Do Not Resuscitate (DNR) in the State of Colorado - Essay Example

Do not resuscitate (DNR) order or the "allow natural death" order is a medical order written by a doctor instructing care providers not to carry out advanced cardiac life support or cardiopulmonary resuscitation in case the patient's breathing stops or his or her heart stops beating. The DNR order request is made by the health care power of attorney or the patient allowing the medical teams taking care of the patients to respect their wishes. The critics against the process support the cardiopulmonary resuscitation arguing that each and every individual has the right to life. Cardiopulmonary resuscitation employs a series of medical procedures all aimed to maintain the patient's perfusion to vital organs. The efforts doctors and medical practitioner's efforts while undertaking the CPR aim at ensuring that the patient is able to breathe and his or her organs function properly. Different states have different directives and requirements towards the "do not resuscitate" process . This essay conducts an analysis of the DNR order in the state of Colorado and three hospitals in the area.

The DNR process is complicated in the United States as each state has different directives and requirements for the process. In case the DNR order is available, the medical practitioners are not obliged to conducting advanced cardiac life support processes or the Cardiopulmonary resuscitation. Many states in the United States also fail to recognize heath care proxies and living wills. Even with these, however, prehospital personnel and settings have the freedom to conduct resuscitation in case there exist state sponsored forms filled out by a licensed physician. Similar to other states in the United States, the Colorado DNR order requires EMTs and paramedics to receive a properly completed form in order to honor the patient's wish not to receive cardiopulmonary resuscitation or the advanced cardiac life support system. In Colorado, the order includes the "comfort care" for conditions in which the patients are in pain, bleeding or have shortness in breathing. In case the patient has a properly filled and signed form, the EMTs and paramedics should always ensure that the patient is in comfort. Even with this, however, the processes of comfort only apply to awake patients

The state of Colorado provides freedom for patients to withdraw from the DNR order. In case the patients decide that he or she wants full treatments, including the advanced cardiac life support or the cardiopulmonary resuscitation, the EMTs and the paramedics disregard the DNR order. In these, the state requires the patient to clearly communicate with the emergency team on what he or she desires. The state also requires the patient to communicate clearly with his or her family on the specific wishes. Clear communication ensures that the forms are destroyed with the presence of the physician that had signed the documents. In these, any copies, including those with the medic alert foundation and any other EMS authority should be destroyed . The patient in the presence of the signing physician or doctor should also destroy any medallion and wallet cards.

In cases where the patients are unable to make the necessary decision regarding cardiopulmonary resuscitation or the DNR order, the state allows two approaches aimed at ensuring that the patient receives the medical care they would need if they were able to express themselves. In these, the state allows the use of advanced care planning which ensures that the patients receive proper medical care and the use of surrogate decision makers. In these, however, the first choice is the advanced medical care. In cases where the patient does not have the advanced medical care plan, then the surrogate decision maker (an individual close to the patient who is familiar with the patient's decision) is identified. In most cases, family members and close friends are the first surrogate decision makers .

Other individuals that have the power to make decisions for patients unable to make decisions for themselves include legal guardians with the decision-making authority, individuals given powers of attorney for the decisions revolving around health care and spouses. In other cases, the adult children (all in agreement) of the patient, the parents of the patient and the adult siblings (all in agreement) can make the decisions for the patients. The state requires the surrogate decision makers to make a decision based on a substituted judgment standard. This standard should revolve around what the patient wand want if he or she had the capability to make her own decision. For children who do not have the decision-making capacity, the state requires the parents to make decisions based on the best of their children .

Colorado directives on "do not resuscitate" order require the doctors and licensed physicians to discuss the decisions with the patients. When a patient approaches a doctor with interests regarding the order, the doctor is required to explain all the available alternatives for the patients. The doctor should also discuss the resuscitation process and preferences with the patient and the surrogate decision maker. The conversation should be documented in order indicate the individuals available in the conversation and the individuals involved in the whole decision-making process. The documents should show the decision made, who made the decision, the contents of the conversations and any detail regarding any disagreement.

Prehospital DNR forms should include signatures from both the patient or the surrogate decision maker and the doctor. The physician's signature should affirm that the patient or the surrogate has given and was in right mind when signing the DNR form. In Colorado, the patient should fill in three forms, in these the patient retains one of the forms, the physician retains the second form while the third is sent to the medic alert foundation in case the patient need medallions or wallet cards. Medallions and wallet cards help alert emergency responders that the patient has a DNR order. The medallions and wallet cards apart from identifying the patient also help in situations where the DNR forms were misplaced . In case the DNR forms are missing, Colorado requires the paramedics and the EMTs to continue with the cardiopulmonary process. The paramedics and EMTs should stop the process in case the signing doctor confirms that the patient had a DNR order. In all cases, it is important for all the family members to locate the documents showing the requirements of the patients.

