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Table of Contents
Think
Assess
Patient: Autonomy
Practitioner: Beneficence & Nonmaleficence
Public Policy: Justice
Conclude
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13. Do Not Resuscitate Order (DNR), DNAR, AND
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Good physicians [medical practitioners] are rarely dispassionate. They agonize and self-doubt over patients.
~ Siddhartha Mukherjee
(The Emperor of All Maladies)
Vanished Directive
The Mysterious DNR Order
It was a typical Tuesday afternoon at St. Mary’s Hospital. Dr. Jessica Wu was in charge of the emergency room that day, and she was busy attending to patients with various medical conditions. Suddenly, the overhead speaker announced a code blue in room 302, and Dr. Wu immediately rushed to the location.
When she arrived, she found that the patient, Mrs. Johnson, had gone into cardiac arrest. The patient was an 85-year-old woman who had been admitted to the hospital for pneumonia. Dr. Wu started performing CPR procedures, but then she noticed something odd. She couldn’t find a DNR order in Mrs. Johnson’s medical records.
As per the medical standard of care, Dr. Wu continued performing CPR on the patient. However, after a few minutes, the patient’s daughter, Ms. Johnson, arrived at the hospital and immediately questioned Dr. Wu about why she was performing CPR on her mother. Ms. Johnson informed Dr. Wu that her mother had signed a living will, which stated that she did not want to be resuscitated if she went into cardiac arrest.
Dr. Wu was taken aback as she had not found any such order in the patient’s medical records. She immediately stopped performing CPR and checked the medical records again. To her surprise, she found the DNR order tucked away in a separate section of the patient’s chart.
Dr. Wu was confused as to why the DNR order was not in the main section of the medical records. She investigated the matter further and discovered that the DNR order had been filed away in the wrong section by a new resident who was not familiar with the hospital’s filing system. This misfiling had caused confusion and delay in patient management.
Dr. Wu was relieved that she had stopped performing CPR on the patient, as she would have violated the patient’s autonomy and the principle of nonmaleficence. She learned that it is essential for healthcare providers to have candid discussions with patients about their preferences for CPR and DNR orders while they still have decisional capacity.
After the incident, Dr. Wu implemented a new protocol at St. Mary’s Hospital, which required all medical personnel to double-check the medical records to ensure that the DNR orders were in the right section. This protocol helped to prevent future misunderstandings and confusion.
The mysterious DNR order in Mrs. Johnson’s medical records had caused confusion and delayed patient management, but Dr. Wu had learned an important lesson. Healthcare providers must always have open communication with patients about their preferences for CPR and DNR orders, and they must double-check the medical records to ensure that the DNR orders are in the right section. Failure to do so can have serious consequences for the patient and the healthcare provider.
Abstract
A Do Not Resuscitate (DNR) order is a patient’s or surrogate’s decision not to undergo resuscitative procedures if they experience cardiopulmonary arrest. It is important for practitioners to have discussions with patients about cardiopulmonary resuscitation (CPR) procedures while they still have decisional capacity. In the absence of such a discussion or a living will, the medical standard of care is to perform CPR. However, if a DNR order is in place, CPR should not be performed. It is a misperception that a DNR order means a patient will receive less care. The patient should receive the same care as a non-DNR patient, excluding CPR. The decision to issue a DNR can be made by the patient, their surrogate as designated by their living will or by state law.
**
Think
[13:1] Do not resuscitate order (DNR), do not attempt resuscitation order (DNAR), and allow natural death order (AND) are all patient or surrogate decisions for the patient to not be subjected to resuscitative procedures if that patient were to have a cardiopulmonary arrest. Cardiopulmonary resuscitation (CPR) procedures typically include chest compressions, artificial ventilation, electrical cardioversion, and anti-arrhythmic medications.
Assess
Patient: 1) Autonomy
[13:2] Since the patient will not have the decisional capacity to provide or refuse consent for CPR while having a cardiopulmonary arrest, it becomes essential for the practitioner to have a candid discussion about CPR procedures before such an event occurs. Having a prior discussion recognizes the patient’s autonomous right to self-determination. Like any medical treatment, the patient has the legal and moral right to consent or decline the CPR treatment. If the CPR treatments are declined, then a DNR order will need to be entered into the medical records.
