End of Life Issues: Do Not Resuscitate Order

Do Not Resuscitate (DNR) order serves as an advance directive that prevents life saving interventions, particularly Cardiopulmonary Resuscitation (CPR), upon client request. According to Morton, Hudak and Fontaine (2004 ), DNR orders are generally being administered to terminal patients with accompanying approval signed by the client or agents (if inept clients) (p. 95). Once the DNR order has actually been made and signed in a composed file, the health center policies may or might not perform evaluation within 24 to 72 hours.

According to Morton, Hudak and Fontaine (2004 ), evaluation is being carried out in order to avoid possible errors or inconsistencies with regards to the patient or representative's condition (95 ).

DNR order is generally requested by the surrogate/ patient who may or might not yet remain in terminal phase of illness, or being advised by health care service provider when no treatment is possible or the condition of the client is irreversible.

According to Orenstein and Stern (1997 ), DNR order breaches numerous ethical concepts, such as (1) beneficence or offering the utmost great for the patient, (2) violates the basic purpose of healthcare- to save lives, and (3) value of life and capacity for survival (p.

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363). The designed function of healthcare is to provide care, to initiate proper life-saving interventions, and to tire every possible resource or intervention that can save an individual's life (Fink, 2004 p.

230). Considering the actual systems for achieving DNR orders, patient or surrogate can totally ask for this under their will and personal judgment; although, some organizations review this request, the right of the client's autonomy enhances the application of the order, which ultimately breaches the standard concept of healthcare (Lo, 2005 p.

121). Despite of the common use of DNR order, issues exist within the application and implementation of this policy.

These problems include (1) inappropriate decision making of most patients requesting DNR, (2) essentially limits the possibility of life saving interventions or further alleviations of the condition, (3) impairs the effectiveness and efficiency of surgical operations if required, (4) increased incidence of death among DNR patients regardless of death potentials, and (5) increased health costs due to longer hospital stays, palliative interventions and dying within hospital premises. Discussion

Even without the confirmation of irreversible condition or actual evidence that no health care options exist, the patient is given the opportunity to impose DNR orders by request, which eventually becomes abusive in nature and essentially defies the purpose of health care (Orenstein and Stern, 1997 p. 363). To justify the first cited problem of DNR (i. e. problematic patient-decision making for DNR request), According to Watcher, Goldman and Hollander (2005), most patients who ultimately receive DNR orders are competent at the time of admission, but not competent (e.

g. experiencing deficits in coherence, under confusion, experiencing severe pain, etc. ) when the DNR order is finally written (p. 123). In the study of Haidet, Hamel and Davis et al. (1998), even with physician or parental discussion of DNR end-of-life care, patients with colorectal cancer have based their decisions mainly on personal intuitions of suffering and pain without the consideration of potential life saving treatment of their condition (63%; n=212 of 339 respondents).

From these statements, patients/ surrogate decision-makers most commonly base the decisions of their end-of-life care due to the pain and experienced suffering regardless of possible medical interventions available or stage of illness. For the second argument (limits the possibility of life saving interventions), according to the study of Beach and Morrison (2002), the presence of a DNR order affects the physicians' initiatives and judgment on whether or not to request a variety of treatments not related to CPR.

In the study, physicians absolutely agreed to initiate lesser interventions for patient’s with DNR order than patients who do not have (First test: 4. 2 vs. 5. 0, P =. 008; Second test: 6. 5 vs. 7. 1, P =. 004; Third Test: 5. 7 vs. 6. 2, P =. 037). In conjunction to the next argument (impairs the effectiveness and efficiency of surgical operations), DNR orders cultivates reluctance of physicians in providing surgical or invasive procedures.

According to Watcher, Goldman and Hollander (2005), general anesthesia, conscious sedation and invasive strategies can greatly precipitate the need for formal resuscitation. If DNR order is present, surgical operation can be very difficult and risky considering the limitations placed on resuscitative interventions (p. 123). Considering such case, DNR patients who insist of acquiring surgery (e. g. surgical operations for bowel obstructions, pain relief, etc.

) are facing critically at-risked operations. Considering the fourth problem of DNR patients (increased incidence of death among DNR patients), in the study of Shepardson, Youngner and Speroff (1999) with the population size of 13,337 consecutive stroke admissions with 22% (n=2898) DNR patients in 30 hospitals between 1991 to 1994, unadjusted in-hospital mortality rates are higher in patients with DNR orders than in patients without orders (40% vs.

2%, P < 0. 001). Meanwhile, the results of the analysis with adjusted odds of death show 33. 9 (95% CI, 27. 4-42. 0). In conclusion, risk of death is evidently higher among those patients with DNR orders even after adjusting the odds of death. Evidently, DNR orders restrict potential life-saving interventions as well as palliative surgical procedures that can further alleviate the suffering and pain of the patient in the most appropriate means.

As for the final argument of the paper (increased health costs of DNR patients compared to those without), according to the study of Maksoud, Jahnigen and Skibinsski (1993), patients dying under DNR orders greatly increase the health care costs due to (1) longer periods of hospital stay, (2) actual death within the hospital and (3) palliative measures being done to alleviate or at least minimize the pain and suffering of the patient throughout the process.

According to the study, average charges for each patient who died were $61,215 with $10,631 for those admitted with a DNR order, and $73,055 for those who had a DNR order made in hospital (Maksoud, Jahnigen and Skibinsski, 1993).

References

Beach, M. C. , & Morrison, R. S. (2002, December). The effect of do-not-resuscitate orders on physician decision-making. Journal of American Geriatric Society, 50, 2057-2061. Fink, A. (2004). Evaluation Fundamentals: Insights Into the Outcomes, Effectiveness, and Quality of Health Programs.

London, New York: SAGE Publishing. Haidet, P. , Hamel, M. B. , & Davis et al. , R. B. (1998, September). Outcomes, preferences for resuscitation, and physician-patient communication among patients with metastatic colorectal cancer. Journal of American Medicine, 105, 222-229. Maksoud, A. , Jahnigen, W. , & Skibinski , C. I. (1993, May). Do not resuscitate orders and the cost of death. Archives of Internal Medicine, 153, 1249-1253. Morton, P. , Hudak, C. M. , & Fontaine, D. (2004). Critical Care Nursing: A Holistic Approach.

New York, U. S. A: Lippincott Williams & Wilkins. Orenstein, D. M. , & Stern, R. C. (1997). Treatment of the Hospitalized Cystic Fibrosis Patient. New York, U. S. A: Informa Health Care. Shepardson, L. B. , Youngner, S. J. , & Speroff, T. (1999, August). Increased Risk of Death in Patients With Do-Not-Resuscitate Orders. Journal of Medical Care Section, 37, 727-737. Wachter, R. M. , Goldman, L. , & Hollander, H. (2005). Hospital Medicine. New York, U. S. A: Lippincott Williams & Wilkins.