Do-Not-Resuscitate: Legal and Ethical Issues Most cultures value life and bringing persons back from the dead is a popular subject of many fictional books. However, as technology evolves and the story of Frankenstein reborn with a bolt of lighting has come true with the external or implanted defibrillators, the natural process of death slows as much of society gains the knowledge to live longer than nature intended.
The Red Cross Association taught many organizations like the girl and boy scouts the methods of mouth-to-mouth resuscitation and Cardiopulmonary resuscitation or CPR, a manual manipulation of the heart, as life saving methods for drowning, electrocution or heart attacks. First aid for laypersons to save lives as well as doctors and no one is thinking that the person did not want to live after such an event. Thus, came the dawning of the provision of the do-not-resuscitate (DNR) order or provision stating not to initiate CPR if the individual is not breathing or the heart stops.
Individuals wishing not to be resuscitated after clinical death can choose to place that advance directive in a living will as a do not resuscitate order directing that no CPR is to be attempted. The ideal of persons exercising their right to autonomy or their right to make decisions about healthcare before they are incompetent to do so is sound, but the DNR is burdened with controversy, complicated and emotionally charged. Eventually, the DNR directive became standard in hospice and end of life care, which led medical and state authorities to create and enforce clearly affirmed policies about when to delay or ensue with the action.
In these policies, emphasis on the patient autonomy and surrogates for the patient can possibly take precedence over the decision of the doctor as a priority decision-maker, especially in the moments of impending death. During this time of incapacitation, the intentions of the patient are important in necessitating the resuscitative/CPR order. However, in an emergency, a controversy centers on who should have the authority over the making of the DNR decision (Olver, I. , and Elliott, J. , 2008).
Many concerns about the conflicting legal and ethical issues of the Do Not Resuscitate order subsist because of the potential deprivation in quality of care and the moral value of life. These apprehension s are present because of the uncertainties that lay between the doctors and family for the decision-making authority over the patient. Legal/Ethical Issues of DNR Originally, the DNR was a response to the confusion in situations involving CPR. When a person in cardiac arrest goes to a hospital or a paramedic gives emergency medical care to a person in their home, the default practice is to give life-saving CPR.
Refusing to perform Cardiopulmonary resuscitation or CPR on a person in critical status is the same as doing nothing to save a life, which holds the possibility of murderous act unless the individual holds proof of the do not resuscitate or DNR directive. Yet, actual CPR performed on persons with cardiac arrest “almost never works” and when a patient has a DNR order, there exists some confusion about care and risks receiving “sub-optimal care” (Murphy, P. , & Price, D. , 2007). The ethical dilemmas the medical profession confronts in the interpretations of the DNR order in regards to delivery of duty to care are numerous.
Hospitals implement ethics committees to assist in sorting out a patient’s legal rights and ethical issues when physicians, family and patients are at a medical impasse. Ethics committees utilize an unbiased, theoretical approach to inform and assist in the decision-making by using several principles to guide the decision-making process. The principle of Beneficence is to prevent harm, do right unto others and show compassion and non-maleficence, which is avoidance of imposing harm on an individual. The principle of justice is the fairness of treatment in benefits and risks or distribution of resources.
The principle of autonomy, an individual’s right to decide what is best for him or her. Autonomy can override beneficence when life-support is withdrawn (Prozgar, 2010). In addition, when a physician takes the position of withdrawing life-supporting equipment, the principle of non-maleficence is severed. Since helping patients die violates the physician’s virtue of duty to save lives,” distributed justice is served by releasing a room in the intensive care unit for a patient who has a higher chance of resolving their medical problems (Pozgar, G. 2010).
There are so many inflict fuzzy gray areas and ideas about conflicting DNR policies that political disputes had to go to the courts to sort out the issues legally. Though ethics committees have been helpful, scores of physician-patient disagreements end up in the U. S. court system with inconsistent results. The states adopted individual “statutes regulating DNR orders and their provisions vary in analysis throughout the U. S. ” (Bishop, Brothers, Perry ; Ahmad, 2010). One ethical dilemma that is constant in emergency rooms, the intensive care unit and terminally ill persons is a futility of treatment.
