Download Do-Not-Resuscitate Orders: Nurse`s Role Requires Moral Courage

Vicki Lachman
Do-Not-Resuscitate Orders: Nurse’s Role
Requires Moral Courage
I
n the past, the moral command was to choose life.
The contemporary moral dilemma is to choose life
under what circumstances. “Now, the emerging trend is
to cede moral authority – and with it, responsibility – to
patients and families (what ought to be done), while
scientific authority (what can be done) remains with
the professional” (Curtin, 2010, p. 1). This shift is far too
simplistic; instead the public and professionals must
determine the separation of what ought to be done from
what can be done.
Do-not-resuscitate (DNR) orders were initiated as
a method to give competent patients the chance to
determine under what circumstances they still
choose life. Unfortunately, the discussion usually
occurs between the surrogate decision maker and the
physician, because the discussion has waited too long
and the patient now lacks the mental capacity to
decide. The focus of this article is the ethical obligation nurses have to support families and patients in
making a DNR decision. Initially, a brief review of the
statistics on cardiopulmonary resuscitation (CPR),
ethical issues surrounding partial do-not-resuscitate
(DNR) orders, and the present timing of DNR discussions will be presented. It will be followed by a discussion of the results of Sulmasy, He, McAuley, and Ury’s
(2008) study on the difference between nurses’ and
physicians’ beliefs and attitudes on DNR. Though this
study points to the acceptance of the majority of
attendings for nurses to initiate DNR discussions, in
reality nurses often are not included in the preparation or implementation of these discussions.
Interwoven throughout this article will be ideas about
what nurses can do to facilitate more open DNR discussions.
Moral courage will be needed to overcome fear
and stand up for the core values surrounding compassionate end-of-life decision making. Nurses need to
put ethical principles, such as veracity, fidelity, and
autonomy, into action for end of life (American
Vicki D. Lachman, PhD, MBE, APRN, is a Clinical Associate
Professor, Drexel University, Philadelphia, PA.
MEDSURG Nursing—July/August 2010—Vol. 19/No. 4
Association of Colleges of Nurses, 2004). Moral
courage enables nurses to face up steadfastly and selfconfidently to ethical dilemmas surrounding the late
timing of DNR discussions and the poor communication by physicians of the bad news about prognosis.
The Truth About CPR All Patients and Families
Need to Know
CPR stands alone as the only intervention the
patient must state explicitly that he or she does not
want. Today, every patient is a “full code” unless a
DNR order is documented clearly in the medical
record. However, the probability of success of CPR
varies based on the cause of the arrest, the patient’s
health status, and the availability of a trained first
responder (Cooper, Cooper, & Cooper, 2006).
Although the right to patient autonomy was
expressed in 1914 and informed consent became a
catch phrase in 1957, not until 1985 did polices to limit
medical care became explicit, in part due to the data
on the outcomes of CPR. Discharge from the hospital
(definition of long-term survival) after CPR originally
was reported as 70%, but this conclusion was based
on a select group of patients resuscitated in the operating room and recovery room (Layon & Dirk, 1994).
Most current rates of survival are recorded to
hospital discharge at 1%-25% for outpatients and 029% for inpatients (Cooper et al., 2006). The summary
of results from the four large studies of arrest survival
demonstrates increased probability of survival for all
rhythms when the arrest happens in the hospital
(6.4% vs. 17.6%). Patients with ventricular fibrillation
fare markedly better than patients in asystole. Current
statistics fail to match modern television dramas,
however, where 75% of the patients survive in programs such as “ER” (Diem, Lantos, & Tulsky, 1996).
The disparity between these statistics and those
of the 1950s is attributed to today’s higher level of
patient acuity as well as non-cardiac causes of arrest.
Also, this cohort of 50 years ago was primarily surgical patients who benefited from intense monitoring.
This cohort also did not demonstrate the brain damage that is a frequent cause of death after cardiac
arrest (Safar & Kochanek, 2002). Perhaps these poor
outcomes are also the result of CPR being performed
249
on patients who should have never received it. CPR
was never meant to be instituted with individuals in
multi-organ failure or with terminal cancer.
