The health care industry changes more dramatically and more often than any other business (Sultz & Young, 2010). One of the most dramatic changes that affect every patient is the extraordinary ability and implementation of life saving measures. Even when there is no brain activity at all, patients can be kept alive on respirators that breathe oxygen in and out of their bodies. When a patient’s heart has stopped beating, a defibrillator can be used to jolt their heart back alive and beating again.
Even though a life saving measure of one kind or another is capable of being utilized, there are some patients that do not wish to have anything done; they do not want to be brought back to life. As with any end of life decision, there are ethical issues that need to be addressed in order to fully and ethically complete a do-not- resuscitate order. A do-not-resuscitate order is one that is “given by a physician indicating that in the event of a cardiac or respiratory arrest “no” resuscitative measures should be used to revive the patient” (Pozgar & Santucci, 2010, pg. 32).
The physician can write the do-not-resuscitate order at the request of the family, appointed caregiver, or from information obtained from an advanced directive (Pozgar & Santucci, 2010). Originally, the history of the do-not-resuscitate order stems from the case of Cruzan v. Director, Missouri dept. of Health, 497 U. S. 261, 110 S. Ct. 28411 (1990); the outcome of the case was that is it “recognized that a competent person had a constitutionally protected liberty interest in refusing unwanted medical treatment” (Pozgar & Santucci, 2010, pg. 21).
If a patient does not want to be resuscitated after cardiac arrest, then they have the right to choose to die. These orders are most commonly used in advanced stages of disease, elderly patients, or when a physician feels that life saving measures would not benefit the patient and only do more harm than good (Pozgar & Santucci, 2010). Since the case of Cruzan v. Director, Missouri dept. of Health, a competent person can make the decision to create a do- not- resuscitate order in the event of cardiac arrest in an advanced directive.
A physician can come to the family with the option of a do-not-resuscitate order, but it can only be written with the express consent of the patient; if the patient is unable to make the decision then a surrogate is appointed. The Patient Self-Determination Act of 1990 was “enacted to ensure that patients are informed of their rights to execute advance directive and accept or refuse medical care” (Pozgar & Santucci, 2010, pg. 53).
Facilities that participate in the Medicare program are required to allow their patients to execute advance directives (Pozgar & Santucci, 2010). Facilities ask patients on admittance to the hospital if they have an advanced directive. If the patient does not have one, then they are asked if they would like information on how to get one. This Act was the beginning of a new information era for patients. As noted in Pozgar & Santucci (2010) The Patient Self-Determination Act of 1990 provides that:
Providers are required to provide individuals written information concerning their rights under state law to make decisions including the right to accept or refuse medical or surgical treatment and the right to formulate advance directives, document the individual’s medical record whether the individual has executed an advance directive, not condition the provision of care or otherwise discriminate against an individual based on whether the individual has executed an advance directive, ensure compliance with requirements of State law regarding advance directives, provide education for staff concerning its policies and procedures on advance directives, provide for community education regarding issues concerning advance directives by defining what constitutes an advance directive, emphasizing that an advance directive is designed to enhance an incapacitated individual’s controls over medical treatment (pg. 116).
The ethical obligations of a physician can sometimes interfere with issuing a do-not-resuscitate order. A physician has an ethical obligation to practice autonomy. Autonomy is “recognizing the right of a person to make one’s own decisions” (Pozgar & Santucci, 2010, pg. 121). A competent patient should have the right to decide what kind of care they want and do not want to receive; they should also have the right to decide whether or not they want to be resuscitated. It is the patient’s body and ultimately it is their decision.
Physicians also have an ethical obligation to practice fidelity. Fidelity is “the virtue of faithfulness, being true to our commitments and obligations to others” (Pozgar & Santucci, 2010, pg. 13). This ethical principle in itself presents conflicting ethical duties the physician has towards the patient with issuing a do-not-resuscitate order. Physicians have an obligation to be true to their commitments; one commitment is to practice autonomy. Another commitment physicians have is to do no harm; when issuing a do-not-resuscitate order, a physician is essentially giving the order to allow a patient to die. This could be seen as a great harm by some.
On the other side, once a patient is living in a painful and debilitating state and then bringing them back time after time from cardiac arrest, could also be seen as a great harm to others. That is why it is important that before issuing a do-not-resuscitate order, a clear understanding of what the patient wants and what the patient’s family wants is essential to ethically making the right decision. The issue of confidentiality is one that is necessary to create trust within the patient-doctor relationship. Patients go to the doctor for routine checkups and minor incidents, but they also go for life threatening illness, embarrassing conditions, and procedures that they would not want anyone knowing about.
It is one of the most important jobs of a physician or health care worker to keep this and all patient information confidential. This is especially true in the matter of a do-not-resuscitate order. If a patient filled out an advanced directive stating that they did in deed want a do-not-resuscitate order and did not give the physician permission to speak with anyone about their health information, it is they physician’s duty to keep this information confidential per the patient’s wishes. Even if the physician thinks that the patient is making the wrong decision, but is wholly competent, the physician cannot discuss this matter with the patient’s family in an effort to persuade the patient to change their mind.
