Do Not Resuscitate Orders

Some elderly and disabled people are reluctant to enter hospital in case DNR orders are placed on their charts without their knowledge or consent.
  • Right-to-die organisations claim they support the autonomy of the patient. Too often this only applies to the right to die, not to continue living.
  • When a DNR order is on a chart, doctors often refrain from implementing other life-sustaining treatment.
  • In Bioethics today, there is a trend to regard those judged to have a "lesser quality of life" as having less value in society.
  • Some patients are pressured to sign DNR orders, worded with medical jargon they don't understand,  when they are in a confused state
  • Legislation is being proposed to allow doctors and hospital ethics committees to refuse to treat a dying or disabled person, without fear of prosecution.
Many elderly and disabled people faced with entering hospitals and nursing homes are concerned that Do Not Resuscitate orders will be written in their medical notes without consultation.
  • Some countries have developed guidelines on when it is okay to not resuscitate a patient.
  • Doctors need to work closely with patients of their families wherever possible.
  • When used in advance directives, DNR orders have been interpreted very narrowly.
  • Bio-ethicists tend to agree that while there should be a right to die, there is no automatic right to live.
  • There is concern that health managers will debate those who live, who die, and who gets what health care.
When entering a hospital some patients are issued with a DNR (Do Not Resuscitate) Order which means in the event of Cardiac Arrest they will not be given Cardiopulmonary resuscitation(CPR).

In New Zealand standard practice is to always resuscitate patients to restore pulse and breathing unless there is a specific order for this not to happen. Patients who do not wish to be resuscitated can contact a staff member to discuss this option, and after a thorough consultation a DNR order can be issued if the patient wishes to proceed. (1)

"...elderly people were terrified to learn that seemingly healthy patients had DNR orders attached to their medical notes."
Ageism
In Great Britain the decision on whether or not to issue a DNR order has been made in the past simply because of the age of some patients being admitted to hospital. Age Concern groups spokesperson Gordon Lishman said elderly people were terrified to learn that seemingly healthy patients had DNR orders attached to their medical notes. This was done without their knowledge or consent! Actions of this nature have caused the group most likely to be in need of medical treatment to stay away from the very hospitals which are supposed to be there to treat them.

Patients Fear Losing Control
Patients fear losing control in medical situations and would welcome the chance to have a DNR order placed on their medical charts claim The Right to Die Society. Some individuals even go one step further, buying bracelets which have this message engraved upon them. 

They claim that: "patients fear losing control and may not want to find themselves being kept alive in a physical state with a lessened quality of life and no way out." (2)
Many patients are not aware of the effects (both positive and negative) of CPR at the time they enter hospital.



Both groups are adamant that clear lines of communication are vital to the well-being of the patient and that many patients are not aware of the effects (both positive and negative) of CPR at the time they enter hospital. Sensitive dialogue with a medical practitioner who is properly trained in how to speak to patients about this treatment is necessary.

Medical Guidelines
In February 2001 the British Medical Association (BMA) issued guidelines to clarify their position on the appropriate use of DNR orders. This was done to help members of the medical profession and members of the public who had expressed concern about the random nature of DNR orders being issued before this time.

The guidelines call for medical professionals to make a thorough examination of all aspects of a patient's condition. Prior to this decisions had been made by a quick examination and with no consultation with the patients. The patients wishes must be taken into consideration before a decision is made about possible non-treatment. This should only happen according to the guidelines when the benefits are outweighed by the burdens.

There may be situations where CPR is not appropriate treatment.
The guidelines do not paint a totally positive picture of CPR however, they claim it can result in broken ribs; fractures or a ruptured spleen. Patients may even suffer brain damage in some cases and may need to spend time in intensive care. There may be situations where CPR is not appropriate treatment.

