Wednesday, May 6, 2015
Case 21: DNR or no? (12May)
Answer the questions at the end of the case. See if you can answer from the point of view of one of your ethical theories (don't all cover the same theory -- spread out your answers). For example, a few of you would answer (1) "What is the most appropriate response in this situation?" from the point of view of a Utilitarian, others from a Kantian p.o.v., others from a Virtue Ethics p.o.v., etc.
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I think there is another problem here. What does "if they can do something mean"? Does it mean to make more comfortable or save my life?
ReplyDeleteDr W or Dr R should assess the mental status of Mr H and then the Dr should explain to the Patient and his family that fixing the bleeding problem will not fix the cancer problem. The Dr should discuss the options available. He, the Patient, could be given medications for comfort and be allowed to die with comfort and dignity per his prior DNR request or they could go to surgery and fix the bleeding problem thereby potentially prolonging his life for a short period. If the Patient is oriented and wants to prolong his life after the options have been discussed surgery should be done and measures taken to follow through with this request. The Pt always has the right override his prior decision for DNR.
If the Patient is confused the Patient should be made comfortable and follow through with the prior DNR request. This decision should be agreed upon by the family.
Using the Utilitarian theory the action of making the Patient and family comfortable produces the most good for the greatest number.
I agree with you Robin. The patient has the right to change his mind about the DNR. I also agree the physicians should access the patient so everyone is on the same page as far as what the patient wants.
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ReplyDeleteA patient has the right to change their mind on a DNR status at any time. In this situation, I believe that the patient's and family's wishes should be met. The physician must be honest and explain to the patient that even if this intervention works, it is only prolonging the inevitable. Kant believed that rational human beings should be treated with dignity and respect. I feel that this means a patient's wishes should be respected and he should be able to proceed with life saving measures.
ReplyDeleteSarah,
DeleteI agree with you and I feel this could be considered a comfort measure. If the doctor explains to patient and family first and then allow them to ask questions, they will make a more informed decision. My own mother asked me if she should follow the doctors recommendation to prepare for dialysis. I got as much information as I could find for her to read and then answered every question she had. Her decision was not to have dialysis. You see she was in her 80's and already had end stage heart failure, EF 10%. She commented that she probably needed a better pump (heart) for it to be successfull. She decided on her own , but knowing how she felt about heroic measures and her diseased heart, I feel sure I would have chosen the same for her. One question that stood out was "Is it like committing suicide if I don't have dialysis?" These are the type of questions I frequently hear from other patients that are faced with similar moral dilemmas. We need to have these discussions with our families while they can decide on their own.
I agree that their wishes should be met also, sometimes it takes that last effort to make the family and patient comfortable with their decision and they will know they gave it everything they could.
DeleteNo long ago we had a family change a DNR status so we could call a rapid response. The daughter became very mad when we had to ask the patient if she wanted a rapid response called since that patient was still in her right mind. The patient agreed however I still think she only agreed because he daughter wanted he to. The doctor finally had the tough talk with the family, saying that if she was placed on a vent, the vent could never be removed since she was end stage COPD.
DeleteI believe a patient has the right to change their mind about their DNR status. The patient clearly had the presence of mind to ask if there was something that could be done, is enough to warrant further consideration. The physician should take the time to inform the patient of the pros and cons of treatment and let the patient and his family consider the choices. The patient should know what to expect and one could consider the measures either stop or slow the bleeding could be a comfort measure.
ReplyDeleteI agree cindy that educating the patient and the family is a big step. Dr's now days i feel are rushed and don't take the time for to explain the topic of dnr status very well to patients and families.
DeleteI agree. DNR status is not the end once someone makes themselves a DNR. They should be explained treatment and diagnoses then given the options to autonomously choose how they want to pursue their own health.
DeleteI agree. DNR status is not the end once someone makes themselves a DNR. They should be explained treatment and diagnoses then given the options to autonomously choose how they want to pursue their own health.
