A DNR is a medical order written by doctor that a patient is not to be given a resuscitative effort if the patient's breathing or heart stops. It is written to help make decision especially when the patient is facing serious or terminal illness and is usually set up before emergency. The patient's wishes are expressed in the DNR and are respected by the hospital professionals and doctors. Advanced DNR allows a patient to make informed decision about the care the patient would like to receive. The patient is given an opinion and advice from medical expert concerning advantages and disadvantages of having a DNR order (Tomlinson & Brody 1988).
A DNR is normally signed by patient's physician after the patient has made decision that he or she needs it. In this case, the patient has lost consciousness before the DNR is signed; therefore, a decision has to be made with respect to wishes of the patient and his or her best interest. The nurse is obliged to prioritize commitment to the patient and thus should ensure that the wishes of the patient are respected. Since the patient expressed the desire not to have resuscitation, the nurse should ensure that the patient has the DNR. A personal welfare deputy can be appointed to make decision on behalf of patient since patient is not in a position to make decision or a surrogate can make decision on the patient's behalf. The family of the patient is usually involved in the process of decision making; they are allowed to understand the wishes of the patient before the decision is made.
Potential dilemma the nurse may face is that patient expressed the wish not to have resuscitation though it had not been written by the time he passed out; however, the healthcare physicians and the family have concern about the wishes of the patient because they have concern that if CPR is performed on the patient, it may help save his life. Since the DNR is decided on the basis of patient's best interest, it may end up in resuscitation which is against the patient's wishes. Therefore, the nurse, being in charge of the patient should ensure that a decision concerning resuscitation is made since the patient was not able to sign because he became unconscious. The patient expressed wish not to be resuscitated; this forms basis for decision making and makes it easier.
The advance directive DNR has compliance with patient's decision; it has legal implication such that it cannot be overridden. Since the patient is not able to make decision, a surrogate can make decision on his behalf which is made easier since the patient asserted interest in having DNR. The family and the hospital organization have to comply and respect the DNR.
Under ANA code of ethics, the fourth provision states that a nurse has authority and responsibility to carry out nursing practice and is accountable to make decision and takes action with the aim of ensuring promotion of health and provision of better services (ANA, 2001). The nurse is responsible and has authority to protect the wishes of the patient. The patient is liable to make decision to ensure that the patient gets the services he requires.
The patient in this case expresses the wish not to be resuscitated and therefore, the nurse is accountable and responsible to respect and carry out the patient's wishes since he or she is bound to be committed to providing care to the patient. Since the patient loses consciousness before the DNR is signed, the nurse has authority and responsibility to advocate for the patient wishes in decision to have DNR on patient's behalf.
Patient autonomy is defined by the right of a patient to make personal decision concerning his or her medical condition. It allows a patient to make informed decisions on the course of treatment. Besides, it allows physician to provide medical advice to the patient but not to make decision on behalf of the patient. It provides principle to seek the consent of a patient before carrying out treatment (Entwistle et al., 2010).
When DNR is written, it has legal implications. DNR relies on patient's autonomy, which implies that it is written with the consent of the patient (Zimmerman et al., 1986). In this case, the patient wishes not to be resuscitated but becomes unconscious before he signs the DNR. The nurse is bound by ANA code of ethics to carry out the wishes of the patient however the family and the medical professional in the organization have an opinion that the patient can be given resuscitation and can be treated.
Since the patient became unconscious before he signed the DNR, the decision concerning the resuscitation has to be made. The personal welfare deputy who makes decision on behalf of the patient with involvement of the family may want to decide that the patient should be resuscitated because if it carried out, advantages outweigh the advantages in that the patient has capability to be treated and recover. Thus, the nurse may be put in compromising situation whether to agree with the family or uphold the decision of the patient.
The nurse should convince the family and the personal welfare deputy that the decision of resuscitation lies on the wishes of the patient who had previously wanted to sign the DNR and therefore respect the wishes and that the patient is an adventurous man who would not wish to compromise the quality of his life. If they go on to resuscitate him, he will have the quality of his life compromised and may lead a court case against the organization.
American Nurses Association. (2001). Code of ethics for nurses with interpretive statements. Nursesbooks. org.
Entwistle, V. A., Carter, S. M., Cribb, A., & McCaffery, K. (2010). Supporting patient autonomy: the importance of clinician-patient relationships. Journal of general internal medicine, 25(7), 741-745.
Tomlinson, T., & Brody, H. (1988). Ethics and communication in do-not-resuscitate orders.
Zimmerman, J. E., Knaus, W. A., Sharpe, S. M., Anderson, A. S., Draper, E. A., & Wagner, D. P. (1986). The use and implications of do not resuscitate orders in intensive care units. Jama, 255(3), 351-356.
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