Different hospitals have different do not resuscitate guidelines, the hospitals analyzed include the Children Hospital Colorado, the University of Colorado Hospital and the Poudre Valley Hospital. The children Hospital Colorado has DNR directives similar to the state directives. The requirements in the hospital comply with the requirements of the state where the doctor or the physician has to give the consent to the directive. The considerations towards the DNR decisions in the hospital are also similar to the considerations provided by the state. In these considerations, the doctors should conduct a full analysis of the patient's conditions and the DNR is the most appropriate process for the condition. After the analysis of the condition, the physicians should discuss the results with the healthcare team, the patient or even the surrogate decision maker. Even with the similarities, there exist differences in the children hospital requirements and the state requirements. These differences revolve around the ethical principles that guide the DNR process in the children's hospital. The children Hospital Colorado DNR requirement state that in each case there should be an analysis of the proportionality aimed at weighing the benefits and the harms the process has to the patient. The hospital also requests a weekly analysis of the DNR order to determine if it is relevant as the days go by .

University of Colorado Hospital also has DNR forms with requirements that greatly differ from the states requirements. Even with the fact that there are directive giving the right to patients to select if they want a DNR form, the requirement only falls in situations where the patients need the life support system. In the University of Colorado hospital, the patient should name and assign the individual to possess a power of attorney. This individual should understand all the patient values, should be easily accessible and should feel free to communicate with the medical care providers. The patient should also name backups that willprovide the necessary directives in case the "medical attorney" is unavailable .

DNR process in the University of Colorado hospital is only applicable to patients in need of life support machine. However, the medical practitioners in this hospital should first implement the CPR process before allowing the NPR order. The NPR order in this hospital also depends on the patient's preferences on how long they want to stay on life support. For example, a patient would want the resuscitation process to be tried on him or her before being put on life support, when in life support the patient medics can apply for the DNR order after a few days as per the patient's wishes. The DNR process in this hospital is similar to the advanced directive that provides the medics to first attempt the CPR process for a set period of time .

Another hospital that allows the DNR system in Colorado is the Poudre Valley Hospital located in Fort Collins Colorado. It's EMS protocols are similar to the guidelines provided by the state. The doctor and the physician just like in the state guidelines should write the DNR form for patients whose medical condition cannot improve and whose resuscitation effort would be futile. Similar to the state guidelines the Poudre Valley Hospital Protocol bans the use of CPR in cases where the patient produces DNR form or has DNR bracelet or medallion. Even with this, however, the protocol differs from the state guidelines as it as it requires the patient to produce directive forms before any care is provided.

In cases where DNR is applied to patients under hospice care by the EMTs, the whole procedure follows a standard that ensures that the patient has comfort before death. The DNR order, in this case, does not change the medical practice standards or the ethics of care. This means that the patient has to receive the care needed same to the care he or she received before. However, under all cases of hospice care, the EMTs should avoid any attempt to resuscitate the patient . The DNRs for patients under hospice care just as for other patients do not streamline death; they only allow patients to have a "comfortable" death. When an EMT is called to attend to a patient with DNR who is under hospice care, he or she should understand that the patient wants comfort care . In these then the EMT should consider the condition facing the patient before calling for the emergency responders. For example, a patient or even the caregiver may request for EMT if the patient is choking or even bleeding. In a situation like this even with the DNR order needs to be taken care of, he or she is in need of comfort care. For cases where EMTs are called to attend to a patient under hospice care, they should ensure that all the steps taken are geared towards providing the patient with proper comfort care .

Even with the fact that there are differences in the DNR guidelines from one hospital to another within Colorado, the guidelines are similar to those provided by the state. Both at State and at the hospital level, the physician or the doctor should first obtain the consent from the patient before issuing the DNR order. In all the DNR cases, the doctors should also check the patient's mental capability in making the decision towards the DNR order. In cases where the patients are unable to decide, the state and the hospitals require the state to make the decision on their behalf. Evident in the guidelines from the state and the hospitals in Colorado, the patient has the right to specify the circumstances for the DNR and the CPR procedures. In that the patient has the right to choose the DNR should be implemented when he or she is permanently unconscious of terminally ill.