Family members might also try to sway the physician in a way regarding the order that would benefit them and might not be in the best interest of the patient. Patients place so much trust in their physician and team of health care workers that it is essential to the very foundation of their relationship to keep information confidential. Without trust in the patient-physician relationship it would be almost impossible to have an honest conversation about end of life decisions. Some patients only tell their physician want they want to hear or what they think they want to hear. It is important to take time and fully understand what your patient wants and explain to the patient what they are exactly deciding before initiating a do-not-resuscitate order.
Patients have rights! The Patient Bill of Rights allows them choose the medical care they receive, know their rights, receive an explanation of their rights, know hospitals adverse events, have the right to admission, quality care, participate in care decisions, informed consent, ask questions, and the right to privacy and confidentiality (Pozgar & Santucci, 2010, pg. 386). The implications of the Patient Bill of Rights are; the patient has more power over their health care decisions, the right to receive informed quality care, the right to the truth about who is caring for them, and essentially the right to ultimately do what is best for them.
When a patient enters a hospital facility they are usually scared, unsure of what is going to happen and unsure of their rights, and confused by the equipment, jargon, and all the unfamiliar faces. Before the Patient Bill of Rights, most patients would just do what their physician told them without question. Now that patients are being informed of their rights coupled with all the medical information that is available on the internet, they are asking questions and making informed decisions about their care. Gone are the days of patients just blindly following their physician’s recommendations; patients are doing research, voicing their opinions, and getting second opinions. Everything about patient’s rights says that they have the ability to make the decision to utilize a do-not-resuscitate order when and/if they want one.
It is the patient’s decision to have complete control over what happens and what does happen to their body. However, physician’s ethical principles have conflicting messages about utilizing a do-not-resuscitate order. Every patient has the right to human dignity and to be treated ethically. It is the physician’s responsibility to treat their patient with as much care and dignity as they are possibly able to give. No patient wants their physician, a person they trust to handle their minor and major health care decisions that affect not only the patient but their whole family, to treat them like an animal or like someone who does not matter to them at all. Every human has the right to be treated with respect and care.
This is essential to all health care facilities, procedures, and patients; not just those with do-not-resuscitate orders. Compassion is an ethical principle that is of the utmost importance when analyzing the patient-physician relationship. Patients come to physicians in their time of need, sickness, and health; they seek advice, recommendations, and care. It is essential for the physician to show compassion for their patients; “a deep awareness of and sympathy for another’s suffering” (Pozgar & Santucci, 2010, pg. 10). In a case where a patient has a terminal illness and suffers from consuming pain, if a physician has deep awareness and sympathy for their patient’s suffering, a do-not-resuscitate order is an ethical decision for the physician to come to.
A physician should understand what the patient wants in the course of their health care plan. Does the patient want to fight? Does the patient want to give up and let nature take its course? What are the patient’s values and morals concerning end of life care? These are conversations that the physician needs to have with their patient in order to garner a better and completely clear understanding of what they want. With the physician’s compassion, the patient should receive great medical advice; the patient becomes more than just a patient; they become a human being. Nonmaleficence is another ethical principle that is essential to making ethical health care decisions.
Nonmaleficence is an “ethical principle that requires caregivers to avoid causing patients harm” (Pozgar & Santucci, 2010, pg. 20). There is always going to be a potential for harm in health care. Procedures are risky, medication has side effects, treatment does not work the way it was hoped to work, and physicians make mistakes in diagnosis, procedure, and treatment options. It is essential to state that physicians should never purposely harm a patient and they should never harm a patient because of poor judgment and carelessness. This ethical principle should make it clear to physicians to do the most effective and less risky procedure first before taking a more drastic approach. This ethical principle should sometimes contradict the principle of autonomy.
When a hysician knows that a patient can be saved in the event of cardiac arrest and the patient has a do-not-resuscitate order, the physician might feel conflicted because of the ethical principle that states “do no harm”. A reasonable person could see letting a patient die as harm. The principle of nonmaleficence is “broken when a physician is placed in the position of ending life… there needs to be a distinction between killing and letting die” (Pozgar & Santucci, 2010, pg. 20). There are contradictions in everyday life as well as in the health care world. What is important is that we do the least amount of harm, respect our patients, and treat everyone with compassion. Social justice needs to be maintained when patients are making decisions and being offered care.
Social justice “demands that persons in similar circumstances be treated similarly” (Pozgar & Santucci, 2010, pg. Every patient in similar situations needs to be treated equally. It should not matter if they have health insurance, how much money they have, or what their sex, race, or creed is. As health care employees it is our job to treat by the seriousness of the illness and the issues that are afflicting the patient and not by the patient themselves. The Patient Self Determination Act of 1990 changed the way that end of life care is handled and approached with patients. However, a do-not-resuscitate order does not mean the same as giving no care at all.
