Ethical complications of DNRs


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Presentation by Neil Pickering at "Making Sense of Death and Dying" Conference, 20th April, 2011, Wellington, NZ.

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  • While we may doubt whether these reveal what would actually happen (the results were based on written cases, and nurses’/doctors’ responses to these) the results are perhaps worrying. We may also doubt what the ethical meaning of them is; do they represent some untoward form of discrimination? We may also doubt what the reason for these results is, and so how, or whether, they can be fixed.
  • Media portrayals of CPR seem to me to support this: very often the arrest is an additional problem on top of whatever the team are trying to do – if it can be dealt with, then the outcome for the patient is otherwise unaffected – CPR succeeds completely
  • Ethical complications of DNRs

    1. 1. Ethical complications of DNR orders Making sense of death and dying Wellington, April 2011 Neil Pickering, Bioethics Centre, University of Otago
    2. 2. Introduction <ul><li>A first complication – unintended consequences of DNR orders for patient care </li></ul><ul><li>Analysing the complication – the autonomy-choice ideal </li></ul><ul><li>Making the ideal actual </li></ul><ul><ul><li>What actually seems to happen when the autonomy choice ideal is applied </li></ul></ul><ul><ul><ul><li>Some sociological evidence </li></ul></ul></ul><ul><li>Second complication: the meaning of the autonomy-choice ideal </li></ul><ul><li>Should we abandon the autonomy-choice ideal? </li></ul>
    3. 3. A first complication: unintended impacts of DNR orders <ul><li>On health carers’ perception of appropriate care and decision making </li></ul><ul><li>‘ Compared with the patient without a DNR order, significantly lower levels of agreement were expressed with interventions involving monitoring for the patient with the DNR order. Agreement with placement of the patient with the DNR order in an intensive care unit may be seen to follow the same pattern’ </li></ul><ul><ul><ul><li>Sherman and Branum, 1995, Critical care nurses perceptions of appropriate care of the patient with orders not to resuscitate. Heart and Lung 24:4, p.321 </li></ul></ul></ul>
    4. 4. A first complication: unintended impacts of DNR orders <ul><li>On health carers’ perception of appropriate care and decision making </li></ul><ul><li>‘ The presence of a DNR order may affect physicians’ willingness to order a variety of treatments not related to CPR’ ‘Based solely on the presence of a DNR order, physicians are less likely to agree to initiate procedures ranging from complex therapies, such as ICU transfer, to simpler interventions, such as blood transfusions …’ </li></ul><ul><ul><ul><li>Beach and Morrison, 2002, The effect of do-not-resuscitate orders on physician decision making. J. Am Geriatr Soc 50, p.2057 </li></ul></ul></ul>
    5. 5. Analysing the complication: The autonomy-choice ideal <ul><li>A framework for ethical analysis </li></ul><ul><ul><li>CPR should be the default good we offer all: it represents a medical option all should have access to </li></ul></ul><ul><ul><li>A DNR order should reflect a patient’s refusal of resuscitation in pursuit of their own understanding of ‘the good’ </li></ul></ul><ul><ul><ul><li>J.S.Mill: pursuit of each their own conception of happiness </li></ul></ul></ul>
    6. 6. Analysing the complication: The autonomy-choice ideal <ul><li>“ Respect for autonomy requires that we acknowledge the patient’s right to make a choice based upon personal values and beliefs … To place the fundamental power for a CPR decision in the hands of physicians will result in medical paternalism with respect to this decision” </li></ul><ul><ul><ul><li>Feen, E. 2010. Leave Current System of Universal CPR and Patient Request of DNR Orders in Place. AJOB 10:1, p.80 </li></ul></ul></ul>
