Research Paper on "Legal and Ethical Issues of DNR"

Research Paper 8 pages (2558 words) Sources: 8

[EXCERPT] . . . .

DNR

Between Life And Death

A DNR or do-not-resuscitate is a written medical order that cardiopulmonary resuscitative intervention measures shall not be performed in the event of a cardiac or respiratory arrest (Roth & Corrigan, 2005 as qtd in Pat et al., 2009; Pozgar, 2010 p 132). The doctor discusses both the prognosis and the DNR with the patient or his family. Their decision will be respected and documented in detail whether to conduct or withhold resuscitative services. The patient's rights receive paramount consideration. He can reverse a DNR order (Roth & Corrigan, 2005 as qtd in Pat et al.). The sole basis of a DNR is the patient's conscious decision or best interest.

"Do Not Resuscitate" Order

A DNR is a decision reached by the patient and his family. It is an extremely difficult decision because it is made when the patient's quality of life has so diminished that extraordinary or heroic rescue methods are resorted to (Pozgar, 2010). The order may evolve from the patient as an executable advance directive. In pursuit, the attending physician or the patient's assignee initiates it. The legal assignee makes the decision if the patient is unable to and expressed willingness to it. A DNR is signed and dated by the attending physician with the consent of appropriate parties. It is generally considered valid in the case of terminally ill patients when the patient's family has no objection to it. It is of short duration and subject to periodic review. It is considered one of the medical decisions a competent patient may make (Pozgar).

The other appropriate parties to a DNR decision are the nurse and the health care team knowledgeable in the matter, such as social workers and the chaplain (NIH Clinical Center, 2010). Ultimately, the decision rests in the competent patient and the doctor. If the competent patient determines or wills that CPR is not appropriate at least at that time, the doctor will write a DNR or "no code" on the patient's record. The CPR will then not be started (NIH Clinical Center).

History of DNR

In 1952, Pope Pius XII condemned the use "extraordinary means" to maintain life against the will of the patient (Mustagh, 2008). All major religions agreed with the Pope. Thirty years ago, a DNR was impossible to obtain legally. In 1976, a New Jersey court ruled in the Karen Ann Quinlan case that all persons had the right to refuse treatment. However, it did not clarify how the right could be exercised without court review and on case basis. Doctors had to go to court to stop using extraordinary life support. They were driven by the "technological imperative" to resort to extraordinary means, regardless of the futility of these means or whether the patient wanted them. But the decision on the June 30, 1978 case of Shirtly Dinnerstein changed all that. The court ruled that DNR orders could be issued without court intervention and placed the decision within the competence of the medical profession (Mass. App, 1978 as qtd in Mustagh). The decision became the basis of the President's Commission on Standards for Cardiopulmonary Resuscitation. It was later adopted by the American Medical Association, which clarified that "the purpose of CPR is to prevent sudden and unexpected death." It is not meant to prolong life in terminal irreversible illness "where death is not un-expected" and resuscitation is useless. The Association also emphasized that resuscitation in terminal cases may even violate the patient's "right to die with dignity." Other medical groups duplicated the Association's initiative until the change got incorporated into medical standards throughout the country as well as in other countries. The emphasis shifted from prolonging the process of dying to promoting dignity. Doctors now balance benefit with burden. They exercise value judgments and make moral decisions with the patient and his family. Quality of life has since become the prime consideration and basis of the decision (Mustagh).

Ethical Theories and Issues

A DNR is guided by the ethical theories and principles of beneficence, non-maleficence, autonomy and justice (Pat et al., 2009).

Beneficence

This moral or ethical theory obligates a doctor or person always to do what promotes the welfare of others (Pat et al., 2009). This consists of the elimination or prevention of harm in another person and contributing positively to his good or welfare. This theory compels the doctor or person to do what is in the best interest of the patient. It is most applicable in the case of a patient in permanent vegetative state when life-sustaining support is no longer in his best interest. Extraordinary means only prolong or extend the dying process and suffering on all sides without medical benefits. Preventing, eliminating or reducing suffering will be an act of mercy and beneficence. At times, death can be in the patient's best interests. Preserving his poor quality of life is tantamount to a denial of his well-being. Under this ethical theory, the decision not to resuscitate is morally right as it allows the patient to die in peace and dignity (Pat et al.).

Non-maleficence

This theory forbids a doctor or moral agent from inflicting harm or evil on another person (Pat et al., 2009). It universally obligates all people to protect one another and themselves from harm. Disease is a kind of harm and treatment is meant to cure the disease and remove the harm. But when treatment becomes ineffective or useless, it turns into harm that assaults the patient. Even successful resuscitation can severely damage the patient's lungs, heart or brain if death is likely in a matter of hours or days. If the patient is successfully resuscitated and survives, he may remain in irreversible coma. The British Medical Association and the Resuscitation Council guidelines state that CPR should not be performed if it is not likely to be successful (Pat el). Thus, resuscitation will harm the patient rather than do him good.

Autonomy

This theory recognizes the patient's independence to determine the direction he takes as long as the rights and liberties of others are respected (Pat el, 2009). A competent patient should be treated as autonomous. He has the right to voluntarily choose treatments and procedures, including life support and extraordinary medical care (Kagawa-Singer & Blackhall, 2001 as qtd in Pat el) for himself. This right, however, can be affected by a defect in controlling his desires or actions. If he makes his wish known, his family and the doctor must follow it. If it is not known, he should be given CPR even if his family opposes it (Pat et al.). This illustrates the inalienability of the right to life.

Justice

This means a fair, equitable and un-biased decision made in favor of the patient (Dunn, 1998 as qtd in Pat et al., 2009). The patient's right is, however, pitted against that of society. No one has the constitutional right to unlimited health care. Shortage of critical care beds, length of stay in the hospital and health care costs are among the non-medical considerations to a DNR. Terminal or end-of-life care exacts overwhelming costs with the least promise of return. It is, thus, deemed reasonable and just to restrict healthcare spending. Some institutions resort to rationing to protect autonomy while equitably apportioning available basic health care to those who stand the greatest chances of benefiting from it. In the face of real-life limited resources, the just choice is not to provide CPR to cases when CPR is unlikely to succeed (Curtis & Burt, 2007 as qtd in Pat et al.). Similarly, resorting to extraordinary medical intervention to prolong the life of a terminally ill patient will mean depriving others who need the resources and stand a better chance at survival or cure. The utilitarian principle applies here. It states that limited resources should go to the greatest number with the greatest chance of benefiting (Pat et al.).

Legal Theories and Issues

The general rule is that a patient has a fundamental right to CPR and the healthcare professional has the duty to perform it (Costello, 2002 as qtd in Pat et al., 2009). The latter's failure to will constitute negligence but performing it against the expressed wish of the patient violates his autonomy right. Through informed consent, the patient and his family learn about the benefits, risks and alternatives to treatment as well as their right to accept or refuse that treatment. The doctor or person making the DNR order must be thoroughly aware of all the relevant information and the consequences of a DNR order (Eckberg, 1998 as qtd in Pat et al.).

Informed consent is the bond between physician and patient (Minkoff & Marshall, 2009). It draws from the principle of respect for persons, the patient's autonomy and voluntariness and the physician's accuracy and good faith disclosure. The twin principles of voluntariness and adequate disclosure are interwoven and interdependent fundamentals in the exercise of individual choice. The choice of shared data, the valuation of facts and the emotional perspective combine with the… READ MORE

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