Do Not Resuscitate Orders

Deontology and DNR: Addressing the Issue
Introduction
Do Not Resuscitate (DNR) orders are an issue for a number of care providers in hospitals, especially those who work within the context of hematology and oncology care. As Weissman (1999) notes, DNR is a stumbling block for many nurses and nursing students: for example, he states that his students unanimously struggle to understand the purpose of asking terminally-ill patients what their preferences are on resuscitation—“We know it’s required under hospital policy to ask patients their preference about resuscitation, but these cancer patients . . . well . . . you know . . . they’re dying . . . it doesn't make sense” (Weissman, 1999, p. 149). Weissman (1999) states that while DNR orders were “designed to ensure patient autonomy while at the same time identifying patients in whom resuscitation is not indicated,” they have come to serve, unfortunately, as “an example of how a well-meaning application of modern medical ethics [leads] to untold patient/family suffering and…health professional distress” (p. 149). To address the issues of suffering and distress so often associated with DNR today, there is significant need to address the issue of DNR orders at the national level—for two reasons: 1) so that there is national uniformity in the approach that nurses must take, and 2) so that a sufficient standard is applied that makes sense and can be adhered to with as little distress, emotional discomfort and moral questioning as possible. This paper will provide an overview of current policy regarding DNR orders, discuss how the deontological ethical system applies appropriately well to the issue, and describe a strategic plan for addressing the issue at the national level.
Overview
Current Policy
There is currently no national policy on DNR. Yuen, Reid and Fetters (2011) note that DNR orders have been used by hospitals across the nation for more than 20 years but that “as currently implemented, they fail to adequately fulfill their two intended purposes—to support patient autonomy and to prevent non-beneficial interventions” (p. 791). One of the major problems that nurses have with DNR is that they find it difficult to sensitively broach the subject. Quite simply, they lack the necessary communication skills needed to discuss the matter of DNR with patients (Weissman, 1999). Ultimately, the problem is one of education: nurses are not trained within an appropriate ethical framework that can give them confidence and ease their moral qualms. They lack, in other words, an ethical perspective that can help them see why it is important to discuss DNR with patients. As Weissman (1999) states, “we must seek DNR policy reform that brings the reality of CPR as a medical intervention in line with the professional responsibility of caring for the dying” (p. 150). That means a national policy has to be devised that can help nurses and physicians overcome their issues of discussing DNR. That policy should be rooted in the ethical system of deontology.
How Deontology Applies
Deontology puts forward the idea that people have a duty to act rightly. What is right may depend at times on the situation. The theory of moral relativity, for example, falls into the category of deontological ethics: it presupposes that in some instance it is right to lie—for example, if one is trying to save another from being found by a killer (Sen, 1983). Not all deontologists agree on that point: Kant would argue that lying is never right and that moral absolutism applies; the duty-based ethics perspective, however, posits that moral relativism is justified—but, of course, the bone of contention is how one defines what is right (Karnik & Kanekar, 2016).
Ethics is a fundamental health care competency: professionals in the health care field have to be well-versed in how to apply ethical frameworks to situations in which they are participants. While different ethical systems call for different types of action—for example, virtue ethics places the emphasis of action on pursuing the good, while duty-ethics places the emphasis of action on doing one’s duty however it may be defined—the deontological perspective applies to the issue of DNR in an important way. According to Kant, one ought to act as though one were a lawmaker in the Kingdom of Ends. In such a Kingdom, all individuals are respected and no one is abused or exploited. From this perspective, the patient can be seen as one whose desires are to be fully respected and appreciated by the nurse and physician. The care provider owes a duty to the patient, and the patient’s wishes provide direction to the care giver. Kant would argue that the nurse or physician has a moral responsibility to treat the patient as the patient wants to be treated—even if the patient’s requests conflict with the ethical perspective of the care provider. On the topic of DNR, the care provider may have moral qualms about not resuscitating—but if the patient has issued a directive, the care provider is bound by the deontological system of duty ethics to abide by that directive. This simple approach helps to take the controversy and sting out of the issue and relieve the care provider of any feeling of guilt one way or another: the ethical framework simply shows that the care provider is duty-bound to respect the patient’s wishes, and no other inclination is relevant to the matter.
Strategy for Addressing the Ethical Issue
The strategy for addressing this issue is based, firstly, in the need to identify what and what not a care provider should be obligated to discuss with the patient in terms of DNR. Many care providers shrink from doing DNR orders because they do not like having the conversation with patients who in an end-of-life phase. They do not like having to explain the various modes of resuscitation or bringing up the subject of death at all for patients who are so near to dying. A proper national policy, according to Weissman (1999), would be to “acknowledge that physicians are not required to discuss the procedure of CPR, in all its gory details, in the setting of expected death” (p. 151). Rather, nurses and care providers should only be required to pose the question and give a general description of the patient’s options with respect to resuscitation. An appropriate recommendation provided by Weissman (1999) that is both professional and situated well within the duty-based ethical perspective would be the following statement: “I will provide you with maximal treatments for your pain or any other symptoms you may experience; I do not recommend the use of breathing machines or other artificial means to prolong your life” (p. 151). The care provider gives a brief description of the tools at the care provider’s disposal; a professional recommendation is given for the end-of-life patient; but the patient is acknowledged, implicitly, as the one who makes the choice. A national policy regarding DNR should incorporate this approach, with the one modification—it should also contain an explicit statement that shows that patient or the patient’s decision-maker that the choice is ultimately up to them. Such a statement could be: “That is my recommendation, but the choice is totally up to you. We’re here to answer any questions you might have on the matter.” This would open the door to taking further questions if the patient should have any, which allows for patient empowerment to take place. It also puts the patient’s wishes at the fore, so that the nurse or physician can be guided by these desires. From the deontological ethical perspective, the care provider is duty-bound to adhere to the patient’s desires—and this is the best way to know what they are.
