DNR Orders and Nursing Ethics in Palliative Care

Introduction

The end-of-life phase is the most important and testing time for all people involved — from the patient to the relatives and care providers. Statistics indicate that fewer than 10% of humans experience sudden death, while the rest die after a prolonged period of illness (EPEC Team). In this stressful environment, nurses are confronted by ethical dilemmas whose efficient management requires a balanced understanding of patient needs and respect for their autonomy. The Do Not Resuscitate (DNR) order is one important and delicate ethical issue faced by nurses providing care to terminally ill patients. This paper offers an overview of the ethical concerns and nursing practice standards in palliative care settings, and in particular the implications of the DNR from the nursing perspective.

DNR Orders and Nursing Implications

The DNR (do not resuscitate) order is a request that advises against the use of cardiopulmonary resuscitation (CPR) to revive the heart function of a patient who has experienced a cardiac or pulmonary arrest. Typically, the request for a DNR is given as an advance directive by the patient, but in cases where the patient is in a comatose state, the physician discusses it with the family before recording the order (Hanna Mari Hilden et al., 2004). The DNR order in effect removes the obligation on the part of the attending nurse or physician to revive the failed heart using CPR.

Nurses in palliative care frequently encounter cases where the DNR is applied in accordance with the patient's autonomy. Invariably, nurses experience moral conflicts with the DNR order, as it tends to contradict their professional motivation to heal and cure. Studies have demonstrated that for nurses providing palliative care, moral distress can be debilitating and can significantly affect job satisfaction. It is also widely recognized that conflicts between physicians and nurses arising from disagreements over interventions in palliative care settings create a stressful work environment. Differences in prognostic expectations between nurses and physicians, combined with families' limited understanding of life-support devices, make palliative nursing a demanding profession (Ariana G. Gross).

End-of-life fatigue is a fairly common symptom observed in palliative care and is most often associated with other symptoms such as pain, dyspnea, and anorexia. Research indicates that fatigue tends to steadily increase over the course of a disease and is most pronounced during the end-of-life period. Patients nearing death frequently experience fatigue, and most of their joint movements become restricted, resulting in the formation of pressure ulcers and acute joint pain. Continuous bed rest without movement leads to the formation of sores, which further aggravate pain (EPEC Team).

End-of-Life Symptoms and Fatigue

It is important for care providers to recognize these symptoms and manage them as effectively as possible. From a nursing perspective, it is essential to understand the physiological changes that occur so that better care can be administered during the final stage of life. As Field and James (1993, p. 27) observe: "The care of dying people is of such central importance to all members of our society that the manifold inadequacies are something which must be redressed, rediscussed and improved." As the patient gradually transitions from illness toward death, the nurse becomes the central figure attending to the psychological, social, and physical consequences of that illness.

In palliative care, the nurse's role is most significant because the focus shifts to the treatment of symptoms rather than to diagnosis or cure. Fatigue and depression at the end stage are not homogenous in nature, making it difficult to understand the underlying psychopathology. Furthermore, many patients fall into a state of dysphoria — sometimes called demoralizing syndrome — in which clinical evaluation is complicated because the condition may result from problems of an entirely different nature. This is further compounded by the prevalence of other mental disorders such as dementia and drug-induced mood disturbances. Nurses need to be well trained in pattern recognition and logical assessment in order to take suitable action (Steve Illiffe, p. 107).

The failure to manage these symptoms results in increased suffering and a poor quality of life during the final stage. A 1993 study of 295 patients admitted for palliative care found that 99% of patients experienced asthenia (fatigue), while more than 76% reported pain. A study by Coyle et al. (1990) further revealed that in 75% of palliative care patients there is typically a combination of symptoms — including fatigue, pain, and anorexia (Kim Kubler). Beyond the DNR, there are other morally distressing issues for nurses to handle. For example, food intake commonly ceases during the final hours as the patient is overcome by fatigue. End-stage fatigue is also marked by the total cessation of fluid intake, which can cause panic among relatives and caregivers. However, research indicates that rapid dehydration and the consequent release of endorphins can significantly relieve pain and discomfort during the dying process. In some cases, introducing parenteral fluids intravenously may produce adverse effects such as breathlessness and may actually prolong the dying process. Forcing fluids in such circumstances increases discomfort for an already suffering patient and is therefore not recommended (EPEC Team).

Conclusion

Being a good nurse advocate means providing better care and service for the patient and the family, and maintaining the dignity of the dying patient. The successful management of palliative care sometimes requires a degree of moral detachment. A good nurse advocate is less affected by moral distress while discharging duties to the terminally ill patient. A DNR order can be emotionally, morally, and professionally challenging for a nurse. If the directive and its implications are not properly understood, it may even compromise the quality of healthcare delivered to the patient. Good palliative care is fundamentally about reducing the patient's distress as much as possible and helping them attain a peaceful death. Since the underlying causes of the condition cannot be reversed, the management of symptoms constitutes the key to palliative care.

EPEC Team. "Last Hours of Living." Accessed March 16, 2007.

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Illiffe, Steve, Linda Patterson, and Mairi M. Gould. (1998). Health Care for Older People. BMJ Books.

Gross, Ariana G. "End of Life Care: Obstacles and Facilitators in the Critical Care Units of a Community Hospital." Journal of Hospice and Palliative Nursing, Vol. 8, No. 2, March–April 2006.

Hilden, Hanna Mari, Pekka Louhiala, Marja Lisa Honkasalo, and Jorma Palo. "Finnish Nurses' Views on End of Life Discussions and a Comparison with Physicians' Views." Nursing Ethics, 2004.

Kubler, Kim. "The Difficulties Surrounding Clinical Decision Making in Advanced Illness." Accessed March 16, 2007. www.minurses.org/apn/Palliative%20Care%20103/PCMod2.pdf

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