Cardiopulmonary Resuscitation - Essay Example

NOT FOR RESUSCITATION ORDERS Cardiopulmonary resuscitation is a life-saving procedure done for a patient with the patient’s best interests at heart, ensuring that the well-being of the patient is safe-guarded. The resuscitation is attempted only when the patient has a good chance of being revived successfully (Jaing, 2007). If it is performed with the result that the patient has a lengthy process of dying or it appears futile or unwarranted, it had better not been done. The medical fraternity may opt for the “do not resuscitate” orders so that the unnecessary use of the CPR is not chosen; however this choice would have implications at ethical and legal levels (Jaing, 2007). The decision of “do not resuscitate” is made by the patient if he is functionally able to convey it. If otherwise, the family members may have to make the decision when it is called surrogate decision (Torke, 2011). The subject has been the topic of discussion along with other end-of life decisions due to the ethical and legal bearings (Sham et al, 2007). The decisions on the withholding of the treatment for sustenance of life would be relaying the message that the patient accepts the progression of the disease and that he trusts the healing physician. There will be an underlying desire to reduce the burden on others. The wish to live and die naturally could also be influencing his decision (Sham et al, 2007). Research has elicited various factors influencing the doctors when the DNR (do not resuscitate) orders are made. These are based on the themes of probability of survival, the desire of the patient, the quality of life prior to present illness and the quality expected after it (Sham et al, 2007). Federal and State policies in the US advice advance care planning where the patient may be encouraged to make his decision for other end-of life decisions but DNR has been excluded (Sham et al, 2007). The BBC News has reported that the British Medical Association and the Royal College of Nursing in the UK have issued guidelines which indicated that the DNR orders could be issued only in consultation with the patients and families (BBC Ethics Guide, 2011). In Australia the not-for-resuscitation (NFR) orders formed part of the medical practice but policies have still not yet provided a fool-proof method of implementation (Sidhu et al, 2007). Researchers indicate that current policies show room for improvement: there are no standardised forms or patient information leaflets (Sidhu et al, 2007). The picture of NFR in an Australian hospital A clinical audit had been conducted by Salins and Jansen as a retrospective study to determine the accuracy of documentation of NFR orders in patients who had died at the Lyell McEwin Hospital (2011). This hospital was part of a teaching hospital in South Australia in 2007. Eighty-eight files could be accessed for information. Senior Registered Nurses from the Hospital’s Palliative Care Service participated in completing the questionnaires (Salins and Jansen, 2011). Most of the patients (96.59%) had an NFR documented in their case sheets. Only 3 patients did not have an NFR documented; two of them had been cancer patients but had not been in-patients in the palliative care. In 47.06 % cases, the documentation was because the patients had specifically declined resuscitation if a cardiac arrest occurred. Some patients (27.06%) decided on NFR as they were sure of having a poor quality of life if resuscitated (Salins and Jansen, 2011). Patients who were mentally incompetent (17.65%) had a surrogate decision-maker. More case sheets (52.94%) indicated a documented discussion about prognosis while only 40% had evidence of an appropriate diagnosis. Sixty-six % cases had received palliative care. CPR procedure or the chances of its successful outcome had not been mentioned (Salins and Jansen, 2011). The case sheets did not have many essential parts like name of doctor (3 nos.), time of entry (50%), grade of the doctor (75.3%), translation of medical notes to nursing notes (75%) and usage of right terminology (11.77%). The NFR decision was documented at the instance of the consultants in 32.94% cases while in 66.66% the junior doctor had documented the NFR but the consultant had seen the patient within 2 days after the documentation. No consultant had changed the junior doctor-documented NFR. Even after the NFR, many patients had received IV fluids and antibiotics, oxygen inhalation, pain relief and non-invasive ventilation so treatment had not been denied due to the NFR (Salins and Jansen, 2011). 