DeleteFirst of all what exactly does no treatment mean.? Does he not want anything at all or only comfort measures. I think that we run into this problem alot in the emergency room. Pt's will have a DNR which is only do no resuciate it is not a do not treat. Their are things that you can do for the patient to make their last months,days,hours, minutes on this earth more comfortable. If this involves a procedure that at the last minute he decides he wants to have then I think he should have it. I think the real problem is that doctors do not take the time to sit down with the patients and families to explain everything that a dnr means. I also feel like the patient also needs to sit down with their family and designate a person to make informed medical decisions for them when they are unable to. This person that they choose needs to know exactly what the patients wishes are and they must not waver in their decision when the time comes to let the patient go. I think that when we are in a great deal of pain, weak or close to death we might all change our minds. I think that when this happens maybe the decision should be made by the designated family member. No matter what the decision is a hard one.
ReplyDeleteI agree with you Sherry! On TCU we deal with this dilemma as well. Some healthcare workers think that a DNR status is do not treat and they are completely misinformed. Years ago when I used to work in a nursing home as an LPN a certain doctor would always ask if the pt was a DNR and what their age was before he would give me simple orders, such as lasix for crackles or even transferring to the hospital for a blood transfusion. I was 20 years old at the time and had the common sense back then to realize that they still deserved to have medical treatment.
DeleteI agree sherry. In today's medicine, it is often difficult to sit down and spend time with the patient and their families. It seems more important to meet the "quota" and not to focus on the communication. Families tend to avoid conversing to each other about the end of life process and expectations. I think if there was a designated person to follow through the patient's wishes, this will minimize the stress and agony for the family.
DeleteSherry I agree with this also having a certain person in the family that will be the back up person for all important medical decisions in the event John H. can not make his own decisions. Knowing the difference in DNR and only comfort measures is a huge deal as well. I feel that sometimes family is a great thing in this situation ans also can be the most stressful thing in this kind of situation. Some families try to take over the patients decisions and they think they need to make them for them. Having a plan put into place is important!
DeleteI agree with all of you. Especially having a plan for these times. During times of extreme stress it can very easily hindered a person's decisions.
DeleteAccording to the principle of Biomedical Ethics, the most appropriate response in this situation would be to treat the immediate need of the hemorrhaging. In doing so, the Dr. would be respecting his current request, doing good to identify the cause of bleeding and to treat it, and being fair to the patient by honoring his wishes. This theory requires moral obligation unless there is a conflict and then best judgement should be used. In this case, I think best judgment is to treat his immediate request. Once stabilized, I feel the Dr. should go over the DNR again with the patient to define what he meant by "no further treatment" or to see if he has decided to rescind the DNR order altogether. When a patient changes his mind about decisions he/she may have made, the best thing to do is to sit down with the patient and really talk with them and try to understand their wishes. If they are not able to do that because of mental capacity, I would defer the conversation to the next of kin to decide whether to continue the current treatment plan or not. I would try to talk to them about the reasons for making the DNR order in the first place and try to help them work through their ambivalence. It may just be they still want a DNR but want to make sure we will do everything we can to keep them from hurting and make them comfortable.
ReplyDeleteI agree. The physician should take time out and discuss in details with the patient to determine the patient's wishes. If the patient is unable to communicate, I think DPOA or next to kin should discuss in detail with the physician, about the patients condition to gain a better understanding of the disease process and prognosis. Prolonging someone's life can give the family members a false since of hope. It is often easy to hold onto the quantity and not to focus on the quality of life.
DeleteThe fact that John H had a DNR in place and then desired to seek treatment when he started to bleed internally is absolutely up to him. If he had sound enough mind to understand what he had been told and he asked the appropriate questions, that would be relevant in the principle of respect for autonomy. Treating John medically would fall under the categories of the principle of beneficence and the principle of nonmaleficence. Treating him fairly would fall under the principle of justice. John should be able to go back and revoke his DNR and be treated with dignity and respect. The physician should clarify with John what he wants and what will happen regardless of what he chooses to do. John needs to be aware of risks and benefits.
ReplyDeleteSo true Tricia, John H can at any time revoke his DNR. Being oriented is key before signing the DNR and when he wants changes made. I've even seen family members revoke a DNR request when the Patient was confused. So it takes a strong Dr. to help the family understand the Patient's wishes.
DeleteSometimes I think patients and family become confused and change their minds because the physicians either don't have time to spend with them to explain and I've seen physicians not be completely straight forward about a patients realistic prognosis. The patients and families deserves to be informed.
DeleteI think also with hospitalized patients who see different rounding physicians on different days, they may hear things from a different viewpoint and that change their thinking and what they have decided.
