The confluence of the factors of greater life expectancy, causes of death precipitating longer periods of disability and dying, and removal of death and dying from the home and the care of families to institutions have produced an unprecedented need to rebuke the unbridled use of life-sustaining technologies. As ethical debate has arisen over the last three decades, two opposing approaches have been used to treat dying patients: either to prolong life or allow patients to die by refusing life-sustaining treatments. A significant reason for the latter was a realization that treatment to prolong life was standard and virtually always utilized and that death was even considered to be the enemy of medicine. Of course, prior to this century, physicians had fewer therapies from which to choose in their efforts to prolong life. As more options became available and technologies, such as respirators and dialysis machines, became widespread, health care professionals, as well as patients and their families, came to face the question of whether some therapies should be used, refused, or limited. A landmark discussion on these issues by the President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research bore the title Deciding to Forego Life-sustaining Treatment (1983).
Many essays and books defined the ethical debate in terms of active and passive euthanasia or distinguished killing from allowing to die (Bayles & High, 1978; Ladd, 1979; McCormick, 1974; President's Commission, 1983). Health care professionals and ethicists frequently employed and debated distinctions between acts and omissions that may lead to an early death; between withholding and withdrawing care; between an intended death and one that was merely foreseeable; or between ordinary and extraordinary means. Many health care professionals and ethicists thought that if such distinctions were carefully employed, then most ethical decisions on whether to prolong life or forgo life-sustaining treatment could be made.
It took more than a decade for health care professionals and ethicists to realize that such distinctions did not settle the moral quandaries of caring for terminally ill patients. While such distinctions may have a usefulness, albeit a limited one, what has emerged as more important is the reasoning and ethical deliberation behind the distinctions. For example, the ethics of what should be done in the care of a terminally ill person is not settled by labeling a treatment as extraordinary even if it is presumed that extraordinary treatment can be forgone. More important is the issue of why any treatment labeled extraordinary could be forgone. The highly publicized case of Karen Ann Quinlan, whose death came in 1985 nearly a decade after she was removed from a respirator, following a series of New Jersey court decisions, raised fundamental ethical issues concerning the reasons for actions (In the Matter of Karen Quinlan, 1975). Among them, the case caused serious rethinking of what should be done for patients with per manent loss of consciousness and medical responsibility toward those patients who are ''hopelessly ill.'' In 1984 the New England Journal of Medicine published a remarkable article authored by ten experienced physicians from various disciplines and institutions on ''The Physician's Responsibility toward Hopelessly Ill Patients'' (Wanzer et al., 1984). The article not only affirmed the patient's right to refuse life-sustaining treatment, but acknowledged the physician's obligation to advise patients on end-of-life decisions and respect the wishes of patients, whether expressed at the time or by advance directive. The article took stands on providing appropriate care to both competent and incompetent patients. It argued that differences in patients' disabilities and illnesses should be a primary consideration in determining the form and intensity of care to be provided or withheld.
To focus our attention in this chapter on the elderly and their families is especially important since death occurs more at older ages and older people are at greater risk of terminal illnesses and dementing diseases than are younger people. As a result, elderly persons are more likely to become candidates for life-sustaining treatments as well as to face decisions to refuse such treatments. Consequently, decisions to withhold or withdraw life-sustaining treatments directly affect older people more frequently than younger people. Such decisions and other care decisions are likely to come at a time when cognitive impairment is present due either to a terminal illness, unconsciousness, or dementia. When one or more of these impairments occur, consent to or refusal of treatment must be made by someone other than the patient. Prior to the extensive use of life-sustaining technologies, families were typically called upon to make such decisions, or, alternatively, very few end-of-life decisions were made since short-term terminal illnesses left little time for long-term-care planning and decision making.
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