NURS 3225 Study Guide - Final Guide: Persistent Vegetative State, Legal Guardian, Elder Abuse
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
• 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;
• 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
• A fellow resident of a nursing home having unprotected sex with a HIV positive partner?
• Someone sharing needles with their spouse?
• ? reasonable belief of transmission risk?
• Have attempts to have pt tell the partner themselves failed?
• Was pt warned public health official or physician would tell if they didn’t?
• Are they both under MD’s care??
• Try not to disclose identity of infected individual
• Only Physicians & public health officials!!
Aging and End of Life
• Trends in today’s society
• 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
• The ninth stage of the life cycle is a time that elders develop to some degree either despair and
disgust or integrity
• Developed by his wife- Very old age- Gerotranscendence
• Still integrity vs. despair or disgust
• 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
• 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:
• Physical abuse
• Sexual abuse
• Emotional or psychological abuse
• Neglect
• Abandonment
• Financial or material exploitation
• Self-neglect
Quality of Life – subjective
• Which tend to be lower? - Personal or observer evaluation??
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• Determinations of quality of life are value judgments, and value judgments imply variations among
the people who are determining value
• The determination of the quality of a life can be divided into categories of personal evaluations and
observer evaluations
• Personal evaluation is the personal satisfaction expressed or experienced by individuals in their
own physical, mental, and social situation
• Observer evaluations refer to quality-of-life judgments made by someone other than the person
living the life
• Values and goals are different among people of different age groups
• Automatic projections of values by nurses and other healthcare professionals are not consistent with
the moral care of elderly persons
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”
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)
• Assessment of patients’ competence to consent to treatment
• 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
• 1) Communicate a choice
• 2) Understand the relevant information
• 3) Appreciate the situation and its consequences
• 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
• 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
• 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
• 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
• American Academy of Neurology
• 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
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• 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)
• (Or Durable power of attorney, term for the document NOT the person)
• Applies any time you lack capacity or can’t communicate preferences
• A written paper appointing a specific person
• 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
• 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
• You can name someone in advance
• They must still follow your wishes expressed in your living will
• Plenary Guardian: A plenary guardian of an adult with mental retardation
• A person, legally authorized state official, or private, nonprofit corporation appointed by a Probate
Court
• 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.
• 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
• However, Catholic bishops do still distinguish between extraordinary and ordinary means
• 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
• Benefit
• Subjective determination
• Made by the patient or surrogate
• Assessment of value and desirability
• Burden
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Document Summary
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 . 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.