    7. 7. Analysing the complication: The autonomy-choice ideal <ul><li>Anything other than patient chosen DNR represents unacceptable medical paternalism </li></ul><ul><li>Paternalism: </li></ul><ul><ul><ul><li>“ The actual medical indication for CPR is cardiopulmonary arrest” (Feen p.80) </li></ul></ul></ul><ul><ul><ul><li>To fail to act upon a medical indication, is clearly to have some agenda other than the medical for doing so </li></ul></ul></ul><ul><li>Unacceptable </li></ul><ul><ul><ul><li>‘ hard’ paternalism </li></ul></ul></ul><ul><ul><ul><li>Patient’s view of own best interests presumed to lie in implicit choice for CPR (absent a patient chosen DNR) </li></ul></ul></ul>
    8. 8. Analysing the complication: The autonomy-choice ideal <ul><li>Apparent danger that professional health carers will treat/investigate those with DNRs less than those without </li></ul><ul><ul><li>Patients with DNR orders miss out on treatments/investigations (including some which might have prevented an arrest) </li></ul></ul><ul><ul><li>DNR orders taken to represent the placing of a lower value on the patient’s life </li></ul></ul><ul><ul><li>DNR orders associated with low value lives </li></ul></ul><ul><ul><li>Danger of DNR orders being applied to low value lives </li></ul></ul><ul><ul><li>Health professionals’ valuation of lives not medically relevant </li></ul></ul><ul><ul><li>Hence, the autonomy-choice ideal should be adhered to </li></ul></ul>
    9. 9. Making the ideal actual <ul><li>CPR when medically indicated </li></ul><ul><ul><li>‘ Legislators made it obligatory for health care providers to initiate cardiopulmonary resuscitation (CPR) in all instances in which it is medically indicated’ </li></ul></ul><ul><li>Patient choice for DNRs </li></ul><ul><ul><li>‘ ethicists and legislators have tried to boost and protect patient autonomy … When patients have decided that they do not want to be resuscitated, the staff should follow the written direction regardless of the patient’s social value’ </li></ul></ul><ul><ul><ul><li>Timmermans, S. 1998 Social death as self-fulfilling prophecy: David Sudnow’s Passing On revisited. Sociological Quarterly 39:3, p.454, p.455 </li></ul></ul></ul><ul><li>The observed reality </li></ul><ul><ul><li>‘ In the liminal space between lives worth living and proper deaths, resuscitative efforts in the ED crystallize submerged subtle attitudes of the wider society. The ED staff enforces and perpetuates our refusal to let go of life and to accommodate certain groups.’ </li></ul></ul><ul><ul><ul><li>Timmermans p.468 </li></ul></ul></ul>
    10. 10. Making the ideal actual <ul><li>Our ‘refusal to let go of life’ </li></ul><ul><ul><li>‘ like so many other structures in medicine, the practice of in-hospital universal CPR is a product of its historical time, when medicine’s technological optimism was ensconced in its policy structures; it is a holdover of a time when medicine had an implicit quest for immortality … Historically the DNR order was an attempt to keep medicine from its implicit quest for immortality. The refusal of a DNR order by a patient continues to operate under the patient choice model – a model that perpetuates the falsehood that all deaths can be prevented and creates the odd and false illusion that all deaths should be prevented’ </li></ul></ul><ul><ul><ul><li>Bishop et al 2010 Reviving the conversation around CPR/DNR. AJOB 10:1 p.65 </li></ul></ul></ul><ul><ul><li>‘ By engaging and investing in resuscitative efforts, we as a society facilitate the idea that mortality can be deconstructed’ </li></ul></ul><ul><ul><ul><li>Timmermans p.468 </li></ul></ul></ul>