The Right to Die Society states CPR has been shown to be have a 0% probability of success in the following clinical circumstances:
  • Acute Stroke
  • Septic Shock
  • Metastic cancer
  • Severe pneumonia
In other clinical situations, survival from CPR is extremely limited:
  • Hypotension (2% survival)
  • Renal failure (3%)
  • AIDS (2%)
  • Homebound lifestyle (4%)
  • Age greater than 70 (4% survival to discharge from hospital) (3)
However despite these grim statistics a patients wishes must remain the highest priority. These statistics should not be used to undermine the patient's confidence in their choice which after all must remain a personal decision.

One of the greatest claims of pro-euthanasia movement is they support the autonomy of the patient but this must surely extend to the ensuring a patient is given the right to live if they so choose.
A close relationship must be developed with the patient who must be told all the facts about resuscitation in language they can understand.


Dr Michael Wilkes, chair of the BMA's medical ethics committee states: "Clear documentation in the medical and nursing notes about any advance decision is essential and junior doctors must be able to access support from more experienced colleagues." (4)

Communication is a key factor in implementing the guidelines. A close relationship must be developed with the patient who must be told all the facts about resuscitation in language they can understand. Wilkes states it is crucial this difficult conversation is handled in a sensitive manner by doctors. It would also be appropriate for medical professionals to receive training in how to properly talk with patients about end of life care.

The AMA (American Medical Association) has a practice whereby if the attending physician judges a case to be inappropriate use of CPR, then he can issue a DNR order onto the patient's record. The physician must alert the patient or the patient's surrogate (if the patient is incompetent) about the order. The physician must take the patient's wishes into account. The AMA states that the DNR order must only be used for CPR and not as a basis to limit treatment in other areas.

Misinterpreting DNR Orders
Research has shown that misinterpreting or overinterpreting of DNR orders by medical professionals is more commonplace that one would expect. Once a DNR order is placed on a patient's medical chart this prejudices opinion about possible treatment of that patient in other areas.
Often a DNR order will have the words 'no heroic measures will be taken to sustain life'. There are different interpretations of this across America, in some states it will include hydration and nutrition and in others it will not.



Often a DNR order will have the words 'no heroic measures will be taken to sustain life'. There are different interpretations of this across America, in some states it will include hydration and nutrition and in others it will not. This can lead to much confusion for both doctors and patients.

Research Shows Doctors Over-reach Their Brief
It is quite clear a DNR order is specifically for withholding treatment of CPR yet a study * by Dr Mary Catherine Beach of Johns Hopkins University and Dr R. Sean Morrison of the Mount Sinai School of Medicine in NYC shows quite different findings.

They surveyed 241 physicians, outlining three case studies involving patients with life threatening illnesses such as advanced cancer or AIDs complicated by pneumonia.

Some of the doctors were told patients had DNR orders and others were not. Beach and Morrison found that for all three patients the doctors were more likely to refrain from implementing CPR and other life-sustaining treatments when that patient had a DNR order.
Decisions to initiate procedures ranging form complex therapies such as intensive care unit transfer, to simpler interventions, such as blood transfusions, should not be based on the DNR order alone."


They state:

"Physicians are less likely to agree to initiate procedures ranging form complex therapies such as intensive care unit transfer, to simpler interventions, such as blood transfusions. These decisions should not be based on the DNR order alone." (This study can be found in the Journal of the American Geriatrics Society 2002:50)

Death Angels
It is no coincidence that in recent years in the US that a culture of death has been prevalent among certain health professionals. Dubbed "Death Angels" premeditated killers cover their crimes in the guise of 'doing them a favour'. They seek out the elderly and infirm to 'end their suffering'.

"In September 2000, in Uniondale, New York, former physician Michael Swango pleaded guilty to killing three patients at a Long Island Veterans hospital with injections that stopped their hearts. Before allegedly killing his victims, he had placed Do Not Resuscitate (DNR) orders on their medical charts to prevent medical personnel from performing CPR. Swango received a life sentence." (5)
Waving DNR orders under the noses of vulnerable patients is a requirement of many hospital administrative bodies these days.