In the case of CPR/DNR, New York State wanted to enact a law that describes the decisive responsibilities of the patient, and the family or surrogate, and physician. “In April 2003, the New-York Attorney General asserted that the DNR law would require a physician to obtain a consent of the patient’s health care surrogate before entering a DNR order, even when the physician concludes that CPR would be medically futile. ” If the physician and healthcare surrogate disagree, they use the ethics committee to mediate and go to litigation if there is on compromise. (Bishop, Brothers, Perry ; Ahmad, 2010).
The issues that encompass the DNR directive are between prolonging life and death, as is the legality and moral acceptance of giving up on a life in futility proffer a questionable gray area. A continuous debate is ensued among ethicists about physicians who intentionally or knowingly end a life are executing a murderous act. Particularly, if a patient has a terminal illness with a low quality of life, suffering and has expressed the wish to forego resuscitative measures why deny that an individual when complications of the illness send that patient to the emergency room?
Just allowing a person die without resuscitation may compare to assisting the patient in committing suicide. Bringing a person back to life who wanted to die, facing a terminal illness suffering by enduring pain and an undignified quality of life is part of the ever-present gray area that continues to perplex medical professionals regardless of guidelines, laws and policies pertaining to the DNR. Medical professionals cannot predict whether the resuscitation will be successful.
Murphy and Price (2007) for Nursing Management, relate that the CPR/DNR order is not “a plan of care” but a plan of “contingency… [and] there are entire classes of hospitalized patients for whom CPR almost never works. ” Physicians following through with a DNR order medically knowing the condition of the patient can still have legal implications. Legally the law observes the wishes of the patient. If the patient postpones their DNR, it is their legal right, which leaves medical personnel in a complicated and conflicting position.
The makers of laws and policies cannot keep up with technology and ultimately ’medical choices involve conflicting moral choices” (Payne, J. , 2007). This conflict has driven the DNR issue into an unresolved ethical and legal conundrum leaving the medical professionals to accept the norm of uncertainty of patient’s rights versus the physician’s autonomy “… with the patient’s body hanging in the balance with the tide turning in favor of the patient’s decision-making” (Bishop, Brothers, Perry, ; Ahmad, 2010).
This leaves the standing order to resuscitate when there no implication of a DNR directive and the chances of living are not yet zero despite the recommendations of the physician. History of the DNR CPR initiated in the 1960’s was used in attempt to save life during surgery and as the process was perfected, CPR became essential knowledge for life saving in both medical and non-medical organizations (Ewanchuck ; Brindley, 2006).
Boy and Girl Scout organizations were encouraged to take basic life support training in classes held by the American Red Cross Association. They used mouth-to-mouth resuscitation and later advanced to classes in life support with cardiac massage to revive the heart, which quickly became a common and universal practice in first aid. Consequently, CPR became popular and gave rise to legal and ethical issues because the practice developed into a vital and efficient resuscitative tool in healthcare settings (Ewanchuck ; Brindley, 2006).
Because of CPR’s proficiency, the act of resuscitation became an implied requirement for medical personnel to perform the process when they deem necessary and the conflicting issues began, as healthcare professionals believed that some of the CPR attempts seem ineffective. “The literature suggests that where resuscitation was believed to be futile or non-beneficial, hospital staff conducted sham resuscitation attempts (‘slow codes’) or did not activate the ‘code team’ at all” (Ewanchuck ; Brindley, 2006 ).
Medical teams created a mock CPR maneuvers for families to see that they had tried to save the patient when the patient would not benefit at all. This scenario brought concerns about a responsibility and documentation about the process and introducing the involvement of patients, and familial surrogates in decision-making for the process. The situation suggested the perpetuation of respecting patient autonomy in making end of life decisions during the final stage of their condition bringing the DNR to the medical field.