DeleteIn this situation, I believe if John H is mentally competent, he can make decisions for himself, and has the right to change his advance directives as he wishes. According to Kant, people should be motivated through their motivation of their actions and not on the goodness of the consequences of those actions. Even though I may feel the procedure is medically futile , I need to listen to his concerns, provide him with the benefits and risk for the procedure. I would respect his wishes and the goals of beings rather than merely using him for my own purposes a person. My maxim would be to treat others like I want to be treated.
ReplyDeleteThis is exactly how I felt. We are nurses and patient advocates and need to back up John H with his wishes if this is what he feels he wants. Even if we know the ending may not be what we want, John H can make his own decisions.
DeleteI thought about using Kant's theory in my explanation and then I went with Act Utilitarian because it seemed more simple and less confusing for me. Man as a rational being with autonomy, dignity, and freedom definitely fit with this Patient's concerns. And after reading the current readings I like your reference to "procedure is medically futile". Nice job!
DeleteI agree that the dr. should sit down with the pt and find out exactly why he has changed his mind now about the dnr an explore those opitions. Maybe he is scared now that the time is getting closer and the patient just needs someone to talk to and give him options without having the surgery. As medical professional we should do what the pt wishes even if it is not what we think should be done.
ReplyDeleteI am not sure that he was asking for his DNR to be changed, I thought he was just asking if there was anything that could be done to stop the bleeding? A patient always has the right to change their mind about what they want. But I don't think the doctor gave the patient enough information to rationally make a decision. He had 2 doctors that he trusted to give him care and they couldn't even come together to help him make an informed decision. I think I would have been scared too.
DeleteI agree, he was not necessarily asking for the DNR to be revoked. He was in distress both physical and emotional and was asking for help. I have worked with oncologists who were very specific about what may happen at the end. If that were a universal theme for all physicians, I feel patients would be better prepared. If John H knew this was a possible outcome, a plan of care could be in place for other comfort measures. I can't imagine the amount of fear he had over the situation.
DeleteI feel that even if a DNR status has been made a patient can change their mind on care at any point that they want. This is their right as a human as we as healthcare providers should fulfill these requests. At this point in the request from John H. the two doctors should talk to him, give him the full picture of what is going on and risks and make sure he does want them to take full measures to keep him alive. I think this probably does happen more frequently than we think due to the patient becoming scared. But in this situation each and every patient always is entitled to their own choices.
ReplyDeletePatients need to be informed about what can and can not be done in a situation like this. As I stated in my blog, DNR means do not resuscitate not do not treat. if someone was a DNR and had a UTI would you not treat the infection? Would you just let them get septic and die?
DeleteI agree patients are entitled to their own personnal choice when it comes to their healthcare. All information should be given up front to the patient to help them make an informed decision. As healthcare workers and humans we should always respect our patient's choice.
DeleteDNR means do not resuscitate, it does not mean do not treat. If the patient was still alert, oriented and able to say do something to stop the bleeding then that is what should have been done. He was not in cardiac or pulmonary arrest, he was bleeding. Now if during the procedure the patient would cardiac or respiratory arrest the physician would then have to make the decision to honor the DNR or not?
ReplyDeleteI think the physician should have done what was requested of him by the patient if possible. He should have informed the patient if there was something that could be done. He then should have also explained the risks of what could happen during the procedure such as cardiac or pulmonary arrest. Give the patient all the options with the possible risk vs benefit and let them make an informed decision.
I agree as well. I think it's possible people believe that when they have a DNR status, they might not be aware of what is happening in cases like cardiac arrest. Therefore it would not be frightening since they are unaware of the situation. But in John's case he was alert and most likely fearful of what was happening.
DeleteTreat the patient. DNR status is only in the event of cardiopulmonary arrest. John H should be given the information needed to make an informed decision about his current bleeding situation. The principles of bioethics states one's autonomous decisions should be respected. He should be given every opportunity to be treated as another person would be treated, regardless of his code status. Patients who are mentally capable have the right to change their minds any time they want.
ReplyDeleteI agree mentally capable patients can change their mind about their care plan at any given time. Treatment should be given to John H no matter what his code status is.
DeleteI agree that John H should be treated as he is not in a code situation at this point. I get very frustrated at the attitude that we sometimes get from physicians and nurses who think the DNR order means we don't continue treating the patient,
DeleteTreat the patient. DNR only gives the right to not resuscitated if the patient should go into cardiac arrest. However, in this case the patient did state he no longer wanted further treatment. This should had been discuss in more detail. What did he mean by treatment. If that patient ask for help it should be given no matter what paper work he has filled out in the past. Patients can change their mind about the care at any given time. It is their choice not the physician.
