Introduction
A vast majority of cultures value life and bringing people back to life is one of the most popular subjects in many fictional books and films. On the other hand, technology has evolved and the stories of people being brought back to life are coming true through implanted and external defibrillators, as well as other technologies (Ahronheim et al. 2009). This means that the natural course of death has slowed down rather dramatically as society acquires knowledge of how to live longer than nature probably intended. Organizations such as The Red Cross Association continue to teach organizations the proper methods of resuscitation such as mouth-to-mouth resuscitation and Cardiopulmonary resuscitation (CPR), which is a manual manipulation of the heart through processes that save patients’ lives. Traditionally, the function of first aiders, as well as doctors, in such situations was to do all they could to restart the patients’ hearts. However, a tricky area came about when the patients were given the right to choose whether or not they desired to be brought back to life after their hearts failed or breathing stopped. This paper will examine the provision of DNR or do not resuscitate order, discussing its inherent ethical issues, as well as the application of various course learning outcomes in the issue under discussion.
The dawn of the provision of the DNR order enhanced the examination of ethics in medicine. The DNR order states that medical professionals are disallowed from initiating CPR when the patients are unable to breath or their hearts stop. People unwilling to be resuscitated after clinical death can elect to place such an advance directive in their living wills (Simpson, 2010). The ideal of people exercising their rights to autonomy, which in essence means their rights to decide whether or not to be resuscitated, needs to be done well before the persons are incompetent to do so logically. The DNR is laden with controversy and is a complex and emotionally charged issue. The DNR direction is standard in the end of life care, as well as hospices, and state and medical authorities continue to enforce and clearly affirm policies regarding when to perform or delay the actions. Throughout these policies, emphasis is laid on the patients’ autonomy and confidentiality. Therefore, the autonomous decision of the patients often takes precedent over what the patients’ surrogates’ desire, in times of impending death.
Pursuant to the advent of life saving technologies with the capacity to restart life, interesting ethical issues continue to arise with regard to when efforts are futile to make additional attempts to resuscitate patients. The ethical question of when enough is enough in terms of saving the lives of patients arises. This question further considers what the patients’ legally endowed Bill of Rights prescribe in the event of a DNR order, particularly when health care professionals fail to agree on whether or not the patient is having a full code status warranting the implementation of a DNR order (Simpson, 2010). Family members and even health care professionals are deeply disturbed by the death of patients. However, for family members, the fact that the patient will die is not all they must contend with. Because available technologies enhance the likelihood of patients being rescued from some form of arrest, family members must respond to questions such as when their patient should be considered a DNR and the person responsible for giving such an order in the absence of a living will, as well as the legal implications of such an order.
Ethics in medicine, often referred to as biomedical ethics, is not a new concept in terms of inquiry. The initial code of ethics discovered dates back to the 5th century BC and is creditable to Hippocrates (Baker, Strosberg & Bynum, 2010). In most senses, Hippocrates’ code is undying. For instance, Hippocrates provided that physicians should never prescribe deadly drugs to patients even when asked for it, nor suggest taking such drugs. This instance deals with the modern issue related to assisted suicide and provides a glimpse into the massive array of ethical concepts developed in previous times, which have evolved into ethical codes and legal concepts that guide the conduct of medical professionals. A lot has, however, changed in the last few decades with medical professionals giving immense attention to the area of biomedical ethics. For instance, in pharmacy, surveys were done in 1963 and 1980 to ascertain the scope of ethics instructions within schools of pharmacy (Ahronheim et al. 2009). Presently, medical schools provide some instruction in the area of biomedical ethics. Although the quantity of ethics instruction remains almost the same, over time, it is critical to note that the quality and depth has improved dramatically. There is no one factor creditable for the increased scope and quality of ethics in medicine, but numerous factors have impacted the evolution of ethics in medicine. These factors include the increasing cost of health care, which calls for impeccable allocation of resources to ensure quality of patients’ lives. Secondly, the explosion of biotechnology, which allows medical professionals the ability to save and sustain life, has also caused the evolution of biomedical ethics. When doctors did not have the capacity to sustain the life of people in vegetative states, the issue of resuscitating was not dealt with.
Presently, in the US, documentation necessitating a DNR order implementation is quite complex since all states accept different forms. In addition, EMS professionals do not accept living wills, as well as advance directives, as legally authentic forms (Baker, Strosberg & Bynum, 2010). When patients have living forms that provide that the patients wish to be DNR but they do not have sufficiently filled out, state sponsored forms, which are co-signed by physicians, then EMS will try to resuscitate. This fact is typically not well known by most patients, as well as primary care professionals, that often cause patients to receive treatments they do not desire. The US is presently evaluating this law for its inherent constitutional challenges. Available resources that allow for the DNR order include the 1976 In re Quinlan, which is a precedent provided when the New Jersey Supreme Court defended the right of the parents of Karen Ann Quinlan to order physicians to remove her from artificial ventilation. Consequently, in 1991, the US Congress passed the Patient Self-Determination Act into law, mandating hospitals to honor patients’ decisions in their health care. Presently, 49 states, with the exception of Missouri, allow patients’ next of kin to undertake medical decisions on behalf of incapacitated relatives (Simpson, 2010). Missouri’s Living Will Statute demands that two witnesses must sign an advanced direct that causes a DNR code status in a health care institution. Overall, in the US, cardiopulmonary resuscitation (CPR), as well as advanced cardiac life support (ACLS) cannot be performed on patients with a present valid, written DNR order. However, a vast majority of US states do not recognize health care proxies, as well as living wills, within the prehospital setting and prehospital personnel in such areas are required to initiate resuscitation measures save for the presence of a specific state sponsored form, which is appropriately filled out, as well as cosigned by a physician.
