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Most, if not all of the videos listed for this module are difficult to watch and may well pull at your deepest emotions. The intent in requiring that you view them is to introduce you to the topic of PAS and Hospice in a way that is more personal than simply reading an academic text or journal. Too often, as we go through a course of this nature, at the speed with which we are covering topics, it is easy to forget that the patients we read about are fathers, sons, mothers, daughters, friends and family very much like our own. Many of us may be able to identify with the scenarios and people we discuss, due to our own personal experience. As you watch the videos, do not worry about taking notes. Simply sit back and reflect upon what is presented.

Watch the following videos and then proceed to the discussion

•Video diary/story of Craig Ewert and Suicide Tourism 
•Final Exit 
•Cost of Dying: One nurse's end-of-life choice was surprisingly simple - and liberating By Lisa M. Krieger, Mercury Newsmercurynews.com Posted: 12/15/2012 03:49:34 PM PST December 17, 2012 12:26 AM GMTUpdated: 12/16/2012 04:26:42 PM PST. 
•Lisa Szabo, USA TODAY - Palliative care prolongs life, reduces suffering, (2011) 
End of life care in the U.S. is far from perfect, and in many ways lags behind other nations in terms of meeting the psychosocial needs and overall wellbeing of the patient. Poor pain management, a lack of support services and unaddressed fear are all components of end-of-life care that are often missing from a patient's care plan. While each of these is a major concern, one of the greatest fears at the end of life is losing one's dignity. So overpowering is the fear that a recurrent paradox in care of the dying is the patient who loves life yet chooses an early death as you saw in all four videos. In Final Exit and the Suicide Tourist, the patients chose to end their life directly, either by their own hand, or potentially with assistance from others. In the same vein, but less overt, the patient in Cost of Dying: One nurse's end-of-life choice was surprisingly simple - and liberating opted for Hospice, foregoing invasive treatments that would have potentially extended her life. In each of the scenarios, the underlying motivation given was a desire for control and the fear of losing their dignity, two concerns often stated interchangeably. 

Ironically, the ideology behind PAS and Hospice are surprisingly similar, although the mechanisms for preserving the patient's dignity are markedly different. In fact, they are so similar that the motto for Hospice is Death with Dignity, while the name of Oregon's PAS law is the Death with Dignity Act. Many argue that PAS and Hospice are not mutually exclusive, as Oregon has both PAS and an excellent reputation for Palliative and Hospice Care. On the surface, it would appear that allowing both options provides the greatest amount of autonomy for all concerned. In a bizarre twist, however, those suffering from progressive, disabling, chronic but non-terminal disease, those who have a terminal disease but are severely physically handicapped and those who do not have capacity can all cry foul. For these patients, PAS is not an option, as two of the requirements under current US law are that the patient must have decision-making capacity and must be able to ingest the lethal medication without assistance. 

With these thoughts in mind, please discuss the following:

A.What does it mean for a person to have dignity, and is it something that we give away or something that is taken away? Neither? Both? 
B.Do you agree with Craig Ewert's decision? Why or why not? Support your answer beyond only giving an opinion. 
Compose your work using a word processor and save it, as a Plain Text or an .rtf, to your computer. When you're ready to make your initial posting, please click on the "Create Thread" button and copy/paste the text from your document into the message field. Be sure to check your work and correct any spelling or grammatical errors before you post it.

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M5D2: Blurry lines: PAS, Euthanasia and Palliative Sedation Module 5


Palliative Sedation is a medical treatment used to treat intractable pain in terminally ill patients. The intent, both ethically and legally, is to alleviate pain that is not manageable by any other means. The intent is NOT to end the patient's life. Moreover, Palliative Sedation is not a paternalistic practice; a doctor cannot order Palliative Sedation without the consent of the patient or the patient's surrogate. The strict standards are probably somewhat akin to "requiring" a patient to sign a DNR. Such a practice is not only ethically ill-conceived, it is legally forbidden. 

In the Netherlands, though not in the US, Euthanasia--the act of injecting a lethal dose of medication intentionally to end a patient's life-- is condoned legally and ethically. Nevertheless, there as here, there is growing concern that the line between Palliative Sedation and Euthanasia has grown increasingly blurry. Many are concerned that the permitted practice in the Netherlands of both procedures has led to a loose interpretation and a lax attitude in terms of consent, leading to involuntary Euthanasia.

Contributing to the fear, requests for Euthanasia in the Netherlands increased 40% between 2005 and 2010. (Olsen, 2010). There is also a significant increase in the number of doctors willing to perform Euthanasia. Of concern is that the increase in the number of deaths appears related to physicians inappropriately inducing continuous deep sedation with the intention of inducing death, in direct contrast to the legal requirements for administering palliative sedation for pain control. Equally concerning is that the practice, under the misunderstood guise of Palliative Sedation is being performed without consent. 

Read the following and then proceed to the discussion:

•Module notes and textbook pages 
•CELLARIUS, V. (2011). 'Early terminal sedation' is a distinct entity. Bioethics, 25(1), 46-54. 
•Olsen, M.L. MD, et al, Ethical decision making with end-of-life care: Palliative Sedation and Withholding or Withdrawing Life-Sustaining Treamtents, Mayo Clin. Proc. 2010 October (85):10 949-954. 
Please read the short scenario and respond to the following problem:

An 85-year old terminal patient with stage IV cancer and virtually intractable pain undergoes surgery to remove a malignant mass pressing on his spinal cord. Although the hope is that the surgery will stave off paralysis and relieve his pain, there is a good chance the patient will die during or immediately following surgery.

•Is this scenario ethically equivalent to the rationale behind Palliative Sedation? Why or Why Not? Please describe your response, using the ethical theories and principles we have discussed throughout the course as appropriate. 
Compose your work using a word processor and save it, as a Plain Text or an .rtf, to your computer. When you're ready to make your initial posting, please click on the "Create Thread" button and copy/paste the text from your document into the message field. Be sure to check your work and correct any spelling or grammatical errors before you post it.

Your work will be evaluated using the SHS Discussion Rubric. 

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