PROBLEMS
WITH
DO-NOT-RESUSCITATE ORDERS (DNR)
WHICH
WILL BE SOLVED BY ELMO
(End-of-Life
Medical Orders)
SYNOPSIS:
Do-Not-Resuscitate orders are widely misunderstood
both by laypersons and even by some medical professionals.
Therefore, simple DNR orders should be replaced
by more comprehensive End-of-Life Medical Orders (ELMO).
DNR orders originally emerged for in-hospital
medical care.
Because the 'crash-cart' was always ready to go to any room
for the purpose of bringing the patient back from the brink of
death,
hospital policies had to be developed for deciding
when to send the
resuscitation team
and when
not to attempt resuscitation.
Repeated medical studies have determined that only a
small percentage
of patients can be save from death by cardio-pulmonary resuscitation.
CPR works much more often on
television than in
real hospital beds.
OUTLINE:
1.
BLANKET DNR ORDERS COULD LEAD TO PREMATURE DEATH.
2.
DOCTORS DO NOT TATTOO THEIR MEDICAL ORDERS ON THEIR PATIENTS:
THE DIFFERENCE BETWEEN DNR
PREFERENCE AND DNR
ORDERS.
3. INFORMED REFUSAL OF MEDICAL TREATMENTS.
4.
DNR ORDERS ARE ALWAYS SUSPENDED FOR SURGERY AND RECOVERY.
5.
DNR ORDERS DO NOT MEAN DO
NOT TREAT OR ALLOW TO
DIE.
6. SOMETIMES DNR ORDERS ARE ISSUED BY DOCTORS
WITHOUT PATIENT CONSENT.
RESULT:
Can this chapter change the minds of most readers?
Do most readers want blanket DNR status?
Because of bad things they know about resuscitations,
they want never to be
subjected to such treatment.
Do most readers want DNR tattoos or bracelets
so that they will never be given resuscitation?
Can an advance refusal of all medical care ever be
rational?
Do most readers believe that DNR applies even during
surgery?
How many people (both lay and professional) believe
Do-Not-Resuscitate means the same thing as Do-Not-Treat?
Who authorizes DNR?
PROBLEMS
WITH DNR ORDERS
by
James Leonard Park
1. BLANKET DNR ORDERS COULD
LEAD TO PREMATURE DEATH.
When patients
think about DNR orders,
they usually think of AT
HOME DNR orders
or outside-the-hospical medical plans.
They want to explain ahead of time
whether they want to be taken to a hospital,
whether they want to have tubes inserted into their bodies,
whether they want to be put on a respirator, receive drugs, etc.
And usually when asked in the abstract,
they want to reject
all such medical attention.
However, rejecting all medical care in advance
might lead to deaths that could have been prevented very easily:
If they start to bleed uncontrollably,
they will probably not embrace such an accident as an opportunity to
die.
Rather, they will call the Emergency Medical Team
to come and stop their bleeding
and restore them to whatever level of health they had
just before the accident or internal event that started the bleeding.
Likewise, if they are diabetic
and they fall into a coma because of low blood sugar,
they do not think that nothing
should be done.
Rather, they know that just sucking a piece of candy
will restore them to their previous health.
And if they are already unconscious,
they want the Emergency Medical Team
to give them the needed sugar by means of an injection
and/or tubes that will restore them to health.
Any heart could be stopped by an accidental
electric shock.
If an electrical accident happens to a patient in a
hospital bed,
everyone would hope and expect that the nurses and doctors
would do everything to re-start that heart.
Drowning and freezing are two other ways that anyone
might die.
But if normal life can be restored by artificial respiration or warming
the body,
then almost everyone wants to be saved from drowning or
freezing to death.
When prospective patients reject all forms of
life-support and medical aid,
they are usually not giving
informed consent,
since they did not consider any of the situations like those named
above,
in which all rational people (who were not already actively dying)
would want to be saved from the unexpected accident.
And this is the actual policy in modern medical care:
Even if there is some kind of DNR order on the patient's record,
if there is a sudden accident
that can be quickly corrected,
the life-saving actions will be applied immediately.
And almost always the patient is happy to have been revived.
We can avoid such unintended negative consequences
of the advance rejection of medical care
by specifying which causes
of death should not be resisted.
