Friday, April 16, 2010

An Ethical Dilema: Do Not Resuscitate Orders

Type of Dilemma: Do not resuscitate orders (DNRs), are orders found in patients’ medical charts, which tell health care practitioners not to perform cardiopulmonary resuscitation (CPR) (Braddock, 1998). A patient with a DNR order in his or her chart has either personally chosen not to be resuscitated, or a family member has chosen for them in the event that they are not capable of making the decision independently (NYS Department of Health, 2010). The main dilemma surrounding DNR orders lies within the issue of autonomy, or an individual’s right to make decisions for him or herself (Crabtree, 1999). More specifically, most cases may involve a conflict between professional autonomy and client autonomy; that is, the health care professional’s knowledge and thoughts on what is best for the patient may differ from those of the patient (Crabtree, 1999). For the professional, underlying principles of justice, veracity and duty may also apply depending on the specific case.

Relevant Information: Typically, when an individual goes into cardiac or respiratory arrest, health care practitioners will resuscitate him or her to restore function of the arrested system (Cleveland Clinic, 2010). Not only does this include manual CPR, but resuscitation drugs, artificial airways, respiratory assistance, cardiac monitoring, and others are considered forms of resuscitation (Cleveland Clinic, 2010). However, CPR has been minimally successful with certain diagnoses and conditions, and patients may choose to sign DNRs based on this information. See Table 1 for more information:


Table 1:

Diagnosis or Condition

Probability of Success

Septic Shock

0%

Acute Stroke

0%

Metastatic Cancer

0%

Severe Pneumonia

0%

Hypotension

2%

AIDS

2%

Renal Failure

3%

Homebound Lifestyle

4%

Age Greater Than 70

4% (Survival to Discharge)

(Braddock, 1998)


The problem: The problem again, lies within the concept of autonomy. With end of life care, there will always be conflicts between the autonomy of the professional, the patient, and the patient’s family, all of which can potentially have different views of how the issue should be handled. A patient may be ready to let go, or he or she may be determined to fight until the end. The family’s feelings on the issue can range across the same continuum. These views will greatly affect the patient/family’s willingness to sign a DNR order. Under the principle of autonomy, the clients should be the ultimate decision makers, choosing what is best for themselves or their loved ones. For the health care professional, a much more complicated ethical dilemma is involved with DNRs. First, the professional has a duty to disclose accurate information about the patient’s condition to him or her. This duty lies under the ethical principle of veracity, which is truth telling (Crabtree, 1999). The professional also has a duty to respect the autonomy of the patient, allowing him or her to make decisions on his or her care if possible. Yet another duty of the professional is to allocate healthcare resources effectively and efficiently, demonstrating the ethical principle of justice (fairness) (Crabtree, 1999). For example, an individual who is not likely to survive cardiac or respiratory arrest should not receive CPR as it may be a waste of precious healthcare time and dollars. DNRs are complicated ethical dilemmas; each differs greatly depending on the case. Doctors and Nurses work closest to DNRs, however, therapy professionals may be involved in DNR dilemmas as well.


Type of Setting or Practice: Because DNRs are used to prevent unnecessary and unwanted end-of-life treatment, they will most likely be seen when working with the elderly populations. Therefore, occupational therapists would most likely encounter DNRs in skilled nursing facilities and inpatient rehabilitation settings. Therapists working with these clients need to be aware of whether their patients have or have not signed DNR orders. If a therapist were to ignore a DNR order or neglect to resuscitate an individual who has not signed a DNR, a serious malpractice lawsuit might ensue.


Six Step Process for Ethical Decision Making: Purtilo’s (2005) six step process for ethical decision making provides therapists with a process for making appropriate decisions in ethical scenarios. The six steps are as follows: gather relevant information, identify the type of ethical problem, analyze the problem using ethics theories or approaches, explore the practical alternatives, act, and evaluate the process and outcome (Purtilo, 2005). This process allows therapists to slow down, think through their actions, and make the best choice for themselves and their patients.


References:

Braddock, C. H. (1998). Do not resuscitate orders. Ethics In Medicine. Retrieved from http://depts. washington.edu/bioethx/topics/dnr.html.


Cleveland Clinic. (2010). Policy on do not resuscitate. Retrieved from http://www.clevelandclinic.org/ bioethics/policies/dnr.html


Crabtree, J. L. (1999). Ethics of culture in rehabilitation. In M. Royeen & J. Crabtree (Eds.), Culture in rehabilitation: From competency to proficiency (59-71). Upper Saddle River, NJ: Pearson.


NYS Department of Health. (2010). Deciding about CPR: A guide for patients and families. Retrieved from http://wings.buffalo.edu/bioethics/dnr-p.html


Purtilo, R. (2005). Ethical dimensions in the health professions. 4th ed. Boston: Elsevier Saunders.

1 comment:

  1. Generally, the mentally ill seem to be conscious even when they are barbarous because they are able to think and justify their actions with various excuses.

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