By Nabil J. Hamam SHU- LDR 650, Medical Law Professor: Shanna
R. Reed, Esq. March 11, 2015
Slide 3
(DNR) Definition A do not resuscitate (DNR) order, is written
by a licensed physician in consultation with a patient or surrogate
decision maker. CPR is a series of specific medical procedures that
attempt to maintain perfusion.
Slide 4
History of Cardiopulmonary Resuscitation and Do Not Attempt
Resuscitation Orders In the 1960s, CPR was initially performed by
anesthesiologists on adults and children who suffered from
witnessed cardiac arrest. CPR became the standard of care for all
etiologies. In 1974, the American Heart Association (AHA)
recognized that many patients who received CPR survived with
significant morbidities.
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Target audiences Patients Families Physicians All medical
professionals
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My position I believe that DNR orders should not be permitted
unless : vegetative state Irreversible conditions Brain death
Cardiac death
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Slide 8
Questions and Concerns Discussions on life and death from
thousands of years ago have been revived; Healthcare providers are
once again concerned with questions such as: What indicates death?
How long and how far should life go on? Can patients wishes put an
end to all these decisions and discussions? Or must there be limits
to the extent of patients wishes? How often are DNR orders written
on a general medical inpatient service? What reasons are given for
DNR orders? How do patients and families participate in DNR
decisions? Finally, what problems occur in the decision-making
process?
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Patient Self Determination Act of 1990, physicians must write a
DNR order if requested by a patient or his or her surrogate. If the
attending physician disagrees with the patients request, and the
differences cannot be resolved, the patient then should be
transferred to the care of another physician.
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Ethical Issues Ethical issues in end-of-life decision-making
are extensive and have their roots in the four key principles of
biomedical ethics, namely autonomy, non-maleficence, beneficence
and justice. Revival of the topic of end-of-life decision-making
confirms the inadequacy of previously existing answers. This is
linked to numerous factors, including culture, religion,
convictions and beliefs, with religious values being among the most
influential.
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dignity of human beings. Acquiring an ethical and legal stance
on the subject of end of life. perspectives on stopping
life-prolonging treatments are contingent on evaluation. What does
religions say about it??
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Islamic and Christianity viewpoints, human life is so valuable
that the Holy Quran and bible Peoples lives do not belong to
themselves Everyone should seek remedy in life-threatening
situations.
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When should CPR be administered? In the absence of a valid
physicians order to forgo CPR, if a patient experiences cardiac or
respiratory arrest, the standard of care is to attempt CPR.
Paramedics responding to an arrest are required to administer CPR.
Since 1994 in Washington, patients may wear a bracelet or carry
paperwork that allows a responding paramedic to honor a physician's
order to forgo CPR. In the state of Washington, the POLST form is a
portable physician order sheet that enables any individual with an
advanced life-limiting illness to effectively communicate his or
her wishes to limit life-sustaining medical treatment in a variety
of health care settings, including the outpatient setting.
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Is CPR always beneficial? The general rule of attempting
universal CPR needs careful consideration (Blinderman et al.,
2012). Even though including patients and families in decisions
regarding resuscitation respects patient autonomy, providing
patients and families with accurate information regarding the risks
and potential medical benefit of cardiopulmonary resuscitation is
also critical.
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Defining Direct Medical Benefit Determining the potential for
direct medical benefit can be challenging. In general, survival
rates in adults following in-hospital cardiac arrest range from
8-39% with favorable neurological outcomes in 7-14% of survivors
(Meaney et al., 2010). In children, the survival rate following
in-hospital cardiac arrest is closer to 27% with a favorable
neurological outcome in up to one third of survivors (AHA, 2010).
Out of hospital arrest is less successful, with survival rates in
adults ranging from 7-14% and in infants and children approximately
3-9% (Meaney et al., 2010; Garza et al., 2009).
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How should the patient's quality of life be considered? CPR
might appear to lack potential benefit when the patient's quality
of life is so poor. When can CPR be withheld? Many hospitals have
policies that describe circumstances under which CPR can be
withheld based on the practical reality that CPR does not always
provide direct medical benefit. Two general situations justify
withholding CPR: When CPR will likely be ineffective and has
minimal potential to provide direct medical benefit to the patient.
When the patient with intact decision making capacity or a
surrogate decision maker explicitly requests to forgo CPR.
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What if the family disagrees with the DNAR order? Ethicists and
physicians are divided. What if there is disagreement?? If CPR is
deemed "futile," should a DNAR order be written? If health care
providers unanimously agree that CPR would be medically futile,
clinicians are not obligated to perform it.
Slide 18
The challenges of the patients right to making choices and
decisions one respondent stated that a persons autonomy extends as
far as God will allow it. God limits the patients physicians must
tell capacitated patients the truth about their conditions, and
patients should always be optimistic and continue to believe in
medicine and miracles.
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Guidelines It seems necessary to develop a guideline that can
assist decision-makers regarding end-of-life. Such a guideline can
be used to clarify limitations and solutions to the ethical
problems.
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Conclusion If the person is unconscious or he is a minor, there
is no need to wait to obtain consent from proxy or guardian. The
physician (or nurse) should do his or her best to save the life,
organ, or limb without waiting for due consent.
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