To Save Life or Respect the Autonomy of Suicidal Patients That Had Offered DNR Orders - Case Study Example

? Case Analysis: to Save Life or Respect the Autonomy of Suicidal Patients that had Offered DNR Orders Symptoms Medical personnel started using cardiopulmonary resuscitation (CPR) during the 1960s, and the procedure was initially aimed at reversing cardiac arrests among patients undergoing surgery. As of 1974, the process had been widely used, to the extent that AMA (American Medical Association) directed that a patient’s CPR status be noted in their medical records. As of 1976, hospitals recommended CPR as the corrective measure for cardiac arrest, unless in a case where the patient had directed – through a written consent – that they should not receive the procedure. Different legal and policy directives, including the self-determination Act of 1990 and rulings like Quinlan and Cruzan – among others – saw the establishment of the rights related to competent patients, regarding the refusal of life-sustaining procedures, which laid the legal and the ethical foundation for DNR (Do not resuscitate). All 50 US states have endorsed statutory standards upholding the autonomy of competent patients, in making personal decisions regarding their healthcare, including those related to CPR; there are also directives on realizing self-determination using authorized surrogates, in the case that decision-making capacity is lost. However, few of these statutory decrees, clearly explore the dilemma related to suicidal individuals requesting for DNR – one of them being the “New Mexico Healthcare Decisions Act." According to a 1997 survey, it was found that many emergency care personnel resuscitated patients, even in cases where the procedure was less likely to advantage the patient or where the case was futile, mainly due to the fear of criticism or litigation. Generally, legal advance directives were considered, but the express requests of patients were not (Marco et al., 1997). According to another study done between 1995 and 2007, the comparative study of emergency care practices related to the CPR initiation, it was found that over 80 percent of advance directives were honored, but the patient’s informal communications of interests were rarely followed. Further, 82 percent of the medical personnel studies revealed that legal concerns were not supposed to influence their resuscitation decisions, yet 92 percent of them felt that their decisions were influenced by such concerns. For those reasons, more than half of the medical personnel surveyed, revealed that they had performed CPR, more than 10 times during the previous 3 years, for cases that did not warrant the procedure; in cases where it would be futile (Marco, Bessman & Kelen, 2009). Many state rules require EMS (Emergency Medical Services) to offer CPR to patients that attempt suicide, so that they can be moved to health institutions where physicians can address the clinical and the ethical issues. For example, the Administrative Code of New Mexico directs that, in the case of questions related to the validity of an EMS DNR, or in a case where suicide or a homicide may have been attempted, resuscitation should be initiated. That should be done, while the persons involved await the resolution of the questions that arise – which may require the consultation of medical control (EMSAD, 2006). Problems Koenig and Salvucci (1997) report of a court case that addressed such an issue, where the San Diego County Counsel held that a legitimate out-of-hospital, DNR has to be observed, even in a case where the patient tried committing suicide. A probable systems-based outlook is also supported, because it would remove the responsibility of the EMS at the scene, but they also question the default model practice for CPR among patients that attempt suicide (Koenig & Salvucci, 1997). The views were that, despite that – in a case where the case presents doubt elements – resuscitation should be initiated; initiating clearly undesired interventions can be regarded as egregious as the acts of withholding a necessary resuscitation. Therefore, there is a need to check the issue in a proactive manner, in order to honor the autonomy of the patient, to the best levels possible (Koenig & Salvucci, 1997). Research shows that there are gaps in DNR discourses, which may lead to the incidence of such dilemmas, particularly at teaching hospitals. There is a need to increase medical personnel education in checking for the express interests of patients. Physicians from the different specialty areas are faced by a different, yet similar issue on the ways of handling DNR orders, especially when the cardiac arrest is triggered by iatrogenic incidents (Ross, 2003). Problem analysis The first problem is that the determination to overrule a DNR request from a patient that had attempted suicide before is ordinarily projected and viewed as a clear case of conflict between the values of beneficence and autonomy. The second problem is that, when many medical personnel encounter a medical case, where the patient expressed their interest for DNR, but their situation deteriorates during a time when they cannot affirm the DNR, the physicians are likely to respond with the prima facie