Legal issues with do not resuscitate orders

Legal Issues With Do Not Resuscitate Orders

Babies born today have a fifty-fifty chance of living to see their 100th birthday, and continuing innovations in healthcare promise to extend the human lifespan even further in the future. An unfortunate concomitant of more people living longer lives has been an increased incidence of debilitating diseases such as Alzheimer's, dementia and osteoporosis that can adversely affect the quality of life for the elderly. Some of these healthcare consumers may want to avoid being trapped in an unresponsive body by making provisions ahead of time to preclude the use of heroic measures in saving them while they still possess the mental faculties to make these difficult decisions. In these cases, so-called do not resuscitate orders can provide healthcare consumers with a choice concerning which alternative they prefer, but there have been some legal issues with do not resuscitate orders that have prevented them from achieving their desired outcomes. For example, in some jurisdictions, nurses are not allowed to initiative discussions concerning do not resuscitate issues while in others, hospitals use differ criteria when applying these orders. Likewise, although the American Medical Association provides some general guidelines for healthcare practitioners with respect to do not resuscitate orders, there remains a lack of a universal and legal patient bill of rights in the United States today. To gain further insights into these issues, this paper provides a review of the relevant peer-reviewed and scholarly literature concerning do not resuscitate orders, how they are addressed in patient bills of rights, a discussion concerning confidentially, fidelity and autonomy issues and the legal rights of individuals using do not resuscitate orders. Finally, a summary of the research and important findings are presented in the conclusion.

Review and Discussion

Legal Issues with Do Not Resuscitate Orders

Patient Bills of Rights and Do Not Resuscitate Orders. During the late 1990s and the early part of the 21st century, there was a groundswell of support for a patient bill of rights, and some legislation was proposed in Congress to this end (Elwood, 2011). Despite this early support, Elwood (2011) reports that, "Following much sound and fury, exhaustion and futility eventually led to the proposed legislation being eased through the door of oblivion and out of sight" (p. 58). Notwithstanding this lack of a formal patient bill of rights, though, patient do have several legal rights that generally fall into three main categories: (a) the right to autonomy and self-determination (which includes the related right to withhold or grant informed consent), (b) the right to privacy concerning medical information, and (c) the right to receive treatment (not be refused treatment) (DeCola, 2011). These rights, though, are not specifically codified in a standard fashion that is universally applied within and without healthcare settings. For instance, according to DeCola, "While some hospitals refer to these collectively as a 'Patient Bill of Rights,' ... there is no such 'bill of rights' document per se, excepting a generally accepted but not mandated version prepared by the American Medical Association and frequently used by hospitals" (p. 151). Salient excerpts from the American Medical Association (AMA) concerning do not resuscitate (DNR) orders and a discussion concerning the relevant confidentiality, fidelity and autonomy issues that are involved are provided below.

Legal Issues. Maintaining clients' confidentiality, remaining truthful (fidelity) and ensuring client autonomy are primary obligations that are included and emphasized in most professional codes of conduct and breaches are only allowed in exceptional circumstances (Lazosky, 2008). Even in those cases where breaches are acceptable, a number of questions result concerning when these breaches cross the line between moral conduct and practices that are more for the benefit of the practitioner than the healthcare consumer (Lazosky, 2008). In fact, some authorities suggest that healthcare providers can manipulate do not resuscitate orders for their own expedience in ways that are detrimental to patients' best interests. For instance, Fenigsen (2011) emphasizes that, "When too broadly and indiscriminately applied, and in particular, when issued without the patient's consent or knowledge (as is often the case), do not resuscitate orders create the danger of untimely and unnecessary deaths" (p. 239).

