4 questions | Applied Sciences homework help

1. Seely DR and others. Ear candles: Efficacy and safety. Laryn- goscope 106:1226–1229, 1996.

Coping with Death It is a myth to think that death is only for the old. Death is there from the very beginning. Herman FeiFel1 Most Americans have difficulty accepting death as a normal physiological process. In the current system of care many dy- ing persons suffer needlessly, burden their families, and die isolated from family and community. ama CounCil on SCientiFiC aFFairS2 No technology is available or even foreseeable that will make immortality possible anytime in the lives of anyone reading this, or their kids, or their kids’ kids. Live a lot longer? Maybe. Live forever? Not a chance anytime soon. artHur l. Caplan, pHD3 Chapter Twenty-One

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• The burden of death may be eased by understanding the emotions involved and planning ahead to deal with various issues that pertain to dying.
• An advance directive can help people control what care they receive when terminally ill.
• Hospice care is worthwhile for many terminally ill individuals and their families.
• Most decisions about purchasing funeral products and services are made by people who are grieving and under time constraints. Some providers take advantage of this situation by selling services that are unnecessary or overpriced. Alternative arrangements to the traditional funeral can be dignified without being costly.
• Many products are marketed with false claims that they can help extend life or slow biologic aging.

Keep these points in MinD as You stuDY this Chapter Key Concepts Figure 21-1. Wallet card for advance directive. The name and address of the signer’s physician and location of the advance directive are noted on the reverse side. Death and bereavement are inevitable aspects of human experience that present significant emotional and financial challenges. This chapter offers information to help you make intelligent decisions about preparing an advance medical directive; viatical settlements; care of the terminally ill; euthanasia and assisted suicide; donating body parts; autopsies; body disposition arrangements; and coping with grief. It also analyzes products and services promoted for life exten- sion and “anti-aging.” Additional preparation for the inevitable should include estate planning (including a will and life insurance) and other financial matters that are beyond the scope of this textbook. aDvanCe DireCtives Consumer Reports on Health4 has stated that the need to prepare for death is pressing because machines often can keep a seriously ill or permanently unconscious patient alive, sometimes indefinitely, with no hope of recovery. However, people do have certain rights to refuse treat- ment. Anyone 18 years or older who wishes to invoke the right to refuse medical treatment should prepare an advance medical directive, which may be a living will, a durable power of attorney for health care (DPAHC), or a combination of the two. A living will—also called a health-care directive—is a document in which a person states whether artificial life-support procedures such as a respirator or intra- venous feeding should be used if the person becomes terminally ill (as defined by state law) or is too sick (e.g., in a coma) to communicate treatment preferences. A durable power of attorney—also known as a health- care power of attorney or health-care proxy—designates another individual (proxy), usually a family member or intimate friend, to make treatment decisions when the patient cannot. Living wills are advantageous because they enable people to specify what they want done. However, a very specific document may not provide guidance for situa- tions that were not anticipated, and a broadly written document may not be clear about actual situations. The DPAHC enables the signer’s agent to make decisions not covered by a living will and to discuss the situation with the patient’s doctor. Its major disadvantage is that there may not be anyone with whom the signer feels comfortable as an agent. Experts advise preparing both documents and mak- ing sure that one’s family and physician are aware of them. Many states provide model forms, and a few states require their use if people wish to execute an advance directive. Forms are also available to patients in hospitals and in long-term-care facilities. Although not required, it is prudent to review one’s advance directives with an attorney and to do so far ahead of the time they are likely to be needed. The American Medical Association (AMA)5 advises that if a state form seems too restrictive, an alternative form can be followed. However, it is advisable to be sure that the form and witnessing procedure comply Chapter Twenty-One Coping with Death 439