Practitioner: 2) Beneficence & 3) Nonmaleficence
[13:3] Normally, there is no time to determine the patient’s decisional capacity in a medical emergency or get a patient’s informed consent without increasing a serious risk of harm or death for the patient. Therefore, the moral principle of beneficence (do good) has the most weight, justifying the performance of the medical standards of care. Cardiopulmonary arrest fits this medical emergency criterion perfectly, and the medical standards of care is CPR. However, if, prior to the CPR procedures a DNR order is revealed, then CPR should not commence. If the DNR order is revealed while CPR is in progress, then CPR should be stopped. The basis of this judgment is that the patient has the legal and moral right for autonomous self-regulation regarding what others are allowed to do or are forbidden to do to the patient’s body. Reasons for a DNR may be because CPR was determined to be futile, more harmful and burdensome than beneficial, or not in line with the patient’s reasonable goals, values, and priorities. Under those conditions, a surrogate who authorizes a CPR order, or a healthcare provider who provides CPR against a patient’s wishes would be in violation of nonmaleficence (do no harm).
[13:4] A common misperception regarding DNR is the false belief that it will result in inferior or less quantitative and qualitative medical treatment or care than if the patient were not DNR. All medical treatments and patient management are identical for both the non-DNR patient and the DNR patient, with the only exception being CPR.
Public Policy: 4) Justice
[13:5] If the patient does not have decisional capacity, there is no living-will, no durable power of attorney (POA), no available surrogate, and no way of determining the patient preferences, then the practitioner should provide the medical standards of care.
Conclude
[13:6] A common misperception regarding DNR is that the DNR patient will receive less care or diminished patient management. The DNR patient should receive exactly the same care and management as the non-DNR patient, other than no CPR. DNR decisions are generally made by the patient, the patient’s surrogate as determined by the patient’s durable power of attorney (POA), or the patient’s surrogate as determined by state law such as the hierarchical list of the patient’s: spouse, adult offspring, either parent or adult sibling.
[13:7] In summary, DNR patients should receive the same care and management as non-DNR patients, with the exception of CPR. Decisions regarding DNR orders are generally made by the patient, their designated surrogate in a living will, or by state law. It is essential for medical practitioners to engage in open communication with patients about their preferences for CPR and DNR orders, in order to respect their autonomy and provide appropriate care.
**
13. Review Questions
1. Because a patient will not have decisional capacity when having a cardiopulmonary arrest, it is essential for the practitioner to have a candid discussion about CPR before such an event occurs.
2. Once CPR has commenced, it is against the medical standards of care to stop, even if it is revealed that there is a DNR order.
3. The practitioner must get the patient to provide informed consent for a DNR order, as surrogates do not have the authority to authorize a DNR order.
4. Although having a DNR order will diminish the standard medical care provided to the patient, at least the patients will not be subjected to futile treatment.
5. If the patient does not have decisional capacity, there is no living-will, no durable power of attorney (POA), no available surrogate, and no way of determining the patient preferences, then the practitioner should provide the medical standards of care.
**
CORRECT! 🙂
[13:2] Since the patient will not have the decisional capacity to provide or refuse consent for CPR while having a cardiopulmonary arrest, it becomes essential for the practitioner to have a candid discussion about CPR procedures before such an event occurs. Having a prior discussion recognizes the patient’s autonomous right to self-determination. Like any medical treatment, the patient has the legal and moral right to consent or decline the CPR treatment. If the CPR treatments are declined, then a DNR order will need to be entered into the medical records.
Wrong 😕
[13:2] Since the patient will not have the decisional capacity to provide or refuse consent for CPR while having a cardiopulmonary arrest, it becomes essential for the practitioner to have a candid discussion about CPR procedures before such an event occurs. Having a prior discussion recognizes the patient’s autonomous right to self-determination. Like any medical treatment, the patient has the legal and moral right to consent or decline the CPR treatment. If the CPR treatments are declined, then a DNR order will need to be entered into the medical records.