If the patient is known to have a weak heart,
which will not survive another heart-attack,
then the End-of-Life Medical Orders
could specify that if this patient begins to die from heart-problems,
then no further attempts
will be made to restore that heart-beat.
Everything has already been tried to save this patient
from his or her well-understood heart-problems.
Thus, cardio-pulmonary resuscitation would be useless.
Likewise, if this patient is dying from a known
lung-disease,
then the doctor and the patient could agree
that no further breathing-support will be applied
if and when the patient's normal breathing gives out.
The ELMO lists the most likely causes of this
patient's death.
And these causes of death can be allowed to run their natural course
---if the terminal-care doctor and the patient so agree in
advance.
They will discuss each possible pathway towards death.
And they will put into writing just what will happen
when the cancer (for example) progresses to a certain stage.
And because the ELMO acknowledges that this patient
is likely to die within the next 12 months,
no elaborate life-saving surgeries will be
attempted.
No joints will be replaced.
The doctor and patient might even decide not to treat serious
infections.
Rather, the patient will be made as comfortable as possible
while the expected process of dying unfolds.
2.
DOCTORS DO NOT TATTOO
THEIR MEDICAL ORDERS ON THEIR
PATIENTS:
THE DIFFERENCE BETWEEN DNR
PREFERENCE
AND DNR
ORDERS.
Many prospective patients believe
that they already have
Do-Not-Resuscitate status
if they say something about refusing Cardio-Pulmonary Resuscitation
in their Advance Directives for Medical Care or similar
documents.
Some feel so strongly against ever being resuscitated
that they go to the trouble of getting "Do Not Resuscitate"
tattooed across their chests.
But a tattoo does not
guarantee that they will not be
resuscitated.
Yes, all patients do have a right to refuse any
medical care,
but only competent refusals
should be honored.
If the patient is unconscious or drunk,
then whatever their prior views about medical care might have been,
they will be given emergency medical care
until the full situation can be clarified.
A Do-Not-Resuscitate PREFERENCE for a particular
patient
can be affirmed in
an Advance Directive for Medical Care.
And it will be honored to whatever extent seems reasonable
in any given situation in which it might apply.
This assumes that the Advance Directive for Medical Care
was created when the patient was fully able to make medical
decisions.
The witnesses to the Advance Directive are supposed to affirm
that to the best of their knowledge, the creator of the Advance
Directive
was of sound mind and making rational decisions
when the Advance Directive was composed and when it was signed.
But a Do-Not-Resuscitate ORDER must be created by a licensed
physician.
And this physician will want to know the reasons for refusing
resuscitation
as completely as possible before he or she will agree to this medical
order.
In some states, laws have been created that allow
bracelets to be created
for patients who have official
medical orders refusing resuscitation.
But this is the closest doctors will ever get to putting their medical
orders
on the actual bodies of their patients.
Thus, we know whenever we see a DNR tattoo
that this was not created by
a doctor.
Patients who definitely want to refuse resuscitation
will have to apply for a medical
order to that effect from their own doctors.
And the discussion of the reasons
for this medical order
will assure that it is an informed decision,
not just a strong fear of
medical treatments of all kinds.
When a patient and his or her terminal-care doctor
create together the End-of-Life Medical Orders,
this might include a prior agreement
not to use Cardio-Pulmonary Resuscitation (CPR)—ever.
And the ELMO would explain the reasons for this choice.
For example, if the patient is drying of cancer,
CPR would be completely useless,
since being brought back to life by the crash-team
would do nothing to cure the
cause of death: cancer.
Each new doctor who might be responsible for this
patient
has a right (and a responsibility) to review the patient's
resuscitation status.
Perhaps the new doctor does not believe
that the reasons for the earlier DNR order still apply to this patient.
If the reasons for refusing resuscitation are still valid,
then the new doctor will create a new Do-Not-Resuscitate order,
which will supersede the earlier one, since it will have a more recent
date.
And this re-affirmation will make the case for DNR even stronger:
More than one doctor issued
medical orders to avoid resuscitation.
3. INFORMED REFUSAL OF
MEDICAL TREATMENTS.
One of the most common misunderstandings of DNR
relates to the preferences explored above:
Some people have decided in advance
that they do not want any
further medical treatments.
Such persons who refuse to become patients
are not thinking
about whether or not to call the 'crash cart'
if they have another heart-attach while in a hospital bed.
