Do Not Resuscitate (DNR) orders, simply put, instruct medical personnel not to initiate CPR upon the patient in case of a cardiac arrest (New York State Department of Health, 2012, p. 1), and they remain a subject of controversy in the medical profession. In their paper on “Ethics and Communication in Do Not Resuscitate Orders”, Dr. Tom Tomlinson and Dr. Howard Brody give a thoughtful look at this very emotional issue. This paper will discuss arguments around the possibility of no medical benefits of CPR, the possibility of poor quality of life after CPR and the possibility of poor quality of life before CPR; it will conclude with a discussion on what recommendations Dr. Tomlinson and Brody make for dealing with these orders.
No Medical Benefit from CPR
The first argument with Brody and Tomlinson lay out in their paper is that there are cases in which the patient would receive no medical benefit from the physician giving CPR, and that while patients do have the right to request treatment and the physician needs to listen to their concern, patients do not have the right to request treatment that the physician believes would offer no benefit to the patient. The authors use an example of giving antibiotics to a patient with a cold, even though it is known that antibiotics have no affect on the course of a virus. (Tomlinson & Brody, 1990, p.1276). Another good example would be, for instance, a patient who has long-term, end-stage congestive heart failure being given CPR, only to die in the ambulance on the way to the hospital because the heart has simply given out. It could be argued that the patient has derived no medical benefit from the procedure and that the end result – the death of the patient – was the same.
Poor Quality of Life After CPR
Another argument the the authors make in regards to resuscitation is the problem with a poor patient quality of life after CPR has been performed. Physicians and other clinicians have a moral obligation to do no harm to their patients (Tomlinson & Brody, 1990, p 1277 ), and this is a value that can be shared by both the patient and clinician. If a physicians feels that the patient’s quality of life after CPR is performed will be poor, that can be argued as a good reason for withholding CPR. A good example of this would be, for instance, a patient with advanced stage Alzheimer’s disease who could be resuscitated with CPR: the CPR itself could prove to be effective in the sense that it saves the person from the immediate prospect of death, but their quality of life afterward would still be poor: in the advanced stages of Alzheimer’s, the patient is completely dependent upon caregivers for all ADL,s including feeding and toileting and can also suffer from confusion and the stress associated with “sun-downing”. Also, it should be noted that for terminally or seriously ill patients, CPR can sometimes only be partially successful and that this can “lead to patient brain damage or leave the patient in a worse medical state than before CPR was performed” (New York State Department of Health, 2012, p. 2). The value here is to place more emphasis on quality of life than quantity of life.
Poor Quality of Life Before CPR
The third argument that Tomlinson and Brody discuss is the issue of poor quality of life before CPR is even considered. The authors argue that it could jeopardize medical practice in general “if the smallest likelihood of survival requires the physical to offer CPR” (Tomlinson & Brody, 1990, p.1277) and that it lies within the physician’s scope of practice to be able to make the values judgments that are part of clinical practice – and not just in cases of life-or-death situations. The example that the authors use is a good one: the question of whether or not to withhold CPR from a patient who has advanced stage metastatic cancer and who already likely has a poor quality of life from pain issues and other symptoms associated with advanced stage cancer. Again, the value here is a matter of quality v. quantity of life, and it is indeed a values judgment.
INCLUDING PATIENT VALUES IN THE DNR ORDER
What Tomlinson and Brody advocate in their paper is that the issue of the DNR order be a matter of “shared power” between the patient and the clinician; they believe that is shared power will come about through what they call “effective social dialogue” between the patient, the patient’s family, and the physician and that the end result will, hopefully, be something that allows for both patient autonomy and the physician’s need for the authority to make the sometimes difficult medical decisions about what course of treatment to offer their patients. They also note that, in this era of trying to cut healthcare costs, that the difference between treatment that would be futile and treatment that would not be cost effective should be made very clear at the outset to patients and their families (Tomlinson & Brody, 1990, p. 1280). Like many end-of-life issues, the controversy surrounding DNR orders is not likely to go away any time soon, but Tomlinson and Brody seem to be promoting a way of discussing this emotional issue that balances the need for patient autonomy with the need for physician authority.
New York State Department of Health. (2012)“Do Not Resuscitate Orders: A Guide for Patients and Families” Retrieved from: www.wings.buffalo.edu/bioethics/dnr-p.html
Tomlinson, T. and Brody, H. (1990). “Futility and the Ethics of Resuscitation”. Journal of the American Medical Association. 264 (10) 1276-1280