Case Study: On the Permissibility of a DNR Orderfor Patient with Dismal Prognosis Nate Pilcher Emily Hockett Sam Kendrick Lori Waldeck
OVERVIEW• Patient is an 86-year old female• Was living independently and in good health• Had severe head injury• Placed on ventilator in ICU
OVERVIEW• Trauma team placed a DNR in patient’s chart• Palliative Care team found her awake and communicative• Ethics consultation was sought by palliative physician
OVERVIEWIs it ethically legal to withdraw the patient from lifesupport without a living will or surrogate present?Is it ethically legal to allow a patient to make decisionswithout a surrogate present or without a familymember?
ETHICAL ISSUES• Follow the family’s wishes and carry out the DNR even though the patient is awake and coherent?• If the patient is able to communicate, shouldn’t the question be directed to her?• Is it possible that the family may benefit from the patient’s death• Is it possible for her to make a full recovery?
PERSONAL VALUES• Everyone deserves a chance to live and make a full recovery, regardless of age• This patient should be involved in decision-makingPROFESSIONAL VALUES• Respect the patient’s wishes• “Do no harm”VALUES OF OTHERS INVOLVED• Family Values
ENVIRONMENTAL FACTORS• Patient’s age• Patient’s mental state BARRIERS• Effects of the fall on the patient’s mental status• Possible barrier to communicate with patient
STANDARDS OF PRACTICE Administration level: • Legal procedures (DNR) • What if her wishes were to live even though there is a DNR on her chart?LEGAL GUIDELINES AND PRINCIPLES• Legal rights of the patient• Now that she is coherent, her wishes should be taken into consideration.
ALTERNATIVESOption 1: Remove the DNR from the patient’s chartArguments for:• Improved state• She was not involved in decisions concerning her own treatmentArguments against:• Decision regarding DNR has already been made• Her recovery is unlikely
ALTERNATIVESOption 2: Leave DNR in placeArguments for:• Decision has already been made• Prognosis is bleak/Waste of time and services to continue life supportArguments against:• She is alert and awake, and she should be given a chance to make her own decision
ALTERNATIVESOption 3: Consult patient & get second opinionArguments for:• She can understand her situation and make her own decision• Another physician may see possible recoveryArguments against:• DNR already in place
FINAL DECISIONThe patient should choose whether or not to have aDNR in place.• She is awake and able to communicate• She had not been asked to give consent
ACTION PLAN1. The patient should be asked if she wants to know her condition/prognosis2. She should be asked if she wants to make decisions about her care3. Ask if she wants the DNR to be in place4. If mental state declines, a surrogate should be named (POA) and they shall make the decision
WHAT REALLY HAPPENED• Patient was asked to be involved in decision-making; she accepted• She agreed to DNR order• She developed pneumonia• Began decline in health on third day• Slipped into coma on day 4• Was withdrawn from ventilator and expired (following her wishes)
If you were that patient, what would you want?