DECLARATION

I, ____________________________________, being of sound mind, willfully and voluntarily make this dec- laration to be followed if I become incompetent. This declaration reflects my firm and settled commitment to refuse life-sustaining treatment under the circumstances indicated below. I direct my attending physician to withhold or withdraw life-sustaining treatment that serves only to prolong the process of my dying, if I should be in a terminal condition or in a state of permanent unconsciousness. I direct that treatment be limited to measures to keep me comfortable and to relieve pain, including any pain that might occur by withholding or withdrawing life-sustaining treatment. In addition, if I am in the condition described above, I feel especially strongly about the following forms of treat- ment: I ( ) do I ( ) do not want cardiac resuscitation. I ( ) do I ( ) do not want mechanical respiration. I ( ) do I ( ) do not want tube feeding or any other artificial or invasive form of nutrition (food) or hydration (water). I ( ) do I ( ) do not want blood or blood products. I ( ) do I ( ) do not want any form of surgery or invasive diagnostic tests. I ( ) do I ( ) do not want kidney dialysis. I ( ) do I ( ) do not want antibiotics. I realize that if I do not specifically indicate my preference regarding any of the forms of treatment listed above, I may receive that form of treatment. Other instructions: _________________________________________________________________________ ____________________________________________________________________________________________ I ( ) do I ( ) do not want to designate another person as my surrogate to make medical treatment decisions for me if I should be incompetent and in a terminal condition or in a state of permanent unconsciousness. Name and address of surrogate (if applicable): _______________________________________________________________________________ Name and address of substitute surrogate (if surrogate designated above is unable to serve): ____________________________________________________ I made this declaration on the ____ day of ________, ____. Declarant’s signature: _______________________________ Declarant’s address: _______________________________________________________________________ The declarant or the person on behalf of and at the direction of the declarant knowingly and voluntarily signed this writing by signature or mark in my presence. Witness’ signature: ______________________________ Witness’ address:________________________________ Witness’ signature: ______________________________ Witness’ address:________________________________ Figure 21-2. Sample form for advance medical directive and living will combination. Part Five Other Products and Services440 with state law. Figure 21-1 illustrates a wallet card for indicating where your advance directive can be located. Figure 21-2 illustrates a simply worded living will and DPAHC combination. A study of more than 9000 hospital patients found that “do not resuscitate” (DNR) orders were not written promptly, many patients still died in pain in intensive care surroundings, and most of the doctors seemed to misunderstand their patients’ wishes to forgo futile medical procedures.6 DNR orders can be written by the attending physician in accord with the wishes of the patient or—if the patient is incompetent—those of the patient’s designated surrogate or next-of-kin. (An incom- petent patient is one who is too ill to communicate or to comprehend the situation.) But the designated person may need to be watchful and assertive. In many states, doctors can get relevant patient- management forms through a POLST Paradigm program (www.ohsu.edu/polst/index.htm). Federal Law The federal Patient Self-Determination Act (1990) applies to hospitals, nursing homes, hospices, health maintenance organizations, and home health-care agen- cies that receive Medicare or Medicaid funding. The law provides that when a person is admitted to a health facility, the medical staff must:

• Inform the individual of the facility’s policy on implement- ing advance directives.
• Provide all adults with written information about their rights under state law to accept or refuse treatment and to execute advance directives.
• Make the person’s living will or advance directive part of the person’s medical record.
• Take no discriminatory action because of any decision regarding life-sustaining medical treatment.

