DNR a small part of overall care plan
It’s important for ED managers to remember that just because a patient has a do-not-resuscitate (DNR) order, that doesn’t mean all of the patient’s wishes have been expressed in writing, says James Espinosa, MD, medical director of the ED at Overlook Hospital in Summit, NJ. A DNR is just one part of a continuum, Espinosa says.
"Unless we are able to pull back and deal with DNRs in a larger framework, the ED will never get out of the ethical imperative process — to save a life," Espinosa says. "It all happens in a time-sensitive framework, but if you step back, there are ways to mitigate the situation so we are not in such a dilemma."
The challenge, he continues, is that you may have all sorts of conflicting ethical duties, and you want to do the right thing at all times, "but you also have a duty to see what’s available and what’s active in terms of advance directives."
Jeanne Kerwin, MMH, MICP, ethics and palliative care coordinator for Overlook and, for most of her career, the director of EMS for Atlantic Health System, Overlook’s parent organization, says one of the largest issues she has dealt with for the last decade is understanding the difference between someone’s advance directive document and a physician’s DNR order, "which is just a small part of a total care plan but needs to be addressed on an immediate basis," she says. "An advance directive or a living will actually talks philosophically about how the patient wants to be treated."
In the heat of the moment, when a paramedic or an ED physician is dealing with cardiac arrest, neither a living will nor an advance directive comes into play, says Kerwin. "Ideally, a DNR should be a document that’s easily visible, but if not, you do what you have to do, and treatments can be withdrawn later if you wish," she says. However, the purpose of a DNR is a physician’s order, Kerwin says. "It is meant to function in a moment of decision-making, because you can’t wait to start CPR."
But the DNR should be part of an overarching plan — a continuum, says Kerwin. "When families come in and you ask what they want for Mother, and they say everything,’ that can mean different things for different people," she notes. Ideally, a care plan should start out in the community, whether the patient is in a nursing home, in a hospice, or receiving home care, Kerwin says. "That’s the time to decide what you mean when you say everything,’" she says.
Without such an overarching plan in place, "the pressure of ethical imperatives in the ED will only go up as time goes on, with the population aging and chronic diseases becoming more treatable," Espinosa predicts.
Sources
For more information on the care continuum, contact:
- James Espinosa, MD, FACEP, FAAFP, Medical Director, Emergency Department, Overlook Hospital, Summit, NJ. Phone: (908) 522-5310. E-mail: Jim010@aolcom.
- Jeanne Kerwin, MMH, MICP, Ethics and Palliative Care Coordinator, Overlook Hospital, Summit, NJ. Phone: (908) 522-5329. E-mail: [email protected].
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