- Health Care, Drugs & Insurance
DNR Orders: When Nothing Is Something
The do-not-resuscitate order (DNR) has been a formally available option since the mid 1970’s in the United States (Ewanchuk and Brindley, 2006). The issue at hand is not the legality of a patient’s request for “no code” to be called, should s/he experience cardiac or respiratory arrest. The legal aspects have been settled since the 1990 Self-Determination Act. Rather, the issues are the conflict experienced by health care professionals both during the decision-making process with their patients and when confronted with a DNR order in a situation where they would normally be expected to take action; and for the patients and family members who may not entirely understand what a DNR order means for them. The purpose of this paper is to explore the attitudes of such professionals, and of the patients and their surrogates or guardians; and to discuss whether the conflict is improving with time or worsening. The conclusion will present a considered opinion, optimistic or otherwise, of the future of this issue.
A Brief History of DNR
The American Medical Association first suggested the “formal documentation and communication” of do-not-resuscitate orders, as cited in Ewanchuk and Brindley (2006), in the mid 1970’s. Cardiopulmonary resuscitation was initially developed for use after “witnessed intraoperative arrests”; it later became common practice for anyone who suffered cardiopulmonary arrest to have CPR performed upon them. Depending on the situation, some medical staffers would use their own judgment regarding how aggressively to administer CPR. If the patient were likely to die regardless of the intervention, a “slow code” (Ewanchuk and Brindley, 2006) might result. This resulted in a decay of trust between caregivers and patients—and patients’ families. After the AMA suggested formalizing the DNR request procedure, self-determination became more prominent for patients. Eventually, “CPR became the only medical therapy that required a physician's order for it to be withheld” (Ewanchuk and Brindley, 2006).
The reaction of staff to a DNR order can vary from environment to environment within the hospital. A terminal cancer patient’s DNR order most likely will not cause so much as a raised eyebrow on the oncology ward. However, a DNR order for a patient presenting for surgery, with a good prognosis for a positive outcome, will probably cause no small amount of consternation and concern amongst the staff. Prior to the 1990’s, “decisions (regarding DNR orders in the perioperative and immediate postoperative stages) were typically left to the attending surgeon and/or anaesthesiologist, and DNR orders were routinely suspended” (Truog, 1991; Cohen and Cohen, 1991, cited in Ewanchuk and Brindley, 2006). Questions about respect for patients’ autonomy led to the concept of “required reconsideration,” by which an extant DNR order is discussed prior to surgery with the patient, the surgeon, and the anaesthesiologist at the least, and perhaps the guardian or surrogate as well.
“Historically, the option to refuse cardiopulmonary resuscitation (CPR) exists because of resuscitation's dismal success rate: only 1-2 percent for out-of-hospital sudden cardiac death. And that's for a typically healthy businessman who collapses on the subway platform from a heart attack, not for someone dying of a terminal illness” (Muller, 2005, p. 1322). It would seem prudent for health care professionals in the position of speaking to patients and families to be sure they understand this statistic. Knowing ahead of time that the chances of survival are actually quite poor could assist with the decision-making process.
The Patient’s Perspective
The Elderly Patient
One study (Adams and Snedden, 2006) suggests that elderly patients have a skewed perception of the likelihood of their surviving CPR—and yet, they choose to enact a DNR order when hospitalized. Eighty-one percent of the respondents “believed that their chance of surviving inpatient CPRand leaving the hospital was 50% or better,” but forty-four percent of them initiated a DNR order. Actual survival-to-discharge rates are closer to 10% (Bedell, Delbanco, Cook, and Epstein, 1983, cited in Adams and Snedden). The percentage of patients who reported getting most of their information from television or their physicians was not reported, but the authors state that “most” patients made this claim.
Recent data indicates that CPR is less effective now than when it was initially developed, because its status as the standard of care means that it is sometimes used on patients for whom it is actually medically futile (Adams and Snedden, 2006). Combine this with the unrealistic portrayals of CPR survival on television shows, and “it is difficult not to speculateon the role medical dramas may play in spreading misinformation.” Better education of the elderly with regards to the actual statistics for CPR survival could quite possibly lead to more realistic enacting of DNR orders for this demographic. At the very least, it could certainly help the elderly understand how poor their prognosis is for surviving inpatient CPR.
