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DNR order and the Operating Room

There are numerous developments that have been recorded in healthcare. Healthcare services in the present generation are a result of developments that have been made by successive generations that have led to current practices. An important dimension in developments made in healthcare is conformance to ethical considerations. There have been considerable developments that have led to an increase in the role played by patients in their management. Patient autonomy in the current healthcare system is quite different from what would have been expected by past generations (Fallat, & Jayat, 2004).

One of the areas that is of ethical relevance and considerably affects the platforms that medics have in basing their decisions is the DNR (Do Not Resuscitate) orders. A decision to consider or fail to put into mind existing DNR orders have both legal and ethical implication in addition to the potential effect that they have on the rate of recovery of a patient. Review Developments in healthcare have generally led to more involvement of the patient in making decision regarding the direction his management will take.

Patient autonomy is cited as being important in ensuring that healthcare practice is brought close to the social fabric that is ethics (Cantor, Murray, Nelson, & Reagan, 2003). It is approximately three decades after the first hospital allowed for DNR orders. Its development was hailed as a landmark in healthcare for it is basically an order that seeks withhold of treatment by the patient. Physicians in the present environment have been faced with a situation where they have written or forced by legal systems that reinforce DNR orders to adhere to one (Truog, Waisel, Burns, Johnson, & Hardart, 2002).

From a patients perspective, a DNR order is as an opportunity to determine the course of death one will undergo in case of terminal illness (Guarisco, 2004). Implication to Medics While making a decision to seek a DNR order by a patient is a person decision that can be guided by seeking counsel of family and friends, medics are placed in tough situation when having to comply by DNR order in emergency and operation rooms. One of the factors that have led to the prevalence of DNR orders is the need for patients to protect themselves from the negative effects of continual CPRs.

Cardiopulmonary resuscitation came in the 1960s as a ‘god-sent’ intervention to addressing the nightmare that medics faced in dealing with anesthesia induced cardiac arrest (Burns, Edwards, Johnson, Cassem, & Truog, 2003). The effectiveness and simplicity of the approach at first hid the effect that CPR had in restoring a patient physiologic ability only to be faced by immeasurable pain and suffering. CPR systems gradually developed a name as being tools used to prolong lives of terminally ill patients so that they can undergo continued suffering.

In fact research has unearthed that it is common medical practice for medics to perform less than full CPR in situations where they believe that CPR attempts will be of no good to the patient (Jones, 2004). A review of such practices points to the intention of medics not to save patients life rather to put themselves out of blame for trying while not wasting critical resources on a patient whose condition is past worse (Ewanchuk, & Brindley, 2006). Such developments were covered in controversy for medical practice though human has documented cases of miraculous recovery even in cases where all hope was gone.

Decision on whether to resuscitate a patient that is suffering anesthesia induced cardiac arrests is a complex decision that has the ability to affect a patient’s health outcome in either direction. The decision is further complicated by the short duration that one has to consider variables involved in making any decision. While making a decision in either dimension may have considerable implication failure to develop a timely decision has far worse implications. DNR orders are therefore seen as a development that has eased decision making regarding CPR in anesthesia related cardiac arrests (Coopmans, & Gries, 2000).

Though this may be the general picture developed in theory, in practice the situation is quite different. Anesthesia invoked cardiac arrest are a common medical phenomenon and they present a danger of death if not well managed. Development in general anesthesia has seen use of anesthesia even in minor surgical operations. Minor surgical operations can go bad when a patient’s body system reacts with an anesthesia in a manner that leads to cardiac arrests (Truog, Waisel, & Burns, 1999).

This presents a situation where medics have the option of choosing to administer a CPR or wait for fate to take its course which may either result in the death or recovery of the patient. A CPR is the most preferred approach to management of such a complication; however, if the patient has a DNR order physicians may be placed between a rock and a hard place. There are two major variables that are often considered in such decision that form the basis of controversies that are inherent of DNR orders. a) Ethical

Autonomy which is at the heart of bioethics is one of the key factors that has to be considered in deciding to uphold or bypass a DNR decision in cases where a patient has suffered an anesthesia induced cardiac arrest (Committee on Ethics, 2002). Should the wishes of patients in such a case be considered as the legally binding DNR order? One the key issue that is definitive of when a patient autonomy should be upheld is their competency. Such a case presents a scenario were the patient is disabled and the only document relaying their wishes is a DNR order (Shepardson, Gordon, Ibrahim, Dwain, & Rosenthal, 1999).