32 patients were unable to decide their NFR while 5 had given an advance directive. Family involvement was found in 87.05% cases however surrogate decision making was found in less than 20% of cases. Salins and Jansen concluded that junior doctors were to be guided through education on the documentation of NFR (2011). The hospital staff was to use a specific format and uniform style in documentation of NFR in case of legal action. The hospital needed to have a specific NFR policy and the staff was to know about it. Standard NFR forms were to be used throughout the hospital (Salins and Jansen, 2011). The NFR and DNR can be better understood by finding out what resuscitation is and the evolution of the subject to its current status. The evolution of Do Not Resuscitate or Not for Resuscitation Cardiopulmonary resuscitation is the technique of providing expired air ventilation and closed cardiac massage as an emergency procedure in saving the life of a patient who had cardiopulmonary arrest (Mohr and Kettler, 1997). “Four aspects of bioethics needed to be considered: ethical theories, principles, rules and particular judgements and actions” (Mohr and Kettler, 1997). The moral rule was that a patient who had cardiopulmonary arrest had a right to be given an opportunity to survive. However over the years, the situation has changed. Now patients have the chance to provide advance directives for end-of-life decisions including DNR. This needs to be respected as the patient’s autonomy. On many occasions, saving the life of the patient may not be the terminal goal (Mohr and Kettler, 1997). CPR for sustenance of life may not always turn out to have good outcomes or improve the quality of the remaining life of the dying patient. This produces situations where CPR is not provided at the instance of the patient himself or his family member by the documentation of an NFR. Decisions where a family member or a close friend is permitted to make the decision are called surrogate decisions (Mohr and Kettler, 1997). Surrogate decisions In the event of an elderly patient being admitted in hospital, the possibility of CPR in cardiac or respiratory arrest needed to be discussed with the patient or family in advance (Torke, 2011). They needed to be provided an opportunity to refuse a procedure that could be considered inappropriate by them. Studies found that the communication and the resulting decision-making were both inadequate. Code status discussions, for the sake of future patient care, were hardly done within 24 hours of admission (Auerbach et al, 2008), with patients who died (Morrell et al, 2008) and with patients who had been resuscitated (Bedell, 1984). It could also be that the discussion was done but the recording was not (Torke, 2011). The discussions by medical residents were found to have been missing in important information. Outcomes were not considered. Moreover DNR orders were recorded when the patient was close to death. Reasons that had been attributed to these drawbacks were that deterioration could have been sudden and prior preparation could not be made, that the discussions were of a sensitive nature and that end-of-life issues were not handled in a timely manner (Torke, 2011). The surrogate decision-maker could have been used in cases where patents were unable to provide the decision. However even the communication with the surrogate did not provide a quick response needed in the situation. Even in situations like the ICU where surrogate decision-making was frequent, communication problems, ineffective response, distress, guilt and ambivalence in surrogates made decision-making really complex (Torke, 2011). The future with the increased aging population, more dementia and more delirium would see more surrogate decision-making (Torke, 2011). Torke and his co-researchers indicated that surrogate decision-making on DNR was on the increase and that it had to be done in a timely manner to allow sufficient time for maintaining the quality of life of the dying patient (2011). Future research needed to define the communicative and ethical factors that could help the surrogates make their decisions on DNR early and without delay. Sham believed that delay of DNR orders was not to be encouraged. Different health care professionals were known to have different views on DNR orders. Attitudes of various stakeholders Sham and his co-researchers indicated that different basic knowledge influenced the viewpoints of medical and non-medical students on the subject of DNR (2007). Most of the participants in the study believed that the patient’s wish was the more important as compared to the family decision. DNR decisions were dependent on the patient’s autonomy. Other factors were functional ability of the patient, prognosis of the illness and quality of remaining life (Sham, 2007). Studies have explored the effects of variables like “probability of survival, a patient’s wish, previous quality of life and expected quality of life after the acute illness” in doctors involved with DNR decisions (Sham, 2007). Sham’s study investigated the issue in medical and non-medical students. It found that medical students