An analysis of dilemmas posed by prehospital DNR orders

doi:10.1016/S0736-4679(96)00250-8

The Journal of Emergency Medicine

Volume 15, Issue 1, January–February 1997, Pages 109-111

https://doi.org/10.1016/S0736-4679(96)00250-8 Get rights and content

Abstract

This article briefly recounts the development of the prehospital do-not-resuscitate (DNR) order and indicates certain situations, such as a choking episode or a suicide attempt, in which the presence of a DNR order may provoke a moral dilemma for the emergency medical technician as to whether or not the patient should be treated. An ethical analysis of this question is performed and concludes that resuscitative treatment is ethical and mandatory.

References (5)

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J Emerg Med Serv
(1994)

There are more references available in the full text version of this article.

Cited by (13)

Suicidal Patients with a Do-Not-Resuscitate Order
2017, Journal of Emergency Medicine
Citation Excerpt :
Suicide is usually not an autonomous decision and treatment must be done to return a patient to a level of functioning where decisions are well informed. ED personnel are not in a position to evaluate the ability of a patient to make an autonomous decision when presented with someone who just attempted suicide (13). In the current case, both the patient's power of attorney for health care and her primary care provider were immediately available and could quickly summarize the patient's terminal illness and previous wishes.
A suicidal person with a do-not-resuscitate (DNR) order presents an ethical dilemma to the emergency physician. Many believe that suicide is an irrational action, and therefore, all suicide attempts must be treated. Others believe a DNR order should be respected even in the setting of a suicide attempt.
An elderly woman with a known terminal illness presented to the emergency department after a suspected suicide attempt. She had a DNR order during her previous hospitalization. The emergency physician felt obligated to intubate the woman despite his recognition that she was terminally ill.
Reasons to both honor and not honor a DNR order after a suicide attempt are reviewed.
Not all patients who attempt suicide are necessarily incapable of making a rational decision about their health care. In some cases it may be appropriate to withhold resuscitation attempts in suicidal patients who have a preexisting DNR order. Institutional policies are needed to provide guidance in this situation.
Outstanding ethico-legal-fiqhi issues
2012, Journal of Taibah University Medical Sciences
Citation Excerpt :
They may undertake futile resuscitation19 because they are uncertain about the prognosis. Emergencies such as choking or suicide attempts in patients with DNR orders create complex legal problems.20 I think that, according to the general principle mentioned above, ambulance personnel should resuscitate whenever they are in doubt, because of the overriding purpose of protecting life, maqsad hifdh al nafs.
To examine the practical issues arising in implementation of DNR from the perspectives of maqasid al shari’at and qawa’id al shari’at.
The purposes and principles of the Law provided a conceptual framework for analyzing practical issues related to DNR orders. The issues were identified from a Pubmed literature search with the key word ‘DNR’ covering about 30 years and were analyzed as they related to the principles of intention, certainty and preventing harm and also to the purposes of preserving life and resources.
It is proposed that DNR orders be written for patients in an established death process, i.e. cardiorespiratory failure beyond Young’s point ‘z’. Patients with terminal incurable conditions who develop acute, reversible cardiorespiratory arrest should be resuscitated if the net benefit will last for a reasonable time. Five components of DNR (cardiopulmonary resuscitation involving chest compression and oxygenation, endotracheal intubation, mechanical ventilation, defibrillation and vasoactive or ionotropic medication) could be provided on a case-by-case basis. The interventions may or may not include renal dialysis, blood transfusion, parenteral nutrition, pulmonary hygiene and normal treatment such as antibiotics. All patients, irrespective of their DNR status, deserve supportive care.
To improve DNR processes, training should be given on end-of-life ethical issues for physicians and nurses, DNR orders should specify interventions, the autonomy of physicians who have a conscientious objection to DNR should be respected, more psychosocial support should be given to the families of DNR patients, more empirical research is required on DNR, and DNR decisions should be audited regularly.
"Do not attempt resuscitation" (DNAR) in the out-of-Hospital setting
2004, Annals of Emergency Medicine
Citation Excerpt :
Emergency medical providers often care for patients in cardiac arrest, and numerous ethical dilemmas may be encountered, including conflicting family opinions, unreasonable requests by bystanders, lack of availability of advance directives, and others.1,2
Prehospital resuscitation practices: A survey of prehospital providers
2003, Journal of Emergency Medicine
Numerous factors affect decision making in the prehospital provision of resuscitative care. This study was undertaken to determine current practices involved in the initiation, continuation and termination of resuscitative efforts, and the impact of advance directives, in the prehospital resuscitation setting. This cross-sectional mailed questionnaire surveyed 3807 members of the National Association of Emergency Medical Technicians. The study instrument included questions regarding the termination and withholding of resuscitative efforts in the prehospital setting, as well as survival rates, local protocols and compliance with advance directives. Of 1546 respondents (41% response rate), with a mean 9.0 years of experience, most (89%) indicated that they would withhold resuscitative efforts in the presence of an official state-approved advance directive. However, very few providers would withhold resuscitative efforts if only an unofficial document (4%) or verbal report of an advance directive (10%) were available. Providers with more than 10 years experience were more likely to withhold resuscitation attempts in the presence of only a verbal report of an advance directive (p = 0.02, Chi-square), and were more likely to withhold resuscitation attempts in situations they considered futile (p = 0.001, Chi-square). Most (77%) respondents have local EMS guidelines for termination of resuscitation in the prehospital setting, but 23% of those consider existing guidelines to be inadequate. The majority of prehospital providers stated that they honor official state-approved advance directives, but do not follow directives from unofficial documents or verbal reports of advance directives. More experienced providers stated that they withhold resuscitative efforts more often in futile situations, or in the presence of unofficial advance directives. Advance directives should be utilized more uniformly among patients who wish to forgo resuscitative efforts in the event of cardiac arrest. Because many local protocols are judged to be inadequate, we support the institution of improved clinical guidelines regarding the prehospital termination of resuscitative efforts.
Communicating advance directives from long-term care facilities to emergency departments
2001, Journal of Emergency Medicine
Many residents of long-term care (LTC) facilities are transferred to Emergency Departments without advance directives (AD). The goal of this study was to describe an ideal model for the transfer of AD from LTC facilities to Emergency Departments. Health care providers were asked to describe their ideal model for the completion and transfer of the ADs of LTC residents. A grounded theory methodology was used to identify significant themes. The model we present as a result of this analysis acknowledges the importance of simplifying and standardizing ADs, but focuses more attention on the process of completing and transferring the AD. A key feature of this model is an emphasis on the education of LTC residents and their relatives about ADs and advance-care planning. This education should involve a variety of resources used in creative ways; it should begin as soon as LTC placement is being considered, and the emphasis should be on providing information and discussing options rather than pressuring residents to make a decision.
Should an advance care directive refusing life-sustaining treatment be respected after an attempted suicide? Development of an algorithm to aid health care workers
2019, Journal of Law and Medicine

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^☆: Ethics is coordinated by Kenneth Iserson, md, mba, of the Arizona Bioethics Program at the University of Arizona, Tucson, Arizona.

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An analysis of dilemmas posed by prehospital DNR orders☆

Abstract

Refusing and forgoing treatment

Difficult decisions: respecting a patient's right to refuse treatment

J Emerg Med Serv