Ewanchuk and Bridley at the University of Alberta note that it was a concern of the The American Medical Association that “…decisions to forego resuscitation be formally documented and communicated” and that the use of CPR is proposed for “…prevention of sudden death – not the treatment of a terminal, irreversible illness”(Ewanchuk and Bridley, 2007). In the 1980’s the medical professionals conceptualized the DNR practice to be “…one of the patient’s rights and not just an intervention” (Bishop, Brothers, Perry, ; Ahmad, 2010).
Current Resources toAddress Issues of DNR Currently, the DNR order and legal and ethical issues continue to evolve. Methods in addressing those conflicting issues in the gray areas keep hampering the progress in achieving transparency with the problems, which are the autonomy of the patients and their prevailing condition for the DNR order. For example, the medical personnel in the operating room might not have much information about the elderly patient coming in for hip replacement that had a DNR order in place.
However, the DNR order is very vague obviously, the patient expected to walk again and the ethics committee suspended the order just during surgery because she had an irregular heartbeat condition and family was not available for consultation. During surgery, the anesthesiologist who monitors cardio-respiratory stability of patients under general anesthesia during surgery can manipulate vital signs that can induce cardiac arrest. Suspending the DNR order the anesthesiologist has the right to use resuscitative measures to revive the patient without jeopardizing the patient’s wishes or the reputation of medical professionals during surgery.
DNR orders can be vague and have to be clarified. If a patient decides to retain the order during surgery, OR nurses have a moral obligation to honor the patient’s right to choose and will not be legally penalized. Conversely, even with the latest technology in CPR, predicting the outcome of resuscitative measures with certainty is almost impossible, which surrounds the moral and legal concerns in the perpetuation of life after death. Universal DNR orders have become necessary for all to initiate the process on common grounds. Decision-making is very determinate on the medical condition of the patient.
Several U. S. studies have associated DNR orders to the acuteness of the patient’s condition. However, Taiwanese studies by Chang and colleagues at the Taipie Medical University, found that “DNR orders were associated with other factors such as being older, having adult children as surrogates and being unable to survive to be discharged” and lengthy stay in ICU; none of the patients in the study signed an informed consent (Chang, Huang ; Lin, 2010). Moreover, there is much misinformation about the condition of the patient after resuscitation.
Some patients would not want to come back into a situation where their life would be physically dependent and useless “…neither of which are compatible with the image of the autonomous adult currently valued in our culture, and not one that they did not desire” (Olver and Eliott, (2008). Although, when surrogates are children of the patient, they may delay the psychological pain of losing a loved one by initiating over-treatment and pay dearly to gain comfort by prolonging life and seeking everything medical technology can offer.
The surrogates and family members want to feel that the medical professionals have done all they could to save the life of the patient, overriding the DNR order given by the patient. “With the DNR-influenced changes of the attitude of healthcare team with the thought that nothing can be done further to the patient, patients autonomy become playful to insist to refuse DNR orders as a one way to keep the team engaged on the patient care” (Truog, 2010). DNR issues are affected by cultural attitudes towards communicating the difficult subject of end of life with medical personnel.
In Britain, patients and family members trust their physician’s medical judgment more than Americans do when discussing medical treatment of the patient. “American patients seem to have taken the post-modernist perspective to heart, resisting the idea that there are “facts” about medical care immune from interpretation and negotiation” (Truog, 2010,). The notion that the cheating death and illness have provided an opportunity for the medical profession and science to create drugs and medical devices that may postpone a patient’s death.
This gives way to even more complicated ethical issues to a patient with a DNR order and surrogates who wish for the patient to survive. Better or Alternative Solutions for DNR Issues Addressed In cases where there is a standing DNR order, unambiguous communication must be initiated with the patient’s surrogates in their understanding of the proposed end of life care. All the risks, complications and consequences need to be addressed (Murphy and Price, 2008).
