- References revised and corrected
- Media added (video)
- Grammar revised and corrected
“Death is the last intimate thing we ever do” – Laurell K. Hamilton
How intimate is death really? And how do we deal with something that is so intimately inevitable, but in the same breath, also on odd occasion in the hands of a stranger?
As students in the health care service, we are faced with unexpected challenges daily. We are forced to deal with certain situations appropriately and accordingly, although it might be the very first time we encounter such an event or situation.
During a clinical rotation, I had grown particularly fond of a certain patient, despite my conscience constantly knocking on the door to tell me I should know better. The patient was diagnosed with a chronic illness that wasn’t terminal at that stage, but as time went on and due to opportunistic infections, the patient’s body stopped responding to treatment and the doctors gave him a very poor prognosis. Upon hearing about his prognosis and knowing the extent of his condition and the damage that had already been done, the patient together with his family decided to sign a DNR. I was not aware of this signage and kept treating the patient as I normally would every day. I was dumbstruck by the patient’s motivation and healthy outlook on life, despite his prognosis and the fact that he had to leave his wife and young children behind very soon. This had affected me in a much greater way than I initially realised.
One day in the ward, just before I was about to go into his room to treat him and just after I came across the DNR in his folder, I suddenly felt as if I was in an episode of some American medical drama series. Screeching wheels of crash carts, beeping vitals monitors, dropping sats and the sound of the doctor asking for adrenaline to be administered via IV. I stood in the doorway watching this “episode” as reality finally hit me in the middle of my forehead like a ton of bricks by the words “are you his physio? could you please jump in and suction?”. As desperately as I wanted to help the patient, the words DNR flashed in front of my eyes. I replied to the doctor with, “I’m sorry doctor, but does this patient not have a DNR?” The doctor had a dumbfounding expression on his face, but despite his shock he carried on in his attempt to save the patient’s life and insisted that I assist with the resuscitation.
I felt as if I was trapped between a rock and a hard place as I desperately wanted to help save this man’s life, but my training and the law had prohibited me to do so.
This brings me to the question, life vs death – who decides? This question could be applied to various situations in the medical profession. What about abortion? What about suicide? What about euthanasia? And moreover, what about our beliefs, values and morals? How does all of this link into each other and match in perfect harmony? Is there even any harmony between these factors?
In this particular situation, I felt that the patient’s rights were violated as he had signed the DNR order, but the doctor went against his wishes.
A study by Trivedi (2013) evaluated the perspectives of physicians on resuscitation status and DNR order in terminally ill patients. The study concluded that there are complex psychosocial, medical, ethical and emotive aspects associated with placing a DNR order. It is essential that the patient, the patient’s family as well as the doctor responsible for the patient are all on the same page. This study also found that patients, their loved ones as well as the junior staff involved in the care of the patient requires early communication and briefing for better acceptance of DNR.
In a reflective account on an ethical dilemma by Jones (2007), Jones writes that healthcare professionals face dilemmas on a daily basis and these vary between vital life and death decisions that need to be made within seconds compared to dilemmas where time constraints are not an issue. Healthcare professionals are expected to make particular decisions based on their knowledge of ethical principles and best judgement informed by a professional code, rather than be influenced by personal emotion or beliefs. However, healthcare professionals are only human and can have lapses in judgement and make poor decisions for which they are then professionally accountable.
Braddock and Clark (1998) writes about the role of patient autonomy, which in my opinion gets overlooked or dismissed sometimes. They state that the rights of adult patients and their surrogates must be respected when it comes to making medical decisions. This is otherwise known as respect for autonomy or respect for persons. This is reinforced legally in the Patient Self Determination Act of 1991 which requires hospitals to respect the adult patient’s right to make an advanced care directive and clarify wishes for end-of-life care. Furthermore, it is emphasized that communication between patients with their families and medical staff needs to be improved and this improvement is preferred over physicians making unilateral decisions based on appeals to medical futility regarding the resuscitation status of their patients.
In some cases, I feel that doctors or other medical professionals do not respect the DNR order as they simply have a poor understanding of what it is and how it is implemented. Here is a video that explains the DNR order:
I believe that as it is a patient’s right and responsibility to be informed about all the possible options, to be able to choose from a variety of services and to have all the accurate and adequate information to make a decision, this decision about whether or not a patient’s life should end lies solely in the hands of the patient (or his/her family) with or without a DNR order. The doctor should merely give his medical opinion and then let the patient decided. Once the decision has been made, it needs to be respected regardless of whether or not the doctor believes the patient still has a long time to live his life.
Braddock C, Clark J (1998). Do Not Resuscitate (DNAR) Orders. Retrieved on September 28th, 2016 from https://depts.washington.edu/bioethx/topics/dnr.html
Horizon Bay (2015). What is a DNR order? Retrieved November 1st, 2016 from https://www.youtube.com/watch?v=ay9xTt6jSW0
Jones, J. (2007). Do not resuscitate: reflections on an ethical dilemma. Retrieved on September 26th, 2016 from http://journals.rcni.com/doi/pdfplus/10.7748/ns2007.07.21.46.35.c4587
Trivedi, S. (2013). Physician perspectives on resuscitation status and DNR order in elderly cancer patients. Retrieved on September 26th, 2016 from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3863213/