role of preserving the patient’s life. The third problem is that, in a case where the patient clearly expressed a DNR order, but then attempts suicide and is saved prior to the success of the attempt, they are also likely to be denied the DNR. The different situations invoke the dilemma related to countering the autonomy of the patient (beneficence), by the ethical pursuit of the physicians – who feel that they need to save the patient – for the patient’s good. In such a case, the rescuing medical professional is not able to satisfy the ethical values that are in conflict. Evaluation of Alternatives The options available to the medical personnel in such a situation can be derived from the advice of Casarett, which directs that the best way to address the situation is not emphasizing on the procedures performed by the medical personnel. Instead, it argues that the dilemma emerges from the failure of the medical personnel - to engage the patient in conclusive deliberations – to collect information on the underlying preferences related to their treatment (Casarett & Ross, 1997). Further, the problem is compounded by a physician’s feeling of responsibility and the risk of the legal action that they may face – which make their decision to overrule the patient’s DNR more likely, although not ethically justifiable. The end result, where the previously offered DNR is overridden demonstrates a failure to consider the interests of the patient, as a person. The second option is based on the consideration that in many cases, the request for DNR by a patient is not a deliberate, independent choice which can be separated from their impulse to commit suicide. These facts are supported by different studies, including Lee et al (1998) which show that the interest of patients about their request for DNR is constant over time, which is characterized by the refusal of care, more than accepting it. For that reason, questioning the patient’s DNR requests after an adverse event, will not prevent – but is likely to attract more harm than benefits. Recommended course of action From the two alternatives explored before, the better course of action is the one, where the physicians in charge of patients engage them in extensive discourse, so that they can establish their true interests about care. Following the extensive discourse between the physician and the patient, the patient is likely to disclose their lack of interest in continuing their lives, which will indicate that in the case that they come to a point where they may need CPR; then they are more likely to have requested for a DNR (Casarett & Ross, 1997). Further, through the discourse, the physicians are more likely to explore whether the patient is suffering from emotions, social or psychological imbalances, which are likely to culminate in their requesting for a DNR. In such a case, the physician will have identify the given patient as one at the risk of emotional or psychological problems, therefore, a DNR request from them may not be accepted, before the problem triggering it has been resolved (Lee et al., 1998). However, in the case that it is verified that they are in an emotional and mental state to get a DNR, then the DNR should override all the interests of other outside agents. Implementation plan The implementation of the option will entail incorporating the services of psychologists, among other professionals, whose input may be required in determining whether the emotional psychological, and the social outlook of patients is balanced. After the verification of their competence, the doctor in charge of the patient can engage the patient in an extensive discourse, through which they will collect the patient’s interests about different medical procedures like CPR. Further, the medical professional can collect information on the course to be taken, in the case that iatrogenic complications take place, where the patient will give the directives to be observed during the administration of care. References Casarett, D., & Ross, L. F. (1997). Overriding a patient's refusal of treatment after an iatrogenic complication. N Engl J Med, 336(26), 1908-1910. Print. Emergency Medical Services Advance Directives. (2006). In: New Mexico Department of Health EaRD, Office of Health Emergency Management, Emergency Medical Systems Bureau, Ed. 7. Vol 27. Santa Fe, New Mexico2. Print. Koenig, K. L., & Salvucci, A. A, Jr. (1997). Out-of-hospital do-not-attempt-resuscitation in the suicidal patient: a special case. Acad Emerg Med, 4(9), 926-928. Print. Lee, M.A., Smith, D.M., Fenn, D.S. & Ganzini, L. (1998). Do patients' treatment decisions match advance statements of their preferences? J Clin Ethics, 9(3), 258-262. Print. Marco, C.A., Bessman, E.S., Schoenfeld, C.N. & Kelen, G.D. (1997). Ethical issues of cardiopulmonary resuscitation: current practice among emergency physicians. Acad Emerg Med, 4(9), 898-904. Print. Marco, C. A., Bessman, E. S., & Kelen, G. D. (2009). Ethical issues of cardiopulmonary resuscitation: comparison of emergency physician practices from 1995 to 2007. Acad Emerg Med, 16(3), 270-273.Print. Ross, L. F. (2003). Do not resuscitate orders and iatrogenic arrest during dialysis: should "No" mean "No"? Semin Dial, 16(5), 395-398. Print. Read More