guidelines – check hospital ethics commi ee.

7. Decide and implement – collabora vely with team and family.

8. Evaluate and re ect – ensure decision upheld dignity and minimized su ering.

Reference Frameworks:
• Philippine Code of Ethics for Nurses (2011).
• Interna onal Council of Nurses (ICN) Code of Ethics.
• WHO Guidelines on Pallia ve Care.

Key Points:
• Nursing’s moral responsibility is not just to preserve life, but to ensure that pa ents die
with dignity, comfort, and peace.
• Euthanasia and assisted suicide are prohibited by law in the Philippines, but
orthothanasia, pallia ve care, DNR, and pain management are ethically and
professionally accepted.
• Nurses must apply ethical decision-making, advocate for pa ents’ wishes, and balance
legal frameworks with compassionate care.
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 END OF TOPIC ACTIVITIES: CASE ANALYSIS

Case 1 – The Terminal Cancer Pa ent

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 su ering quickly, even if it means he might
not wake up again?”

Guided Ques ons

1. What ethical principles are at stake in this situa on?

2. How does the Doctrine of Double E ect 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 administra on 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 Ques ons

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

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

3. What alterna ve care op ons (orthothanasia, pallia ve care, psychosocial support) can
be o ered?

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

Case 3 – The DNR Dilemma

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

Guided Ques ons

1. As the a ending nurse, what should you do rst?

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

3. What ethical principles are involved (autonomy, bene cence, delity, jus ce)?

4. What is the legal and ins tu onal basis of honoring DNR orders in the Philippines?

Case 4 – Dysthanasia in the ICU

A 78-year-old pa ent with mul -organ failure has been on a ven lator 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 Ques ons

1. De ne dysthanasia. Is this situa on an example of it?

2. What ethical issues arise when families request fu le 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 Direc ve Con ict

Mrs. Santos, a 72-year-old woman, signed an advance direc ve refusing intuba on. 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 Ques ons

1. What is the purpose of an advance direc ve?

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

3. What legal protec on exists in the Philippines regarding advance direc ves?

4. How can the nurse mediate between the pa ent’s autonomy and family pressure?
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 Ac vity Instruc ons

1. Divide students into groups.

2. Assign one case to each group.

3. Each group will:

o Iden fy the ethical principles involved.

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

o Propose the nursing interven ons/decisions.

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

Module 4
Bioethics and Research in Nursing

Introduc on
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 Research is essen al to advance nursing knowledge, improve pa ent outcomes, and support
evidence-based prac ce. However, history shows that research has also caused harm,
exploita on, 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

• Signi cance:

o First interna onal set of principles for human research ethics.

o Founda on for later documents like the Declara on of Helsinki and Belmont Report.

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 o For nurses: emphasizes the duty to protect pa ent rights and autonomy in any research
se ng.

• Key Principles:

1. Voluntary informed consent is essen al.

2. Research must aim for the good of society.

3. Avoid unnecessary physical and mental su ering.

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

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

• Nursing Implica on:

Nurses involved in research must ensure pa ents/subjects understand what they

consent to and are free from coercion.

2. Declara on of Helsinki (1964, updated)

• Historical Background:

o Dra ed by the World Medical Associa on (WMA) to guide physicians in clinical

research.

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

o Con nuously updated to respond to advances in research and bioethics (latest

revision: 2013).
• Core Principles:

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

2. Risks must be carefully assessed—bene ts should outweigh risks.

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

(IRB/REC) before star ng.

4. Informed consent is required, and par cipants must be informed of risks, bene ts, and
rights.

5. Vulnerable popula ons (children, disabled, economically disadvantaged) require special

protec on.
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 6. Research par cipants’ well-being takes priority over scien c or societal interests.
• Signi cance:

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

o Ins tu onal Review Boards (IRBs) and Ethics Commi ees are based on its
provisions.

Nursing Implica on:

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

2. In clinical prac ce, nurses should protect vulnerable pa ents from being exploited in
research.

3. Belmont Report (1979)

• Historical Background:

o Wri en by the U.S. Na onal Commission for the Protec on 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
a er penicillin was available, just to observe disease progression.
• Core Principles:

1. Respect for Persons (Autonomy):

▪ Individuals must be treated as autonomous agents.

▪ Vulnerable popula ons (children, mentally ill, prisoners) deserve special

protec on.

▪ Requires informed consent as a safeguard.

2. Bene cence:

▪ Obliga on to maximize bene ts and minimize possible harm.

▪ Researchers must perform risk-bene t analysis before conduc ng studies.

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 3. Jus ce:

▪ Fair distribu on of research bene ts and burdens.

▪ Par cipants must not be selected simply because they are vulnerable,
poor, or easily exploited.
• Signi cance:

o Became the founda on of modern research ethics guidelines and IRB

regula ons.

o Core principles (Respect, Bene cence, Jus ce) remain the gold standard in
nursing research and evidence-based prac ce.

o For nurses: guides their role in protec ng subjects, ensuring fairness, and
prac cing evidence-based care ethically.

Nursing Implica on:

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

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

The Nuremberg Code, Declara on 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.

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

commi ees.

• Belmont Report – established the three fundamental principles guiding modern research
ethics: respect, bene cence, and jus ce.

B. Ethical Issues in Evidence-Based Prac ce (EBP)

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 Evidence-Based Prac ce (EBP): the integra on of best current evidence, clinical exper se, and
pa ent preferences in decision-making.

Ethical Issues:

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

2. Pa ent Autonomy: Respec ng pa ents’ choices, even if they di er from evidence-based

recommenda ons.

3. Jus ce and Equity: Ensuring all pa ents have access to evidence-based care, regardless of
socioeconomic status.

4. Con den ality: Using pa ent data in research or prac ce must comply with privacy laws
(Philippines: Data Privacy Act of 2012, RA 10173).

5. Con icts of Interest: Pharmaceu cal funding or ins tu onal bias may distort evidence.
Nurses must be vigilant against unethical in uence.

C. Ethico-Moral Obliga ons of the Nurse in Evidence-Based Prac ce

Nurses, as both care providers and knowledge users, have speci c moral du es:

A. Advocate for Pa ent Rights

B. Ensure pa ents understand treatment op ons, including risks and bene ts.

C. Uphold autonomy in decision-making.

D. Commitment to Integrity and Honesty

E. Report accurate data in research and prac ce.

F. Avoid fabrica on, falsi ca on, 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 prac ce when applying evidence in pa ent care.

C. Apply evidence in ways that maximize pa ent bene t and minimize harm.

D. Ques on outdated or unsafe prac ces.

E. Respect for Cultural and Individual Di erences

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