Imagine that you are a severely ill patient lying in a hospital bed. Around you circulate a procession of doctors, nurses, family and friends. One question needs to be addressed. If your heart and breathing stop, should they try cardiopulmonary resuscitation (CPR)? Should you or your appointed decision-maker apply a ‘do not resuscitate’ (DNR) order in your medical chart? This is a decision that cannot be taken lightly. It is important when making this decision that the dignity and value of all human life is based on conclusion of evidence-based survival prospects rather than value-of-life statements. This ethical dilemma can occur because of a DNR order that you, your family and friends, and medical professional staffing will face in the event that a life-threatening illness or injury were to occur.
Do Not Resuscitate (DNR) orders are medical directives to withhold efforts to revive a patient who has a cardiac or respiratory arrest. The decision not to resuscitate is unique in health care as it is the only treatment decision that has to be made beforehand, i.e. before the event has occurred. Without a DNR decision by the physician, all staff is required to start CPR in the case of a heart stop even if it is obvious that this is not the best choice. These orders came into practice in the 1970s because of the New Jersey Supreme Court decision in the In re Quinlan case (Wikipedia).
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Medical professionals follow DNR orders when a person is not able to communicate his or her wishes to refuse medical treatment that may result in their death (US Legal).
Through the 1970s and 1980s, many hospitals and physician would routinely create DNR orders without any discussions with the patients or patient’s family. The Quinlan case decision put an end to these practices as the case started the bioethics movement and the court emphasized the right of the patient and the patient’s surrogate decision maker to refuse the medical treatment, including life-sustaining therapies such as CPR.
One ethical dilemma that medical professionals are face with is to determine whether a patient is competent or in the right mind to make a decision to add a DNR order in their medical chart. In this situation, however there is normally the possibility of discussing the medical diagnosis, treatment options, and DNR order with the relatives or friends of the patient. In many cases, the patient will have appointed either the family member or friend as a surrogate decision maker. However, if the patient is able to communicate, no matter if they are competent or incompetent it is the patient’s right to add a DNR order. As such, in the United States, the legal situation is laid down in a set of so-called ‘right-to-die cases’. These establish that a person has a right to refuse life-sustaining treatment whether he/she is thought of as competent or incompetent. US law sees no difference between not starting (withholding) and stopping (withdrawing) a treatment.
In addition, medical futility is an ethical dilemma that medical professional will come across while treating a patient. Is the medical treatment going to be futile? Medical futility is extremely difficult to define, but in general, it is the physician determination if a therapy or treatment will be of no benefit to a patient, and therefore should not be prescribed. For example, a physician may argue that is a futile attempt to resuscitate or CPR on a patient who is in a permanent vegetative state. Many physicians have a difficult time with this ethical dilemma because what they may determine as a futile service other medical professional may not arrive to this same conclusion. In addition, if they have personal Christian religious beliefs the physician may be torn between the thought that human life is not futile, no matter how poor, ill, disabled, or even in pain the patient is in and if the medical treatment will be beneficial to the patient’s life. The physician does not take this decision lightly as it is a decision that can determine if the patient lives or dies.
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There are two very well know court cases relating to futility, “Wanglie” and “Baby K”. Both of these cases were about patients that were in need of long-term medical care. The Wanglie case was about an elderly woman in a vegetative state, on a ventilator, and in the intensive care unit. Her physician’s and hospital went to court to have a guardian appointed, with the ultimate objective of having life support withdrawn. The court declined to address the question of futility and only held her husband the best person to be her guardian. The case of Baby K involved an infant who was born with anencephaly, a condition involving absence of the cerebral and cerebellar portions of the brain, for which there is no curative or ameliorative treatment (Ascension Health).
Baby K was unable to breathe on her own or to interact meaningfully with others. Her mother insisted that Baby K should have all medical treatment necessary to keep the child alive. Again the hospital went to court to obtain a ruling that it should not be required to provide artificial ventilation and other treatment when the child was sent to the hospital from the nursing home where she live. The courts used a narrow reading of the Emergency Medical Treatment and Active Labor Act (EMTALA), commonly known as the “anti-dumping statute” to determine that the hospital had an obligation to provide necessary care (Ascension Health).
Do Not Resuscitate orders not only pose ethical dilemmas for the medical professional but also on the person’s family and friends alike. Like medical professionals, family and friends experience ethical dilemmas when it comes to decision-making and communication. Decision-making and communication are both related to the ethical principle of autonomy. Autonomy essentially means “self-rule,” and it is a patients most basic right. As such, it is a health care worker’s responsibility to respect the autonomy of their patients. However, at times this can be difficult because it can conflict with the paternalistic attitude of many health care professionals.
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Moreover, it is the responsibility of the patient’s family, friends and surrogates decision-maker to make the decision based on the patient’s wishes and authentic to his/her values, vision, and goals. This ethical dilemma is known as beneficence, which simply means doing good. According to Peter Facione, Ethics Center Scholar, “Beneficence demands serving the patient’s interests as well as possible while doing no harm.” The patient’s family and friends may not agree with the patient’s decision, but they must accept and be willing to implement the request to decline or terminate medical treatment when they are acting as the surrogate decision-maker. The surrogate decision-makers should follow those wishes rather than make their own judgment about what to do. This is referred to as “substituted judgment” because the surrogates substitute the patients’ prior judgment about treatment matters for their own. This is not only an important legal concept, but also one that has practical application in counseling surrogate decision-makers at the bedside. Many surrogates feel uncomfortable in deciding to forgo life-prolonging interventions because they see themselves as deciding between life or death for another person. The actual role of the surrogate, however, is not to make the decision but to help carry out the patients’ wishes. This is relatively easy when the patient has taken the time to complete an advance directive. In such cases, the surrogate’s role is often to clarify the interpretation of vague statements in the directive and to help craft the details of the patient’s palliative care plan. Matters can become more difficult when the surrogate must recall past oral statements by the patient about how he or she would want to be cared for in an end-of-life or terminal situation.
Many times the patient will chose the DNR order not only as a personal preference to avoid or end any pain and suffering, but also with the belief that in the long run it may save his/her family and friends enormous grief. This decision is the patients’ choice, as they have the right to die with dignity. In the situation of an end-of-life care or terminal illness, it is best of the patient has a plan outlining their wishes. It is their responsibility to choose a surrogate, of whom they trust, communicate their wishes to both the surrogate and their physician, and ensure that the legalities are taken care by having your wishes put into writing. By doing so, while you lay in the hospital bed, severely ill, watching the procession of family, friends, and physicians circulate around you, there will be no reason to worry about any needs that may need to be addressed. You have already provided your last wishes in the trust of your surrogate decision-maker who will have no guilt, only love, as they follow your final wishes. Allowing you as the patient to pass in peace and die with dignity.
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“Do Not Resuscitate Order Law & Legal Definition.” Legal Definitions Legal Terms Dictionary. Web. 07 Sept. 2011. <http://definitions.uslegal.com/d/do-not-resuscitate-order/>.
“Do Not Resuscitate.” Wikipedia, the Free Encyclopedia. Web. 07 Sept. 2011. <http://en.wikipedia.org/wiki/Do_not_resuscitate>.
Ascension Health. Web. 07 Sept. 2011.