Guidelines for Physicians The AMA Council on Ethical and Judicial Affairs7 states that it is ethical to stop or withhold life-support treatment to let a terminally ill patient die, but that a physician should not intentionally cause death. The council also has ruled that when the duty to prolong life conflicts with the duty to relieve suffering, the physician, the patient, and/ or a surrogate decision-maker (usually a family member) have discretion to resolve the conflict. In 1988 participants in a landmark international conference proposed guidelines to help physicians deal ethically with issues related to forgoing treatment. They concluded that physicians should (a) feel morally obligated not to inflict harm or risk harming others; (b) respect patients’ choices selected according to their own conscience, values, and religious convictions; and (c) act fairly and justly in allocating scarce resources. The other guidelines included: For patientS witH an aDvanCe DireCtive wHo beCome inCompe- tent: If the advanced directive states that the patient does not want certain treatments, the physician should not impose them even if potentially life-prolonging. Regardless of what Dying, which was once viewed as natural and expected, has be come medicalized into an unwelcome part of medical care. It has been distorted from a natural event of great social and cultural significance into the end point of untreatable or inadequately treated dis ease or injury. Worse, death has be come medicine’s enemy—a reminder of our limitations of medical diagnosis and management. After an anticipated death from a known terminal illness, for example, medical colleagues would be ex pected to make humane efforts to help family and caregivers un- derstand this natural event and assuage their feelings of loss and sadness. Instead, the medical decisions leading up to the death may be defensively reviewed with the family, then scrutinized for mistakes by peers at clini- copathologic conferences, reported to risk management to be certain that liability issues are addressed, or critiqued in man dated quality assurance reviews. It is little wonder Personal Glimpse that physicians engage in inap propriately heroic battles against dying and death, even when it may be apparent to physician, patient, and family that a rapid, good death is the best outcome. Viewing dying and death as merely a failure of medi- cal diagnosis and therapy . . . trivializes the final event of our lives, stripping it of important non medical meaning for patients, family, and society. This narrow view of dying may be a particular concern for the very el derly, for whom death is an expected and sometimes desired event. Respect for the wholeness of life requires that we not debase its final stage; art, literature, and the social sciences teach us that a good death can be a natural, courageous, and thoughtful end to life. Jack D. McCue, M.D.8 © 1995 American Medical Association The Naturalness of Dying Chapter Twenty-One Coping with Death 441 has been stated, the physician should not be obligated to provide physiologically futile treatments. For patientS witHout an aDvanCe DireCtive wHo beCome in- Competent: The physician: (a) should try to follow patients’ preferences as much as possible, (b) has a duty to discuss all alternatives with the family or significant others and seek an acceptable plan of action, (c) should consult with other professionals if the patient has no family or friends, and (d) need not provide futile treatment even if asked to do so. For patientS wHo Have never been Competent: The physician: (a) does not have an absolute duty to order life-prolonging treatment; (b) should weigh benefits and burdens of treat- ment in terms of quality of life; (c) should involve family, surrogates, physicians, and other caregivers in decisions; (d) should act in a trustworthy manner; and (e) may withhold life-prolonging treatment if its burdens outweigh potential benefits. SCarCity oF reSourCeS: (a) Society must establish limits and priorities, (b) processes used to establish limits should be open and fair, (c) established policies that are restrictive must be publicized in advance of patient admission, and (d) the patient has no right to any treatment that has no reasonable expectation of benefit.9 Drafting an Advance Directive The requirements for advance directive vary from state to state. State-specific forms and instructions can be downloaded free from the Web sites of Caring Connections (www.caringinfo.org) or Compassion & Choices (www.compassionandchoices.org). The Caring Conversations10 workbook, which can be downloaded from the Center for Practical Bioethics Web site (www. practicalbioethics.org), is a helpful step-by-step guide to planning and discussing advance directives. It is possible to complete an advance directive without legal help. However, it may still be advisable to consult an attorney to be certain that the implications of alternative choices are clearly understood. The docu- ments must be witnessed, and many states require that they be notarized. To be on the safe side, both procedures are advisable. The completed documents should be kept in an eas- ily accessible place, and photocopies should be given to everyone named in the documents and possibly one’s attorney and primary-care physician. The documents will stay in effect unless cancelled or replaced, so it is important to review them periodically. viatiCal settleMents Faced with the financial burden of a terminal illness, some people choose to sell their life-insurance policy for an immediate lump sum. The viatical settlement company (or a third-party investor who purchases the policy) pays any subsequent premiums and collects the face value when death occurs. The 1996 Health Insur- ance Portability and Accountability Act permits people with a life expectancy of less than 2 years to receive the distribution tax-free. A viatical settlement company may pay 75% of the face value of a policy to a person whose life expectancy is 6 months or less. However, any such sale can hinder eligibility for Medicaid coverage. Decisions about insurance benefits can have a pro- found