Patients who are in their end of life stage have the right to receive compassionate and quality care even if they have a do-not-resuscitate order. Hirst & Stec (2008) state that when a patient fills out a do-not-resuscitate form “it is important to note that the form itself is not the client’s plan of treatment. The form is a way to communicate a DNR wish for a client is part of the treatment plan” (pg. 30). A plan of treatment still needs to be discussed and implemented. The Patient Self-Determination Act of 1990 states that health care facilities will “not condition the provision of care or otherwise discriminate against an individual based on whether the individual has executed an advance directive” (Pozgar & Santucci, 2010, pg. 116).
However, this is a general fear among patients; “people are concerned that, once a DNR order is written, all treatments will be terminated and levels of care will fall” (Chang, Huang, & Lin, 2010, pg. 446). Social justice is also compromised when intensive care units are reluctant to give a patient with a do-not resuscitate order a bed; they prefer to keep the beds open to those that can be saved (Chang, Huang, & Lin, 2010). If any patient is need of intensive care then they deserve a bed in the ICU. It should not matter what the treatment plan for the patient’s end of life care is; while a patient is still alive and under the facilities care, they should receive the same care that every other patient does. Patients who have signed an order should not be seen as a patient who has given up on life in general.
Although social justice and the quality of care that do-not-resuscitate patients receive in the ICU and “despite societal and legal barriers, half the patients dying in the ICU received a decision to limit therapy mostly as withholding or DNR orders” (Mani, et al, 2009, abstract). Good communication when initiating a discussion regarding a do-not- resuscitate order is imperative to the understanding of everyone involved. If the physician misunderstands what the patient and/or their family is saying and initiated a do-not-resuscitate order anyway, then the physician can be held liable. It is just as equally important for the patients, their families, and the surrogate decision makers to thoroughly understand what a do-not-resuscitate order is.
Before the patient rights movement, competent patients who requested a do-not-resuscitate order were often passed on for psychological treatment; these referrals usually resulted in the patient doing what the referring physician originally wanted for the patient (Field, 2008). “In the era of increasing patient’s rights, court decisions slapped down presumption of incompetence in the absence of concrete evidence” (Fields, 2008, pg. 253). Surrogate decision makers are used when a patient is incapacitated and cannot make the end of life decisions for themselves; “the initial burden on the surrogate is to make decisions using substituted judgment based on her previously stated wishes or an understanding of her values” (Nash, 2009, pg. 80).
It is a huge responsibility to determine what decisions someone else would make regarding their own end of life care; “the process of signing a DNR order can raise many negative emotions, including guilt, ambivalence, and conflict” and the surrogate feels that “prior discussions, documents such as living wills, and consensus among family members make it easier” (Handy, Sulmasy, Merkel, & Ury, 2008, pg. 15). If the surrogate has no information on what the patient did want, then they are to decide “using the lower standard of what would be in the patient’s best interest” (Nash, 2009, pg. 80). These decisions need to be taken very seriously and under the advisement of the patient’s physician. Interviews for research purposes found that some “surrogates believed that signing a DNR order is a prerequisite to obtaining adequate opioid analgesia” (Handy, Sulmasy, Merkel, & Ury, 2008, pg. 15).
Surrogate decision makers might feel pressured and make the wrong decision based on what they think the patient would want or based on only empathy for the patient. Although some surrogate decisions regarding end of life care are based on misguided reasons, most surrogate decision makers sign a do-not-resuscitate order the day of the patient’s death (Levin, et al, 2008, abstract). There are no real alternatives to a do-not-resuscitate order. If a patient makes the decision to have an order put in place, they have every right to do so. The decision to sign or not to sign a do-not-resuscitate order stems from each person’s personal beliefs and views regarding end of life care and treatment.
There are alternative solutions to the miscommunication, misunderstanding, orders not being upheld, and relief of a surrogate decision maker that surround the creation of a do-not-resuscitate order. “A portable DNR order is a do-not-resuscitate directive that travels with the patient. “One way to improve continuity among providers and organizations is to develop statewide portable DNR and end-of-life orders that ensure patients’ wishes are followed regardless of setting” (Payne & Thornlow, 2008, pg. 11). This portable do-not-resuscitate order would clear up any miscommunication, misunderstanding, issues of orders not being upheld, and would give relief to a surrogate decision maker.
The portability of this order could give the patient piece of mind that wherever they go, their wishes regarding resuscitation will be honored. I believe that with open and honest communication about end of life decisions, this issue will be addressed. I am hopeful that a state wide system will be put in place for advanced directives as well as for all electronic medical records. It would be very disheartening to have a do-not-resuscitate order in place at your local hospital and then you find yourself in another hospital, fully resuscitated, and on a ventilator. Above everything else, we should respect our patient’s wishes to make their own decisions. Patients put their trust in us to do the right thing; not what is right by us, but by what is right by them.