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...

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…