The American Nurses Association (ANA) “Position
Statement on Nursing Care and Do-Not-Resuscitate
(DNR) Decisions” (2003) addresses the duty nurses
have in educating patients and families on the realities
of CPR and DNR, as well as helping them gain access to
explicit DNR discussions with physicians. This position statement also identifies nurses’ obligation to take
an active role in developing DNR polices, specifically
in clarifying “potentially confusing orders such as
‘chemical code only,’ or ‘resuscitate, but do not intubate’” (p. 2).
Partial DNR Orders
DNR orders appeared in the literature in the early
1980s; references to partial DNR appeared before the
end of the decade (Ross & Pugh, 1988). Limited data
showed bleak survival rates (Dumot et al., 2001).
Though “slow codes” have been labeled medically and
ethically inappropriate, limited attention has been
paid to the ethical issues in partial DNR. “With only
particular exceptions, partial attempts to reverse a
cardiac or pulmonary arrest are medically unsound
because these interventions are often highly traumatic and consistently inefficacious” (Berger, 2003, p.
2271). Such resuscitation commonly violates the ethical obligation of nonmaleficence.
What are the medically based exceptions? If cardiac and respiratory arrests are pathophysiologically
discrete and the prognosis is good, cardiac resuscitation alone and “do-not-intubate” orders would be
acceptable. For example, quick cardioversion for
malignant arrhythmias is standard medical practice.
Respiratory resuscitation alone would be appropriate
for a patient with an asthmatic exacerbation or aspiration of a foreign body, or for an intubated patient with
a DNR order who was found self-extubated in respiratory arrest. Mostly “cardiac DNR only” orders are inappropriate for cardiopulmonary arrest because oxygenating a patient without circulation is physiologically senseless and violates nonmaleficence (Berger,
2003; Dumot et al., 2001).
Berger (2003) advocated the avoidance of partial
DNR orders and instead suggested care plans contain
the following five elements for life-threatening conditions in the patient with DNR orders:
1. Identification of the patient’s treatment goals (e.g.,
maintenance of specific cognitive or functional
ability).
2. Identification of specific medical interventions
declined because of burden or discomfort (e.g.,
feeding tubes or hemodialysis).
3. Physician discretion in determining the utility of
specific treatments within context of patient’s care
objectives (e.g., orders for IV pressors for
hypotension due to urosepsis because patient can
return to functional level he or she desires).
4. Correlated goals of care with only medically
appropriate interventions (e.g., discussion of how
pulmonary resuscitation only would not meet
patient’s goals).
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5.
Care plan easily translated by any physician first
responder to medical emergency.
Discussion of these five elements and the subsequent
documentation would provide all physicians and nurses with a clear view of a patient’s desired end-of-life
care.
Nurses can support patients in clearly identifying
goals of care and desired cognitive and functional ability, as well as weighing the benefits and burdens of recommended interventions. The Code of Ethics for Nurses
(ANA, 2001) specifically identified nurses’ obligations
in supporting a patient’s interests and right to selfdetermination, as well as those of the surrogates.
The nurse preserves, protects, and supports
those interests by assessing the patient’s comprehension of both the information presented and the
implications of decisions…The nurse supports
patient self-determination by participating in discussions with surrogates, providing guidance and
referral to other resources as necessary, and identifying and addressing problems in the decisionmaking (pp. 8-9).
The physician is responsible to assess competence for decision making and to enter the DNR order
in the medical record (Lemiengre, de Casterle, Van
Craen, Schotsmans, & Gastmans, 2007). However,
nurses have the ethical obligation to assure the
patient or surrogate has timely and frequent discussions on the changing goals of care in order to make
appropriate decisions.
The Patient and Family Who Need Help
Which patient is most likely to need help gaining
access to DNR discussions? Based on the study by
Bacchetta, Eachempati, Fins, Hydo, and Barie (2006),
the patient with a diagnosis of malignant disease (with
or without metastasis), cardiovascular disease, or
endocrinopathy, and the patient receiving chronic glucocorticoid therapy had a higher incidence of DNR
orders. The patient who experienced chronic illnesses
was more expected to have a DNR order, possibly
because that person understood the burdens of lifethreatening diseases. A history of dementia, cirrhosis,
or renal failure did not influence DNR status in this
study.