The Right to Live
The quiet persuasion of the medical profession is pervasive in this area, waving DNR orders under the noses of vulnerable patients is a requirement of many hospital administrative bodies these days.

There seems to be a trend in bioethics today whereby the 'lesser quality of life' experienced by the elderly, infirm and disabled makes them of less moral value in society. That their deaths are not counted in the same way as a 'normal' person.

But the AMA makes it quite clear in the statement on policy that the patient has every right to live if they so choose.

"The physician has an ethical obligation to honour the resuscitation preferences expressed by the patient. Physicians should not permit their personal value judgements about quality of life to obstruct the implementation of a patient's preferences regarding the use of CPR." (6)
"Age Concern will not rest until the 'writing off' of patients lives on the basis of their age has been stamped out."



Gordon Lishman, Britain's Age Concern's director general states: "Age Concern will not rest until the 'writing off' of patients lives on the basis of their age has been stamped out." (7)

Two Case Studies
"Joe Ehman, a news reporter in Rochester, N.Y., who uses a wheelchair, told me he was 'literally hounded by social workers' to sign a DNR when he was hospitalised in 1995 for back surgery. 'A few hours after surgery, still delirious from the anaesthesia and from postsurgical morphine and Demerol, I had to hear from yet another social worker who wanted to force-feed me a DNR. I mustered all my strength and screamed, I'm 30 years old. I don't want to die.'" (8)
'When I wouldn't sign it [a DNR order], they said it didn't matter anyway. Because I use a ventilator, they told me nothing would be done if I had a cardiac arrest.'



"Maria Matzik, a woman in her thirties who lives and works in Dayton, Ohio, says she had a frightening battle with nurses during a 1993 hospital stay. 'They kept asking me to sign a DNR order,' she told me. 'When I wouldn't sign it, they said it didn't matter anyway. Because I use a ventilator, they told me nothing would be done if I had a cardiac arrest.' Matzik escaped that fate, but others have not." (9)


Who Makes the Decision
In theory in the US it is the patient, in consultation with a physician who makes the decision about whether or not to fill out a DNR order.

In practice however this is not always the case according to E.J. Kemp a writer for The Washington Post. He claims some disabled people reporting instances in which hospitals have pressurised patients into signing a DNR order. Those most likely to be pressured are those with disabilities, the uninsured and the severely ill.
The wording of medical documents is not for the benefit of the patient. It is to cover the legality of the procedure and therefore a person can become confused about what it is.



This can happen because of a number of different factors. The wording of medical documents is not for the benefit of the patient. It is to cover the legality of the procedure and therefore a person can become confused about what it is. They can then sign this document without being fully aware of what it entails.

A doctor, although being required to discuss the order with the patient is not given guidelines on how to discuss it and may confound the patient with medical jargon.

A DNR order is supposed to be voluntary and according to Kemp this is something patients and their families are often unaware of. He claims also that DNR orders are often included in a pile of routine papers to be signed by an individual when entering a hospital.

All of the above factors do not lead the patient toward giving their 'informed consent' and could instead be reflective of the current trend in medicine to cut costs in line with hospital policies.
It is convenient for health insurance providers and others concerned with the 'business' of health care to use right-to-die arguments as a basis for cost-cutting administrative decisions.



Money Speaks Loudly
Unfortunately we live in a society where money matters, in some cases to the exclusion of other more important matters. In the US health care is a major expense and the families of those who do not have private health care are not able to withstand hospital bureaucracy when it comes to providing expensive treatment for loved ones.

It is convenient for health insurance providers and others concerned with the 'business' of health care to use right-to-die arguments as a basis for cost-cutting administrative decisions.

