THE SOUL OF BIOETHICS (Jan. 15, 2003) Edited by H.R. Moody - Is Openness an Orthodoxy? - This Just In From Down Under - Partial DNR Orders: A Case Study - Bibliography on Ethics and Aging - Old Age Suicide, Assisted or Not - RWJ Report on Dying in America - Ethics of Hospital Discharge Planning - Web Seminar: Ethical & Legal Issues - Lessons of Illness ====================================================== IS OPENNESS AN ORTHODOXY? Letter from a Subscriber I am writing in response to last month's article about a daughter, Sylvia, who has not told her mother that she has Alzheimer's, and who is now involved with a home care agency that is open about such matters as a matter of policy. You state it as an ethical dilemma, but if it is one there is a strong bias against Sylvia's choice. Lack of openness is neither a sin nor a crime so that Sylvia now "has a strong burden of proof to defend her reason because she has involved the home care agency in her conspiracy." (your words). A conspiracy--really? Not a family pattern or an active choice? Why should the agency not have the burden of proof, especially since I bet mother and Sylvia don't have many options to go elsewhere? Sylvia has already been labeled a serious transgressor against what seems to be an orthodoxy of openness. It's not an ethical dilemma to the agency if they see no value in her approach. I do think all of us who are pro-openness in our personal or professional lives have to be careful how we promote it, or don't, particularly with those who are dependent on us. An insistence on openness can be coercive. And there are some studies raising questions about whether openness is all it's cracked up to be. Women with breast cancer don't live any longer if they're in support groups. In cancer treatment generally a person does as well physically if "in denial" (focusing on life, maybe?) as one who visualizes, is in a support group, etc. The key is that the treatment be consistent with the patient's values and personality. Openness is an important value, not an absolute value. Julia Spring, MSW, JD For the original case study "Who Is Sylvia?" see: http://www.hrmoody.com/backissues/soulbio/Dec02.txt See also "Not Telling Bad News" available at: http://www-hsc.usc.edu/%7Embernste/BIOETHICAL_DILEMMA4.HTML ----------------------<<< >>>------------------------ THIS JUST IN FROM DOWN UNDER Just when you thought it was safe to travel to Australia... A promoter of voluntary euthanasia from Australia has developed his own new "suicide machine" to enable people to end their own lives with a quick breath of carbon monoxide. Dr. Philip Nitschke, founder of Australian group known as EXIT, plans to sell his machine to members of his own organization. But Dr. Nitschke has a special message for elders: "The commonest way people die over the age of 75 in our society is by hanging themselves," he told journalists, arguing that there ought to be a better way. Dr. Kevorkian is in jail in Michigan and apparently didn't take out a patent on his own machine. Is it imitation or independent invention? To read more, visit: http://www.internationaltaskforce.org/austr.htm Editor's Comment. Isn't it reasonable to ask why we can't come up with something other than clever technological alternatives in response to whatever prompts people over 75 to hang themselves? Maybe better palliative care, psychotherapy, even friendly visiting? Just wondering. (HRM) ----------------------<<< >>>------------------------ PARTIAL DNR ORDERS: A Case Study The Committee at Winthrop University faced the case of a 71-year old man with congestive heart failure and chronic obstructive lung disease. A tracheostomy was placed for airway protection and he was periodically attached to a mechanical ventilator for episodes of mucous plugging and exacerbations of heart failure. He desired every treatment, including mechanical ventilation, if in, his physician's estimation, the intervention would allow him an acceptable quality of life. He did not, however, wish cardiac resuscitation, so a "no cardiac" resuscitation order was written. Preliminary Analysis and Questions The committee found that a partial DNR order is a seriously limited mechanism for communicating in the medical record with other health team members. The cardiac order inadequately transmitted the patient's treatment preferences because the order implied use of mechanical ventilation irrespective of both the cause of respiratory insufficiency and the likelihood of receiving the quality of life the patient desired. Furthermore, such an order might be interpreted as prohibiting cardioversion for some life-threatening arrhythmias, irrespective of likely treatment outcome. The committee concluded that a supplemental directive was needed and set out to develop one. What are the ethical issues involved in creating a partial DNR order in cases such as this one? What information would be necessary for a sufficient order? How does a medical team identify such information? How does an ethics committee develop a structured progress note to address life-threatening conditions in patients with DNR orders? Presented by Jeffrey T. Berger, MD, FACP, Director of Clinical Ethics, Department of Medicine, Winthrop University Hospital. This case is from the forthcoming Bioethics Grand Rounds: Ethics of Partial "Do Not Resuscitate Orders" and the Development of a Structured Progress Note Addressing Life Threatening Conditions in