Should the decisions made by the patient before he got into this unforeseeable position be upheld at the expense of what he would really be in need of? Determination of the exact wishes of a patient in any given situation is important to ensuring ethical practice and DNR orders present a situation where a patient’s wishes are defined from his past perception and not necessarily the position a patient is in at any given instant. Inclusion of family members has come up as an avenue that can be used in ensuring the ethical issues involved in making CPR related decisions are amicably addressed (Ball, 2009).

Healthcare institutions have come up with a number of guidelines to aid medics into taking the right course of action. While such guidelines are often associated with legal ramifications, they rarely address the ethical perceptive of medicine as a social practice. b) Legal Legal systems just like ethical issues have to be considered in coming up with any objective decision or line of action. Legal obligations in deciding the right course of action with respect to administration of CPR to a patient who has a DNR order has been one of the key areas that the healthcare systems has recorded considerable development in (Journal Compilation, 2006).

Healthcare systems have come up with procedures and standards that seek to ensure that the rights of patients are upheld while making objective decisions. Irrespective of the statements, guidelines and procedures developed by healthcare systems, dilemmas are inherent especially in cases where established systems require the DNR order to be upheld while a physician is of the view that the condition is manageable and even the life a of a patient can be saved by simple administration of CPR (Committee on Ethics, 2002).

The effects of legal systems are that they reduce the flexibility that medics have in making decisions in a space that is already constricted. Recent researches postulate differences in rates of DNR orders in African Americans than in other races in the US (Baker, Einstadter, Husak, & Cebul, 2003). Though the reason for such an eventuality is yet to be determined, the existence of a clear guideline on how DNR should be carried out would aid determine them. The guidelines are also important in ensuring effective management of patients.

Theoretical Framework Ethics, law and the healthcare systems are all part of a working system referred to as the society. To effectively address a potentially volatile situation within that such a system the input of all these components must be sought (OR Manager, 2007). All inclusive approaches though slow and time consuming if effectively carried out lead to development of systems that are efficient. Unilateral decision making or development of guidelines and procedures does little to address a problem (Committee of Origin, 2008).

Such systems have been definitive of existing approaches to addressing the dilemma that medics face in administration of CPR under DNR. Though an amicable solution may not be reached, all inclusive approaches will at least lead to the representation of the interest of all parties in developing a solution to this tricky problem. Research Questions The following questions are raised from the review that need to be further researched on in addressing the dilemma presented by DNR orders in anesthesia induced cardiac arrest cases that require CPR:

a) Should healthcare institutions develop stiff guidelines on the course of action to be taken? b) Which stakeholders should be involved in making immediate decisions regarding the right course of action on cases of an anesthesia induced cardiac arrest involving patients with DNR orders? c) What long term solution should be instituted to ensure the legal an ethical issues are both included in the solution? Hypothesis The following are some of the hypotheses will aid seek the answers to the research questions:

a) Healthcare institutions have no use of stiff guideline in defining the course of action in dealing with DNR orders encountered in managing anesthesia induced cardiac arrests that requires CPR. b) Patients’ family or friends, medics and healthcare administrators must be involved in making immediate decisions regarding the right course of action wit respect to CPR in anesthesia induced cardiac arrests. c) The developments that have so far been made in DNR have been a result of the interaction between all healthcare stakeholders.

Emerging cases and arising ethical issues should also be considered in developing a robust and conclusive approach to management of DNR. Summary A lot has been attained in healthcare management though there is still a lot that has to be addressed. Without and effective guideline DNR orders would cause both legal and ethical issues, a stringent system on the other hand reduces the levels of objectivity and flexibility that can be attained. What then should be the correct path out of this dilemma that could be definitive of death or life to a patient and a medic’s career?

References

Baker, D, Einstadter, D, Husak, S. , & Cebul, R. (2003). Changes in the use of Do-not- resuscitate orders after Implementation of the Patient Self Determination Act. JGIM, 18, 343-349. Ball, K. A. (2009). Do-Not-Resuscitate Orders in Surgery: Decreasing the Confusion. AORN Journal, 89(1), 140-146. Burns, J. , Edwards, J. , Johnson, J. , Cassem, N. , & Truog, R. D. (2003). Do-not-Resuscitate order after 25 years. Crit Care Med, 31 (5), 1543-1550.

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