Unfortunately, the patient who faces life-threatening illness has difficulty gaining access to discussions
with a physician for a variety of reasons, one being the
physician’s failure to predict accurately and consistently survival or death. A study by White, Engelberg,
Wenrich, Lo, and Curtis, (2007) was designed to discover the content of physicians’ prognostic reports to
family members of ICU patients. Results indicated families with low literacy rates received less information
about potential treatment outcomes and thus may
have been more likely to misunderstand the patient’s
true clinical picture. Nurses need to advocate strongly
for the patient and family in this situation.
Another reason for physician’s disinclination to
write DNR orders earlier in a patient’s hospital stay is
the emotional and time-intensive nature of this type of
conversation. In a study by Morrell, Brown, Qi,
Drabiak, and Helft (2008), as well as in the SUPPORT
MEDSURG Nursing—July/August 2010—Vol. 19/No. 4
study (Hakim et al., 1996) and other studies conducted in the mid-to-late 1980s, the median time from DNR
order to death was 2 days. In the SUPPORT study, only
52% of patients who preferred not to be resuscitated
actually had written DNR orders. Despite many initiatives over the past decade to improve the care of the
dying (e.g., hospice, palliative care consultation, and
competency-based curriculum on delivering bad news
for medical students and residents), patterns of DNR
ordering have changed little since the passage of the
Patient Self-Determination Act in 1991 (Morrell et al.,
2008). However, more extensive documentation of discussion of end-of-life wishes was correlated with more
and earlier ordering of DNR (30% increase in the time
between order and death). This is especially important given the lack of significance advance directives
had in the outcome. If physicians resist making the
time for these discussions, nurses must muster the
moral courage to push for family meetings and, if
unsuccessful, for ethics committee consults.
Changing DNR to Allowing Natural Death
(AND)
Are Nurses Better at DNR Conversations?
Conclusion
Sulmasy and co-authors (2008) studied the difference between nurses’ and physicians’ beliefs and attitudes about DNR orders. Largely undocumented is the
fact nurses already play a role in the process leading
to a DNR physician order. Because of their intimate
knowledge of the patient and patient advocacy duty,
nurses were at least informally involved in DNR discussions. This study surveyed the attitudes of internal
medicine attending physicians, medical house officers, student nurses, and medical staff nurses on the
topic of DNR discussions, the role nurses ought to
play, and providers’ confidence in talking about DNR
with the patient and family.
Findings indicated a favorable attitude toward
nurses’ initiating DNR discussions (Sulmasy et al.,
2008). Nurses were the least likely to find talking about
DNR decisions with patients or surrogates as difficult.
In fact, unlike the house officers and attending physicians, they viewed these conversations as a gratifying
task. They also were more confident in their discussions than house officers, but less confident than
attending physicians (p<0.001). Though only 10% of
the nurses had a master’s or doctoral degree, no associations existed between confidence and professional
training. Neither was there an association with nation
of birth, religious denomination, or number of DNR
patients treated in the previous month.
Sulmasy and colleagues (2008) noted nurses were
not even consulted in the process in many places, yet
alone allowed to initiate the DNR discussion. However,
69% of attending physicians in the study agreed nurses should be allowed to initiate DNR discussions. Also,
nurses were more likely than physicians to believe it
was not their place to recommend a DNR order.
Perhaps this nondirective attitude, while not challenging the professional boundaries, supports patients in a
different way from the usual physician-directed DNR
process. These results raise questions about what policy would best serve the patient’s interests.
Nurses are on the front line of clinical situations in
which lack of DNR orders creates ethical dilemmas
requiring moral courage to advocate for the patient
and family. According to Sulmasy and colleagues
(2008), nurses are ready to take a more active role in
initiating these discussions. With nursing intervention,
perhaps the partial DNR orders and the late timing of
the discussions can be eliminated and the truth about
CPR will be told.
Family members often misconstrue DNR as giving
permission to terminate an individual’s life. However,
allowing natural death (AND) makes the intent of the
order very clear because death is used in the title. By
changing the wording, the acronym is more descriptive and less threatening (Knox & Vereb, 2005).
Venneman, Narnor-Harris, Perish, and Hamilton
(2008) conducted the first empirical study on the difference between the phrases DNR and AND. Data were
collected from 687 participants, with working nurses
representing 2/3 of the sample. The remaining 235 participants were almost evenly divided between nursing
students and controls (non-nursing students). Even
though the working nurses commonly supported the
order, regardless of the title (85%), a significantly
increased level of acceptance was noted by control
group and nursing students. The results of this study
support endorsement of a term such as AND.
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