Ethical Dilemmas Surrounding DNR Do Not Resuscitate Orders

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 treatment; whether it is ethical to give medication that only extends pain and anguish; and whether it is ethical to withhold treatment that might save a life. It is not easy for physicians to determine when resuscitation might just save a life or when it might just be futile. Physicians have the responsibility of saving lives, but they should also respect the patients' end of life preferences.

These ethical principles also pose serious challenges to the health care providers when handling patients, who are suicidal. These dilemmas come up because of the conflicts among the principles in addition to the legal, economic, and religious standards. The advance directives movement initiated thought and ideologies that it is not appropriate to extend a life without giving a person an accepted quality of life. This has influenced the society to take the autonomy of the patient's decision regarding life as paramount (Cook et al. 10). This poses a dilemma to the health care professional as they have to prove to the disagreeing parties that the decision of the patient, in cases of a suicidal patient, is due to lack of decisional fitness or capability.

In addition to the ethical dilemma that medical professionals face with regard to Do Not Resuscitate directives, they may also face legal challenges. In considering Do Not Resuscitate orders, health care professionals should consider Legal issues, which include the state and professional interests in preventing suicide; the statutory and common-law fortification of the rights of a person to independence in making healthcare choices; and theories of remuneration for injury. This implies that a patient has the right to make decisions concerning their health, and as such, there should be respect for their decisions. For example, the United States common6 and statutory law7 indicate that those who have the capability to make decisions have a right to do so with issues that pertain their health care (Cook et al. 20).

Patients may have written advance directives, which allow patients who have a decision-making capability to recruit extrajudicial means to affirm their health care treatment preferences in case there reaches a time when they cannot have the competency to do so. Such directives include living wills and powers of attorney for healthcare, ad all states have passed regulations that present some machinery over which patients may develop advance directives that care-providers can rely upon without fearing that they may face legal action. In addition, Federal law encourages people to adopt advance directives, by requiring most healthcare amenities to get into discussions with their patients concerning advance directives (Cook et al. 21).

Physicians have protection against liabilities in the process of respecting and honoring a valid Do Not Resuscitate order entered into a given patient's chart. However, a health care provider or a health facility that fails to prevent a hospitalized patient from committing suicide may face legal and administrative actions. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has given a mandate to healthcare organizations to make out patients who are at risk of attempting suicide (Cook et al. 22). Health care professionals should take this mandate seriously in order to avoid legal implications.

Sometimes, health care providers taking measures to avert suicide trials by ignoring a Do Not Resuscitate order, may also be susceptible to legal accusations on the basis that they failed to get a patient's informed consent. The health care providers may also face charges of damages for unwanted living or unlawful prolongation of life. This claim means that the physician is saving a given patient's life against his or her wish making the life prolong beyond his or her autonomous decision. This will require that the health care profession or amenity compensate for the injury of the patient living beyond the desired length of time. In addition, if the medical licensure boards feel that the health care provider violated ethical positions of the body, then they can take disciplinary actions. Although such legal frameworks exist to address legal matters in connection with Do Not Resuscitate orders, there are extremely rare successful lawsuits (Cook et al. 23).

Patients, health care providers, and the patients' family often discuss the end-of-life decision in order to come up with a treatment plan that patients feel is appropriate for them. If a patient decides that he or she does not like to go through Cardiopulmonary Resuscitation, then it is good that all the involved parties respect this decision. This is beneficial in cases of terminal illnesses because the process will just be futile, as it will not save the patient's life. The aggressive procedure will only prolong the patient's anguish instead of allowing the patient to die painlessly. The most salient aspect of the Do Not Resuscitate is that with proper communication, it allows the family members to have a good time with their ailing relatives before they die, as they will not be going through a painful procedure (Brewer 26).

On the other hand, it is paramount to note that in some instances, respect for patient autonomy in making choices may create the potential for harm of the patient (Alan 3). More often physicians administer medical treatments in combinations in order to work successfully. A separation of such combinations because of patient or surrogate decisions may lead to the omission of vital elements of life- saving care, and the patient may receive futile or hurtful treatment. An incomplete Do Not Resuscitate order is an example of such decisions, which may cause harm to the patient under the Do Not Resuscitate order. It is for this reason that Medical and bioethics societies have created guiding principles and proposals on the use of complete Do Not Resuscitate orders, as opposed to the use of partial Do Not Resuscitate orders. According to Alan (3), a partial Do Not Resuscitate order presents larger ethical problems because it leads to a misunderstanding of scope and meaning of a Do Not Resuscitate order and leads to a need to discuss the goals of health care.

Health care givers should take into account a number of considerations in addressing ethical and legal dilemmas that they face. Instead of wishing away the Do Not Resuscitate order, they should work towards alleviating the ethical dilemma because such an order remains to be a popular phenomenon. This is because more than before people have appreciated that death is a logical end to life and they should get a dignified death rather than undergo painful treatment procedures, which might be futile (Brewer 20). This means that Do Not Resuscitate orders will be in use more in the future than they are presently because people are realizing that Cardiopulmonary Resuscitation may not be a solution to all illnesses, especially terminal diseases.

For emergency cases, it is paramount that patients have a different Do Not Resuscitate Order in the ambulance and at home. An Out of Hospital, Do Not Resuscitate order from a doctor will ensure that Emergency Medical Personnel do not resuscitate a terminally sick person at home against his or her wishes. This is because a Do Not Resuscitate order for a hospitalized patient will not be valid when the patient is at home. The Out Of Hospital Do Not Resuscitate in an ambulance and at home will compel the Emergency Medical Personnel to apply other methods of remedying the cardiac arrest.

States need to establish a legislative exemption, for the applicability of a manageable Do Not Resuscitate order, when a patient gets admission for voluntary or involuntary mental health treatment, might resolve ethical problems that arise from psychiatric illnesses. Whereas Do Not Resuscitate laws do not consider the condition of the mentally ill person, developing a Do Not Resuscitate order may be a preparatory step for suicide (Cook et al. 40). This means that physicians should take care while developing the Do Not Resuscitate orders by evaluating patients for any mental disorders. If they feel that the Do Not Resuscitate request is a result of psychiatric illness, they should refer the patient for assessment and treatment. This will enable them make a better decision that will be a result of an informed consent process.