Rather, they are thinking almost exclusively of at-home situations
or other situations at work
or on the street.
These are the people who think about getting a DNR tattoo,
as discussed in just above.
Under all systems of modern medical care,
the patients (or potential patients) always have the right to refuse
any and all medical treatments offered or available.
Patients should not be given
medical care without their consent.
What about advance
refusal of medical
treatments?
Should future possible patients have the right (and the methods)
to refuse some medical interventions they do not want?
The most common treatments not wanted include:
cardio-pulmonary resuscitation, intubation, & hospitalization.
(And these can be refused using a POLST.)
In contrast to a DNR medical order,
which is always a formal document issued by a licensed physician,
the informed refusal of medical treatments
is a decision that can be
made by the (potential) patient alone.
In fact, usually this rejection of future medical care
will be against medical
advice (AMA).
If a doctor is involved at all,
he or she might record any such decision
as being chosen by the
patient
in contradiction of explicit
recommendations from the doctor.
Such rejection of medical treatments becomes an informed decision
when it is clear that the patient has considered the pros and cons
of any specific medical intervention that has been offered.
For example, the doctor might have recommended a specific surgery
in order to deal with a medical problem of the patient.
All the benefits and burdens have been explained to the patient,
but after due consideration, the patient chooses some alternative,
such as coping with the problem using some less-drastic solution.
Or the patient might rationally decide to accept death
rather than having another surgery with a small chance of success.
Quite frequently, however, the blanket rejection
of all future medical care is an irrational decision,
based on incomplete information and/or groundless fears.
Especially in emergency situations, medical
treatments will be given.
Detailed questions will be asked and answered later.
The immediate fears of the potential patient
will be overridden by the emergency medical personnel
in the best interests of the patient.
A good set of End-of-Life Medical Orders will
resolve such problems:
The most likely causes of this patient's coming death are detailed.
The desired pathway towards death has been selected
—with
details about the best medical methods of managing
dying.
And in this full context of medical facts and recorded prior decisions,
it becomes clear just what
medical treatments would be appropriate.
The heart-patient
has been evaluated for a
heart-transplant.
If that form of treatment will not work in this patient,
then the patient might decide in advance
to do nothing when the next heart-failure or heart-attach occurs.
Likewise the patient who is dying of lung cancer
might approve medical orders rejecting further breathing support
if and when the failing lungs can no longer absorb enough oxygen.
For each kind of organ-failure, there are possible
interventions.
The terminal-care doctor and the specific patient
have discussed the most likely pathway towards death.
And they have agreed about possible forms of medical care.
When so explained, such rejections of specific medical interventions
become informed refusals
—in
contrast to blanket rejection of all doctors and all hospitals.
An informed
refusal of a specific medical treatment
emerges when both the patient and the doctor
can agree that the patient understands the pros and cons
of the proposed medical intervention.
And the patient has rationally decided to reject that form
of
care.
4. DNR ORDERS ARE ALWAYS
SUSPENDED
FOR SURGERY AND RECOVERY.
When prospective patients agree to
Do-Not-Resuscitate orders,
they often are not aware that DNR
will not apply in the operating
room.
If this patient has agreed to undergo any
form of
medical care
that includes tubes and machines,
then any prohibitions of tubes and machines in the DNR order
will not apply for the
duration of the surgery
and any reasonable recovery period after the surgery.
Blanket prohibition of "tubes and machines"
will mean that the surgeon will not operate.
No surgeon should be told in advance what tools to use
and what medical methods to avoid.
And if the patient's heart stops during surgery,
every effort will be made to re-start it,
even if there is a standing DNR order
saying that no cardiac resuscitation should be attempted.
When the patient and/or the proxies authorize any
surgery,
they are agreeing to all of
the standard operating procedures
of the surgical department and the surgeon they employ.
Rigid application of rejection of medical supports and
care
should result in no
surgeries being attempted.
And if this patient is definitely dying
no matter what happens on the operating table,
probably this surgery should not have been proposed at all.
End-of-Life Medical Orders could specify
just what kinds of medical care this patient and this doctor
are agreeing (in advance) to use or to omit.
Which possible surgeries (if any) should be considered?
And when specific medical treatments are authorized,
this contemporary written authorization for medical care
supersedes any prior blanket
rejection of medical treatments.
