DNR Orders: Ethics, Law, and End-of-Life Decision-Making

Introduction to DNR Orders

A do-not-resuscitate (DNR) order is a written medical directive specifying that cardiopulmonary resuscitative interventions shall not be performed in the event of cardiac or respiratory arrest (Roth & Corrigan, 2005, as cited in Pat et al., 2009; Pozgar, 2010, p. 132). The physician discusses both the prognosis and the DNR order with the patient or his family. Their decision — whether to authorize or withhold resuscitative services — is respected and documented in detail. The patient's rights receive paramount consideration, and he may reverse a DNR order at any time (Roth & Corrigan, 2005, as cited in Pat et al., 2009). The sole basis of a DNR is the patient's conscious decision or best interest.

A DNR is a decision reached by the patient and his family. It is an extremely difficult decision because it is made when the patient's quality of life has so diminished that extraordinary or heroic rescue methods are being considered (Pozgar, 2010). The order may evolve from the patient as an executable advance directive; in that case, the attending physician or the patient's legal assignee initiates it. The legal assignee makes the decision if the patient is unable to do so and has previously expressed willingness. A DNR is signed and dated by the attending physician with the consent of appropriate parties. It is generally considered valid in the case of terminally ill patients when the patient's family has no objection. It is of short duration and subject to periodic review, and it is considered one of the medical decisions a competent patient may make (Pozgar, 2010).

The other appropriate parties to a DNR decision include the nurse and the health care team — among them social workers and the chaplain — who are knowledgeable in the matter (NIH Clinical Center, 2010). Ultimately, the decision rests with the competent patient and the physician. If the competent patient determines that CPR is not appropriate, the physician will write a DNR or "no code" notation in the patient's record, and CPR will not be initiated (NIH Clinical Center, 2010).

History of DNR

In 1952, Pope Pius XII condemned the use of "extraordinary means" to maintain life against the will of the patient (Mustagh, 2008). All major religions agreed with the Pope. Thirty years ago, a DNR was impossible to obtain legally. In 1976, a New Jersey court ruled in the Karen Ann Quinlan case that all persons had the right to refuse treatment. However, the ruling did not clarify how that right could be exercised without court review on a case-by-case basis. Physicians had to go to court before discontinuing extraordinary life support, driven by a "technological imperative" to resort to extraordinary means regardless of their futility or the patient's wishes.

The decision in the June 30, 1978 case of Shirley Dinnerstein changed all that. The court ruled that DNR orders could be issued without court intervention and placed the decision within the competence of the medical profession (Mass. App., 1978, as cited in Mustagh, 2008). This ruling became the basis of the President's Commission on Standards for Cardiopulmonary Resuscitation and was later adopted by the American Medical Association, which clarified that "the purpose of CPR is to prevent sudden and unexpected death." CPR is not intended to prolong life in terminal, irreversible illness "where death is not unexpected" and resuscitation is useless. The Association also emphasized that resuscitation in terminal cases may even violate the patient's "right to die with dignity." Other medical groups followed the Association's lead until the change was incorporated into medical standards throughout the United States and in other countries.

The emphasis shifted from prolonging the process of dying to promoting dignity. Physicians now balance benefit against burden, exercise value judgments, and make moral decisions collaboratively with the patient and his family. Quality of life has since become the prime consideration and basis of the DNR decision (Mustagh, 2008).

Ethical Theories and Issues

A DNR decision is guided by the ethical principles of beneficence, non-maleficence, autonomy, and justice (Pat et al., 2009).

This ethical principle obligates a physician or any person to do what promotes the welfare of others (Pat et al., 2009). It encompasses the elimination or prevention of harm and the positive promotion of another person's good or welfare. The principle compels the physician to act in the patient's best interest. It is most applicable in the case of a patient in a permanent vegetative state, when life-sustaining support is no longer in his best interest. Extraordinary measures in such cases only prolong the dying process and extend suffering on all sides without yielding medical benefits. Preventing, eliminating, or reducing suffering becomes an act of mercy and beneficence. At times, death can be in the patient's best interests, and preserving a poor quality of life is tantamount to denying his well-being. Under this ethical principle, the decision not to resuscitate is morally justified as it allows the patient to die in peace and dignity (Pat et al., 2009).

This principle forbids a physician or moral agent from inflicting harm or evil on another person (Pat et al., 2009). It universally obligates all people to protect one another and themselves from harm. Disease is itself a form of harm, and treatment is meant to cure disease and remove that harm. But when treatment becomes ineffective or useless, it transforms into a harm that assaults the patient. Even successful resuscitation can severely damage the patient's lungs, heart, or brain if death is likely within hours or days. If successfully resuscitated, the patient may remain in an irreversible coma. The British Medical Association and the Resuscitation Council guidelines state that CPR should not be performed if it is unlikely to succeed (Pat et al., 2009). In such circumstances, resuscitation harms the patient rather than helps him.

This principle recognizes the patient's independence to determine the course of his own care, so long as the rights and liberties of others are respected (Pat et al., 2009). A competent patient should be treated as autonomous; he has the right to voluntarily choose or refuse treatments and procedures, including life support and extraordinary medical care (Kagawa-Singer & Blackhall, 2001, as cited in Pat et al., 2009). This right may be affected by a defect in the patient's capacity to control his desires or actions. If the patient has made his wishes known, his family and physician must follow them. If his wishes are unknown, CPR should be given even if the family opposes it (Pat et al., 2009). This illustrates the inalienable nature of the right to life.

Justice in the context of a DNR means a fair, equitable, and unbiased decision made in favor of the patient (Dunn, 1998, as cited in Pat et al., 2009). The patient's right is, however, set against the rights of society. No one has a constitutional right to unlimited health care. Shortage of critical care beds, length of hospital stay, and health care costs are among the non-medical considerations relevant to a DNR. Terminal or end-of-life care exacts overwhelming costs with the least promise of return, making it reasonable and just to exercise restraint in healthcare spending. Some institutions resort to rationing in order to protect autonomy while equitably distributing available basic health care to those who stand the greatest chance of benefiting. In the face of limited real-world resources, the just choice is not to provide CPR in cases where it is unlikely to succeed (Curtis & Burt, 2007, as cited in Pat et al., 2009). Similarly, resorting to extraordinary medical intervention to prolong the life of a terminally ill patient deprives others who need those resources and have a better chance at survival or cure. The utilitarian principle applies here: limited resources should go to the greatest number of people with the greatest chance of benefiting (Pat et al., 2009).