who had the benefit of medical education preferred the DNR proposal for patients who opted for DNR. They also believed that persons with lesser chance of survival or a poorer quality of life also could have the DNR decision (Sham, 2007). Non-medical students preferred to move away from the DNR proposal. Prior knowledge of the concept of DNR also influenced the viewpoints. Sham indicated that promoting the concept could allow people to make better choices (2007). Sham et al also hinted that cultural differences could influence individual decisions on DNR. The Hong Kong doctors believing more in the family decision-making were not vigilant in initiating the discussion of DNR early when the patient was able to provide his decision. Participants of the study also indicated that a patient of suicide attempt should not be denied CPR as wishing to die did not entitle the patient to DNR automatically (Sham, 2007). Relatives of patients suffering for long with illness opted for the DNR faster. Other researchers had indicated that several doctors practiced the DNR even if no consent had been obtained. Schildman et al (2006) investigated the views of pre-registration house officers on ethical and legal issues regarding end-of-life decisions. They were frequently called upon to discuss these issues by the patients and their families. Their medical education provided them the background for their positive outlook in end-of-life decisions. Future research could focus on the views of doctors on ethical issues of treatment limitation (Schildman, 2006). Medical practitioners had been known to take two opposing views of whether patients should be made to participate in early decision-making when the patient is still communicating well (Schildman, 2006). One group believed that this early decision-making could affect the feeling of hope that should be present in all patients to maintain a good quality of remaining life. The other group preferred the patient to retain his autonomy and participate in his own end-of-life decision (Schildman, 2006). The attitude of the nurses needed to be gauged too. Australian nurses in legal matters Registered nurses in Australia appeared to have the same desire for legal education whether they were hospital-trained or whether they were tertiary educated and graduated from a University (Savage et al, 2011). Their anxiety about legal situations was fairly high. It was mostly about the lack of support from the organizational systems they worked in. In the 21st century, the clients of the healthcare services were able to claim compensation for what they claimed to be failures of the system. The law had therefore been a shadow in the lives of the healthcare staff including the nurses (Savage, 2007). Savage et al (2011) investigated the beliefs of 30 registered nurses working in the Queensland Health services. Interview groups had explored the perceptions and beliefs of the nurses regarding the legal problems that they had to face. Hospitals had their own institutional policies apart from the common law and legislation in Australia (Savage, 2011). Registration in the ANMC required the nurses to be competent in legal and ethical issues (ANMC, 2005). The fact that legal issues could potentially harm the career of the nurses had further stressed the necessity of the nurses being well-informed. The nursing educational curriculum had included the legal aspects of practice. One obvious disadvantage of the law to the nurses was that their professional work had not been understood and the law had missed out on the nurses’ activities (Savage, 2011). Older nurses in the profession had no way of being informed about the latest changes in the legal aspects concerning them as these issues were missed in their journals. The role of the nurses in end-of-life decisions was the most essential factor in DNR and NFR. Nurses in end-of-life decisions Nurses had a difficulty of deciding prognosis just like physicians when it was time to help make an end-of-life decision (Adams et al, 2011). They were fearful of removing hope or being perceived as giving up too soon or making an untimely decision. Deciding to give up curative care was a difficult proposition where professional health care staff and families were concerned. The health care staff felt that their training for initiating end-of-life decisions was inadequate as to when and how (Adams et al, 2011). The nurse waited till the physician provided the go-ahead sign and this could be when the patient was too ill and the decision had to be taken by the families. The Support study by Connors et al of 1995, a landmark research for end-of-life decision making, indicated that a late decision could make patients endure distress, pain and life-sustaining care when they did not want them. The second phase of the study included a nurse intervention of provision of emotional and