financial and emotional impact on dependents, Who Should Determine When Someone Has the Right to Die? In 1990 the U.S. Supreme Court affirmed that compe- tent people have a right to refuse life-sustaining treat- ment, including artificially given food and fluids. But when patients are incompetent, the court said, they are unable to make informed and voluntary choices. States are therefore justified in requiring “clear and convinc- ing evidence” of the patient’s wishes before allowing withdrawal of such support measures. The ruling was applied to the case of 32-year-old Nancy Cruzan, who had been in a coma as a result of irreversible brain damage since a 1983 car accident. By a 5-4 vote the Supreme Court11 upheld a Missouri Supreme Court ruling that Ms. Cruzan’s guardian could not terminate her treatment because there was not sufficient evidence of her wishes. The verdict stimulated many hospitals to become more aggressive about having patients sign a living will or other “advance directive” to be used if they become irreversibly ill and are unable to speak for themselves. The most publicized case since that time is that of Terri Schiavo, who died in 2005 after a 7-year legal struggle between her husband and her parents. In 1990, she suffered a cardiac arrest (heart stoppage) that re- sulted in severe brain damage and eventually led to a persistent vegetative state that required feeding through a tube to keep her alive. In 1998, her husband petitioned in court to remove the feeding tube, contending that Terri would not have wanted to be kept alive artificially. Her parents argued that she had no such wish and could get better with treatment that included oxygen adminis- tration and medication to increase her blood pressure. (Neither of these methods has any scientific support.) The courts concluded that she could not recover12 and permitted her feeding tube to be withdrawn. She died a few days later. The autopsy confirmed that the parts of her brain needed for awareness and vision had been irreversibly destroyed. Personal Glimpse Part Five Other Products and Services442 friends, and caregivers. People considering a viatical settlement should investigate carefully and consult a professional adviser.13 It is best to deal with a company that uses institutional rather than private funding. Some agents fraudulently recruit terminally ill people to apply for multiple policies.14 They misrepresent the truth and answer “no” to all of the medical questions. Healthy impostors then undergo the medical evaluation. In many cases, the insurance agent who issues the policy is a party to the scheme. The agent or one applicant may even submit the same application to many insurance companies. Viatical settlement companies then purchase the policies and sell them to unsuspecting third-party investors who may receive little or nothing in return for their “guaranteed” investment. The insurance industry is at risk for huge damages with this type of scheme. Donations oF organs anD tissues Transplantation is usually thought of in terms of major organs such as the heart, kidney, or lung. However, many body tissues can also be used to help the living. Corneal transplants can restore sight. Skin grafts can help burn victims. Heart valves can aid those with congenital heart disease. Ligaments can help people with athletic injuries. Bones are also suitable for grafting. Bone marrow from a live donor can be used to save certain patients with leu- kemia and several other disorders. However, this section focuses mainly on posthumous (after-death) donation. The best opportunities for organ donation occur when death results from a head injury or stroke that results in brain death. However, if death results from heart disease, donation may be limited to eyes and certain tissues. The National Transplant Act of 1984 initiated development of a national system to ensure equitable allocation. In 1986, the Department of Health and Hu- man Services contracted with the United Network for Organ Sharing (UNOS) to operate the Organ Procure- ment and Transportation Network (OPTN). Mansfield15 has noted that one deceased donor can save eight lives through organ donation and enhance up to 50 through tissue donation. OPTN maintains a patient waiting list and an organ matching system; coordinates the logistics of matching the organs; collects, analyzes, and publishes transplant data; and educates health professionals about the dona- tion process. Its centralized computer network links all organ procurement organizations and transplant centers and is accessible 24 hours a day, 7 days a week, with specialists available to answer calls. The waiting list in December 2011 had about 112,500 registrants. When a donor becomes available, the transplant center or organ procurement organization will access the computer, which generates a list of patients ranked according to OPTN policies. The transplant coordinator then asks the transplant team to select a patient for further evaluation. The factors that affect rankings include tissue match, blood type, urgency of need, length of time on the waiting list, immune status, and distance from the available organ. The identities of the donor and recipi- ent are confidential, but some basic information may be shared. OPTN16 reported that in 2008, 21,065 organs were transplanted from deceased donors and 6216 organs were transplanted from 6991 living donors. About 96% of the living donors were kidney donors between the ages of 18 and 64. Most of the posthumous donors were killed by a motor vehicle accident, another source of head injury, or a stroke. The 5-year survival rate for transplant recipients ranged from 45% for heart-lung recipients to 91% for people who received a kidney from a living donor. Americans generally feel favorably toward organ donation, but misconceptions still influence whether people become donors. The positive factors include hu- manitarian feelings and pride experienced by the donor. The negative factors include fears of body disfigurement, religious concerns, and fears of receiving inadequate medical treatment when one’s life is at risk.17 Such fears are unfounded:

• When people are admitted to a hospital, the number one priority is to save their life. Donation has no relevance un- less death is imminent or has occurred.
• All major organized religions approve of organ and tissue donation and consider it an act of charity.
• Donated organs are removed surgically, in an operation similar to gallbladder or appendix removal. Donation does not change the appearance of the body for the funeral service.

In some parts of the world the selling of body or- gans is a commercial enterprise. In the United States, the interstate sale of body parts is a federal crime, but because the number of people awaiting body parts greatly exceeds the number of donors, proposals have been made to provide financial aid or material incentives to the heirs of posthumous donors. This might come in several ways: (a) burial expenses, (b) rebates or deferral of state and federal income taxes, (c) a fixed grant for the surviving spouse and/or dependent children, and (d) a government-sponsored or paid-for insurance policy payable to a designated beneficiary. In 2010, a bone marrow specialist, the mother of three children who needed a bone marrow transplant to save their lives, Chapter Twenty-One Coping with Death 443 and several other plaintiffs filed a lawsuit that argued that the government should not put bone marrow in the same category as solid organs, such as kidneys, and should permit compensation to attract more donors.18 In December 2011 the 9th U.S. Circuit Court of Appeals sided with the plaintiffs, but the U.S. Attorney General may appeal this decision. How to Donate Every state has adopted some form of the Uniform Anatomical Gift Act, which recognizes the right of all Americans to have their organs and tissues donated after they die. These laws provide that when the individual’s intent is not known, the next-of-kin can make this deci- sion. The simplest way to make posthumous donation possible is to fill out an organ donor card that can be carried in one’s wallet or other easily locatable place. The decision should also be discussed with family and friends. In some states, permission to use tissues after death may be indicated on one’s driver’s license or an attached card. A Uniform Donor Card is available from UNOS and several other organizations (Figure 21-3). Identification bracelets indicating a wish to donate are available from Medic Alert Foundation. The Living Bank maintains an unofficial national registry and publishes a free newsletter. Family wishes take precedence over what the donor card indicates. However, several stud- ies suggest that both medical professionals and family members are more likely to favor what is indicated on a donor card.19 hospiCe Care Hospice care is a way of providing support to people who are expected to live six months or less and their family members. It is provided mostly in the home by family and friends with the support of health professionals and volunteers. Beresford20 describes it as “an alternative to conventional, cure-oriented medical treatment aimed at fighting the disease by any means possible, at the time when that approach has become counterproductive.” This includes situations where continued treatment could delay death a bit longer but would have severe side effects. The modern hospice movement began in 1967 with the founding of St. Christopher’s Hospice in England.21 The first American program began in 1974 in Connecti- cut. In 2009 there were about 5000 hospices in the United States, about 63% of which were Medicare-certified. To achieve certification, a hospice must provide 24- hour availability; medical and nursing care; home care services; access to inpatient care; social work services; medications, medical supplies, and durable medical equipment related to the illness; and physical, occupa- tional, and speech therapy as appropriate. At least 5% of the hours required must be contributed by unpaid volunteers. Most hospices in the United States are independently based community organizations (57.7%) or divisions of hospitals (21.4%) or home health agencies (19.5%). A few are divisions of hospice corporations or nursing homes.22 Most hospice programs belong to the National Hospice and Palliative Care Organization (NHPCO), a nonprofit advocacy group founded in 1978. The NHPCO estimates that in 2009, about 40% of hospice patients had cancer, 13% had unspecified debility, 12% had heart disease, 11% had dementia, and 8% had lung disease. Hospices provide palliative (symptom-relieving) care to patients and families in both home and hos- pital settings. This includes physical (personal care); psychologic (fear, anxiety, grief); social (individual and family support); and spiritual (religious) aid by a medically supervised, interdisciplinary team of profes- sionals and volunteers. Specialists in death awareness are available. Medications are generally given not to prolong life but to relieve distressing symptoms such as pain. Emotional support is also offered during the bereavement phase of care. Hospice care was originally designed to help termi- nally ill individuals (particularly cancer patients) who wished to be as pain-free and alert as possible. This has been broadened so that programs now cover general care for anyone who may be dying. The emphasis is on quality of life rather than quantity. Figure 21-3. Uniform Organ Donor card. The back of the card states that it is a legal document under the Uniform Anatomical Gift Act or similar laws. It also asks for the donor’s date of birth, the signature of the donor and two witnesses, and the date signed.

