Donotresuscitateorders

Ethicalaspectsondecisionmakingandcommunication

amongphysicians,nurses,patientsandrelatives

BY

RURIKLFMARK

.ABSTRACT
LfmarkRurik. Donotresuscitateorders.Ethicalaspectsondecisionmakingand
communicationamongphysicians,nurses,patientsandrelatives.
ISBN9162845284
Thepurposewastodescribeethicalaspectsonhowdonotresuscitate(DNR)deci
sionsaremade,established,andcommunicatedbetweenphysicians,nurses,patientsand
relatives.
Arandomsampleof220physiciansandnursesansweredaquestionnaireabouttheir
attitudestoandexperiencesofthemakingandcommunicationofaDNRdecision.The
responseratewas73%.Twentyseriouslyillpatients,and21relativesofpatientswho
died with a DNR order, were interviewed. The literature on medical futility was
searchedforconditionsforfutilityandmoralconsequences.
Theresultsshowedthatmanyphysiciansandnursesareuncertainabouttherulesand
ethics of DNR orders. There are discrepancies between guidelines and attitudes
regardingDNRorders,aswellasbetweenattitudesandbehaviour.Seriouslyillpatients
estimateopenandstraightforwardconversations abouttreatments intheendoflife.
Relatives seem to get acceptable information and counselling. Conditions and
consequencesofmedicalfutilitymaybeapproachedinanewclinicalway.Thereare
numerouspossibleethicalconflictswithinandbetweentheprinciplesofautonomy,
nonmaleficence,beneficence,andthevirtuesandidealsoftheprofession.
Startadialogueaboutendoflifesupportwithchronicallyillandelderlypatients,and
theirrelatives,whiletheystillarecapableofunderstandingandauthorisation.Theclinical
conversationmodelmaymakeiteasier.Allinvolvedshouldunderstandwhycertaindeci
sionsaremade.Conditionsandconsequencesoffutilityshouldbeascertainedtogetherwith
thepatients,therelativesandthestaff,afterwhichajointdecisioncanbereached.

Key words: DNR orders, futility, decision making, communication, physicians,

nurses,patients,relatives,ethics

RurikLfmark,DepartmentofMedicalEthics,Facultyofmedicine,Lund
University,SE22222Lund,Sweden.Email:rurik.lofmark@lg.se

RurikLfmark2001
PrintedinSwedenbyUniversitetstryckeriet,Lund2000
2

ORIGINALPAPERS
Thedissertationisbasedonthefollowingpapers,whichwillbereferredtointhe
textbytheirromannumerals:
I

LfmarkR,NilstunT.DoNotResuscitateordersshouldthepatientsbein
formed?JInternMed1997;241:4215

35 LfmarkR,NilstunT.Decidingnottoresuscitate.Responsibilitiesofphysicians
andnursesaproposal.ScandJCaringSci1997;11:20711
61 LfmarkR,NilstunT.InformingpatientsandrelativesaboutDoNotResuscitate
decisions.JInternMed1998;243:1915
IVLfmarkR,NilstunT.Notif,buthow:onewaytotalkwithpatientsaboutforgoing

lifesupport.PostgradMedJ2000;76:2628
22 LfmarkR,NilstunT.Experiencesandattitudesofrelatives:expectationsofcare
arefirmanddiverse,butdonotresuscitateordersarealmostinvisible.Submitted
forpublication.
VI LfmarkR,NilstunT.Conditionsandconsequencesofmedicalfutilitya
proposalforanewclinicalapproach.Submittedforpublication.

Reprintsweremadewithkindpermissionfromthepublishers.

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