Unfortunately, many people become critically ill or otherwise diminished in capacity without providing any advance directives concerning these issues, but even when they do, it is reasonable to suggest that they may chance their minds when confronted with the harsh realities of death. Indeed, many people may believe they do not want any special or heroic efforts made on their behalf while they are lucid, they may vigorously fight to survive even when they lose this capacity (Fenigson, 2011). According to this authority, "Wise people understand that what they feel and desire while healthy and unwilling to accept any limitations, is not the same as what they may desire when gravely ill. Morally sensitive people question whether their present selves have the right to bind their future, changed selves" (2011, p. 240). Clearly, there are some profoundly complicated issues involved in applying DNR orders, but there are some guidelines available to help inform the process. For instance, the American Medical Association's Opinion 2.22 (Do Not Resuscitate Orders) stipulates that, "DNR orders and a patient's advance refusal of CPR preclude only resuscitative efforts after cardiopulmonary arrest and should not influence other medically appropriate interventions, such as pharmacologic circulatory support and antibiotics, unless they also are specifically refused" (2005, p. 3). In addition, the AMA provides guidance concerning who is authorized to initiate DNR orders when the patient is incapacitated or otherwise unable to provide it based on the patient's expressed desires, as well as when healthcare providers can initiate these orders in the absence of any such authorization.

Despite this guidance, some physicians may be reluctant to order supplemental interventions in the presence of a do not resuscitate order, even if it does not specifically refuse these interventions. In this regard, Fenigsen adds that, "A substantial study showed that do not resuscitate orders inhibit doctors' readiness to administer other treatments, those unrelated to resuscitation. If the patient had a DNR order, the doctors were significantly less willing to order blood cultures, place a central line, or give blood transfusions" (p. 240). Conversely, patients with premium insurance who have DNR orders may receive these interventions (Nordquist, 2007). In reality, these are chilling and even disturbing trends but they are being driven, at least to some extent, by the pragmatic decisions regarding the availability of current resources, and these issues are discussed further below.

Current Resources to Address the Issue

Increasing numbers of American baby boomers are retiring, and people are generally living longer than ever before. Irrespective of the availability of Social Security to provide for the economic needs of these elderly, they will be consuming ever-larger percentages of available healthcare resources. For example, Nordquist emphasizes that, "Health care resources are limited, and demand far exceeds supply. States spends in excess of one trillion dollars a year on health care; still, estimates of the number of uninsured persons in this country range from 41 to 44 million, and the number of underinsured has been estimated at an additional 56 million" (2007, p. 76). Some authorities suggest that DNR orders can be manipulated to healthcare facilities' advantage, a tendency that may be further fueled by increasing pressures on available healthcare resources (Nordquist, 2007). While the outcome of the upcoming presidential election may spell the end of so-called "Obama Care," the available healthcare resources will continue to be stretched to their limit as growing numbers of baby boomers swell the ranks of the elderly in the United States, making the need for timely alternatives to current approaches to the administration of do not resuscitate orders all the more imperative, and these issues are discussed further below.

Analysis of Future Effects and How These Will Be Addressed

Providing healthcare providers with the ethical training they need to make informed decisions during ethical dilemmas represents a useful starting point, but the exigencies of the human condition mean that people's desires change over time, but they will always need timely and accurate information about the alternatives that are available to them. People experiencing the rigors and stresses that are involved in end-of-life decisions are naturally anxious about the appropriateness of their choices, as are their loved ones and friends. Therefore, by authorizing nurses to initiate discussions concerning DNR orders, patients could receive the information they need to formulate informed decisions where they may not know alternatives exist.

Conclusion

Across the board, clinicians have a fundamental responsibility to provide patients with the truth, maintain their confidentiality, and ensure their autonomy. Beyond these fundamental responsibilities, the research showed that there are some differences concerning how do not resuscitate orders are initiated and administered, as well as how healthcare providers respond when these orders are present. Despite the absence of a legal patient bill of rights, patients were shown to have certain legal rights in all jurisdictions including the right to autonomy and self-determination, the right to privacy concerning medical information, and the right to receive treatment or refuse treatment. Although a multidisciplinary approach is frequently the most effective in delivering healthcare services, patients should be able to discuss their concerns with any clinician they feel can provide them with the help they need. Therefore, it is incumbent on healthcare providers of all types to read as many signs as possible when confronted with DNR discussions, and nurses should be authorized to initiate these discussions when they feel it is in the patients' best interests.