ORGAN DONOR CARD ____________________________________________________________

Print or Type Name of Donor In the hope that I may help others, I hereby make this anatomical gift, if medically acceptable, to take effect upon my death. The words and marks below indicate my desires. I give: (a) _______ any needed organs or parts (b) _______ only the following organs or parts ___________________________________________________________ Specify the Organ(s) or Part(s) for the purposes of transplantation, therapy, medical research or education; Part Five Other Products and Services444 In 1983 Medicare began offering an option to cover hospice care for physician fees, nursing care, counsel- ing, medical social services, short-term inpatient care, medical supplies, and the services of home health aides and homemakers. To qualify, the patient must (a) be medically certified as terminally ill with a life expectancy of 6 months or less and (b) sign a statement choosing hospice care instead of standard Medicare. A Medicare beneficiary may elect to receive hospice care for two 90-day periods, followed by a 30-day period, and, when necessary, an extension period of indefinite duration. In 2005 the daily Medicare rates were about $122 for routine home care and $543 for general inpa- tient care. More than 90% of hospice-care hours are provided in the patient’s home, thus substituting for more expensive multiple hospitalizations. In 2003 the average length of enrollment for patients admitted to hospice care was 55 days and the median length of service was 22 days. Locating and Selecting a Hospice The names and addresses of hospice care organizations and agencies may be obtained from NHPCO (www. nhpco.org, 800 658-8898); the National Cancer Institute (800 4-CANCER); a discharge planner, community relations person, or social worker at a local hospital; or a local religious institution, health department, social service office, bureau of aging, or American Cancer Society office. The following questions may be useful: About the Program • Does the hospice mainly involve home or inpatient in- stitutional care? How does it arrange for hospital care if necessary?

• Does the program serve nursing home residents? • Is the hospice Medicare/Medicaid certified? • What kind of accreditation does the hospice have? • Does the program adhere to National Hospice Organization standards?
• Are any nurses certified in hospice care?

About Services • What nurses, doctors, volunteers, or others will provide services? What services will they provide?

• What will the physician’s role be, and will the hospice be communicating with the physician?
• What services will be available 24 hours a day? • Will someone help with the insurance forms? • How often will the nurse, doctor, or other staff member visit the home or provide services?
• How are middle-of-the-night crises handled? • What follow-up services are provided if the patient must return to the hospital?
• Will bereavement counseling be available after the patient dies?

