Do NotResuscitate (DNR)
DoNot Resuscitate (DNR) refers to a legal order drafted either on alegal form or in the hospital to withhold Advanced Life Support(ACLS) or Cardiopulmonary Resuscitation (CPR) by the patient`s wishesif he or she was to stop breathing. Directives on "not toresuscitate" require one to withhold aggressive types of newlife saving techniques such as CPR and ACLS. By definition, theselifesaving interventions are meant to revive individuals who havejust succumbed (Ehlenbach et al., 2009). What is known about DNR isthat aggressive treatment short of these interventions may beacceptable to particular patients. These patients may have incurableend-stage conditions, and may not want to be saved from dying as longas there is clarity in understanding the intended treatment andtreatment objectives of the patient.
Again, when "resuscitation" is offered to patients, theymay be wrong in thinking that it will turn out to be successful,especially in tightly controlled clinical conditions. The wayclinicians phrase their thoughts and beliefs to patients, and expertsportray CPR and ACLS in the media may largely misrepresent thereality of the matter (Burkhardt & Nathaniel, 2014).Additionally, shared and responsible decision-making approaches byphysicians and their patients regarding the preferences andindications of CPR and ACLS requires thatthe patients are educated appropriately concerning all the benefitsand modalities` risks.
Forming a basis for this, research shows that approximately 5% of thepatients requiring CPR outside the healthcare facility and 15% ofthose inside the hospital survive. Elderly patients living in nursinghomes are diagnosed with multiple medical conditions. Those withadvanced cancer are less likely to survive. Of importance is that DNRdoes not suppress any treatment apart from that which may require CPRor intubation. Again, DNR patients can continue to undergochemotherapy, dialysis, antibiotics, or any other preferabletreatment.
EthicalDimension of DNR
The ethical dimension of DNR is determined by autonomy, informedconsent, non-maleficence, and utilization of available resources. Incertain situations, DNR orders are subject to ethical discussion. Inmany healthcare facilities, it is customary or a mandate for apatient undergoing surgery to have automatic resuscitation. Here, theethical dimension is dictated by outcomes from the CPR. Though thebasis for this may be valid, the impact on the autonomy of thepatient has been discussed. It is thought that hospitals engageeither the patients or those making decisions for them in the"consideration of DNR orders" to avoid making forceddecisions.
Ethical dilemmas arise when patients with DNRs attempt suicide andthe preferable treatment involves CPR or ventilation. In such cases,it is argued that the beneficence principle assumes precedence overthe autonomy of the patient. Also, the DNR could be revoked by thosein charge, for example, physicians (Bishop et al., 2010). Anotherdilemma arises when a medical error occurs to a DNR patient. In thiscase, if the error can only be reversed with ventilation or CPR, thenthere is no consensus as to whether resuscitation should be carriedout or not.
There are also certain ethical concerns as to how patients arrive ata decision for DNR. Mohindra (2007) noted that when these patientsare questioned in detail most of them having undergone DNR would havepreferred interventions, which depends on outward results. Majoritywould choose life-saving intubation when in angioedema scenario,which typically resonates in days. Approximately one-fifth of thesepatients would prefer resuscitation for other situations like cardiacarrest, but for this care to be withdrawn after a week. Therefore, itis highly likely that medical providers engage in a "leadingconversation" with their patients or leave out crucialinformation when discussing DNR. Additionally, there is the ethicalissue of ICD (Implantable Cardioverter Defibrillator)discontinuation, especially in DNR patients experiencing medicalfutility.
Relevance ofthe Issue to Health Professions
The significance of DNR issue comes into play every time a healthprofession asks, "Do you want us to undertake any emergencyapproaches like the CPR if your heart ceases to beat?" Thecommon answer to this is “Yes!" While such a response maysound correct, health professionals cannot take it as an informeddecision. To health professions, the issue requires a laymanunderstanding of the entire process and its impacts on both thepatients and their families.
Theissue is relevant since nurses’ commitment to maintain thepatients’ dignity are considered to be non-maleficence, whichrequires patients’ recognition to benefit from DNR orders. It isimportant for health professionals to understand factors likefrailty, age, comorbidity, and well-known wishes like an advanceddirective, which can motivate them to provide more information topatients and families about all matters resuscitation care. Ehlenbachet al. (2009) noted that ethical and professional mandates requirethe health professional to act as a patient advocate if appropriatefor DNR. The risk of emergency cardiac situations is critical andreal, thus, conversations on the same are important, especially forthe elderly patients in the United States regarding the issue of DNR.
In addition, DNR allows health professionals to make sound decisionsin accordance with the wishes of the patients and families withoutjeopardizing the ethics in place. The physicians can clarify anyprognosis by proposing a directive to the relatives. In some cases,this may involve deferring to the decisions made by the patients,especially when medical evidence and judgment may not be conclusive(Sandroni et al., 2007). In a different scenario, it may mean arecommendation that CPR is not applied. Consistent with thesafeguards, which ensures physicians` accountability and where statelaws would grant broad nursing discretion.
Points ofConsensus and Difference Concerning the DNR
One point of consensus involves having an informed consent betweendifferent parties concerning DNR. Through informed consent,clinicians are better placed to provide full information aboutpotential risks and benefits of carrying out CPR or ACLS, conveyparticular recommendations, and indicate clearly the proposed coursethat both the patient and the family have a right to disagree withthe judgment by the clinician. The patient or family is in agreementthat they can always make choices in accepting the clinicians orphysicians to undertake the CPR or ACLS.
