Do-Not-Resuscitate Orders Ethical and Legal Issues - Research Paper Example

and number: Paper Do-Not-Resuscitate Orders – Ethical and Legal Issues submitted: Do-Not-Resuscitate Orders One of the ways of saving a person’s life during or after an episode of heart failure is through emergency resuscitation. When the resuscitation effort is successful, most patients normally regain normal breathing and can go on with their lives. However, there are patients who have a different view of resuscitation. They normally refuse resuscitation on both ethical and legal terms (Mani, et. al, 2005). Do Not Resuscitate Orders are medical documents that state that the patient declines any medical effort to restart his failed heart. The orders are normally written for patients who may be at home, in the hospital or in a nursing home. If the patient is not in a hospital, the DNR orders normally state that the medical practitioners in charge of the patient should not take him or her to a hospital for emergency resuscitation. In many cases when the patient is too sick to request for a DNR order, the closest family members or friends can order for one on his behalf (Piers, Benoit and Schrauwen, 2011). Even though all adult patients have the right to request for a DNR Order, its usage is quite a controversial issue in the medical field. The medical profession is one that strives to uphold the ethical principles of human dignity, compassion, non-malfeasance and social justice. Every individual has a right to accept or refuse emergency resuscitation. However, it is also the duty of the medical practitioner to save the lives of the patients he is attending to (Moss, 2003). This is where the ethical and legal implications of DNR come in. Whereas it is within the doctors’ prerogative to save the lives of his patients, he must also respect their wishes if they do not want to be saved. DNR raises the legal and ethical concern that giving consent to the order may lead to a loss of life that may otherwise have been saved (Crozier, Santoli and Outin, 2011). The DNR order should be honored if the patient who fully understands his medical situation consents to it. There are provisions in law that give the patient the right to chose the form of treatment that he deems best. It is the duty of the care giver to consider the needs and wants of his patients. Therefore if the patient consents to or gives DNR orders and signs the DNR form, the care givers should employ other treatment options to try and save his life. Sometime the options available are not efficient enough and the result is normally catastrophic (Ani, 2005). The ethical question still remains on whether the care givers should not do everything possible to save the lives of their patients regardless of whether the patient wants to be saved or not. History of DNR In the United States, the first DNR law was passed in In re Quinlan in 1976. This was when the Supreme Court in New Jersey upheld Quinlan’s rights to have her removed from artificial respiratory machines. 15 years later in 1991, the US congress passed the Patient Self-Determination Act which required hospitals to honor and accept the decision of patients regarding their preferred nature of treatment. Today, most states also allow the patient’s next of kin to make medical decisions for patients who are medically deemed to be incapacitated to make the decisions for themselves. DNR laws now are included in both Advanced Cardiac Life Support (ACLS) and Cardiopulmonary Resuscitation (CPR). In both of these medical processes, a DNR form has to be availed to the patient or his relatives for them to make a decision on whether to continue with the resuscitation or not (Murphy, 1989). The Patient’s Bill of Rights One of the goals of this bill is to help patients feel confident with their healthcare system. To achieve this pertinent goal, the bill of rights sets out to assure the public that the system is fair and created to meet all the needs patients. The bill also allows patients to have a way of addressing any medical problems that they might be having. The second goal is to stress on the importance of having a strong and trustful relationship between patients and their care givers. The third goal, which is relevant to this paper, is to emphasize that patients have a key role to play in the matters of their health. To achieve this particular objective, the bill of rights lays out the rights of all patients and their healthcare providers (Loke, Rau and Huang, 2011). The Bill of Rights allows the patient to take part in decisions pertaining to treatment. Any individual seeking medical care has the right to know the treatment options that are available are available to him. This way the patient can make a well informed decision about whether or not to accept treatment, a decision which the healthcare giver is obliged to honor. The law also makes it possible for the guardians, parents and family members to make the decisions on behalf of the patient (Truog, 2009). This means that if the patient or his relatives do not want resuscitation procedures to be carried out, then the medical care giver is obligated to respect the wishes of the patient. The Process for Ethical Decision Making One of the main reasons why DNR orders pose some significant ethical concerns is because they are related directly to patients’ dignity. This is particularly true as DNR involves the identification of and following the wishes of the patient. Another ethical concern for DNR orders is related to the fact that there has to be some considerations about what patients think about life and death in general (Jackson and Norman, 2007). Before any care giver makes consent or a refusal for DNR orders, care should be taken to ensure that the views of the patient are put into consideration. One of the reasons why a person may chose a DNR is because of the nature of the disease. In some cases, there is normally decline in the quality of life as the disease progresses. In such cases, the patient normally feels that his condition or illnesses is a burden to himself and to others. Such patients may decide that continuing living is not an attractive idea and they prefer dying (Murphy, 1989). When one realizes that life must come to an end, then it is his in his own right to decide whether or not to continue treatment. In such a case as this, the patient may refuse last minute resuscitation efforts that might save his life (Piers, Benoit and Schrauwen, 2011). Although it might be instinctive for the caregivers to try to save the patient’s life, it is also their duty to respect the individual’s decision to let nature take its course. Different individuals have different views about life and death and these views are normally informed by the cultural environment in which they live. Some people consider heart conditions which may require resuscitation to be normal medical conditions and they therefore would not have any problems with resuscitation processes. However, there are those individuals who believe that the problems of the heart should not be interfered with and many of them normally refer to not be resuscitated in case of heart failure (Crozier, Santoli