educational support to patients and families. It was found that the nurse intervention did not change the time of decision for the DNR order or shorten the length of stay in the ICU or utilization of resources. However the patients and families were supported immensely to be prepared to withdraw care (Adams et al, 2011). The relationship built by the nurses with the patients and families was a trusting and lasting one. The needs of the patient and family were gauged accurately by the competent nurse who was an information broker for the health care team; this was the first role. Nurses had a better intuition to understand when the patient was not responding to treatment and were therefore in a unique position to facilitate end-of-life decision making (Adams et al, 2011). Secondly they provided emotional support to family members to help them make their end-of-life decision. Acting as strong advocates for end-of-life decision making was the third role (Adams et al, 2011). However in all of these functions, the timing of involvement and advance care planning had not been good so that the patients did not enjoy the best that could be delivered at end-of-life. Advance directives Federal and State laws had recommended that clinicians were to be able to discuss end-of-life issues and there were systems for monitoring most of them. However the implementation of DNR had not been monitored yet. Guo et al had explored the advance directives and the presence of DNR orders in patients with metastatic cancer affecting the spinal cord (2010). It was found that in spite of patients with metastatic cancer in the spinal cord having short survival times, advance directives were not provided sufficiently early for DNR (Guo et al, 2010). This had been attributed to the poor and untimely communication (or suboptimal communication) between the clinician and patient and family. It could also be due to a delayed palliative care which should have been instituted earlier. Guo and co-researchers appeared to have made the first study on advance directive and DNR orders (2010). Out of 87 participants, 20 had wills ready. Twenty-seven patients had already selected a health care proxy or surrogate decision-maker. Five had an out-of-hospital DNR and 8 had a DNR (Guo et al, 2010). An essential point noted in this study was that only a short period existed between the date of DNR and the death of the patient, just 16.5 days. Advance directives had been given only for 26 out of 59 patients who had died. End-of life care was usually not discussed between the doctor and patient due to their close relationship and poor prognostication (Guo et al, 2010). If prognosis were appropriately surmised and discussed with the patients, there would have been no undue delay in initiation of end-of-life decisions and advance directives. Cancer patients usually showed a dying trajectory whereby they showed a decline during the last three months. This was the period during which discussion was to be initiated for the advance care planning (Guo et al, 2010). Conclusion Cardiopulmonary resuscitation is a life-saving procedure done for a patient with the patient’s best interests at heart, ensuring that the well-being of the patient is safe-guarded. If it is performed with the result that the patient has a lengthy process of dying or it appears futile or unwarranted, it had better not been done. The patient himself or the surrogate decision-maker makes the end-of-life decision of DNR or NFR. ). In Australia the not-for-resuscitation (NFR) orders formed part of the medical practice but policies have still not yet provided a fool-proof method of implementation (Sidhu et al, 2007). Researchers indicate that current policies show room for improvement: there are no standardised forms or patient information leaflets (Sidhu et al, 2007). Different health care professionals held differing views on DNR. The role of the nurses in end-of-life decisions was the most essential factor in DNR and NFR. Nurses were competent information brokers, provided effective emotional support and strong advocates for end-of-life decisions like DNR. Advance directives were essential for the DNR and NFR. References: Adams, J.A., Bailey, D.E., Anderson, R.A. and Docherty, S.L. (2011). Nursing Roles and Strategies in End-of-Life Decision-Making in Acute Care: A Systematic Review of the Literature. 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Not-for-resuscitation” orders in Australian public hospitals: policies, standardised order forms and patient information leaflets. MJA 2007; 186 (2): 72-75 Torke, A.M., Sachs, G.A., Helft, P.R., Petronio, S., Purnell, C., Hiu, S. and Callahan, C.M. (2011). Timing of Do-Not-Resuscitate Orders for Hospitalized Older Adults Who Require a Surrogate Decision-Maker. J. Am Geriatr Soc. 2011 July ; 59(7): 1326–1331. doi:10.1111/j.1532-5415.2011.03480.x. Read More