All parties arrive at a consensus when making decisions on DNR. Forinstance, an important aspect of this issue is when the familymembers, patient, and clinician determine each role a party wants toplay in making decisions on the issue. An agreement is arrived atwhen family members allow the clinician or when the clinician iswilling to allow DNR to be carried out on the patient (Sandroni etal., 2007). An agreement by the parties to obtain informed consent onthe issue is ethically acceptable, especially when the clinicians arenot sure about the chances of success. Again, a consensus on theissue is reached when the clinicians` value judgments would result inthe patient`s quality of life.
Onthe other hand, the difference is the disagreement between allparties concerning the issue. The difference occurs when a preferreddecision-making is required. For instance, it involves withdrawing aCPR that had already been started, but due to the clinical course ofthe patient, it is no longer shown. Mohindra2007) noted that themajority of medical ethicists argued that withdrawing CPR and ACLStreatments are both legally and ethically equivalent. The decisionsregarding the withdrawal of the above interventions, which clinicianshad viewed earlier to be potentially beneficial, more often than nothave different and powerful impact onboth patients and families. Accordingly, successful communicationwith the families regarding the withdrawal decision should take thosedifferences into account.
The DNR issue is both in the operative suite and in post-operativesetting presents ethical issues. Ethical issues arise when DNR isrescinded during an operation, and thus the time frame andcircumstances reordered should be specified (Ehlenbach et al., 2009).Respect for autonomy is emphasized when dealing with adult patients.Here, the emphasis placed on improving communication with familiesand patients is often preferred over the clinicians making individualdecisions based on medical futility appeals over the resuscitationstatus. In such cases, relevant ethical principles include autonomy,non-maleficence, beneficence, and justice.
Ethical issues surrounding DNR require principle of beneficence toassist patients to advance their rights during decision-making. Theprinciple of Justice is also needed to allow fairness and handlingcases of CPR equally. The principles of DNR order also require areevaluation process to be incorporated into the informed consentprocess. By allowing parents, clinicians, or patients the option ofmaking decisions on resuscitation, the patients` needs are likely tobe individualized for the better (Bishop et al., 2010). Suchscenarios are dictated by ethical theories, one of them being thenatural law, whereby those specific individual rights are inherentlybased on human nature. Additionally, the principle of non-maleficencedictates parties to do no harm during the decision-making process.
Ethical theories represent both the integration of rules andprinciples, which depends on the individuals’ customs and beliefs.For example, metaphysical, diverse scientific and religious beliefsdetermine proper interpretation of the ethical theory and thescenario. These ethical theories act as justifications of theprinciple, judgment, and rule. However, they are abstract and may notapply in clinical practice. The justification of these principles isdictated by ethical theories such as duty theories, virtue theory,and consequentialist theory. Again, justification of these principlescalls for standards of practice to be incorporated in scenariosinvolving DNR and CPR. For instance, standards of practice applied bynurses include assessment, diagnosis, outcome identification,planning, and implementation. Once the patient is assessed, it isimportant that diagnosis is applied to determine identification ofoutcomes. These standards of practice use the nurses’ ability toconnect between the patients’ wishes and his or her professionalprocedures.
PersonalNursing Professional Response to the Issue of DNR
Asa nursing professional, having enough knowledge on DNR means betterdecision-making techniques. A clinician, for instance, willunderstand that a decision on resuscitation ought to be based on thecombination of individual preferences and values coupled with factsand options during treatment. Burkhardt & Nathaniel (2014) notedthat this should occur when the patient is conversing with his or hernursing professional known and trusted.
The generalized rule of trying out universal CPR needs, which formsa big part of DNR, requires careful consideration. From here, andwith the right knowledge on DNR, it is important to note thatengaging families and patients in decision-making respects thepatient`s autonomy, provides these parties with accurate informationon potential risks and medical benefits of CPR, which is critical.Under specific circumstances, such knowledge on DNR means CPR may notgrant the patient with direct clinical advantages. Here, it is eitherbecause the resuscitation may not be successful or because to surviveit will result in co-morbidities, which will merely lengthen thepatients` suffering and not have to reverse the condition.
The paper identified DNR as a legal form used as a measure over CPRand ACLS according to the patient’s wishes if his or her heart wasto stop beating. Resuscitation seeks to offer patients an alternativeto life whenever their hearts stop beating. The paper identified fourethical dimensions of DNR used during the decision-making process.These aspects include autonomy, justice, beneficence, andnon-munificence. Again, during decision-making between differentparties, there are points of consensus and differences regarding DNR.The consensus is reached when the patient, family members, and theclinician agree to the withdrawal of CPR.
Bishop, J., Brothers, K., Perry, J. & Ahmad, A. (2010). Revivingthe Conversation Around CPR/DNR. Taylor & Francis Publishers, TheAmerican Journal of Bioethics, 10, 1, 61-67
Burkhardt, M.A., & Nathaniel, A.K. (2014). Ethics and issuesin contemporary nursing (4th ed.). Clifton Park, NY: DelmarPublishers. ISBN: 978-1-4180-0561-5
Ehlenbach. W. J ., Barnato, A .E.,Curtis, J . R., Kreuter, W.,Koepsell.T.D., Deyo, R. A., & Stapleton, R. D. (2009).Epidemiologic study of in-hospital cardiopulmonary resuscitation inthe elderly. The New England Journal of Medicine.36(1)22-31
Mohindra, R. K. (2007). Medical futility: A conceptual model. Journalof Medical Ethics 33(2): 71–75.
Sandroni, C., J. Nolan, F. Cavallaro, and M. Antonelli. (2007). Inhospital cardiac arrest: Incidence, prognosis and possible measuresto improve survival. Intensive Care Medicine 33(2): 237–245.