CORRECT! 🙂
[13:3] Normally, there is no time to determine the patient’s decisional capacity in a medical emergency or get a patient’s informed consent without increasing a serious risk of harm or death for the patient. Therefore, the moral principle of beneficence (do good) has the most weight, justifying the performance of medically medical standards of care. Cardiopulmonary arrest fits this medical emergency criterion perfectly, and the medical standards of care is CPR. However, if, prior to the CPR procedures, a DNR order is revealed, then CPR should not commence. If the DNR order is revealed while CPR is in progress, then CPR should be stopped. The basis of this judgment is that the patient has the legal and moral right for autonomous self-regulation regarding what others are allowed to do or are forbidden to do to the patient’s body. Reasons for a DNR may be because CPR was determined to be futile, more harmful and burdensome than beneficial, or not in line with the patient’s reasonable goals, values, and priorities. Under those conditions, a surrogate can authorize a CPR order, and providing CPR against a patient’s wishes would be a violation of nonmaleficence (do no harm).
Wrong 😕
[13:3] Normally, there is no time to determine the patient’s decisional capacity in a medical emergency or get a patient’s informed consent without increasing a serious risk of harm or death for the patient. Therefore, the moral principle of beneficence (do good) has the most weight, justifying the performance of medically medical standards of care. Cardiopulmonary arrest fits this medical emergency criterion perfectly, and the medical standards of care is CPR. However, if, prior to the CPR procedures, a DNR order is revealed, then CPR should not commence. If the DNR order is revealed while CPR is in progress, then CPR should be stopped. The basis of this judgment is that the patient has the legal and moral right for autonomous self-regulation regarding what others are allowed to do or are forbidden to do to the patient’s body. Reasons for a DNR may be because CPR was determined to be futile, more harmful and burdensome than beneficial, or not in line with the patient’s reasonable goals, values, and priorities. Under those conditions, a surrogate can authorize a CPR order, and providing CPR against a patient’s wishes would be a violation of nonmaleficence (do no harm).
CORRECT! 🙂
[13:3] Normally, there is no time to determine the patient’s decisional capacity in a medical emergency or get a patient’s informed consent without increasing a serious risk of harm or death for the patient. Therefore, the moral principle of beneficence (do good) has the most weight, justifying the performance of medically medical standards of care. Cardiopulmonary arrest fits this medical emergency criterion perfectly, and the medical standards of care is CPR. However, if, prior to the CPR procedures, a DNR order is revealed, then CPR should not commence. If the DNR order is revealed while CPR is in progress, then CPR should be stopped. The basis of this judgment is that the patient has the legal and moral right for autonomous self-regulation regarding what others are allowed to do or are forbidden to do to the patient’s body. Reasons for a DNR may be because CPR was determined to be futile, more harmful and burdensome than beneficial, or not in line with the patient’s reasonable goals, values, and priorities. Under those conditions, a surrogate can authorize a CPR order, and providing CPR against a patient’s wishes would be a violation of nonmaleficence (do no harm).
Wrong 😕
[13:3] Normally, there is no time to determine the patient’s decisional capacity in a medical emergency or get a patient’s informed consent without increasing a serious risk of harm or death for the patient. Therefore, the moral principle of beneficence (do good) has the most weight, justifying the performance of medically medical standards of care. Cardiopulmonary arrest fits this medical emergency criterion perfectly, and the medical standards of care is CPR. However, if, prior to the CPR procedures, a DNR order is revealed, then CPR should not commence. If the DNR order is revealed while CPR is in progress, then CPR should be stopped. The basis of this judgment is that the patient has the legal and moral right for autonomous self-regulation regarding what others are allowed to do or are forbidden to do to the patient’s body. Reasons for a DNR may be because CPR was determined to be futile, more harmful and burdensome than beneficial, or not in line with the patient’s reasonable goals, values, and priorities. Under those conditions, a surrogate can authorize a CPR order, and providing CPR against a patient’s wishes would be a violation of nonmaleficence (do no harm).
CORRECT! 🙂
[13:4] A common misperception regarding DNR is the false belief that it will result in inferior or less quantitative and qualitative medical treatment or care than if the patient were not DNR. All medical treatments and patient management are identical for both the non-DNR patient and the DNR patient, with the only exception being CPR.
Wrong 😕
[13:4] A common misperception regarding DNR is the false belief that it will result in inferior or less quantitative and qualitative medical treatment or care than if the patient were not DNR. All medical treatments and patient management are identical for both the non-DNR patient and the DNR patient, with the only exception being CPR.
