Alternatives: List alternative solutions and develop multiple plans in parallel. Assessment: assess possible solutions according to historical moral/ethical theoretical frameworks. Identify and prioritize stakeholders affected by decision. Perform risk analysis if appropriate Action: Decide on plan of action; keep alternate action plans under consideration, adjust and adapt plan as new information comes to light or flexibility is needed to consider new options. In this course we will use a didatic approach known as The 4A s (Budinger & Budinger, Chapter 1):
Lecture 1 Diagnosis of Persistent Vegetative State The American Academy of Neurology (AAN) defined the PVS standard : did Karen Quinlan fit the bill? •No evidence of awareness of self or environment and an inability to interact with others 㾎•No evidence of sustained, reproducible, purposeful, voluntary behavioral responses to visual, auditory, tactile, noxious stimuli㾎? •No evidence of language comprehension or expression 㾎•Intermittent wakefulness manifested by the presence of sleep-wakecycles㾎•Sufficiently preserved hypothalamic and brainstem autonomic functions to permit survival with medical and nursing care㾎•Bowel and bladder incontinence㾎? •Variably preserved cranial nerve and spinal reflexes. 㾎
Lecture 1 Was Karen Quinlan Dead or Alive? What is the Definition of Death? Death is generally considered as the separation of the soul and body; in which sense it stands opposed to life, which consists in the union thereof . Historically this was (typically) determined by cessation of respiration and heartbeat. Karen Quinlan s case made clear that for the first time, breathing and heartbeat could be maintained indefinitely using life support technologies. Therefore focus became brain activity, and throughout the 1970 s and early 1980 s there was much debate of whether to define death by whole-brain versus cerebral criteria.
Lecture 1 What is the Medical Definition of Death? Cognitive Definition : Loss of higher order brain function: reason, memory, and self-awareness. Could still have a functioning brain stem (and therefore still have respiration and heartbeat). Harvard Definition of Brain Death (1968, ): "irreversible unconsciousness with complete loss of brain function," including brain stem. Diagnosed as fixed/dilated pupils, no eye movement, absence of respiratory reflexes, unresponsiveness to pain, total lack of electrical activity in the brain by 2 EEGs taken 24 hours apart. Uniform Determination of Death Act (1994, ): Endorsed more conservative position of the Harvard definition: person is not dead until all brain functioning has cease. Further evidence that patient has experienced a disease or injury that could cause brain death, and not due to origins that may mimic brain death such as hypothermia or drug toxicities (English literature example?).