Why is it important to know?
When it comes to end of life care, no matter the patient’s age, gender, sexuality, religion, etc. every patient has the option to sign a DNR which stands for “do not resuscitate.” This important document is usually signed when the patient is chronically ill or when the patient is elderly. It’s usually presented at the time of admission to the hospital, nursing facility, home health or hospice program. If DNR’s are justified in hospitals, should there be certain criteria outlining if a patient is a candidate to sign a DNR. Volunteering at Yale-New Haven Hospital on a variety of different medical units such as hematology and oncology, I understand what the atmosphere of the patients is in when they are categorized into these units. Most of the time the patients are older (65 years old or older) who feel as if they are already at the end of their lifetime and possibly have no hope of leaving the hospital due to the unknown outcome of their medical conditions.
Let’s define what a DNR truly is:
One might ask, how does this relate to bioethics? Well, let me tell you…
One model of ethical competence for healthcare staff includes three main aspects: being, doing and knowing, suggesting that ethical competence requires abilities of character, action, and knowledge. Ethical competence can be developed through experience, communication and education, and a supportive environment is necessary for maintaining a high ethical competence. The aim of the present study was to investigate how nurses and physicians in oncology and hematology care understand the concept of ethical competence in order to make or be involved in, DNR decisions and how such skills can be learned and developed. A further aim was to investigate the role of guidelines in relation to the development of ethical competence in DNR decisions. Source: https://bmcmedethics.biomedcentral.com/articles/10.1186/s12910-018-0300-7
The following chart displays the break down bewteen the health status of the patient and how many sign DNRs.
What is the conversation like between the patient and the physician?
In this video, it gives insight into what the conversation would be like when the possibility of a DNR is applicable. Also, it gives an example of what a patient feels about their current state and how that affects their decision to sign a DNR.
Examples of ethical dilemmas in DNR decisions in oncology and hematology care as revealed by our previous studies include: disagreement in the team regarding whether a patient should have a DNR order or not; when patients and relatives think differently about DNR; when a choice of whether or not to implement a DNR order stands between patient autonomy and the patient’s medical prognosis; and when the patient and family have not been informed of the DNR order by the physician and ask the nurse about what has been decided. Healthcare providers and physicians have to consider the patient’s perspectives and preferences. They have to work against the egoistic theory by working for the good of the patient. Patient’s family members, when implied with the task of making appropriate treatment choices or end-of-life care choices for the incapacitated patient, should put aside their self-interest and judge the situation and come to a decision in the patient’s best interest. This act of working towards achieving the greatest good for the patient by family members and by the physician can be termed under “Virtue theory” of ethics. Physicians have to judge the situation and provide appropriate treatment prognosis so that patients’ can make an autonomous choice of treatment preferences or patients’ families can make these choices for them and work towards an act of beneficence for the patient. While carrying out this act of beneficence, the physician has to provide information about the treatment, especially in the case of futile treatment so as to avoid any undue harm to the patient. Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6007064/
Cases where DNR’s were not consented to:
Let’s bring this all back the question at hand, should doctors be allowed to administor DNR order at all?
When ethical dilemmas occur, different values, norms or interests must be weighed against each other. Different models have been developed for such moral judgments and there are well-established examples of theories that judge ethical dilemmas based on consequences. These traditions are mirrored in the four well-known ethical principles of autonomy, non-maleficence, beneficence and justice. The principles of autonomy and justice are derived from deontological reasoning, meaning that we have a duty to respect human dignity in every person and treat everyone as equals, regardless of consequences. The principles of non-maleficence and beneficence are utilitarian in character, as they prescribe maximizing the well-being of others by promoting good consequences and limiting harm. A person is virtuous in that s/he develops certain characteristics. Thereby, s/he can develop a suitable manner of action for a certain context or practice. A basic assumption is that a ‘good’ person performs ‘right’ actions. Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6007064/
It has been proven that when a patient signs a DNR order, it is usually when death is expected soon. Persons with a terminal illness may not want aggressive interventions but prefer a natural, peaceful death. Personally, I would want exactly that. The whole point on having the right to die is to have the freedom and autonomy to choose, if applicable, when to die and when to stand and keep fighting. Everyone knows death is inevitable, and there comes a time where you have the choice to make it come sooner rather than later. The funny thing about ethical questions and even mine is that there is no right or wrong answer; there are just different answers. In my response to my ethical question and what I am leaving you, the reader with is this: the end of any life is not pretty nor easy, but it can be painless. When signing a DNR, you, the patient, or your loved one, is not deciding to give up or “got the easy route.” They are simply taking their life into their own hands and steering their route to happiness. When it comes to the end of a person’s life, I believe that DNR’s should be an option and given to the patient as a “treatment option” with obviously knowing all the options and what exactly a DNR does. To me, it is fair for the physician or primary healthcare provider to administer a DNR order when all other options have been exhausted. Yes, I understand that depending on the physical or mental state of the patient, the situation changes, but the medical and legal teams have guidelines put into place already to make the next steps very clear in these situations. All an all, DNR’s have been the course of action for certain individuals that provided peace and comfort, and that is why they should be allowed.
I hope you enjoyed!
Please do not be afraid to give me feedback or opposing ideas in the comments below!!
Pettersson, Mona, et al. “Ethical Competence in DNR Decisions -a Qualitative Study of Swedish Physicians and Nurses Working in Hematology and Oncology Care.” BMC Medical Ethics, BioMed Central, 19 June 2018, www.ncbi.nlm.nih.gov/pmc/articles/PMC6007064/.
Sandman, L., et al. “Ethical Competence in DNR Decisions –a Qualitative Study of Swedish Physicians and Nurses Working in Hematology and Oncology Care.” BMC Medical Ethics, BioMed Central, 1 Jan. 1970, bmcmedethics.biomedcentral.com/articles/10.1186/s12910-018-0300-7.