and Outin, 2011). Some individuals also make decisions to sign DNR order forms due to religious beliefs and personal inclinations. It is the responsibility of care givers to honor and respect the autonomy and wishes of their patients. If the patient does not want to have resuscitation administered, then the care giver should not attempt it as this could have serious legal implications (Piers, Benoit and Schrauwen, 2011). Case Study A 58 year old man was admitted to hospital and diagnosed with hepatitis and hepatic encephalopathy. The man had been suffering from disorientation, body swelling and was also passing blood in his stool for three days. He was admitted to the gastroenterology and hepatology department of the hospital where he was given some antibiotic administration and had his central venous pressure monitored. This was all done in the operating room since access to his peripheral venous system was difficult. The doctor decided that his was the best way to treat the patients and he discussed the same with the patient’s family. The patient was diagnosed with chronic hepatic disease, but he was not treated like he was terminally ill. This meant that there was no need for the presentation of DNR orders. Before he was taken to the operating room, the patient was said to be clinically sick, but his haemodynamic state was said to be stable. His heart rate was normal at 104 per minute and his blood pressure was stable at 110/60. In the operating room, he was administered an oxygen mask with a rate of 5.5 liters per minute. A pulse oximeter was used to monitor oxygen saturation in the arteries. A nurse who accompanied the patient to the operating room stated that he showed signs of life while he was being taken to the operating room. However, when the patient reached the operating room, he had no pulse and not a single sign of respiratory activity. The medics, determining this to be an immediate event, quickly started an external cardiac massage, which involved the intubation and ventilation of the patient. For close to five minutes, the doctors administered intratracheal and intravenous drugs while at the same time trying to resuscitate the patient. These efforts resulted in the patient regaining cardiac activity and had reverted to sinus rhythm after 20 minutes. After resuscitation, the medics checked to ensure that his papillary reflexes were normal, and they did find that they were intact. This timely intervention meant that it was now safe to continue with the resuscitation in a more controlled environment in the operating room. After this episode, the doctors and nurses who had carried out the resuscitation process sat down with the patient’s relatives and explained everything to them. Surprisingly, the relatives were against the resuscitation and they declined to offer any financial support for his further resuscitation and terminal medical treatment and care. The patient was then transferred to the High dependence Unit in the gastroenterology department where he was kept under mechanical ventilation. The relatives requested for the inotropic support to be withheld, following which the patient died after less than 24 hours . The ethical concerns that arise from this case study include the limited amount of time there was for the resuscitation discussions between the medics and the patient’s relatives. The issue of DNR directives in such a case is also paramount to ethical and legal issues that arise from this case (Moss, 2003). The autonomy of the patient was not sought when it was decided that resuscitation should be carried out. The other issue related to DNR was that it was not very clear of who actually is eligible to give consent and to whom the responsibility of financial support falls. One of the questions that should be asked in this situation is whether or not it was appropriate and worthwhile to resuscitate the patient. The patient was not given the chance to exercise his right to choose the form of medical care he preferred, instead, his doctors and nurses made that decision for him. There had been no consideration of DNR up until the patient had already been resuscitated and his relatives made it clear that they did not support the idea of resuscitation. However, the medical implication of the refusal for resuscitation was severe since it resulted to the death of the patient. If the relatives had consent to the resuscitation, the man’s life would probably have been saved (Loke, Rau and Huang, 2011). Conclusion The issue of Do-Not-Resuscitate orders has important legal and ethical implications. The law is very clear that patients have the right to choose the form and nature of treatment that they prefer. Therefore if the patient does not want to have resuscitation then it is only right for the care givers to respect the wishes of the patient. However, this poses the problem of how doctors and other medical professionals should handle their job, which is essentially to save the lives of their patients through any means necessary. However they are also bound by the law to respect the autonomy of the patient. He question that comes up is whether the care giver should allow the patient or the patient’s family to make medical decisions even when these decisions may lead to fatality. Although it would be right to try to save the patient through the administration of resuscitation, it would also mean that the care giver is flaunting the patient’s bill of rights which allows the patient to accept or refuse treatment. This could lead to legal problems for the caregiver. The best way to avoid such ethical and legal complications is for care givers to ensure that they are competent enough to administer other life saving forms of treatment other than resuscitation. References Ani RK. (2005). Limitation of life support in the ICU: ethical issues relating to end of life care. Indian J Crit Care Med. Vol. 7, pp.112-117. Crozier, S., Santoli, F. and Outin, H. (2011). Severe Stroke: Prognosis, Intensive Care Admission and Withhold and Withdrawal Treatment Decisions. Rev Neurol Jackson SH, Van Norman GA. (2007). Goals- and values-directed approach to informed consent in the "DNR" patient presenting for surgery: more demanding of the anaesthesiologist? Anaesthesiology. Vol. 90, pp. 3-6. Loke, S.S., Rau, K.M. and Huang, C.F. (2011). Impact of Combined Hospice Care on Terminal Cancer Patients. J Palliat Med. Mani RK, Amin P, Chawla R, Divatia JV, Kapadia F, Khilnani P. (2005). Limiting life-prolonging interventions and providing palliative care towards the end of life in Indian intensive care units. Indian J Crit Care Med. Vol. 9, pp.96-107. Moss, A. 2003. Discussing Resuscitation Status with Patients and Families. The Journal of Clinical Ethics. Vol. 4, No. 2, pp.180-182. Murphy, D. 1989. Outcomes of Cardiopulmonary Resuscitation in the Elderly, Annals of Internal Medicine, August. Vol. 3, No. 3, pp. 199-205 Piers, R.D., Benoit, D.D. and Schrauwen, W.J. (2011). Do-Not-Resuscitate Decisions in A Large Tertiary Hospital. Acta Clin Belg. Vol. 66, No.2, pp. 116-122 Truog RD. (2009). Do-not-resuscitate orders during anaesthesia and surgery. Anaesthesiology Vol. 74, pp. 606-608. Read More