About Costs • What are the fees? Are they charged by the hour, day, or visit?

• Will the hospice accept payments by private insurance, Medicare, or other payee? Will there be additional charges not covered by these providers?
• Will the hospice handle billing with Medicare or a private insurance carrier? Will the hospice negotiate with the insur- ance carrier should charges be denied?

Other organizations that can provide information are the National Association for Home Care and Hospice and the Joint Commission on Accreditation of Healthcare Organizations. euthanasia anD assisteD suiCiDe This section does not address the philosophical or moral issues involved in actions taken to induce death to re- lieve suffering. Rather, it presents information about the nature of these actions, related laws, and physician responsibilities. Euthanasia is derived from a combination of Greek words that mean “a good death.” The term is used to describe situations in which a compassionate decision is made to terminate a person’s life by applying a lethal treatment (active, or direct, euthanasia) or by with- holding life-sustaining treatment (passive, or indirect, euthanasia). If the patient asks for and gives competent consent to euthanasia, the euthanasia is called voluntary. If the patient cannot give consent or has not issued an advance directive, the euthanasia is called nonvoluntary. If ac- tion were taken against the will of a patient, it would be termed involuntary and would be illegal. Voluntary active euthanasia is legal in the Northern Territory, Australia, and is government-sanctioned in The Netherlands, where physicians can administer a drug to someone who is suf- fering from an incurable disease or condition. However, it is illegal in the United States. Many hospitals have an ethics committee to help hospital staff members deal with ethical issues related to patient care. Its activities include education of staff members; formulation of hospital policies, particularly about death and dying; and advising providers and pos- sibly families. Garrett and others23 have stressed that ethics committee opinions are most valuable if they reflect independent judgments rather than those of the institution or its dominant figures. In assisted suicide, lethal doses of drugs are given or prescribed to suffering patients who intend to end their lives. This practice is illegal in almost all states. Chapter Twenty-One Coping with Death 445 Derek Humphrey, president of the Euthanasia Research and Guidance Organization (ERGO), states that, “As- sistance in suicide should be voluntary, legal and rare and arranged by a team of health professionals, not one acting alone and covertly as now.”24 However, the AMA thinks it should remain illegal.25 In 1994 voters in Oregon narrowly passed a state law allowing physicians to prescribe lethal drugs to adults who are mentally competent and who request the drugs so that they can self-administer them. From 1998, when the law went into effect, to January 7, 2011, 525 patients took lethal medications prescribed to them under the law.26 In 2008, voters in Washington approved a similar measure by a 58% to 42% margin. Infant Euthanasia With dramatic advances in the technology available in neonatal intensive care units (NICUs), survival of premature and congenitally deformed newborns has dra- matically improved since the early 1960s. NICUs have enabled many such infants to survive and live a produc- tive life. But some infants have such serious defects that, even with the best medical and surgical treatment, there is no hope for significant development and expensive NICU treatment can only prolong their suffering. Decisions about the appropriate way to care for hopelessly imperiled infants can be complicated. Physi- cians and hospital ethics committees may provide help- ful input. The courts generally recognize that parents have the primary responsibility for deciding whether to withhold or withdraw care. However, in 1992 the Florida Supreme Court upheld a lower court ruling that prevented an anencephalic infant from being declared dead so her organs could be used for transplants as requested by her parents. In 1994 the U.S. Supreme Court turned down an ap- peal by a Virginia hospital to discontinue life-sustaining treatment after 2 years for “Baby K,” an anencephalic infant. Anencephaly is a rare neural tube defect in which all or part of the brain is absent, thereby precluding the possibility of consciousness or feelings.27 Most anen- cephalic infants survive no more than a few days. Baby K’s anencephaly had been diagnosed during pregnancy, but the mother completed the pregnancy and asked for maximal care for the infant, who was placed on a respirator. The hospital ethics committee was unable to convince the mother that such care was futile. A district court ruled