Did you know that the growing use of DNR orders has increased the potential for iatrogenic arrests (IA) for residents with DNR orders and has, at the same time, created an ethical dilemma as well? An IA arrest (a cardiopulmonary arrest in a resident as the result of treatment or failure to treat) in a DNR resident poses an ethical dilemma between respecting the perceived autonomy of the resident, benefiting the resident, and respecting the integrity of the healthcare providers. Some view that there can never be any justification for overriding a resident’s advance directive and resuscitating a resident after an IA and “although various ethical principles might be cited as justification for overriding such a patient’s advance directive, we believe that none have merit” (Casarett & Ross, 1997). Others, such as Christensen and Orlowski (2000), note that situations often arise where resuscitating a resident from an IA makes ethical and moral sense. For example, one situation where a resident with a DNR order should be resuscitated despite the DNR order, would be if “there would be reason to believe that it would be consistent with the resident’s goals.” While Christensen and Orlowski have no problem with that kind of case scenario, they disagree with Casarett and Ross that it should be the only circumstance in which a resident with a DNR order should be resuscitated. Where Christensen and Orlowski have difficulty is when a DNR resident (who suffers an IA arrest) is not able to communicate, and there is no surrogate present to speak for them, and no conversation has transpired with regard to the resident’s wishes in the event of an IA. In this kind of situation, Christensen and Orlowski state that they “would prefer to weigh the circumstances (the patient’s prognosis, the patient’s reason for deciding on a DNR order, the circumstances of the IA, and the likelihood of success of CPR) and err on the side of life.”

Does the DNR document need to be made more specific with regard to the circumstances that might arise? Or will the increased specificity lead to interpretation problems and ambiguity/uncertainty, as is sometimes the case with other types of advance directives? Clearly, discussion on the topic is needed in advance and should an individual decide to remain DNR despite an IA, those wishes must be respected. To read more about this, including several case scenarios see the following:

Casarett, D., & Ross, L. F. (1997). Overriding a patient’s refusal of treatment after an iatrogenic complication. New England Journal of Medicine, 336, 1908-1910.

Christensen, J. A., & Orlowski, J. P. (2000). Iatrogenic cardiopulmonary arrests in DNR patients. The Journal of Clinical Ethics, 11(1), 14-20.

Did you know that since the “did you know” segment appearing in the last newsletter, several readers have voiced opinions about “AND.” While many like the concept of “Allow Natural Death” and its positive connotation, some readers foresaw the potential for problems. For example, “AND” is a frequently used word and the acronym AND could easily be misread in a medical chart. Writing the words “Allow Natural Death” might be a solution but as one person said that somehow “reading the words Allow Natural Death doesn’t seem to imply continuous comfort care.” What might be some of the alternatives? --Allow Comfort Care (ACC)? Allow Palliative Care (APC)? Aggressive Comfort Care (ACT)? Back in 1995, an article in the American Journal of Nursing appeared that was entitled “ACT.” In that article, it was argued that it is better to tell families what we are going to do for their loved ones rather than what we won’t do as is the case with the DNR order.

Did you know that JCAHO suggested that the measurement of pain as a vital sign was an appropriate method to achieve compliance with standards that require regular assessment of pain? See JCAHO standard R1.1.2.8 in Comprehensive Accreditation Manual for Hospitals (2000).

Did you know that the catch all phrase “non-pain symptom management” can describe as many as 55 different symptoms, and that these symptoms may cause significant problems at the end-of-life? The list, which can be found in The Oxford Textbook of Palliative Medicine, reports that the most prevalent symptoms are constipation, dyspnea, nausea and vomiting, and dry mouth. The importance of many of these symptoms in end-of-life care is often underappreciated.

Did you know that the role of artificial nutrition and hydration in end-of-life care continues to be an area of controversy? Apparently, the location of your death dictates whether or not you receive artificial nutrition and hydration. In hospitals, tube feeding remains commonplace with most dying people being given artificial nutrition and hydration. In hospices, most people die without IVs. See Dr. Hallenbeck’s article on Best Practices in the Care of the Dying for more about this topic and also other areas of controversy (as well as consensus) in end-of-life care practices. The article appears in the Annals of Long-Term Care Online at: http://www. mmhc.com/nhm/articles/NH0007/hallenbeck.html.

Posted on 12/22.00.

Did You Know? was published in the Winter 00-01 edition of the Ethics Network News and is posted on-line at: https://www.angelfire.com/on/NYCLTCethicsnetwork/dec_jan00-01/know.html

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