Patients with DNR Orders. Sponsored by the Metropolitan New York Ethics Network at the New York Academy of Medicine. For more information on attending the Bioethics Grand Rounds event contact Lauren Collogan at (212) 822-7222 or email at: lcollogan@nyam.org ----------------------<<< >>>------------------------ BIBLIOGRAPHY ON ETHICS AND AGING Don't miss the outstanding suggested reading list for the course "AGING AND ETHICAL ISSUES" (Revised January 2, 2003) which is available at: http://www.uvm.edu/~scutler/soc222/?Page=ethics.html ----------------------<<< >>>------------------------ OLD AGE SUICIDE, ASSISTED OR NOT A notable case of assisted suicide was recently reported from France. "I'm 92 and It's Time for Me to Leave" proclaimed a letter from Mireille Jospin, 92-year-old mother of former Socialist Prime Minister Lionel Jospin. In her note she explained why she ended her own life recently. Her act has been cited as part of a campaign to legalize euthanasia, which Madame Jospin called "the peace of the body in its time." For details, see: http://www.observer.co.uk/international/story/0,6903,860228,00.html In another similar case a Dutch physician was found guilty of aiding an assisted suicide of an 86-year old man who suffered from no ailments but was "tired of living." For details, see: http://news.bbc.co.uk/1/hi/world/europe/2603709.stm Old age suicide is, literally, a staggering problem of global proportions. A recent report from the World Health Organization indicates that, on a global basis, violence kills 1.6 million people every year. About half those deaths are suicides and three times as many people over age 75 kill years themselves as 15-24 year olds. ----------------------<<< >>>------------------------ RWJ REPORT ON DYING IN AMERICA The Robert Wood Johnson Foundation has issued a report on dying in America, MEANS TO A BETTER END. Among the key findings: Only 25% of Americans die at home, although over 70% of Americans say that's where they would prefer to end their days In any given state, at least one in four nursing home residents experiences pain for at least two months without proper pain management Specialists agree that 95% of serious pain can be effectively treated, but half of all dying patients experience serious pain 35 states require NO mandatory forms and NO specialized language in order to complete advance directives. People can state their own wishes in their own way. ----------------------<<< >>>------------------------ ETHICS OF HOSPITAL DISCHARGE PLANNING What do you do if managed care demands that an elderly patient be discharged under circumstances that threaten that patient's quality of life?the value"civil disobedience" an option? For a discussion of thevalue dilemmas posed by these cases,see "Hospital Discharge Planning: Carrying Out Orders?" available in full text at: http://www.hrmoody.com/art2.html ----------------------<<< >>>------------------------ WEB SEMINAR: LEGAL & ETHICAL ISSUES "Legal and Ethical Issues of Aging" is a new Web Seminar produced by the American Society on Aging. The Seminar includes 3 one-hour sessions broadcast over the World Wide Web featuring Faculty Marshall Kapp, JD, Professor of Geriatric Medicine and Gerontology at Wright State University. This "On Demand" Web seminar is available 24 hours a day, 7 days a week starting Feb. 10, 2003. Continuing education credit is available for nurses, nursing home administrators, social workers, care and case managers, counselors, and other professionals. Additional web seminars include "The Secrets of Aging: Body, Mind, Longevity and Society," "End-of-Life Issues," and "Culture Change in Long-Term Care." For more information on cost and registration for all web seminars, visit: http://www.asaging.org/webseminars/ ----------------------<<< >>>------------------------ LESSONS OF ILLNESS "The moral lesson illness teaches is that there are undesired and undeserved pains that must be lived through, that beneath the facade of bland optimism regarding the natural order of things, there is a deeper apprehension of a dark, hurtful stream of negative events and troubles. Change, caprice, and chaos, experienced in the body, challenge what order we are led to believe-- need to believe-- exists. Disability and death force us to reconsider our lives and our world. The possibility for human transformation, immanent or transcendent, sometimes begins with this disconcerting vision." -Arthur Kleinman, THE ILLNESS NARRATIVES ----------------------<<< >>>------------------------ The Project on Dying in America has awarded $1 million for Palliative Care Fellowship Programs. For details, see: http://www.fdncenter.org/pnd/news/story.jhtml?id=21300026 ----------------------<<< >>>------------------------ ETHICS IN AN AGING SOCIETY (Johns Hopkins Univ. Press, 1992, paperback, 1995). The first single author monograph on bioethics and aging, including issues of suicide, Alzheimer's Disease, autonomy in long term care and justice between generations. Application of the Critical Theory of Jurgen Habermas to applied ethics. For details on the book, visit: http://www.press.jhu.edu/press/books/titles/s96/s96moet.htm xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx This electronic newsletter, edited by Harry (Rick) Moody, is published by the Institute for Human Values in Aging with the support from the Robert Wood Johnson Foundation. 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