The Religious Patient
Another study (Sullivan, Muskin, Feldman, and Haase, 2004) investigated the connection between patients’ religious beliefs and the depth thereof with their feelings about DNR orders. Strikingly, of the sample in this study, 75% of the patients “said they believed they understood the meaning of DNR status, yet less than one-third of the subjects could give an accurate definition” (abstract). Also, “(the authors) found that the patients who were least knowledgeable abouttheir religious traditions were also the least likely to consulta clergy member. This finding predicts a bimodal distributionof patient knowledge, with persons who were least informed religiouslyalso being least likely to be informed by others about whatis at stake with a DNR choice” (p. 127). Physicians need to discuss the options with their patients within the framework of the patients’ religious and moral beliefs, and should involve a chaplain, pastor, priest, or other religious figure appropriate to the patients during such discussions in order to assist in the decision-making process.
One of the most important points found by this study is that religious patients tended to equate a DNR order with suicide. This fallacious belief needs to be clarified by the physician and chaplain in order for the patient to make an informed decision. An explanation that “resuming basic physiological processes may not restoreany meaningful quality of life” (Sullivan, Muskin, Feldman, and Haase, 2004, p. 127) needs to be made very clear to the patient considering a DNR order. Also, the fact “that the DNR procedure does not actively end life, as doesthe act of suicide” (p. 127) needs to be explained.
Patients Need Information
Regardless of age, gender, race—regardless of any differences among them, all patients have the right to informed decision-making. The more information their physicians can provide with regards to the DNR order process, the better for everyone involved—health care professionals, patients, family and friends. Doctors need to take their patients’ cultural and religious backgrounds into account when discussing the option for a DNR order. They also need to determine whether the patients’ understanding is correct or skewed by misinformation, and take appropriate steps to assist in that decision-making process alongside their patients.
An EMS Worker’s Perspective
Emergency medical service (EMS) workers often find themselves responding to a 911 call from a family member whose loved one is in cardiac arrest. Their training requires them to immediately begin CPR. However—what if the loved one has a DNR on file at his physician’s office? What if the family member knows that the loved one does not wish CPR to be performed, per a verbal request made prior to this incident? Is it fair of the caller to be upset with the EMS worker for doing what he or she is trained to do, when it goes against the wishes of the patient? These are questions addressed by Feder, Matheny, Loveless, and Rea (2006) in Annals of Internal Medicine. “An unwanted resuscitation effortmay violate the patient's right to self-determination, causesuffering and emotional distress for the patient and the family,be troubling for EMS providers, and expend resources unnecessarily” (p. 634).
In King County, Washington, a new guideline was provided to EMS providers, allowing them “to withhold resuscitation if 1) the patient had apreexisting terminal condition and 2) the patient, family, orcaregivers indicated, in writing or verbally, that the patientdid not want resuscitation” (p. 634). Participation in this study was voluntary; sixteen districts’ EMS services took part. At the end of the time period, it was determined that withholding of CPR/resuscitation efforts did increase. EMS workers reported that they were comfortable following the directions of the guidelines, which gave them clear permission to “do nothing” in order to honor a DNR request that before they would have had to ignore. The workers also reported that family members were grateful to them for listening and not performing CPR on a terminally ill loved one who did not want it. In nearly half of the cases in the study (48%), the EMS teams cancelled paramedics who were en route. “In the remaining 25 cases, paramedics arrivedand assisted the family but did not override the decision ofthe EMTs and begin resuscitation” (p. 634).
Clearly, written guidelines giving EMS workers permission to honor verbal DNR requests is one way to ensure patient autonomy under a very stressful circumstance. Not only does this help the EMS staff, it also benefits the family of the patient; they no longer need to worry about their loves one’s wishes being trampled by training that does not take verbal DNR orders into account.
Without such guidelines in place, EMTs could find themselves performing CPR on a dead body over the vigorous protestations of family members (Muller, 2005, p. 1320). Despite the existence of an out-of-hospital DNR order, and the fact that the mother passed away at home peacefully, the grief of the surrounding family members caused a well-meaning neighbor to call 911. The EMTs duly arrived, and when the daughter could not show them the order as requested, they proceeded to remove Mrs. Santos’s body from her bed and began CPR—even though she was already deceased.