In addition, it is important that all other medical personnel involved with the patient, including members representing the ethics committee need to be present so that the surrogates can understand all options and understand that some expectations are false like medical technology cannot save a life of a terminal patient at this time. DNR rules and policies need to continue to kindle the patient’s autonomy by keeping open options while still maintaining a rational attitude about their medical condition. Decision-making on DNR requires sharing …but issues such as involvement of emotions, reluctance to carry the order due to fears of accountability, and other conflicts must be cleared over”(Oliver ; Eliott, 2008). Even though there is governmental intervention with legal aspects of the DNR, it is the ethical aspects, which jeopardize the practice further. Society can benefit from all the scientific advancements and technology however; the government must monitor the ethics in the end of life dilemmas. The Future of DNR Continuance
The DNR order is here to stay and the ethical issues will continue to swim in the vagueness of its interpretations in the future. Until the legal and ethical matters involved can be clarified, although by the time that is done advancements in medical technology will again cause more difficulties in interpretations of the DNR as the older will be out of date. Respect for cultural differences must be acknowledged now that the U. S. has so many people of many nations with various races and religious beliefs about death. In an example contrasting the United States, the United Kingdom recognizes the limitations of medicine.
Physicians have the right to order and convince the patient’s surrogates to initiate a do not attempt to resuscitate (DNAR) where there is no benefit. Just recently in Texas, the Texas Medical Association updated a bill with the House Human Services committee about “…how the end of life decisions should be made and by whom…” (Dallas County Medical Society, 2011). The bill bestows full control over the length and type of care a critically ill patient can receive in a hospital despite the appropriateness of medical care and limits the abilities and the willingness of physicians to order a DNR, possibly making it a criminal act.
The states differ about how the DNR is enacted and the future will depend on how close the states can get to a universal DNR. In the universal DNR, the rules will be common to all citizens of the United States and perhaps a world or global DNR order. Conclusion Understandably, the legal and ethical issues produced by the do not resuscitate orders (DNR) are aplenty. Historically, the DNR came to life after CPR became a life-saving sensation in first aid. I surmise that the DNR will be ever changing as laws, culture and moral views as well as technology differ with time.
Nonetheless, bringing people back from the dead into what quality of life is the moral issue. The ethical issues that medical professionals are confronted with in using advanced medical knowledge in making the right decisions for their patients using the guiding principles of autonomy, beneficence, non-maleficence and justice along with the Hippocratic Oath and code of Medical Ethics. Yet, there exits a vague gray area where the DNR order can be misinterpreted as to how, when and by whom a patient’s preferences are elicited and honored,” because resuscitation is more than a simple choice of life (Chang, Huang ; Lin, 2010). References Bishop, J. P. , Brothers, K. B. , Perry, J. E. , ; Ahmad, A. (2010). Reviving the Conversation Around CPR/DNR. American Journal of Bioethics, 10(1), 61-67. Retrieved October 15, 2011 from EbscoHost. Brooke, P. (2005). Bowing to family pressure. Nursing, 35(4), 24-26. Retrieved October 15, 2011 from EBSCOhost. Chang, Y. , Huang, C. , and Lin, C. (2010). Do-not-resuscitate orders for critically ill patients in intensive care. Nursing Ethics, 17(4), 445-455. Retrieved October 15, 2011 from EBSCOhost.
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D. (2010). The Conversation Around CPR/DNR Should Not Be Revived—At Least for Now. American Journal of Bioethics, 10(1), 84-85. Retrieved October 14, 2011, from EBSCOHOST database. Payne, J. (2007). Historical Perspectives on Do Not Resuscitate Orders and Advance Directives in Patient Care. Oncology Nursing Forum, 34(2), 545-546. Retrieved October 15,2011 from EbscoHost database. Murphy, P. , ; Price, D. (2007). How to Avoid DNR Miscommunications. Nursing Management, 38(3), 17-20. Retrieved October 15, 2011 from EbscoHost.