L.E.A.R.N – Critical Analysis Paper
I. Look Back
In one significant scenario that happened in the operating room, a 78-year-old patient diagnosed with aspiration pneumonia with presence of foreign objects was rushed inside the O.R for removal of aspirated objects and fluids. Upon entry, the patient was already experiencing severe difficulty of breathing with rate of 36 breaths/min (hyperventilation; tachypnea), chest pains and tachycardic heartbeat of 120 beats per min. However, an ethical-clinical issue arises with patient’s noted DNR status, which greatly compromises the health care provider’s ability to rescue the patient without conforming to different procedures and forms of life-support.
The issue on conducting life-saving clinical procedures on patients with DNR orders has always been an ethical and clinical issue in the field of healthcare. Rudolfo – a 78-year-old male- has an aspirated fluids and solid substances from his meal after he accidentally lost control of his swallowing. At that time, the patient was already on his 2nd week of admission and recovering from knee fracture. DNR request was placed after his hip fracture surgery. The tasked health care provider, family members and the patient had reviewed the request, found basis for approval and eventually agreed of granting his request. After approval, Rudolfo was expecting to proceed with his home treatment at home after the 3rd week of his recovery; however, in his 2nd week of admission, the accidental aspiration occurred leaving him in-need of a manual removal of aspirated substances.
Prior to the surgery, the health care provider emphasized the need to use general anesthesia on the patient for them to operate manually on the patient’s thoracic area. However, general anesthesia may lead to series of hemodynamic instability that may require periods of resuscitation as the procedure’s follow-up maneuver. In this case, the surgery had to suspend the DNR status of the patient in order to alleviate the patient ‘s discomfort; although, suspending DNR order could mean bypassing the patient’s rights of autonomy and possibly breach the agreement between the patient and health care provider in relation to the approved DNR status. In this discussion, I will explore the existing and possible ethical-clinical conflicts in rendering surgical interventions for a patient with DNR status.
Ethical-clinical conflicts of duty, autonomy and role fidelity confronted the case of Mr. Rudolfo. In order for the health care provider to alleviate the patient’s discomfort and life-threatening status, the health care provider must suspend the DNR order and render a manual surgical removal of the aspirated substances. However, by doing so, the agreed DNR status of the patient will be bypassed defeating the actual agreement and legally acknowledged rights of the patient. According to Rothstein, Brody and McCullough et al. (2001), in order for patients to gain the benefit of surgery, DNR patients must agree in the temporary suspension of their DNR status (p.245). DNR status prevents the required follow-up maneuver for possible arrests or hemodynamic changes during surgery, which can only be resolved through forms of resuscitation. According to Ahronheim, Moreno and Zuckerman (2005), if the coverage of resuscitation includes any procedure or intervention used to maintain life during a cardiac arrest, then by theory health care providers rendering operations to patients with DNR status are prohibited from using any form of resuscitative forms of interventions during cardiac arrests (p.243).
DNR order, considered as an advance directive, is the legally and ethically acknowledged decision of the patient to withhold any forms of CPR or cardiopulmonary resuscitation in the event of a cardiac or respiratory arrest (Murray, 2002 p.47). The very purpose of DNR order is to “preserve the patient’s right of self-determination by limiting the use of modern-day technology during the terminal phase of illness” (Sieber, 2006 p.356). According to Marcucci (2007), DNR order has been originally created to serve the purpose of preventing resuscitation from cardiac arrest resulting from the terminally ill patient’s existing primary disease; however, the contents of rendering DNR order have become vaguely documented (p.832). The hallmark of this conflict relates to the vague distinction of resuscitation from the routinary anesthetic or surgical interventions (Sieber, 2006 p.356). DNR order is derived from the patient’s basic right of autonomy, which is usually expressed by default throughout the health care delivery processes.
