Transcript WHAT DOES DNR REALLY MEAN?

WHAT DOES DNR
REALLY MEAN?
COMFORT MEASURES ONLY
C. Antonio Jesurun, MD
Professor of Pediatrics
Director of Neonatal Intensive Care
June 29, 2005
Resuscitation or CPR
Medical procedure which seeks to restore
cardiac and/or respiratory function to
individuals who have sustained a
cardiac/respiratory arrest
Why All the Concern?
Withholding life-sustaining treatment
 CMO-Does not mean abandoning the
patient
 1983: The President’s Committee for the
Study of Ethical Problems in Medicine
 “Deciding to Forgo Life-Sustaining
Treatment”

Ethical Principles
Autonomy
 Beneficence
 Nonmaleficence
 Justice
 Truth-telling
 Promise-keeping

Ethical Issue Analysis
1.
2.
3.
4.
Medical Indications
Patient preferences
Quality of life
Contextual features
Quality of Life
Object of medical intervention is to
restore, maintain, or improve quality of
life
 Whose quality is used for judgment?
 Subject to bias & prejudice
 General measures: mobility, performance
of activities of daily living, absence of
pain, social interaction, mental acuity

Contextual Issues

Should be evaluated in terms of their:
 Psychological, emotional financial,
legal, scientific, educational, religious
impact on patient & others
Paternalism
The days of the physician making
independent decisions are gone.
 Today’s standard—self-determinism

One Ethical Principle

Respect for Autonomy means:
 Self-determination to make choices based
on one’s own values & belief system
 Others refrain from interfering with choices
 Patient free from coercion in deciding to act
 True informed consent
 One should tell the truth
 Privacy and confidentiality respected
Definition of Death

An Individual who has sustained either:
1. Irreversible cessation of circulatory and
respiratory functions, OR
2. Irreversible cessation of all functions of the
entire brain, including the brain stem
1980 Uniform Determination of Death Act
Comfort Measures Only
Shift of goal from curative to palliative
 Therapeutic measures directed towards
comfort
 Excludes specific interventions as listed
on “Resuscitative Status Form”

Resolution of Conflicts
If irreconcilable w/ moral view-withdraw
& provide alternative care
 If conflict with generally accepted
standards or policies-concern should be
voiced to appropriate institutional body
 If this is not possible within time-frame
then care should adhere to patient’s
directives

ASA House of Delegates Oct. 1993. amended 2001
Vegetative State


Loss of cognitive neurological function and
awareness of the environment. Retention of
noncognitive function and a preserved sleep-wake
cycle.
Sometimes described as when a person is technically
alive, but his/her brain is dead. That description is not
completely accurate. In a persistent vegetative state
the individual loses the higher cerebral powers of the
brain, but the functions of the brainstem, such as
respiration (breathing) and circulation, remain
relatively intact.
National Institute of Neurological
Disorders and Stroke,
National Institutes of Health
Decision-Making
Competent person
 Family
 Court
 Substituted judgment (based on what the
patient would have wanted)
 Surrogate (based on what the surrogate
believes is right)

Surrogate Decision-Making
Hierarchy
1.
2.
3.
4.
5.
Legal guardian
Spouse
Adult children
Parents of patient
Adult siblings of patient
Institutional or Judicial Review
No family member wants to be surrogate
 Dispute among family members
 Provider does not believe patient would
have made specific decision
 Provider does not believe decision could
be reasonably judged in the patient’s best
interest

AMA Code of Ethics, 150th edition
Ethics Committee
To act as a consultant in difficult
medical/ethical cases
 Forum for open and free discussion
 Review of cases involving ethics
 Education in Ethics

Approach to Patient

Discussion with patient regarding:
 Quantitative likelihood of various
outcomes
 Qualitative aspects of outcomes and
meaning to patient & family
 Burden of reaching various quantitative
and qualitative outcomes
Dilemmas-Values in Conflict

Conflicting
 Values
 Rights
 Duties
 Ethical
principles
Ethical Principles
Autonomy
 Beneficence
 Nonmaleficence
 Justice
 Truth-telling
 Promise-keeping

Approach to
Comfort Measures Only
Sensitivity to the issues
 Empathy
 Founded in ethics
 Familiarity with guidelines & protocols
 Sound communication with patient,
family, health-care team
