DNR Orders and Patient Choice

As the population as a whole ages, there’s been an increased emphasis on living wills and do-not-resuscitate (DNR) orders. The ANA has always been a strong supporter of the patient’s right to autonomy and self-determination, and this includes the right to choose appropriate end-of-life measures, such as a natural death without resuscitation attempts. Nurses, as patient advocates, have an ethical duty to support patient choice.

DNR orders are designed to promote death with dignity and to prevent prolonged suffering when resuscitation attempts offer no clear benefit to the patient. Patients who are elderly and/or terminally ill often sign a DNR while they still have full mental capacity, in order to make it clear which medical interventions they do not choose for themselves. They may have a fear of being allowed to linger, hooked up to machines, or worry about becoming a burden to their children.

Yet despite a clear consensus that DNR orders should be honored, sometimes they are not. Often this is an error, as in a transition of care: an elderly nursing home resident is transferred to the hospital and the DNR doesn’t go along. Or perhaps in the midst of a medical crisis, a paramedic or emergency department physician does not know the patient’s DNR status and elects to attempt resuscitation.

Sometimes, however, clinicians feel ethically conflicted about whether or not a DNR should stand. Some surgeons have been known to suspend DNR orders during surgery and the post-op period. The idea here is that cardiac arrest would be an adverse event resulting from surgery or anesthesia and not a natural death. In a similar vein, imagine a nurse who is called away from bathing an elderly person and returns to find the patient submerged in the bath water, not breathing. What do you do in this case, if the patient has a DNR in place? Is it appropriate to attempt resuscitation when this type of adverse event occurs?

These types of ethical gray areas may not arise often, but they do pop up. If DNR orders are to be suspended during surgery, the patient should have say as to the time period and circumstances under which it will be reinstated—and all this should be carefully documented in the chart and communicated clearly to all staff involved in the care process. Since transitions of care are most likely to be the point at which errors occur, all healthcare facilities should have systems in place to ensure the patient’s wishes are honored. Some facilities use colored bracelets that indicate DNR status, or EMRs that immediately flag DNR status when a physician logs into the patient record.

Nurses should always strive to make sure DNR orders and other advance directives are implemented according to the patient’s wishes. As frontline caregivers, they should make sure paper orders are entered into the EMR, that DNR orders are reviewed and updated as needed to reflect a change in the patient’s condition, and that relevant information is always available to physicians and other caregivers.

True advocacy goes beyond advocating for the needs of the patients currently under your personal care. It means having the passion and the knowledge to identify opportunities to advocate for every healthcare consumer who relies on our current healthcare system. While nurses have an individual responsibility to advocate for individual patients, they also have the ethical responsibility to approach broader advocacy issues like DNR orders as a united group of nursing professionals.

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