This paper presents a case study from the perspective of a new EMT responding to a call involving a 78-year-old male cancer patient with a Do Not Resuscitate (DNR) order. The paper applies two theoretical frameworks to the encounter: Boykin and Schoenhofer's "Nursing as Caring" theory and Elisabeth Kübler-Ross's stages of grief and dying. The analysis examines how both theories address individual dignity, patient autonomy, and compassionate care, while arguing that Kübler-Ross's framework is particularly relevant given the patient's deliberate DNR decision. Key ethical principles—including autonomy, beneficence, and paternalism—are explored in the context of end-of-life nursing practice.
This case study is presented from the perspective of a new EMT. The patient was a 78-year-old male presenting with breathing difficulties. He had early-stage cancer and wore a DNR (Do Not Resuscitate) bracelet, accompanied by a written DNR order. The patient's wife was aware of the DNR, but her natural reaction was to try to save her husband. The call, therefore, was directed more toward reassuring the wife than the patient himself, who had accepted his situation, though he remained visibly distressed.
"Nursing as Caring" was developed by Boykin and Schoenhofer in the 1980s as they examined the dimensions of caring and how those dimensions applied to the overall patient–healthcare paradigm. In general, the theory functions as a framework and toolkit for addressing common issues in modern healthcare. Its central dimensions hold that caring is what makes humans fundamentally human, that caring is a moment-to-moment and uniquely individual model required within healthcare, and that the medical professional's own personhood and empathy are developed through a caring model (University, 2010).
In many traditional cultures, the process of dying is accepted as a natural part of the rhythm of human existence and is treated with reverence. In the modern developed world, however, death is frequently feared, and those who are dying are often institutionalized and removed from general society. Rather than allowing a person to die with dignity, every possible measure—even if uncomfortable and invasive—is taken to keep a loved one alive, not for the patient's sake, but for the sake of the living.
Elisabeth Kübler-Ross believed the opposite: that grief and loss are transformative experiences, and that a person's process of dying is a natural outgrowth of life (Kübler-Ross, 2007). Her framework challenges the medicalized suppression of death and instead affirms the dying person's right to experience the end of life on their own terms.
"Comparing theories against DNR case and ethics"
Kübler-Ross's theory was developed in response to the prevailing view that death and dying were processes to be feared and concealed within modern society. The overall purpose of the theory is to affirm that patients are unique individuals with unique and important rights to determine the circumstances of their own death—even if that means refusing heroic and medically possible interventions (Kübler-Ross, 2013). Within the nursing model, this stance may initially seem at odds with certain ethical principles centered on aiding the patient and doing no harm. However, the ideals of patient-centered care are fundamental to the modern nursing profession, and these two perspectives are not necessarily incompatible.
At the very heart of both Kübler-Ross's framework and medical ethics are three core principles: autonomy (allowing a rational individual to make uncoerced, self-determined decisions), beneficence (doing no harm, and not causing pain or discomfort that prolongs illness rather than curing it), and paternalism (respecting the individual's choices and opportunities) (Kübler-Ross; Rai, 2009).
Kübler-Ross herself clarified that her grief stages "have evolved since their introduction, and they have been very misunderstood over the past three decades. They were never meant to tuck messy emotions into neat packages. They are responses to loss that many people have, but there is not a typical response to loss. There is no typical loss. Our grief is as individual as our lives" (Kübler-Ross, 2007). Thus, the overall concept is broad in scope but narrow in application. Family members, friends, and medical professionals should of course attempt to heal and comfort the individual. However, within the healthcare paradigm, there is a natural cycle in which heroic measures can prolong suffering and pain while stripping the patient of the right to choose the manner of their death and to preserve their dignity. Kübler-Ross indicates that one can be compassionate and caring—providing comfort and alleviation of pain—while still ensuring full respect for the individual's choice.
Both the Theory of Nursing as Caring and Kübler-Ross's framework on grief and dying offer meaningful guidance for an EMT or nurse encountering a patient with a DNR order. Where Nursing as Caring emphasizes the moment-to-moment empathic relationship between caregiver and patient, Kübler-Ross provides a philosophical and ethical foundation for honoring the patient's autonomous decision to forgo aggressive intervention. In this case, the most important role of the responding EMT was not to override the patient's documented wishes, but to provide compassionate presence and comfort to both the patient and his distressed wife—affirming the dignity of a life well lived and a death chosen on the patient's own terms.
University. (2010, June). Anne Boykin & Savina Schoenhofer — Nursing as Caring. Retrieved from stritch.edu.
Kübler-Ross, E. (2007). On grief and grieving. New York: Scribner.
Kübler-Ross, E. (2007, April). The Kübler-Ross grief cycle. Retrieved from Changing Minds.
Kübler-Ross, E. (2013, January). On death and dying. Retrieved from EKR Foundation: http://www.ekrfoundation.org/
Rai, G. (2009). Medical ethics and the elderly. New York: Radcliffe Publications.
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