Term Paper on "Difficulty With Do Not Resuscitate Orders (Dnrs)"

Term Paper 6 pages (1967 words) Sources: 4 Style: APA

[EXCERPT] . . . .

Difficulty with do not resuscitate orders (DNRs), advanced directives and medical power of attorney are not unheard of and decisions regarding these issues are often left to the nurse to make, as a great deal of discretion is afforded the nurse, especially in the triage aspect of emergency room care. Emergency room care requires quick thinking and logical judgment utilized to make the best possible decisions for a critically ill patient, that has not yet been medically stabilized. It is a common practice to withhold pain medications, such as morphine to patients who are suspected of respiratory or cardiac distress as morphine is know to depress these functions, as a process of its pharmacology. It is the job of the emergency room nurse and other staff to err on the side of caution and withhold any treatment that might further compromise the patient. (Saunders, 2003, p.12)

It is also clear that entrance to an emergency room, usually implies a desire to be treated with the whole cornucopia of life saving techniques and technologies possible to save ones life. (Saunders, 2003, p.12) for this reason when a patient with DNR orders and advanced directives for no life support measures enters the scene there is likely to be confusion and possibly delay of comfort measures, such as the administration of treatment that can potentially further compromise the acute condition of the patient. In many situations, where such orders are in effect the patient will bypass the emergency room altogether, as they are often transferred from other facilities, such as extended care centers and the emergency room staff is made aware of their treatment choices as they are briefed from the other facility and the individual is transferred to a bed in another area of the hospital, in most cases the medical floor or unit, where palliative care can be administered. Yet, when a patient is admitted to the ER either from the street or by an ambulance from home and has an acute condition, such as a suspected MI, regardless of their advanced directives or DNR orders confusion about treatment needs can and often do arise, either before staff is made aware of the patents wishes or before a primary care physician is contacted. (Mantz, 2002, 359)

The ethics scenario detailed in the information for this work demonstrates a valid concern for patient viability, as the foundational concept of health care in an emergency room setting is clearly to perform life preserving medical care and yet, with a clear documented advanced directive which details that no life support shall be provided, as well as a DNR order signed and in the chart the conflict within the nursing situation should be minor and should include only the wishes of the patient for comfort measures or what is commonly referred to as palliative care. (Saunders, 2003, p.12) (Mantz, 2002, p.359)

In one rather interesting journal article, beginning with a case study, regarding a patient with DNR orders and a durable medical power of attorney, held by the patient's daughter (who was in contact with physicians) the situation is clearly detailed and the result was a full reversal of palliative care, including full life support and a transfer to the ICU. The work expresses the problem, as it is associated with the view of palliative care as doing nothing. It is clear that palliative care is a viable medical response to end of life scenarios and should be utilized in cases where it is indicated, by the wishes of the individual and his or her legal voice. Palliative care being a set of treatments that focus not on life saving techniques but on those that impart comfort and treat uncomfortable symptoms, such as acute pain. The author indicates that the problem lies in the fact that this society, and especially the medical industry (here sighting new doctors) are consummate death deniers, seeking life saving options above all others. (Saunders, 2003, p.16) in the case specific to this write up the treatment change has certainly not gone to the point of a complete denial of patient wishes, as the denial of one form of palliative care, erring on the side of caution does not constitute full application of life support, though without patient advocates, as are seen by the present family, there is a danger of just such an occurrence.

Legal Issues:

There are several issues at stake though with regard to information that is not given in the case brief. One is the documentation itself, is the advanced directive clear with regard to life saving measures, as the denial of morphine in this case is clearly a life saving measure? Is the documentation current and was it signed and witnessed at the current institution? There are many experts who would demand the universalization of the documentation, as well as the demand that the documents be signed and witnessed by staff as a measure of legal protection. (Forsythe, 2005, p.475) Some would say that these are not nursing issues and should be dealt with by legal experts, but the truth is that the luxury and time for a full legal review, in an acute care setting, like an ER is unheard of and medical decisions must be made accordingly. (Andre, 2002, p. 19)

Ethical Issues:

Another issue that is not discussed, in the case brief, is the length of time that the patient has been in the emergency room. This information could potentially change the outcome of any ethical determination of action or inaction. If the patient presented in the ER less than 1 hour from the time of the shift change, when the first nurse handed to the oncoming nurse the responsibility to deal with the acute decision made by her or him to withhold Morphine, then there has been little harm done. If on the other hand the patient, had presented eight hours prior to shift change and the entire time the Morphine had been denied then considerable harm could have been done by the denial of palliative care. In the second time scenario the nurse and other staff would have had sufficient time to become aware of the documentation, and potentially review it if needed, as well as confer with the attending physician and the primary care physician, with regard to the patient's long-term condition, and desires. If in this second scenario the nurse still denied the Morphine, without notifying the supervisor of this decision a poor ethical decision had been made. Clear communication between care providers, should in this case and any like it clear up the concerns one individual has about administering palliative care and should in the event that the particular staff member still refuses to provide palliative care, he or she should be removed from the case and another staff member assigned it.

For that matter, if it had been a week day between 8 and 8 a bioethics committee could have convened and helped everyone involved solve the question. Though this may seem like an unlikely scenario as bioethics committees don't usually convene to answer a single patient question, as they usually do such things as recourse to bioethical concerns. Though this may not be the case forever, as a new trend in electronic bioethics communication may make it possible for ER staff in the future to type an email to an expert or a group of them and have an answer back in a few minutes, rather than as a posthumous response to fear of legal reprisal for omission or commission. A leading expert on bioethics sited this very scenario, in place and hosted by the Medical College of Wisconsin. (Andre, 2002, p. 149) in this book Andre, stresses that the medical industry as well as bioethics professionals need new skills, skills that stress the patients rights and voice over heroic measures of care. He calls the progress toward deeming palliative care as bioethical and sound innovative and seeks to help bioethics groups redefine standards based on and including such options, as hospive and palliative care programs and procedures. In a sense Andre deems these issues new to medical care, as the sole focus of allopathic medicine has been in the past to extend life, by completely avoiding the idea of death as a viable and possible outcome. The work stresses that the medical industry has gone to far, with its heroic measures and seeks to extend life past the point of quality, and past the point of reason, by relying solely on the techniques and technologies that save lives without regard for future quality or cost to the patient or those who might be left behind to pick up the increasingly cost prohibitive bill. (Andre, 2002, p. 36)

Discussion:

These issues may seem extreme in the discussion of the current case, regardless of the time the patient, in question spent in the emergency room, but they are relevant in that the patient's rights and voice was at least for some time ignored by an individual or… READ MORE

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