NURS 3225 Study Guide - Final Guide: Legal Guardian, Persistent Vegetative State, Elder Abuse
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Note- ** You may be required to write out this information in a fill in the blank question, rather than merely recognize it
to answer a multiple choice question.
Aging and Introduction to End of Life
Laws related to HIV testing and results
• No longer need separate consent but pts can opt out
• Medically emancipated condition so minors can be tested w/o parental permission
o Minors- may be tested w/o parent consent but HCP needs to counsel about informing
• Nonconsensual testing can be required in cases of accidental exposure, prisoners, etc;
o Nonconsensual testing allowed if:
▪ Donor in occupational exposure
▪ Pt. unable to consent
▪ Prisoners
▪ By court order
• Duty to warn contacts MAY apply if pt. refused to inform partners
o A fellow resident of a nursing home having unprotected sex with a HIV positive partner?
o Someone sharing needles with their spouse?
o ? reasonable belief of transmission risk?
o Have attempts to have pt tell the partner themselves failed?
o Was pt warned public health offical or physician would tell if they didn’t?
o Are they both under MD’s care??
o Try not to disclose identity of infected individual
o Only Physicians & public health officials!!
Aging and End of Life
• Trends in today’s society
o Although the number of human life years has been extended, questions remain about how the quality of those
years is threatened by chronic debilitating conditions, ageism, and limited support and resources for elders and
their caregivers
• Erikson’s 9th stage added
o The ninth stage of the life cycle is a time that elders develop to some degree either despair and disgust or
integrity
o Developed by his wife- Very old age- Gerotranscendence
o Still integrity vs. despair
o But termed Involvement vs. Resignation
▪ Stop new activities- “no point in even trying”
▪ Courage needed at this time
Ageism
▪ Stereotyping and discrimination against older adults based on age
o Has influenced some people within society to view elders as fundamentally different from others
Paternalism
▪ Occurs when a healthcare professional makes choices for a patient based on the healthcare professional’s beliefs about
what is in the best interest of the patient or what is best for the patient’s own good
Elder abuse (physical, emotional, sexual or neglect, self- neglect as well as financial or material exploitation)
▪ The moral care of elders requires nurses to be interested in recognizing the signs of abuse and in taking appropriate
actions
▪ Elder abuse includes:
o Physical abuse
o Sexual abuse
o Emotional or psychological abuse
o Neglect
o Abandonment
o Financial or material exploitation
o Self-neglect
Quality of Life – subjective
• Which tend to be lower? - Personal or observer evaluation??
•
Death anxiety
▪ “Dread of death that resides in the unconscious, a dread that is formed early in life at a time prior to the development of
precise conceptual formation, a dread that is terrible and exists outside of language and image”
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Imaginative dramatic rehearsal of death
▪ A person can imagine one’s own death by reconstructing the ideal death scenario; on continued reflection, may later
discover a rich meaningful experience through this imagination
Determining decisional capacity (criteria by Appelbaum in slides)
• Sometimes referred to as having “Moral agency” (ability to make deliberate choices & decisions for oneself, Butts p.
248)
o Assessment of patients’ competence to consent to treatment
o Ability to make deliberate choices and to act deliberately in regard to important life experiences affecting the
suffering and well-being of sentient beings, including oneself
▪ Implies that people are responsible for their beliefs and actions
• Criteria for determining decisional capacity include the person’s ability to
o 1) Communicate a choice
o 2) Understand the relevant information
o 3) Appreciate the situation and its consequences
o 4) Reason about treatment options
Human Suffering
▪ Human suffering can be connected to many episodes, contexts, or events, but a large part of the literature is associated
with chronic disease and illness or dying patents and their families
▪ Suffering
o Is a perceived undesirable inner experience that could threaten the whole existence of being, yet it is a necessary
element of life, as are joy and happiness
o Involves the whole person and body
End of Life Phase
▪ “A phase of life when a person is living with an illness that will worsen and eventually cause death”
Terminal condition
▪ “Means the final stage of an incurable or irreversible medical condition which, without the administration of a life support
system, will result in death within a relatively short time period, in the opinion of the attending physician.”
Persistent Vegetative State vs Permanent Vegetative State (after 1 year for adult, 2 yrs. for kids)
▪ Persistent Vegetative State
o A clinical condition of complete unawareness of the self and the environment accompanied by sleep wake cycles
with either complete or partial preservation of hypothalamic and brainstem autonomic functions
o American Academy of Neurology
o Do have some spontaneous movement but not purposeful
▪ Is persistent if present at one month after acute traumatic or non-traumatic brain injury
▪ Permanent vegetative state adds the dimension of irreversibility to the definition
Advanced Directives – 2 different types
1. **Living wills- Restricted to 2 conditions only terminal conditions or permanently unconscious
o Applies to life support and Artificial H & N but not stopping pain meds or normal food/drink
2. Appointing of a Health Care Representative (HCR)
o (Or Durable power of attorney, term for the document NOT the person)
o Applies any time you lack capacity or can’t communicate preferences
o A written paper appointing a specific person
o Much broader- can make all health care decisions for you (except stopping oral feedings or pain meds)
Patient Self Determination Act of 1990 – requirements for hospitals??