A Daughter’s Perspective
As if facing the death of a parent is not traumatic enough on its own, imagine the horror of finding that one’s mother has been intubated against an existing DNR order because she seized while playing bingo, and the paramedics followed their medical training to the letter (Fields, 2007, p. 294). The daughter did her best to advocate for her mother’s wishes, as set forth in the advance directive on file—and was accused of attempting to “euthanize” her mother for doing so. The community hospital to which the mother was rushed by ambulance had no protocols in place for dealing with palliative care and hospice options. This, sadly, is more the usual than the exception. For family members like this woman’s daughter, the already horrific situation became exponentially worse, especially after her mother was admitted to the ICU.
“An alternative to this unfortunate incident would have been to admit the patient to a palliative care unit, which could have helped with the transition from aggressive care to comfort care with an emphasis not on giving up, but rather, on helping everyone to accept the inevitable” (Fields, 2007, p. 294). While that is easily said, it is not always so easily done if no such center is available to the patient and his/her family. If there were more such care centers, undoubtedly fewer traumatic deaths would occur—because more patients would be able to receive the kind of care they desire, and have made clear in written DNR orders, advance directives, living wills, and so forth. More hospitals need to educate their staff about end-of-life issues for which palliative care could be more useful, in the end, than attempts at heroic measures. As the population ages, this will no doubt become more of an issue. Everyone—staff, patients, and families—would benefit from increased awareness and availability of information on all aspects of DNR orders.
A Nurse’s and Physician’s Perspective
Another issue at hand here is the attitude of the physicians. While the family physician was entirely “on board” with the patient’s known desires and those of the daughter, the other physicians—two specialists—he requested for consult refused (Fields, 2007, p. 294). “The critical care nurses rallied around the family, and to the umbrage of the specialists, suggested an opinion from a neurologist. According to Gajewska, Schroeder, De Marre, and Vincent (2004), this represents typical behavior for ICU nurses, as they more frequently advocate for early termination and comfort measures than physicians” (p. 294). Even when the primary care physician is aware of the patient’s wishes and the extant DNR order, he may be constrained—as was the doctor in Fields’s article—by rules of the health care facility requiring consults before removing a ventilator, for instance. Until all the physicians involved in the case are on the same page with regards to honoring a DNR order, there will be conflict that may or may not be readily resolved.
As mentioned in the previous paragraph, nurses tend to be the ones who advocate most strongly for the patient’s (and family’s) rights to have the DNR honored. They are the ones closest to the patient and the family, the ones who see the degradation of vital signs, the ones who notice the slipping in and out of consciousness, and so forth. Especially in the ICU venue, the nurses often fight for palliative measures instead of heroic ones. Fields goes so far as to suggest that nurses spearhead the movement within their facility to establish or improve end-of-life protocols, to spare other patients and their families the horrors that this one elderly woman and her daughter experienced. “Nurses should attend and organize palliative care in-services and other education offerings and make sure all new employees attend palliative care and hospice classes during their orientation. In addition, nurses need to be proactive with end-of-life care and refuse to accept substandard patient care from healthcare workers that are not familiar with end-of-life issues” (p. 296).
“Doing nothing is still doing something”
A paradigm shift is called for in the realm of the OR and emergency caregivers. The realization that “doing nothing”—not performing CPR, because of an extant DNR order—is in fact doing something of great importance. Honoring a DNR order is granting that patient autonomy, telling his or her family that their loved one’s wishes are more important than “doing something.” This same shift is also needed for nonemergency medical personnel, such as surgeons and nurses; for them, however, the urgency is not necessarily as strong. The underlying truth is that of honoring the patient’s wishes, even when that seems to go against what the healthcare provider has been taught. Training these professionals in compassionate methods of discussing DNR orders, either initially or in the reconsideration phase, would be beneficial to everyone involved in the process (Ewanchuk and Brindley, 2006).
“Do not resuscitate does not mean no care; it means a different kind of care that can best be achieved through end-of-life protocols and education” (Fields, 2007, abstract). This is the core of the issue for everyone involved when a DNR order is being considered, written, or followed. It bears repeating: The legality of DNR orders is not in question. The ethics of how best to work with the patients and families of patients who have DNR orders in place, or who request one to be written, is something that continues to be difficult, nearly 20 years after the law was created. Education, discussion, and openness are the keywords for healthcare professionals, patients, and families.
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