ReplyDeleteI agree at further clarification with, for instance, an advance directive would have been more helpful. I actually missed that sentence where he requested no further treatment in the scenario. Since the information was limited here, the physicians have the duty to treat the patient's bleeding as he is not in a code situation.
DeleteI saw the sentence but made the assumption they were talking about chemotherapy or radiation.
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ReplyDeleteThere is a difference between resuscitation and treatment. A patient has the right to change his mind regarding DNR status at any time. This is Kant’s concept of autonomy and the ability to act freely and make decisions for oneself. In this situation they should be treating the bleeding. There needs to be communication from the physician about issues and complications that arise and an opportunity for the patient to get all questions answered to confirm his DNR status.
Sort of a funny story to tell that goes along with this. In the mid 1980's, my husband's grandpa was in end stage heart failure. His PCP spoke with him and his wife on numerous occasions about how his disease would progress (I know because I would take him to the office and the Dr. would come to the car to see him). His wife knew the plan, when he died they were to call his Dr. and then the coroner. The night it happened, he was sitting at the kitchen table, and stayed with his head on the table. He was a big man and she was worried that the coroner would not be able to get him to the floor, so she called the fire department. As soon as they got there and lowered him to the floor he must have released some air and they began CPR. She called me in a panic to make sure they didn't put him on a ventilator. I was working ICU and ran to ER to meet the squad. The firefighters and to a certain degree the ER MD were perturbed that she called 911. Even with the best education and plan in place, we are all human and will stray from the plan at times. As healthcare providers we need to be ready to go with it, even in life and death situations.
DeleteJust to be clear, not funny that he died-grandma was able to laugh at what she did, even though she was told so many times what to do.
DeleteI think this is a growing concern of nurses. My understanding of DNR does not mean do not treat the patient. This does not seem to be a belief by all nurses, however. In this case I think we should ask- Would intervening save this patient's life? The patient does not appear to be in a cardiac or respiratory arrest situation, so administering treatment would seem reasonable at this point. Using Kantian theory that we are autonomous beings who choose freely , I think that John's request should be honored.
ReplyDeleteThere is a big difference between DNR and do not treat. It's sad that so many people and doctors can't distinguish between the two. This man may have a terminal illness but he also has the right to make his own decision and this includes changing his code status. It should not be up to the doctor to make this decision. If the doctors truly believe this something should not be done then choices need to be discussed with the patient and the family so everyone is on the same page and understands, his request should not simply be ignored.
ReplyDeleteI believe that the doctors should first speak with John's close family members if they are present during this time, if they are not then the doctors should continue with treatment try to sop the bleeding. If John goes into cardiac arrest I think they should continue with the DNR request since John asked them "to do something" he may only have been talking about trying to treat. Virtue Ethics focuses on the person's character. The extreme nature of this event could be hindering John's normal character however it is better that the doctors treat him as his wishes in this time of crisis.
ReplyDeleteIf the bleed can be stopped safely then I believe it should be done. A DNR order does not mean do not treat. I have seen rapid responses be called on patient's with DNR orders. I took him saying no more treatment as no more cancer treatment. Providing him this would be giving him comfort. Healthcare workers should want to do the most good for their patients. This would be doing the most good for John.
ReplyDeleteI will look at this from the viewpoint of act utilitarianism. Regardless of the pre-stated wishes of DNR, if he or she states they want treatment, it should be given. I find it somewhat surprising Dr. W has seconds thoughts about taking steps to stop the bleeding. Having a patient bleed to death is horrific no matter what the cause of the bleeding. So from the utilitarianism point of view, the outcome for the patient and the staff who is caring for the patient is bad. Obviously any treatment may not have an impact and the patient may die. I am going to assume the patient is well known to both physicians, at this point a great deal of compassion is called for. This is where I struggle with the line between keeping a patient comfortable and euthanasia. Should the patient be offered sedation knowing that he will die from either the sedation or the bleeding? This is where having a strong relationship with your physician could make a huge difference. Even so, if the patient is lucid enough to ask for help I think there has to be an attempt to honor that wish.
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