Ethical Dilemma

Ethical Dilemma

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Ethical Dilemma

 Master’s prepared nurses face several complex ethical dilemmas in their practice, for which they have to take a nursing position based on best evidence-based practices. One such complex ethical dilemma is related to do-not-resuscitate orders given by a patient or the physician. Although nurses are obliged to provide ethical care, patient resuscitation is often a complex situation that a graduate nurse will often confront during nursing practice (Robbins, 2021). This situation has been complicated further by the ongoing Covid-19 pandemic in which elderly patients have required protracted care amid high fatality risk (Curtis, Kross & Stapleton, 2020). Besides, although resuscitation can restore life, it can also prolong the suffering of and injure patients.

The purpose of the ensuing discussion is to identify the ethical dilemma surrounding a do-not-resuscitate order (DNR) and how it affects patients, nursing practice, and the research process. After formulating a research question related to this order, a graduate nurse should comply with it based on the evidence of the possible adverse resuscitation outcomes. The advantageous use of information technology in addressing this ethical dilemma is also discussed.

Description of a Do-Not-Resuscitate Order as an Ethical Dilemma

A do-not-resuscitate order (DNR) is a directive ordered by a medical doctor instructing healthcare providers, including nurses, not to perform cardiopulmonary resuscitation (CPR) if a patient stops breathing or his or her heart stops beating. This includes the denial of mouth-to-mouth resuscitation, intubation to open up the airway, and electrical cardioversion or defibrillation (Robbins, 2021). This order is made following consultation and agreement with the patient. However, without a patient’s consent or instruction, a family member or a proxy designated by the patients can provide their consent. Such orders, once given, cannot be overridden by any other individual apart from the patient. Although a do-not-resuscitate order adheres to the patient’s right to autonomy, it may present an ethical dilemma to graduate nurses because it may contradict their duty for care and save lives.

Impact of a Do-Not-Resuscitate Order

Once a do-not-resuscitate order has been issued, a nurse cannot perform cardiopulmonary resuscitation (CPR) when the patient undergoes an emergency. The outcome of refusing to perform cardiopulmonary resuscitation (CPR) has a significant impact on the patients, nursing practice, and the research process.

On Patients

A do-not-resuscitate order can lead to the death of a patient. A patient that is not breathing cannot deliver oxygen to the brain and vital organs in the body. These organs are starved of oxygen and can stop functioning. Similarly, a ceased heart will not pump blood and, in turn, not deliver oxygen and vital nutrients to the brain and other organs in the body. The resulting oxygen starvation kills the brain and other vital organs in the body. Notably, elderly patients with Covid-19 and comorbidities have easily requested this order to avoid prolonged life support (Curtis, Kross & Stapleton, 2020). Therefore, the patient must be well informed about the consequences of requesting and consenting to a do-not-resuscitate order. Besides, the order must conform to the patient’s beliefs and values (Naghshbandi et al., 2019). Balancing these considerations can challenge a misinformed patient.

On Nursing Practice

A do-not-resuscitate order places nurses in a precarious and confusing situation. For nursing practice, such an order raises the question of the patient’s autonomy against the beneficence of the order. Patients have the right to autonomy, which means they can refuse any form of medical care (Engels et al., 2020). In other words, patients have a right to make their own decisions related to medical care without being influenced by healthcare providers, including nurses. It also means that patients have a right to self-determination. This right indicates that patients can accept or refuse suggested treatment or care, and in this case, resuscitation in case of an emergency. In this regard, a graduate nurse should not make a resuscitation decision for a patient, or apply or deny providing a patient with resuscitation if the patient does not will it, regardless of his or her state of mind.

On the other hand, graduate nurses also have significant autonomy based on their advanced professional position tenets. This means that graduate nurses can make decisions about patient care without consulting the physician. This is particularly critical when a nurse has to make a swift decision to optimize the quality of care. However, the nurse’s autonomy is bounded by the non-critical health environment, which does not require the involvement of a doctor’s consultation.