Four significant reasons have bee cited by McCullough, Jones and Brody (1998) in relation to the conflicts of DNR status and life-saving surgical procedure (p.68). First, surgeries without grants of DNR suspension risk the name of the hospital, credentials of the health care provider and the statistical records of the institution’s O.R deaths, which can greatly affect the public standing of the surgical expertise at the involved institution. In the case of Mr. Rodolfo, if the risks associated to his condition led to unfortunate complications, such as death, the O.R credential and public figure may suffer untoward reactions from the community people. Secondly, since O.R is directly maneuvered by the health care provider’s verdict and well judgment, DNR orders can greatly compromise the health care providers’ available actions and alternatives limiting as well the credibility of surgical interventions possible. According to Marcucci (2007), patients who undergo surgery ideally expect positive results and reasonable benefits from surgery; however, with DNR order immobilizing or limiting the capacities of both nurses and physicians, these expectations risk both the patient and the credentials of the professional (p.833). Nurses, physicians and surgeon is confronted by the conflict of fulfilling his role as a lifesaver, which conflicts with the patient’s right of autonomy, or adhering to the patient’s DNR request and bypassing the health care provider’s role fidelity. Third, it is a generally accepted fact that patients under general anesthesia and surgical operations acquire significant risks of cardiac arrests or reversible life-threatening complications. According to Devettere (2000), there are cases when patients or proxies refuse to provide consent for DNR suspension, especially if they view the suspension as an unnecessary part of the procedure (p.246). Lastly, with all these considerations and consequences, DNR order implies the usage of health care provider, anesthesiologist, physicians and nurses involved in the surgery as agents of the patient’s assisted suicide. As stated by Devettere (2000), “by refusing a DNR order, the patient or proxies are really ordering, by default, other people to provide inappropriate medical treatment” (p.246).
In the analysis of the nursing actions, it is most significant to preserve a respectful attitude towards the patient’s right of autonomy. In this case, the best revision to employ would be to search out possible alternatives wherein delivery of surgical care will not compromise the patient’s rights, duty of the health care provider and success of the surgical procedure. According to Cohn, Smetana and Weed (2006), in a ideal situation of resolving DNR conflict during the need of perioperative procedures, involved health care provider and surgeon discuss the issue with the patient or candidate proxy (appointed through advanced directive) (p.36). Nurses function as the fundamental advocate of the patient’s rights; hence, it is part of their obligations to ensure that no breach of right occurs throughout the process of health care delivery. Some of the options available for health care providers confronted by a DNR patient requiring perioperative care are as follows: (a) suspension of DNR order documented and formalized through signed consent from both parties, (b) establish a procedure-directed order that selectively permits or prohibits specific resuscitative interventions (e.g. postoperative mechanical ventilation, tracheal intubation, chest compressions, etc.), and (c) establish goal-centered order set to emphasize the achieving of targeted surgical outcomes instead of procedure limitations (Sieber, 2006 p.356).
V. New Perspective
At the end of the scenario, respect for the patient’s rights and nurses’ tasks as the advocate of health care delivery have helped me evolved my understanding of nursing care delivery in the O.R. DNR order may be imposing and limiting in nature. Nurses are tasked to render aid in the process of care and to act as innate advocate of the patient throughout the process of health care interventions. As supported by the analysis made, despite the impositions of DNR or responses made by the patient, nursing actions are still important in planning and negotiating other alternatives from both physicians and patients.
Ahronheim, J. C., Moreno, J. D., & Zuckerman, C. (2005). Ethics in clinical practice. New York, London: Jones & Bartlett Publishers.
Cohn, S. L., Smetana, G. W., & Weed, H. G. (2006). Perioperative Medicine: Just the Facts. New York, U.S.A: McGraw-Hill Professional.
Devettere, R. J. (2000). Practical Decision Making in Health Care Ethics: Cases and Concepts. New York, London: Georgetown University Press.
Marcucci, C. (2007). Avoiding Common Anesthesia Errors. New York, London: Lippincott Williams & Wilkins.
McCullough, L. B., Jones, J., & Brody, B. A. (1998). Surgical Ethics. Oxfordshire, U.K: Oxford University Press US.
Murray, M. (2002). Critical Care Medicine: Perioperative Management. New York, U.S.A: Lippincott Williams & Wilkins.
Rothstein, M. A., Brody, B. A., & McCullough et al., M. B. (2001). Medical Ethics: Analysis of the Issues Raised by the Codes, Opinions, and Statements. New York, London: BNA Books.
Sieber, F. E. (2006). Geriatric Anesthesia. New York, London: McGraw-Hill Professional.