Nia Sofia M.

Morales BSN IV-A

Do Not Resuscitate (DNR)

Do not resuscitate (DNR) order is a part of advanced medical directives allowed by federal law passed in 1991, expanding the notion of patient autonomy to situations in which they may not be able to make crucial medical decisions due to incapacitation. It instructs medical personnel not to perform life-saving cardiopulmonary resuscitation (CPR) or other procedures to restart the heart or breathing once they have ceased. By law, the DNR directive must be offered as an option to patients by health providers in, and in some states, out of a hospital setting. Once signed, the DNR directive must be placed in the in the patient's chart.

The usual circumstances in which it is appropriate not to resuscitate are:

when it will not restart the heart or breathing When there is no benefit to the patient When the benefits are outweighed by the burdens

Although DNRs can be regarded as a form of passive euthanasia, they are not controversial unless they are abused, since they are intended to prevent patients suffering pointlessly from the bad effects that resuscitation can cause: broken ribs, other fractures, ruptured spleen, brain damage.

PURPOSE
With such advanced cardiopulmonary techniques as CPR, it is possible to keep almost any patient's heart and lungs functioning, independent of how terminal or hopeless their medical condition becomes. T The DNR program is designed to help people in the final stages of a terminal illness or who have intractable pain the option for deciding against life-saving measures that may only prolong their pain and death. The option of deciding against life-saving measures is considered to be a formal part of patient autonomy and is respected as an ethical subset of medical informed consent.

Advance directives An 'advance directive' gives patients the legal right to give, or withhold, consent to specific medical treatments prospectively. Their use should ensure that health professionals are aware of individual patients' wishes if their condition should deteriorate and they suffer loss of mental capacity. The British Medical Association (2000) published a code of practice which stated that competent informed adults have an established legal right to refuse medical procedures in advance and that, where valid and applicable, an advance directive must be followed.

Ethical considerations
Decisions about resuscitation pose many ethical dilemmas for those involved and should take into account the patient's wishes, quality of life and prognosis. The guiding ethical principles of non-maleficence, beneficence, autonomy and veracity can be used to help guide decision-making when resuscitation status is being considered.

Non-maleficence
The principle of non-maleficence states that harm should not knowingly be done to a patient or another person. Non-maleficence argues against performing CPR when the outcomes are harmful or when usage is inappropriate.

Beneficence
Beneficence is the principle that dictates that a person should do right unto others and prevent harm (Edwards, 1997). Therefore beneficence supports the use of CPR when it is likely to be most effective.

Autonomy
Autonomy refers to respecting a person's individuality, and his or her right to make decisions about his or her health.

Veracity
The principle of veracity requires an obligation to tell the truth. Ethical theory and reasoning do not resolve ethical dilemmas but they do provide a framework for structuring and clarifying them.

Role of health professionals in decision-making

The primary goal of medical treatment is to maximize benefit and minimize harm. Doctors have traditionally focused on quantity of life and not quality, seeing a patient's death as personal failure. Medical paternalism asserts that beneficence can legitimately take precedence over respect for autonomy because professionals have superior knowledge to determine the patient's best interests. Paternalistic decision-making is inappropriate; patients have ethical and legal rights, which must always be considered.

Some health-care professionals do not like to discuss end-of-life decisions with patients as they feel that such involvement may be harmful and upsetting in what could be their last days of life. However, evidence shows this is not the case. Loewy (1991) suggests that involving patients in resuscitation decisions is perhaps more painful for the health-care professional than it is for the patient; perhaps this could be a reason for the lack of open discussion. The views of the medical and nursing team involved in the patient's care are valuable in forming a DNR decision. It is usually nurses who initiate the discussion regarding the resuscitation status of specific patients. This is probably because nurses spend more time with patients than other staff and are therefore more likely to observe any deterioration in their condition.

Role of the patient in decision-making

Although it would not be appropriate to discuss DNR orders with all patients, there are situations in which exploration of a patient's wishes should be undertaken, especially with those in the latter stages of terminal disease who might be at risk of cardiac arrest To be able to make autonomous decisions regarding resuscitation patients must have a realistic understanding of the process. It has been demonstrated that comprehension of the issues can lead to a significant decrease in consent to resuscitation in older people, especially when an advance directive could be utilized.

Role of the family in decision-making

Family members currently have no legal authority to make decisions on behalf of adult patients who are unable to make decisions for them. However, should they wish to do so, relatives must be able to contribute to the decision-making process. Communication should help avoid unnecessary anxiety and stress. Box 3 contains some considerations for good practice. When quality of life is being considered and the patient is unable to express his or her views, the opinion of relatives may be sought regarding the patient's best interests. However, relatives will not be able to demand treatment that the health-care team feel is wrong. If the patient is incapable of making an informed decision then, ultimately, it is the medical team who will have the final say.