WHAT DOES DNR WHAT DOES DNR REALLY MEAN?REALLY MEAN?

COMFORT MEASURES ONLYCOMFORT MEASURES ONLY

C. Antonio Jesurun, MDC. Antonio Jesurun, MD

Professor of PediatricsProfessor of Pediatrics

Director of Neonatal Intensive CareDirector of Neonatal Intensive Care

June 29, 2005June 29, 2005

Resuscitation or CPRResuscitation or CPR

Medical procedure which seeks to restore Medical procedure which seeks to restore cardiac and/or respiratory function to cardiac and/or respiratory function to individuals who have sustained a individuals who have sustained a cardiac/respiratory arrestcardiac/respiratory arrest

Why All the Concern?Why All the Concern?

Withholding life-sustaining treatmentWithholding life-sustaining treatment CMO-Does not mean abandoning the CMO-Does not mean abandoning the

patientpatient 1983: The President’s Committee for the 1983: The President’s Committee for the

Study of Ethical Problems in MedicineStudy of Ethical Problems in Medicine ““Deciding to Forgo Life-Sustaining Deciding to Forgo Life-Sustaining

Treatment” Treatment”

Ethical PrinciplesEthical Principles

AutonomyAutonomy BeneficenceBeneficence NonmaleficenceNonmaleficence JusticeJustice Truth-tellingTruth-telling Promise-keepingPromise-keeping

Ethical Issue AnalysisEthical Issue Analysis

1.1. Medical IndicationsMedical Indications

2.2. Patient preferencesPatient preferences

3.3. Quality of lifeQuality of life

4.4. Contextual featuresContextual features

Quality of LifeQuality of Life

Object of medical intervention is to restore, Object of medical intervention is to restore, maintain, or improve quality of lifemaintain, or improve quality of life

Whose quality is used for judgment?Whose quality is used for judgment? Subject to bias & prejudiceSubject to bias & prejudice General measures: mobility, performance General measures: mobility, performance

of activities of daily living, absence of of activities of daily living, absence of pain, social interaction, mental acuity pain, social interaction, mental acuity

Contextual Issues Contextual Issues

Should be evaluated in terms of their:Should be evaluated in terms of their: Psychological, emotional financial, Psychological, emotional financial,

legal, scientific, educational, religious legal, scientific, educational, religious impact on patient & othersimpact on patient & others

PaternalismPaternalism

The days of the physician making The days of the physician making independent decisions are gone.independent decisions are gone.

Today’s standard—self-determinismToday’s standard—self-determinism

One Ethical PrincipleOne Ethical Principle Respect for Autonomy means:Respect for Autonomy means:

Self-determination to make choices based Self-determination to make choices based on one’s own values & belief systemon one’s own values & belief system

Others refrain from interfering with choicesOthers refrain from interfering with choices Patient free from coercion in deciding to actPatient free from coercion in deciding to act TrueTrue informed consent informed consent One should tell the truthOne should tell the truth Privacy and confidentiality respectedPrivacy and confidentiality respected

Definition of DeathDefinition of Death

An Individual who has sustained either:An Individual who has sustained either:

1. Irreversible cessation of circulatory and 1. Irreversible cessation of circulatory and respiratory functions, respiratory functions, OROR

2. Irreversible cessation of all functions of the 2. Irreversible cessation of all functions of the entire brain, including the brain stementire brain, including the brain stem

1980 Uniform 1980 Uniform Determination of Death ActDetermination of Death Act

Comfort Measures OnlyComfort Measures Only

Shift of goal from curative to palliativeShift of goal from curative to palliative Therapeutic measures directed towards Therapeutic measures directed towards

comfortcomfort Excludes specific interventions as listed Excludes specific interventions as listed

on “Resuscitative Status Form”on “Resuscitative Status Form”

Resolution of ConflictsResolution of Conflicts

If irreconcilable w/ moral view-withdraw If irreconcilable w/ moral view-withdraw & provide alternative care& provide alternative care