That basis helps with the approach—but the timing of the approach is also a matter of concern. Many nurses do not feel comfortable broaching the subject because death is such a private and potentially emotional issue for patients and their families. Discussing it in such a clinical manner can seem insensitive and emotionally undercutting. For this reason, the national policy should be to have DNR orders filled out on a standardized form that patients can read or have read to them by a family member. This takes the onus off the nurse or physician—and it is also something that can be taken care of during the admission process. That way it is quickly addressed and then removed from the environment: the patient is educated by way of form upon admission, is advised by the care provider, and is given the opportunity to declare a desire or intention based on the information provided.
The form should be a standardized copy form that is one page in length and that briefly but precisely outlines the resuscitation options available to a patient. Each option should be bulleted in the following manner:
· Apply resuscitation techniques that are natural and do not rely on machines to facilitate the breathing process
· Do not apply any resuscitation technique
· Use all available machines to facilitate the breathing process
These bullets can be elaborated upon on the same form so that the patient has enough information to make an informed decision. The Cleveland Clinic (2018) provides a DNR Protocol example that can be applied nationwide for its explanation of what the care provider will do and will not do with respect to resuscitation practices. The DNR Protocol is also helpful for having as a national standardized protocol in the event that a DNR order is not prescribed by the patient for the care provider and the care provider is obliged to make a decision on whether or not to resuscitate and what means to use. The DNR Protocol takes the decision-making process out of the hands of the care provider and defines the exact actions that the care provider is duty-bound to take as a provider for the patient in the absence of a declared statement from the patient. The Cleveland Clinic’s (2018) DNR Protocol consists of the following points and should be used as the national standard in lieu of a patient declaration: The nurse or physician will:
· WILL suction the airway, administer oxygen, position for comfort, splint or immobilize, control bleeding, provide pain medication, provide emotional support, and contact other appropriate health care providers, and
· WILL NOT administer chest compressions, insert an artificial airway, administer resuscitative drugs, defibrillate or cardiovert, provide respiratory assistance (other than suctioning the airway and administering oxygen), initiate resuscitative IV, or initiate cardiac monitoring.
Implementing this policy at the national level, moreover, allows patients and potential patients to review these policies and protocols prior to ever being admitted to a hospital, no matter where they are in the country. The use of an electronic health record (EHR) management system database would, furthermore, allow all patients to state their desires for resuscitation up front and ahead of time. Care providers could easily access the directive when needed before initiating any course of action, no matter where the patient is—the declaration would be accessible by the care provider at the facility because of the fact that it would stored in a nationwide database.
Furthermore, the options for resuscitation should be made available on the federal government’s health website so that patients can review their options ahead of time. By standardizing the national policy on DRN options, the patient could easily choose the preferences he or she wishes to be implemented. The nurse or physician would, therefore, be completely removed from the situation and would have no moral quandaries about discussing the issue: the patient’s preferences would already be known ahead of time and the nurse or physician would merely have to follow the orders given by the patient. In a deontological system, the care provider would be duty-bound to adhere to these desires anyway.
For education and training purposes, national nursing curriculums should be revised to teach the deontological perspective with respect to DNR orders so that there is no confusion about the moral duty that the care provider must demonstrate in this particular situation. The more attentive all stakeholders can be to the issue in this case, the more smoothly the entire problem can be addressed. There is, on the national level, a serious need for all stakeholders and professionals in the health care field—from doctors to nurses to educators and students—to collaborate and unite as one. That is the purpose of standardizing policies at the national level.
To clarify options for the patient and the care providers, there should also be a clear point at which the DNR orders should be implemented. The Cleveland Clinic (2018) again provides the following guidance on this matter, which could be used at the national level to facilitate standardization: 1) the first level of care—DNR Comfort Care—applies to the implementation of the DNR Protocol before and during cardiac or respiratory arrest—not after; 2) the second level of care—DNR Comfort Care Arrest—is implemented only at the time of a cardiac or respiratory arrest—but not before or after; and the third level of care—DNR Specified—refers to the patient’s specified request (already obtained) regarding resuscitation methods. These are to be implemented in the manner and at the time specified by the patient. The third level of care is the level that all care providers should strive to obtain, from a deontological perspective—and the standardization of the DNR Protocol and the national access to forms via the health website of the federal government would facilitate this process.
Conclusion
The strategy for addressing the DNR issue among health care providers is thus to tackle it at the national level where a protocol can be standardized and used universally by all hospitals and care providers. This would allow patients to understand their options ahead of time. It would also remove the moral distress that care providers can sometimes feel regarding broaching the subject with terminally ill patients. The Protocol would allow care providers to adhere to the patient’s wishes regarding resuscitation and the teaching of the deontological ethical system with regard to DNR would help nurses to understand that their duty is first and foremost to the patient and that all respect for the patient’s wishes should be shown.
References
Cleveland Clinic. (2018). DNR policy. Retrieved from
http://www.clevelandclinic.org/bioethics/policies/dnr.html
Karnik, S., & Kanekar, A. (2016). Ethical issues surrounding end-of-life care: a
narrative review. In Healthcare (Vol. 4, No. 2, p. 24). Multidisciplinary Digital Publishing Institute.
Sen, A. (1983). Evaluator relativity and consequential evaluation. Philosophy & Public
Affairs, 113-132.
Weissman, D. E. (1999). Do not resuscitate orders: a call for reform. Journal of Palliative
Medicine, 2(2), 149-152.
Yuen, J. K., Reid, M. C., & Fetters, M. D. (2011). Hospital do-not-resuscitate orders:
why they have failed and how to fix them. Journal of General Internal Medicine, 26(7), 791-797.