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Ethical dilemmas surrounding DNR (Do Not Resuscitate) orders
Ethical dilemmas surrounding Do Not Resuscitate orders
In carrying out their duties, health care givers face many ethical issues that sometimes affect their personal lives. These require that they make ethical decisions, which may affect them and their patients, as well. An example of a situation that puts the health care givers into an ethical dilemma is the application of the Do Not Resuscitate, which seeks to counter the invasive and painful experience of Cardiopulmonary Resuscitation. A health care profession needs to make a critical decision on when he or she should obey the order and on when he or she should ignore it. The purpose of this paper is to discuss these ethical and legal issues, and give recommendations of addressing them.
In the 1950s, the world witnessed the development of Cardiopulmonary resuscitation, by closed chest massage, to help patients who suffer cardiac and/or unexpected respiratory arrest. Since its invention, it has been the standard practice for medical facilities unless health care providers receive a restraining order. This restraining order is for curbing the invasive nature of Cardiopulmonary resuscitation. According to Brewer, this practice is one of the invasive medical practices, which healthcare professionals can carry out without seeking consent (2). Although this medical intervention practice saves life to some extent, the percentage rate of survival to discharge is relatively small. This indicates this medical intervention method does not always save lives (Brewer 4). This realization led to a new phenomenon that has become the heart of debate within the medical field.
Studies into the effectiveness of Cardiopulmonary resuscitation, indicating that it was not as effective as the media had displayed it, led to the Do Not Resuscitate orders and position papers in the early 1970s (Brewer 5). The patient in question is the one who initiates A Do Not Resuscitate order, and it means that healthcare professionals should let the patient die naturally if he or she experiences respiratory or cardiac arrest (Zinn 1). The argument is that patients should die peacefully without undergoing painful and ineffective treatment. The Do Not Resuscitate orders are usually well documented indicating the patient's wishes, and doctors often determine the Do Not Resuscitate decisions in the last days of the patients and in cases where physicians do not understand a "patients' preferences regarding resuscitation" (Brewer 8). Many controversies surround the newer development, whose main goal is forgo aggressive and invasive medical interventions that may be futile in terminal illnesses.
Depending on the locality, health care professionals may or may not give other medication for patients with a Do Not Resuscitate order. Whereas some doctors may only hold back chest compressions, they may still provide sophisticated care like mechanical ventilation. On the other hand, other doctors may withhold any further treatments for a patient in possession of a Do Not Resuscitate order. The unpredictable appliance of, Do Not Resuscitate orders, implies that some patients may not get the best possible care as soon as providers are aware that the patient has a, Do Not Resuscitate order. Some healthcare providers will even pay no attention to fundamental care to patients with Do Not Resuscitate orders.
Most critically ill patients fall somewhere between being terminally ill and an unexpected respiratory or cardiac attack. This poses a challenge of uncertainty to the health care professionals concerning the ethical considerations of resuscitation (Brewer 10). Another ethical dilemma with regard to the application of Do Not Resuscitate orders is that medical interventions range from "comfortable measures only" to aggressive measures, but most patients fall in the precinct of ambiguity. According to Brewer, this raises a number of questions to the health care professionals. Such questions include whether the patient should undergo Cardiopulmonary Resuscitation in case of a cardiac attack, the implication of a Do Not Resuscitate order, whether they should suspend treatment, or whether a Do Not Resuscitate order is an implied admittance of giving in. Other questions with regard to this dilemma include the implication of a written Do Not Resuscitate order, whether they should leave patients with Do Not Resuscitate orders to die, and how the patients and their families will view its application (Brewer 11).
Effective pre-arrest management strategies for Do Not Resuscitate patients may confuse the healthcare providers creating ethical hazards while caring for patients in critical conditions (Sanders et al. 8). Clinicians may feel that they should stop administering other medications, which are not part of a Do Not Resuscitate order. The health care providers may withdraw some medications that are not part of the Do Not Resuscitate order endangering the lives of the patients (9). May be these drugs could have addressed further cardiovascular attacks, and their withdrawal is contrary to the wishes of the particular patient. In addition to this dilemma, a patient may receive detrimental and/or unhelpful resuscitation. This is especially common where the doctor feels that a Cardiopulmonary Resuscitation is not the appropriate treatment, but fears that if he or she does not administer it, the primary health care givers may not give the patient the treatment he or she needs. It is also common in cases where there is no documented Do Not Resuscitate, making it difficult for the health care giver to make the best decision.
The writings on Do Not Resuscitate orders propose that physicians have a high probability of overriding a Do Not Resuscitate order if a cardiac attack is because of a complication that arises from treatment or a miscalculation (Cook et al. 15). This sees the use of a policy of required reconsideration upon the admission of an inpatient to give room for the management team to talk about the patient's Do Not Resuscitate order. They seek to find out whether there are definite conditions in which they should or should not ignore it, or even whether they should suspend Do Not Resuscitate completely. This discussion would let the admitting health care professional to make sure that the patient did not create the Do Not Resuscitate order resulting from the patient's impractical worries, but the patient made the decision by an informed choice. This can raise ethical dilemma because the physician may not be able to know that the complication is irreversible.
Clinicians have diverse views of what a Do Not Resuscitate order means especially in cases where a patient is going through a surgical procedure, and the patient needs anesthesia (Zinn 1). This creates a moral dilemma in the sense that health care providers do not understand how they should take care of the patients, in a safe manner while honoring the desires of the patient. A number of preoperative health care providers have the opinion that Do Not Resuscitate orders are contradictory with surgery and anesthesia administration. This has seen clinicians suspend the Do Not Resuscitate orders during the per anesthesia period of patient minding (Zinn 1). This could raise an ethical dilemma because the health care givers may not understand what is ethically right for them to do.
In a surgical procedure, a Do Not Resuscitate order raises another ethical dilemma stemming from the surgical contract that the patient and the surgeon establish during the process of informed consent (Zinn 10). In the contract, the surgeon agrees to carry out the surgery while the patient agrees to have the surgeon carry out the surgery on him or her. This implies that the patient undertakes to take part in all the necessary care that the health care providers will provide to aid in full recovery regardless of the method. This presents a dilemma in the healthcare provider's decision to apply aggressive interventions in order to save the patient's life in case of a cardiac attack (Zinn 10).
As Zinn explains, the respiratory attacks or cardiac bout during surgery is not similar to the same attacks under different conditions (9). This means that the medical interventions will go beyond the Cardiopulmonary Resuscitation to include other practices. This is because the surgical process on itself involves an introduction of products like sedatives and opioids, which could cause cardiac attacks. In normal circumstances, if a patient who is under aesthetics experiences a cardiac arrest, then the health care provider will secure the airways and subject the patient to ventilation (Zinn 9). However, in the situation of a Do Not Resuscitate order, this raises a critical ethical issue it is not clear whether it is a procedure to save a life or it is a resuscitative measure.
Health care professionals can use ethical principles of beneficence, distributive justice, autonomy, and nonmaleficence in analyzing the ethical dilemmas that they face, with regard to medical interventions. However, the underlying consideration when applying them should be the weight of the value and relevance of these principles. These ethical principles raise a dilemma at the end of life, and health care professionals raise a number of questions in this line (Brewer 13). Such questions include whether it is ethical to make a decision of applying a painful, invasive, and regularly unsuccessful…[continue]
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