Federal Judge Stephen Reinhardt puts it this way in the case of Glucksberg v. State of Washington decision:
"...in a society in which the costs of protracted health care can be so exorbitant, we are reluctant to say that is improper for competent, terminally ill adults to take the economic welfare of their families and loved ones into consideration." (10)
A  hospital ethics committee ruled that [Marjorie Nightbert] was 'not medically competent to ask for such a treatment [i.e. food and water].' Until her death more than 10 days later, Nighbert was restrained in her bed to prevent her from raiding patients' food trays."


Battle Lost
"Marjorie Nighbert, a 76-year-old Florida woman, was hospitalised in 1996 after a stoke. Before her hospital admission, she signed an advance directive that no "heroic measures" (that is CPR) should be employed to save her life.

On the basis of that directive and at the request of her family, the hospital denied Highbert's requests for food and water, according to reports in the Northwest Florida Daily News. A hurriedly convened hospital ethics committee ruled that she was 'not medically competent to ask for such a treatment.' Until her death more than 10 days later, Nighbert was restrained in her bed to prevent her from raiding patients' food trays." (11)

A New Definition of Death
Dr Marcia Angell, executive editor of New England Journal of Medicine has a radical approach to end-of-life care, she believes patients diagnosed as permanently unconscious should be refused treatment so 'demoralised' caregivers would not be forced to give care they believe is useless.

Her suggestion is to change the definition of 'death' to include a diagnosis of permanent unconsciousness. Prior to this she supports placing a mandatory time limit on providing treatment, after which time care would be withdrawn.

She would also introduce means whereby families would be forced to prove in court that their loved one would want such care before treatment could take place. This would turn the law around in that the family would have to present a case for life to continue. (12)

Case Study - New York
"In 1999-2000 New York Legislative session, AB 4114 was introduced which would permit doctors to refuse to render treatment that is against their religious beliefs or "sincerely held moral convictions." In the past, such language has generally been applied in cases where a physician or nurse doesn't wish to be involved in an abortion or some other controversial procedure.

But with the coming of Futile Care Theory it would not apply to situation where the physician doesn't wish to treat a dying or significantly disabled person.

A surrogate could authorise the DNR order, keeping the patient in the dark.

AB 4114 was astonishingly radical. The legislation would permit 'do not resuscitate" (DNR) orders to be placed on a competent patient's chart - without consulting the patient - if the attending physician determines, to reasonable degree of medical certainty, that the patient would suffer immediate and severe injury from a discussion of cardiopulmonary resuscitation. NY Assembly Bill 4114, 8 Feb 1999.

In that event, a surrogate could authorise the DNR order, keeping the patient in the dark. The legislation would also have authorised hospital ethics committees to "review and approve or disapprove recommendation to withhold or withdraw particular treatments or recommendations about a patient's course of treatment. Moreover, the power would be exercised in utter secrecy, even against court or government regulatory agency subpoenas." (13)

References
(1) Dunedin Hospital - Patient Information Handbook
(2) World Federation of Right to Die Societies: Webpage FAQs
(3) Ibid.
(4) New Guidelines for Reviving Patients. BBC News. 28 Feb 2001. www.bbc.co.uk
(5) Smith, W.J. The Culture of Death Angels. www. euthanasia.com
(6)AMA paper on Professionalism E-2.22 Do Not Resuscitate Orders.
(7) New Guidelines for Reviving Patients. BBC News. 28 Feb 2001. www.bbc.co.uk
(8)Kemp, E.J. Article on Assisted Suicide - The Washington Post
Jan 5 1997; page C01
(9) Ibid.
(10)Kemp, E.J. Article on Assisted Suicide - The Washington Post
Jan 5 1997; page C01
(11)Kemp, E.J. Article on Assisted Suicide - The Washington Post
Jan 5 1997; page C01
(12)Angell, Marcia, "After Quinlan: The Dilemma of the Vegetative State," New England Journal of Medicine 330 (May 1994) p 1524
(13) From Smith, W.J. Culture of Death - The Assault on Medical Ethics in America.2000 -Encounter Books New York