• Outlines process of Advanced Care Planning (ACP)
• Federal law that all states must protect individuals rights to make decisions about end of life
• All hospitals must ask about Advanced directives on admission
Hierarchy for Next of Kin (if no HCR)- Spouse, Adult son or daughter,……
1. The spouse of the patient
2. An adult son or daughter of the patient
3. Either parent of the patient
4. An adult brother or sister of the patient
5. A grandparent of the patient
Standards used by Surrogate Decision Makers
• Pure Autonomy standard- follow person’s known wishes: based on a decision that was made by an autonomous
patient while competent but later drifts to incompetency
• Best Interests Standard: evaluation of what is good for an incompetent patient in particular health care situations when
the patient has probably never been competent
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• Substituted Judgment: used to guide medical decisions for formerly competent patients who no longer have any
decision-making capacity
Terms for HCR appointed by court depending on type of person:
• Conservator: Person appointed by probate court when someone becomes incapable of caring for themselves and/or
making decisions for themselves
o You can name someone in advance
o They must still follow your wishes expressed in your living will
• Plenary Guardian: A plenary guardian of an adult with mental retardation.
o A person, legally authorized state official, or private, nonprofit corporation appointed by a Probate Court
o Role is to supervise all aspects of the care of an adult person who, by reason of the severity of his or her mental
retardation, is “totally unable to meet essential requirements for his or her physical health or safety” and “totally
unable to make informed decisions about matters related to his or her care.”
• Guardian Ad Litem: A person appointed by the court during any proceeding in which a minor child, undetermined or
unborn or class of such person or a person whose identity or address is unknown, or an incompetent person is a party, to
represent and protect the interests of such parties.
o A lawyer appointed as “guardian ad litem” for a child is an officer of the court appointed to protect the child’s
interests without being bound by the child’s expressed preferences.”
Artificial Hydration and Nutrition (AH & N)
• No ethical distinction between withholding and withdrawing care anymore, or extraordinary or ordinary measure
o However, Catholic bishops do still distinguish between extraordinary and ordinary means
o Okay to withhold AH&N in PVS or terminal pt. when it only prolongs life
▪ However in pts. with other chronic conditions, providing food and water to the disabled is an ethical
obligation
• Decision based on Proportionality of benefits vs. burdens
o Benefit
▪ Subjective determination
▪ Made by the patient or surrogate
▪ Assessment of value and desirability
o Burden
▪ Subjective and objective determinations
▪ Made by both patient and physician
▪ Cost
▪ Comfort, discomfort
▪ Pain
▪ Inconvenience
▪ Quality of life assessments
• Courts decided AH & N can be refused just like any other medical treatment (Cruzan case)
End of Life Continued
• Right of Refusal vs. Withdrawal of Care (by pt., next of kin, or HCR)
o Famous Cases of Persistent Vegetative State (recognize names and know significance of each)
• Karen Quinlan
o 21 y.o, lapsed into a coma after collapsing at a party after ingesting multiple drugs
o On a ventilator & Parents requested removal from vent
o Physicians refused because she wasn’t “brain dead”, rather is a coma
o Supreme court of NJ ordered vent removed
o However, she survived 10 years until died from pneumonia
o Established 3 precedents regarding Withdrawal of Life Support
▪ 1. Parents and legal guardians have the right to refuse medical treatment
▪ 2. Lead to definition of PVS
▪ 3. Lead to formation of ethics committees in most Health care settings
▪ 4. Lead to push for Advanced Directives
• Nancy Cruzan
o 1983 Injured in MVA – CPR on Scene
o Due to TBI in a PVS
o Nutrition via gastrostomy tube, parents wanted GT removed, hospital refused
o 1985 Missouri Probate Court ordered the tube removed as petitioned by her parents claiming on several occasion
she had expressed such wishes
o Gastrostomy feedings were life-sustaining NOT medical treatment
o Request to d/c feeding tube granted on 12/14/90, 7 i/2 years post accident
find more resources at oneclass.com
find more resources at oneclass.com
Document Summary
Note- ** you may be required to write out this information in a fill in the blank question, rather than merely recognize it to answer a multiple choice question. Resignation: stop new activities- no point in even trying , courage needed at this time. Ageism: stereotyping and discrimination against older adults based on age, has influenced some people within society to view elders as fundamentally different from others. Paternalism: occurs when a healthcare professional makes choices for a patient based on the healthcare professional"s beliefs about what is in the best interest of the patient or what is best for the patient"s own good. Dread of death that resides in the unconscious, a dread that is formed early in life at a time prior to the development of precise conceptual formation, a dread that is terrible and exists outside of language and image .