    11. 11. Making the ideal actual <ul><li>Our ‘refusal … to accommodate certain groups’ </li></ul><ul><li>‘ Unfortunately, the attitudes of the emergency staff reflect and perpetuate those of society generally not equipped culturally or structurally to accept the elderly or people with disabilities as people whose lives are valued and valuable’ </li></ul><ul><ul><ul><ul><li>Timmermans, S. 1998 Social death as self-fulfilling prophecy: David Sudnow’s Passing On revisited. Sociological Quarterly 39:3, p.467 </li></ul></ul></ul></ul><ul><ul><ul><ul><li>But see Davey, B. 2010. Do-not-resuscitate decisions: Too many, too few, too late? Mortality 6:3 pp.247-264 </li></ul></ul></ul></ul><ul><ul><li>The idea of ‘social death’: this is a death which is not identical with either legal death, or biological death </li></ul></ul><ul><ul><li>Social death a predictor of biological death </li></ul></ul><ul><ul><li>Social death is unjustly distributed </li></ul></ul><ul><ul><ul><li>The old, the disabled </li></ul></ul></ul><ul><ul><li>Having a DNR, in so far as it predicts lesser interventions to prevent death, is a route by which social death can cause biological death </li></ul></ul>
    12. 12. Second complication: the meaning and implications of the autonomy-choice ideal <ul><li>First aspect of autonomy-choice ideal: CPR is indicated for arrest </li></ul><ul><li>Isolated focus: </li></ul><ul><ul><li>Cardio-respiratory arrest dislocated from its ‘distal’ causes </li></ul></ul><ul><ul><li>Undermining notion of futility: ‘CPR is rarely physiologically futile’ Pope 2010 Restricting CPR … AJOB 10:1 p. 82 </li></ul></ul><ul><li>Staff discomfort with this approach </li></ul><ul><ul><li>Choices made re CPR despite regulatory framework </li></ul></ul><ul><li>Where should the ethical focus be? </li></ul><ul><ul><li>On the judgement per se </li></ul></ul><ul><ul><li>On its distribution </li></ul></ul>
    13. 13. Second complication: the meaning and implications of the autonomy-choice ideal <ul><li>Second aspect of the autonomy-choice ideal: Patient autonomy entails the sole right to refuse CPR </li></ul><ul><li>The problem of unrealistic expectations of CPR </li></ul><ul><li>The problem of internalisation of discrimination </li></ul><ul><ul><li>Health care professionals’ views ‘more than 80 percent would rather be dead than live with a severe neurological disability’ (Timmermans p.467) </li></ul></ul><ul><ul><li>When confronted with the reality of survival rates and post-CPR quality of life evidence, many change their minds about having it (cf. Scripko & Greer 2010 Practical considerations for reviving the CPR/DNR conversation. AJOB 10:1 p.75) </li></ul></ul><ul><li>Patients applying to their potential disabled future selves the judgement of society that these are not worthy lives </li></ul>
    14. 14. Second complication: the meaning and implications of the autonomy-choice ideal <ul><li>Individual choice and social impacts </li></ul><ul><li>The choice for DNR by the individual may not only reflect but also entrench the social evaluation of e.g. being old or disabled </li></ul><ul><li>Note: this doesn’t show that the choices are wrong – and given the existing values structure they are entirely understandable </li></ul><ul><li>Nor does it suggest that they are inauthentic </li></ul><ul><ul><li>Just because a choice is in line with socially validated choices doesn’t show it isn’t a genuine personal choice </li></ul></ul><ul><li>But we should take account of their knock-on effects </li></ul><ul><ul><li>One ironic effect is to further entrench the values in the minds of the health professionals </li></ul></ul>
    15. 15. Should we modify the autonomy-choice ideal? <ul><li>No </li></ul><ul><ul><ul><li>If the autonomy-choice ideal is the right ideal independent of any actual attempt to apply it and its consequences </li></ul></ul></ul><ul><ul><ul><li>(consequent ethical and professional challenge to talk about CPR/DNR as a matter of routine) </li></ul></ul></ul><ul><li>Possibly </li></ul><ul><ul><ul><li>If the autonomy-choice ideal works to support genuine choice and autonomy only in the presence of some values but not of others </li></ul></ul></ul><ul><ul><ul><li>if the autonomy-choice ideal has consequences (whether direct or indirect) which are morally too costly </li></ul></ul></ul>