Unexpected Events Make Patient’s DNAR Status Complex
July 1, 2022 2 minutes read
A patient presents with a Do Not Attempt Resuscitation (DNAR), and has accepted death due to a progressive illness, but wishes to live until the illness becomes terminal. That patient experiences anaphylactic shock after an insect sting and cannot communicate with clinicians. No one knows if the patient would want the DNAR status to stand in this unexpected situation, or if that patient would want to be resuscitated.
“The prevalence of dichotomous orders requires either arbitrarily overriding the order or allowing an avoidable death,” explains Richard Stuart, DSW, ABPP, clinical professor emeritus at the University of Washington’s department of psychiatry and behavioral sciences.
There is no way for clinicians to know if the patient would want resuscitation under the circumstances. “Some patients consider heart stoppage a blessing, regardless of its cause, and that desire should be honored. But many others, while preferring limited or comfort care, prefer to survive reversible life-threatening events. They must be offered that opportunity,” Stuart says.
Medical orders such as DNAR can be ethically problematic since they are geared toward patients always or never wanting a procedure, according to a group of ethicists led by Stuart.1 “Patients should not have to suffer avoidable deaths due to unexpected events,” Stuart says.
Patients could experience an insect sting, an accident, or the iatrogenic effects of medical errors, and would want to be resuscitated despite documented DNAR status. If clinicians are aware of the patient’s DNAR status and he or she cannot communicate, the situation becomes ethically tricky.
To address this, Stuart and colleagues developed a conditional medical orders form, which summarizes preferences for resuscitation, ventilation, and artificial hydration and nutrition. The form is meant to be used when offering advance care planning or at the bedside of terminally ill patients. It can facilitate more ethical care in nuanced situations, according to Stuart.
Learning about conditional orders might lead to more interest in advance care planning. During advance care planning workshops, Stuart finds some people resist creating an advance directive if forced to accept a two-option decision. However, they readily do so when conditional orders are offered. “We consider it ethically imperative to offer patients the conditional option, and a violation of their rights to offer only a dichotomous choice,” Stuart says.
REFERENCE
- Stuart RB, Birchfield G, Little TE, et al. Use of conditional medical orders to minimize moral, ethical, and legal risk in critical care. J Healthc Risk Manag 2022;41:14-23.
Ethicists developed a conditional medical orders form, which summarizes preferences for resuscitation, ventilation, and artificial hydration and nutrition. The form is meant to be used when offering advance care planning or at the bedside of terminally ill patients. It can facilitate more ethical care in nuanced situations.
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