On the Research Process

A do-not-resuscitate order is based on the knowledge about the patient and his or her current and pre-existing health conditions. A graduate nurse is expected to be familiar with the correct interpretation of the do-not-resuscitate order. In this regard, master’s prepared nurses are expected to be conversant with other terminologies related to do-not-resuscitate orders that often bring confusion in nursing practice, such as allowing natural death of a patient and the current use of such terms to avoid miscommunication (Engels, et al., 2020). Besides, the graduate nurse must be familiar with the patient’s conditions that could influence the resuscitation outcomes, either positively or adversely.

Such understanding of the application of do-not-resuscitate orders requires graduate nurses to continuously upgrade their knowledge using the current evidence and evidence-based practice surrounding resuscitation. Resuscitation efficacy is unique to every patient and its outcomes vary across patients, despite the incredible advancements in in-hospital and out-of-hospital resuscitation techniques and technologies.  

Research Question

The suggested research question related to the do-not-resuscitate order is what would be the patient’s conditions that would necessitate the adherence to a do-not-resuscitate order?

Position on a Do-Not-Resuscitate Order

The position to the ethical dilemma associated with the do-not-resuscitate order is that such an order should be adhered to, provided the patient provides informed consent. Compliance with this order is ethical because it respects the patient’s right to self-determination and autonomy. However, while graduate nurses should comply with this order, they should not abscond on their duty to care. Upon knowing that a patient has requested and consented to a do-not-resuscitate order, it is the graduate nurse’s duty to ensure that the patient still receives the highest quality of care before an emergency, such as a cardiac arrest and sudden cessation of breathing (Engels, et al., 2020). Besides, the graduate nurse has a duty of helping the patient and his or her family understand the implications of such an order and providing as much support as possible.

Advantage Information Technology May Have On a Do-Not-Resuscitate Order

Information technology has become an integral tool for graduate nurses. One critical advantage information technology presents to the dilemma associated with a do-not-resuscitate order is to facilitate the acquisition of knowledge and the latest evidence to guide the nurse’s evidence–based practice. Information technology enables graduate nurses to access data about the efficacy of resuscitation across patients with diverse conditions, which could justify compliance with the do-not-resuscitate order. In the same vein, information technology can help graduate nurses access the latest research-based evidence regarding advancements in resuscitation and the outstanding complications.

Conclusion

A do-not-resuscitate order presents an ethical dilemma to graduate nurses. It implies that graduate nurses should let a patient die following an emergency arrest by withholding resuscitation efforts. Although, this conflicts with the nurses’ mandate of offering the highest level of care to patients, the order’s ethical implication is that patients have a right of self-determination and autonomy, which makes compliance to such an order ethical. Nonetheless, the graduate nurses must continuously update their evidence-based knowledge to facilitate the execution of this order and support patients and their families pending the execution of such an order.

References

Curtis, J. R., Kross, E. K., & Stapleton, R. D. (2020). The importance of addressing advance care planning and decisions about do-not-resuscitate orders during novel coronavirus 2019 (COVID-19). JAMA, 323(18), 1771-1772. https://doi.org/10.1001/jama.2020.4894

Engels, R., Graziani, C., Higgins, I., Thompson, J., Kaplow, R., Vettese, T. E., & Massart, A. (2020). Impact of do-not-resuscitate orders on nursing clinical decision making. Southern Medical Journal, 113, 330-336. https://doi.org/10.14423/smj.0000000000001112

Naghshbandi, S., Salmasi, S., Parsian, Z., & Rahmani, F. (2019). Attitude of nurses in intensive care units towards Do Not Resuscitate order. Journal of Research in Clinical Medicine, 7(4), 122-128. https://doi.org/10.15171/jarcm.2019.023

Robbins, K. C. (2021). Do-not-resuscitate orders–What exactly do they mean? Nephrology Nursing Journal, 48(4), 421-423. https://doi.org/10.37526/1526-744X.2021.48.4.421