With regard to alternative solutions for the issue of DNR orders, organizations such as religious organizations continue to endorse alternatives such as allowing natural death. Health care professionals on all levels, physicians, case managers, nurses and social workers unintentionally terrify patients, as well as their families with medical terminology that are considered harsh, confusing and harsh (Baker, Strosberg & Bynum, 2010). The DNR order is one such instance. An alternative to this provision would be to allow natural death (AND). Whenever health care professionals speak to patients and their relatives regarding DNRs, in most cases, the families deem physicians as abandoning care and stopping all treatments. However, the DNR is only desired to convey the information, which is the patient and family do not wish to institute resuscitation attempts if the patient is proclaimed as clinically dead. Regardless of the time and energy spent to explain DNR orders to the family, all they grasp is the term “not” in DNR. Such negativism confuses most people who consider approving a DNR order as permitting the termination of their loved one’s lives (Lachman, 2010).
In this sense, most relatives are reluctant to agree to the DNR order since they feel guilty for not assisting their loved ones as they deem they should. An order that allows natural death aims at ensuring that merely comfort measures are offered to terminal patients. Through an allow natural death order, medical professionals acknowledge that the person is dying and that all efforts done for the patient, for instance, withdrawing hydration and nutrition only allow the dying process to take place as comfortable as possible (Beauchamp & Childress, 2010). This means that while a DNR patient in the ICU might be on artificial hydration, ventilator and have an intravenous feeding tube, an AND patient would have these things discontinued, or not started, because these treatments are burdensome and painful for terminally ill patients. In essence, AND is a suitable alternative to DNR since it prevents unintentional pain by permitting natural death to take its course. Allow Natural Death is presently being introduced to nursing homes and hospices in order to reflect better the needs of terminally ill patients (Scoy, 2011).
The potential effects of the DNR are quite vast. This includes death, which occurs from the withholding of CPR, particularly in situations when CPR is considered to be of inconsequential medical benefit. Additionally death will occur when patients with sound decision making capacities clearly articulate that they do not want CPR when the need arises. DNR also causes distress among family members who are forced to decide the withdrawal of life-sustaining care (Pozgar, 2012). This typically occurs when CPR is considered as inconsequential when the quality of life of patients is so poor that meaningful survival is not expected even when CPR is successfully administered to restore circulatory stability. Judging a patient’s quality of life encourages prejudicial statements regarding patients with chronic disabilities or illnesses. Such patients and family members typically rate the patients’ quality of life higher than health people rate theirs. However, it is evident that patients in permanent vegetative conditions possess a quality of life, which few people would consider acceptable. Consequently, CPR is often deemed as futile for patients experiencing persistent vegetative states. In addition, the position of DNR orders among patients undergoing surgery continues to present immense challenges for patients, their substitute decision makers and health care professionals. It is critical that all parties appreciate the essence of each DNR order, considering not only the content of the order, but its context with regard to timing, location and circumstances (Geyman, 2009).
When CPR is not considered futile, but the patients desire a DNR order, the concept of respect for patients’ autonomy and confidentiality takes precedent. This concept provides the foundation for ethical and moral decision making by assuming that the patient involved is a rational agents capable of making voluntary and informed decisions. Medical professionals need to respect the autonomy of the patient by allowing the patient to act intentionally, with sufficient understanding of the implications, as well as without controlling influences, which would diminish the possibility of a free and voluntary act. This concept is the foundation of the medical practice of informed concept in physician-patient interactions pertaining to health care provision. This interaction also provides for the implementation of patient’s Bill of Rights as it concerns DNR orders (Lachman, 2010). The concept of respect for all persons guides, informs and dictates the approach followed by patients and medical professionals. The Bill of Rights provides for meaningful dialogue between physicians and patients wishing to establish a DNR on their lives. This also involves physicians providing sufficient information to facilitate the reconsideration of pre-existing orders in order to ensure that patients are fully aware of doctors’ strategies regarding saving their lives (Miller-Thiel, 2010). This means that physicians are not justified to automatically suspend or automatically continue DNR orders, particularly in patients undergoing surgery. This is primarily since there is no single solution applicable for all DNR-related issues, especially in terms of the pre-operative period. Issues that appear obvious to anaesthetists can often be considered differently by the patients, as well as members of the care provision team.
Presently, there are monitory provisions, which aim at ascertaining patients’ needs are met with regard to DNR orders (Maidens, 2012). The Patient Self-Determination Act (PSDA) requires that health care providers to offer patients regarding advance health care directives. One of the most critical provisions of this act is the concept of respect for persons. PSDA ensures that patients are offered written notices upon admission to health care facilities, as well as policies concerning advanced directives in the state and the institution they are admitted. Patients’ rights monitored by this act include the right to accept or deny medical treatment, right to make advance care directives and the right to establish their own health care decisions (Baker, Strosberg & Bynum, 2010). Therefore, facilities are required to inquire whether patients already have advance health care directives. The act deters health care providers from discriminately treating or admitting patients on the basis of whether or not they possess advance heath care directives. Health care institutions that breach these basic principles are held liable and are bound to be prosecuted under the law of the state. Some states, as well as local programs typically address emergency life-saving treatments in addition to CPR. These programs are referred to as Physician Order for Life-Sustaining Treatment (POLST).
References
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