1. Death Inevitable No, you are not invincible Yes, even at your age, people die Example Binge drinking and alcohol poisoning Obligation to Extend life Define death

2. Definitions of Death Technological—process versus event Medical Social Whole brain definition Higher brain function definition Cardiac definition

3. Whole Brain Neurological/technical definition Requires MD/coroner ACLS standard as an aside in acute settings Not workable in Settings of futility of treatment AND organ donation situations/settings where vents are present Integrated functions versus primary organ function

4. Higher Brain Definition Solves the donation/futility problems Requires standards of what higher function IS Much more social and societal a definition that is socially constructed around the concepts of quality of life—a concept that is very difficult to define and defend What does personhood Mean?

5. Policy in Higher Brain Formulations Who decides What criteria Ethics committees Qualifications to decide Is it best to allow OUTSIDE decision-makers Advanced directives Medical Futility

6. Cardiac Death Vital signs have stopped Required actions by MDs to restart the vital signs Standards are social and scientific Death as a process

7. Modern issues Suicide DNRs Medical benefit/futility Quality of life Euthanasia Death with dignity (Oregon)

8. Decisional Capacity Competency exams Defining competence Who decides Decision-relative ideas Who is competent—communication, reasoning and deliberation Alcohol, suicide, drugs, mental incapacity

9. Competence Depends on the situation and no one standard fits all situations Related to the concept of consent in medicine Implied consent Prior discussion Evidentiary standard—reasonable man

10. Advanced Directives CPR Directives Surrogate Medical Power of Attorney or POA for medical decisions Living wills Terms to be executed should certain criteria be met and the person can no longer legally speak for self/legally binding on the medical and non-medical community IF

11. Scenario 47 year old female with terminal cancer in the last stages Has living will and advanced directives Found unconscious by home health aid 911 call What do you do? No evidence of documents/call to doctor/suicide?/resuscitate or not/relative and POA indecisive or obstructionist

12. Proxy Decision Makers Bound by statute Bound by person Must accept responsibility Only person that can decide when the person in question meets the criteria of lack of decisional capacity What if this is not done? Who decides?

13. In re Claire Conroy Incapacitated person with multiple chronic debilitating illness—bed ridden Aphasic, minimal movements, smiled (lower brain function) Not brain dead, comatose or vegetative Feeding tube at issue

14. Conroy Case on the borders Social and legal issue Life-sustaining to tube feed her Quinlan standard—what did the person want, how do we know? / placed in the position of prior competence Trustworthy evidence that the patient in this situation would have refused treatment

15. Personal Decision Making The legal standard is that of personal CONTROL over decisions on care MUST be fully and clearly stated to be valid Subjective standard What if no clear statement?

16. When Does this Come Up? Congenital malformations Mental incapacity Trauma Old age/dementia Parkinsons and age/neurodegenerative disorders (Tuesdays with Maury)

17. Summary Personhood and rights Technology makes the issues harder Capacity Prior discussion Legal implications Can you in a similar situation plan your own way of dying—even at your age?

18. You and death What needs to be done? Think first, describe circumstances in your own mind that admit your mortality and defend your right to decide Trust one other person to make that happen Make a formal written and legally binding document Inform your social networks of the decision and who can decide for you Update it frequently as situations change