Do-Not-Resuscitate and Ethical Standards Research Paper

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Resuscitate (DNR)

What is a Do Not Resuscitate (DNR) order?

First used about fifty years ago, the do not resuscitate (DNR) order continues to elicit questions and discussion among medical experts and patients. The do not resuscitate order is a directive from a patient who specifically refuses consent for certain forms of medical interventions related to life-saving actions by hospital personnel. The presence of the DNR order makes it important that informed discussions between a specific patient, family, and physicians and staff are made regarding their medical conditions. In the modern day world, advances made in medical therapy that include end-of-life treatments, have made the presence of a DNR order even more crucial.

Epidemiological research has greatly enhanced our knowledge of the different forms and outcomes of resuscitation. However it is the physicians, patients, and institutional (hospital) policies that greatly influence the occurrence of DNR orders (Loertscher, Reed, Bannon, & Mueller, 2010).

A do not resuscitate order records the patient's directive to rule out the use of cardiopulmonary resuscitation (CPR) should circumstances arise so he/she becomes unresponsive or apneic, with or without a heartbeat. A DNR order must be in written form. The DNR order also prohibits other kinds of resuscitation interventions including: chest compressions, rescue-breathing, defibrillation, and use of sophisticated cardiovascular life support systems.

The DNR order instructs healthcare providers not to introduce a tube into the patient and start mechanical ventilation in the occurrence of acute respiratory distress or even sleep apnea. The order may only be given by patients who have severe chronic conditions that cannot improve, or those that are receiving end-of-life treatment. It prevents the caregiver from intervening to resuscitate a patient who is not breathing or does not have a heartbeat. A DNR order, however, does not prevent other forms of medical interventions. A patient can at any time cancel a DNR order (Barlow, 2014).

The difference between the DNR and a living will or power of attorney

A power of attorney is a written legal document that grants an appointed individual or board authority over certain affairs in the event the individual becomes incapacitated. The durable power of attorney (DPOA) authorizes the appointed individual to carry out bank transactions, sign social security documents, and/or sign checks to pay bills. These legal documents allow for specific appointees to act on one's behalf in particular cases. For example, one individual can be given a medical power of attorney while another can be appointed with a legal and/or financial power of attorney (Nabili, 2015).

A living will on the other hand is a written record that gives directives on what kind of medical interventions may be initiated in the event that one is incapacitated. The living will can be general or precise. The most prevalent statement in a living will is usually to the effect that if one suffers an incurable illness or disease that has been determined to be terminal by a physician, then the individual directs that all life-sustaining interventions that might help to prolong life are to be prohibited, suspended, or stopped (Nabili, 2015). Under New York State laws, a do not resuscitate order directs medical caregivers not to initiate cardiopulmonary resuscitation, i.e. emergency intervention to restart the heart or lungs in the event that such care is needed. This order instructs physicians, nurses, and/or paramedics not to give emergency treatments including intubation to open the airways, chest compressions, electric shock, injection of drugs into the heart or chest, or even the basic mouth-to-mouth resuscitation.

In New York State, any person who is 18 years and over can obtain either a Hospital or Non-hospital DNR order. A Hospital DNR order is given if one is in healthcare facility such as a hospital or hospice that is registered by the State. Paramedics are under obligation to respect a Hospital DNR Order during transit to or from the hospital. However, if one is not in any of these facilities then one should obtain a Non-Hospital DNR Order (Schneiderman).

Effects of the DNR on Medical experts and relatives

The instruction to prevent resuscitation is different in the medical profession because this is the only treatment decision that has to be made prior to the occurrence of the event. In the absence of a DNR order, the physician and all caregivers are supposed to initiate CPR in the event that the heart stops, even in cases where it is apparent that this is not the best option. Therefore all staff must be made aware if a DNR order has been issued.

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In the end, because the autonomy of patients has to be prioritized in making these decisions, there is a need for patients to be fully informed (Lofmark)

Before DNR orders became available and/or routine, most physicians had a different, more paternalistic way of doing things. Many of their choices were made solely on the physician's best choice, medical basis without consultations with patients. This was basically accepted by most patients, and often a long-term prognosis was only provided if one asked for it. In the long run, it was discovered that many of the choices physicians had to make were not entirely medical, but also encompassed other sets of more personal and/or moral values impinging upon both patients and physicians. Nowadays the autonomy of the patients has become prioritized and right(s) of a patient to be informed have also been strengthened. Knowledge addressing ethical principles of medical practice has become widely spread and older ethical principles have been redefined to match the modern world. Apart from autonomy, other ethical principles such as non-maleficence, beneficence and justice have also been taken into account. Professional virtues including integrity, responsibility, truthfulness, fairness, persistence, courage, discernment, faithfulness and conscientiousness also need to be considered (Beauchamp, 1994).

Studies have been done on the approach and experiences of caregivers such as nurses to DNR orders. One particular study found that about 10% of the patients who gave DNR orders were prompted to do so by nurses. Studies conducted in Netherlands reported that 20% of the nurses did not agree with DNR choices of 68 out of the 148 patients. A study done in the United States (U.S.) reported that half of the nurses said they had executed duties against their principles in giving care to the terminally ill. Of house officers, about 70% had similar experiences, many of them because of what they termed as "overly burdensome" therapies. Almost half of the physicians were content with the level of involvement of patients in making treatment decisions; this is in contrast to only 25% of the nurses. Furthermore only 20% of the nurses were content with the way in which patients wishes were documented in the medical reports. (Lofmark)

Several authors have dealt with the opinions of family members prior to and after the death(s) of their loved one. In one particular study, 461 family members were asked for their views on the treatment and the decision-making of their loved one during the last month of life. Out of this number, 23% could not remember any consultation on the treatment decision; 44%, the majority, stated that they demanded increased communication; and a further 17% had asked for more time with the physician (Hanson & Garrett, 1997). A different American study involved 32 relatives who were reported to have asked for prior planning, well-timed communication, and definition of the role to be played by relatives, including facilitation of harmony within the family, and taking into account the family's grief. Actions that made the relatives feel as if they were not involved, or gave them more personal grief were not appreciated including: postponing consultations on withdrawal of treatment, hesitation in enacting withdrawal once it was agreed upon, entrusting the decision-making process to only one relative, or the definition of death as failure (Lofmark).

Euthanasia or physician-assisted suicide

Euthanasia is the act of deliberately assisting or inducing the death of another person for his or her supposed benefit. To some extent the meaning of euthanasia can be made clear by comparison with suicide. Suicide is generally considered to be an act of murder wherein the victim is the perpetrator. Therefore assisted-suicide is an act that when an individual provides another individual with instructions, support, or the means to take their own lives. When a physician is the one who assists someone to take his or her own life it is referred to as "physician- assisted suicide" (Goel, 2008).

Active Euthanasia

This entails killing someone using a direct action when asked to do so by the individual himself. (Goel, 2008)

Physician-Assisted Suicide (PAS)

In this case the physician gives instructions and means by which the recipient can commit suicide, for example, giving a prescription for a lethal dose of drugs. The phrase "Voluntary Passive Euthanasia" (VAE) is also used interchangeably with PAS. (Goel, 2008)

Involuntary Euthanasia

This term describes the killing of someone who has not directly or clearly asked for help in dying. Many a times this is done to patients who have.....

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