If conflict with generally accepted If conflict with generally accepted standards or policies-concern should be standards or policies-concern should be voiced to appropriate institutional bodyvoiced to appropriate institutional body

If this is not possible within time-frame If this is not possible within time-frame then care should adhere to patient’s then care should adhere to patient’s directivesdirectives

ASA House of Delegates Oct. 1993. amended 2001ASA House of Delegates Oct. 1993. amended 2001

Vegetative StateVegetative State Loss of cognitive neurological function and Loss of cognitive neurological function and

awareness of the environment. Retention of awareness of the environment. Retention of noncognitive function and a preserved sleep-wake noncognitive function and a preserved sleep-wake cycle. cycle.

Sometimes described as when a person is technically Sometimes described as when a person is technically alive, but his/her brain is dead. That description is not alive, but his/her brain is dead. That description is not completely accurate. In a persistent vegetative state completely accurate. In a persistent vegetative state the individual loses the higher cerebral powers of the the individual loses the higher cerebral powers of the brain, but the functions of the brainstem, such as brain, but the functions of the brainstem, such as respiration (breathing) and circulation, remain respiration (breathing) and circulation, remain relatively intact.relatively intact.

National Institute of Neurological National Institute of Neurological Disorders and Stroke,Disorders and Stroke,National Institutes of HealthNational Institutes of Health

Decision-MakingDecision-Making

Competent person Competent person FamilyFamily CourtCourt

Substituted judgment (based on what the Substituted judgment (based on what the patient would have wanted)patient would have wanted)

Surrogate (based on what the surrogate Surrogate (based on what the surrogate believes is right)believes is right)

Surrogate Decision-Making Surrogate Decision-Making HierarchyHierarchy

1.1. Legal guardianLegal guardian

2.2. SpouseSpouse

3.3. Adult childrenAdult children

4.4. Parents of patientParents of patient

5.5. Adult siblings of patientAdult siblings of patient

Institutional or Judicial ReviewInstitutional or Judicial Review No family member wants to be surrogateNo family member wants to be surrogate Dispute among family membersDispute among family members Provider does not believe patient would Provider does not believe patient would

have made specific decisionhave made specific decision Provider does not believe decision could Provider does not believe decision could

be reasonably judged in the patient’s best be reasonably judged in the patient’s best interestinterest

AMA Code of Ethics, 150AMA Code of Ethics, 150thth edition edition

Ethics CommitteeEthics Committee

To act as a consultant in difficult To act as a consultant in difficult medical/ethical casesmedical/ethical cases

Forum for open and free discussionForum for open and free discussion Review of cases involving ethicsReview of cases involving ethics Education in EthicsEducation in Ethics

Approach to PatientApproach to Patient

Discussion with patient regarding:Discussion with patient regarding: Quantitative likelihood of various Quantitative likelihood of various

outcomesoutcomes Qualitative aspects of outcomes and Qualitative aspects of outcomes and

meaning to patient & familymeaning to patient & family Burden of reaching various quantitative Burden of reaching various quantitative

and qualitative outcomesand qualitative outcomes

Dilemmas-Values in ConflictDilemmas-Values in Conflict

ConflictingConflicting ValuesValues RightsRights DutiesDuties Ethical principlesEthical principles

Ethical PrinciplesEthical Principles

AutonomyAutonomy BeneficenceBeneficence NonmaleficenceNonmaleficence JusticeJustice Truth-tellingTruth-telling Promise-keepingPromise-keeping

Approach to Approach to Comfort Measures OnlyComfort Measures Only

Sensitivity to the issuesSensitivity to the issues EmpathyEmpathy Founded in ethicsFounded in ethics Familiarity with guidelines & protocolsFamiliarity with guidelines & protocols Sound communication with patient, Sound communication with patient,

family, health-care teamfamily, health-care team