5. DNR ORDERS DO NOT MEAN DO
NOT TREAT OR ALLOW TO
DIE.
Surprisingly, sometimes nurses and doctors do
not understand DNR.
Because most Do-Not-Resuscitate orders are written for dying patients,
medical personnel might assume that every patient with a DNR
is on the downward pathway towards death.
Thus, everyone on the medical staff might assume
that DNR also includes no antibiotics to treat infections,
no consultations for newly-discovered medical problems,
no more physical therapy, etc.
But when correctly applied, Do-Not-Resusciate orders
only say that this patient should not be brought back to life
if a life-threatening event
like another heart-attack happens.
However, if there is no new heart-attack
(perhaps because of medical care to prevent future heart-attacks),
this patient can be saved from dying at least for this year.
And all other forms of medical care should be continued
with the honest expectation
of full recovery.
Many patients with DNR orders do
survive their hospital treatment.
And they are released from the hospital
once they are able to live on their own once again.
Some hospitals, however, use DNR orders as a way to classify patients:
Patients with DNR orders are given less medical care
because the medical staff has been told they are expected to die.
The staff might even say among themselves
that this patient should be allowed
to die.
However, Allow
Natural Death (AND)
is a completely
different medical order.
AND actually does say
that this patient is
expected to die
during this, the final hospitalization.
Then, the medical orders might be to
provide comfort-care only.
All of the medical treatments aimed at curing the patient
have now been suspended or withheld.
Pain and other distressing symptoms will be controlled.
But no CPR will be applied when the patient dies.
This dying patient has correctly been put into a new classification:
Do not treat the disease; do not operate;
do no rehabilitate; do not resuscitate; allow to die.
End-of-Life Medical Orders provide complete
opportunities
to discuss and decide upon all such end-of-life medical
options.
This doctor and this patient are agreeing:
Which medical problems should be treated?
Which kinds of resuscitation (if any) will be attempted?
Which expected declines towards death will not be resisted?
Which methods of managing
dying
would be best for this patient?
6. SOMETIMES DNR ORDERS ARE
ISSUED BY DOCTORS
WITHOUT PATIENT CONSENT.
Do-Not-Resuscitate decisions were originally a
secret within the
hospital:
The doctor would decide that a certain patient should not be
resuscitated.
He would issue secret orders
to that effect,
which only the staff members of the hospital would know about.
But in modern medical practice, the patient and/or
the family
is definitely supposed to be involved in the decision about
resuscitation.
The patient or the proxy is asked to give informed consent
to the decision not be call the 'crash-cart' if this patient begins to
die.
The next heart-attack, stroke, or other organ-system failure
will be allowed to follow its normal course,
probably resulting in the patient's death.
However, sometimes doctors are still found
to be issuing DNR orders
without first consulting the
patient or the family.
The family might discover this DNR order only after the patient has
died:
What the doctor expected did happen.
And no further attempts were made to save the patient from death.
Without attempts at resuscitation, the patient died.
This might come as a complete surprise to the family
because none of them was consulted about
resuscitation.
End-of-Life Medical Orders signed by both the doctor
and the patient
would make such unplanned pathways towards death impossible.
The doctor would explain the likely causes of death,
with the possible ways of responding to each medical crisis.
And if it seemed wise, this doctor and this patient would agree
that specific kinds of
resuscitation would not be used for this
patient.
AUTHOR:
James Leonard Park advocates patients controlling
their medical care.
Medical
Ethics and Death & the Right-to-Die
are two of the ten sections of his personal website.
He does not have any Do-Not-Resuscitate orders in effect.
He does have a comprehensive Advance
Directive
for Medical Care.
His largest book is: How
to Die:
Safeguards for Life-Ending Decisions.
Created
June 4, 2015; Revised 6-8-2015; 6-22-2015; 10-2-2015; 10-7-2015;
6-2-2016; 6-13-2016; 12-20-2016; 10-31-2017; 11-27-2018; 12-27-2019;
Did this discussion of DNR change
your thinking?
Before you started to read,
did you think that you wanted a blanket DNR order?
Do you now think that certain medical interventions might be
wise?
Did you know that approving surgery suspends a DNR?
Would it be better to specify which
causes of death
should be allowed to run their course?
Do you now prefer a more comprehensive end-of-life plan?