that the hospital was obligated to provide full medical care under both the federal Emergency Medical Treatment and Labor Act and the Federal Rehabilitation Act of 1973. By 1994 the total cost to the state of Virginia exceeded $800,000.28 Baby K died in 1995. reasons For an autopsY When there is a sudden, violent, or unexpected death, the coroner or medical examiner may be called to inves- tigate. A coroner is an elected official who may have no medical background or training. A medical examiner is an appointed public official who is a qualified physician, generally with special training in forensic medicine. If it appears that foul play is involved, the coroner or medical examiner will order an autopsy. An autopsy is a comprehensive postmortem exami- nation done for the purpose of determining the cause of death. Unless ordered by a government official, consent of the next-of-kin is required. The county or state pays for autopsies requested by the coroner or medical examiner. If a hospital physician requests the autopsy, the hospital is legally obliged to bear the cost. If the next-of-kin makes the request, that person would be responsible for the cost. Such a request might be made if the cause of death is uncertain or if medical malpractice, a hereditary disease, or a serious contagious disease is suspected but not confirmed. BoDY Disposition When someone dies, the bereaved must consider two things: disposal of the body and a ceremony acknowledg- ing the person’s death. Funerals and memorial services provide opportunities for expressing and validating grief, celebrating the life of the deceased, reaffirming religious or community ties, and expressing sympathy for the bereaved. The body of the deceased is present at a funeral, but not at a memorial service. Death certificates state the cause of death and are necessary to settle the financial affairs of the deceased. The business that provides help to bereaved persons is called a mortuary or funeral home. Morticians (fu- neral directors) can arrange funerals, notify friends and relatives, obtain permits and death certificates, handle arrangements for the body, place obituary and funeral notices in the newspaper, assist with cremation and cem- etery arrangements, provide transportation to and from the funeral, and attend to various other details. Some also provide a modest amount of counseling. Nearly all states license funeral directors, and all states license embalmers. (Embalming replaces the blood and other body fluids with disinfecting chemicals that retard the decomposition of the corpse.) Funeral director training includes courses in anatomy, microbiology, pathology, communicable diseases, business practices, and the psy- chology of grief. There are about 20,000 funeral homes in the United States.29 Part Five Other Products and Services446 In 2009, the average cost of a traditional funeral, including a casket and vault, was $7755, but “extras” like flowers, obituary notices, acknowledgment cards, limousines, and an unusually expensive casket can add thousands of dollars.29. This figure does not include the cost of a cemetery plot or opening, closing, or perpetually caring for the grave. However, alternative arrangements to the traditional funeral can be dignified without being costly. Funerals are much more expensive than simple burial, cremation, or cremation plus a separate memo- rial service. Big national funeral home chains tend to charge more than independent funeral homes or small local chains. Methods Three general options for body disposal are available: burial, cremation, and donation. The corpse can be buried below ground in a grave or above ground in a mauso- leum. Direct burial, usually within 1 day, is the least expensive burial option—especially if an inexpensive casket is used—because mortuary services are minimal and refrigeration and/or embalming are not needed to preserve the body. The casket is frequently the most expensive funeral item, but prices vary widely. Caskets are usually made of metal or wood, although some are constructed of fiberglass or plastic. Most metal caskets are made from rolled steel; the lower the gauge, the thicker the steel. Wooden caskets come in hardwood, softwood, and plywood. Some metallic caskets have a rubber gasket or other feature that delays the penetration of water and retards rust formation. Some also come with a warranty for durability. Protective features add to their cost. Wooden caskets are usually not gasketed and do not carry a warranty for durability. However, both types are usually warranted for workmanship and materials. Burial requires a cemetery plot and involves the cost of opening and closing the grave, a grave marker, and cemetery upkeep. For below-ground burials, cemeteries typically require that the

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