Wrong 😕
[13:5] If the patient does not have decisional capacity, there is no living-will, no durable power of attorney (POA), no available surrogate, and no way of determining the patient preferences, then the practitioner should provide the medical standards of care.
CORRECT! 🙂
[13:5] If the patient does not have decisional capacity, there is no living-will, no durable power of attorney (POA), no available surrogate, and no way of determining the patient preferences, then the practitioner should provide the medical standards of care.
13. Clinical Vignettes
1. Ms. Unity Jones, an 82-year-old retiree presents to the clinic for a routine check-up. During the appointment, the practitioner realizes that the patient does not have an advanced directive in place, which includes their wishes regarding cardiopulmonary resuscitation (CPR) in the event of a cardiac or respiratory arrest. What is the best approach for the practitioner to take in this situation?
2. Mr. Tanner Taylor, an 83-year-old retiree presents to the emergency department with sudden cardiac arrest. The medical team quickly assesses the patient and initiates CPR. During the resuscitation efforts, the medical team discovers a Do Not Resuscitate (DNR) order in the patient's medical chart. What should the medical team do in this situation?
3. Ms. Iris Thompson, a 68-year-old fashion designer has been admitted to the hospital with a serious medical condition, does not have decisional capacity, and is not expected to recover. The patient has previously designated a surrogate decision-maker through a power of attorney (POA). The healthcare team is considering a do not resuscitate (DNR) order. What is the proper process for determining the patient's DNR status?
4. Ms. Amber Ali, an 85-year-old retiree is admitted to the hospital with a serious medical condition, and the healthcare team is considering a do not resuscitate (DNR) order. The patient's surrogate decision-maker is concerned about the quality of care the patient will receive if a DNR is in place. What is the relationship between a DNR order and a patient's quality of medical treatment and care?
5. Mr. Winston Ahmed, an 88-year-old retiree has been admitted to the hospital and is unable to make decisions about their medical care due to a serious medical condition. The patient does not have a living will, durable power of attorney (POA), or any available surrogate to make decisions on their behalf. Additionally, there is no way to determine the patient's preferences. What should the practitioner do regarding the patient's medical care?
CORRECT! 🙂
Explanation: The scenario describes a patient who does not have an advanced directive in place, which includes their wishes regarding cardiopulmonary resuscitation (CPR) in the event of a cardiac or respiratory arrest. The best approach for the practitioner to take in this situation is to inform the patient about the importance of discussing CPR [13:2] and encourage them to make an informed decision. This is because the patient has the right to make decisions about their own healthcare [13:2], and it is important for the practitioner to provide the patient with all the necessary information to make an informed decision about their wishes for CPR. The option of documenting that the patient declined to discuss CPR and moving on with the appointment, is not appropriate as it does not address the patient's lack of advanced directive and leaves the patient at risk of receiving unwanted or unnecessary medical interventions. The option of waiting until the patient experiences a cardiac or respiratory arrest to make decisions about CPR, is not appropriate as it can lead to suboptimal care for the patient [13:1] and can also be considered a violation of professional ethics. The option of assuming that the patient would not want CPR and not discussing it further, is not appropriate as it is not possible to know what the patient's wishes are without discussing the matter with them.
Wrong 😕
Explanation: The scenario describes a patient who does not have an advanced directive in place, which includes their wishes regarding cardiopulmonary resuscitation (CPR) in the event of a cardiac or respiratory arrest. The best approach for the practitioner to take in this situation is to inform the patient about the importance of discussing CPR [13:2] and encourage them to make an informed decision. This is because the patient has the right to make decisions about their own healthcare [13:2], and it is important for the practitioner to provide the patient with all the necessary information to make an informed decision about their wishes for CPR. The option of documenting that the patient declined to discuss CPR and moving on with the appointment, is not appropriate as it does not address the patient's lack of advanced directive and leaves the patient at risk of receiving unwanted or unnecessary medical interventions. The option of waiting until the patient experiences a cardiac or respiratory arrest to make decisions about CPR, is not appropriate as it can lead to suboptimal care for the patient [13:1] and can also be considered a violation of professional ethics. The option of assuming that the patient would not want CPR and not discussing it further, is not appropriate as it is not possible to know what the patient's wishes are without discussing the matter with them.
CORRECT! 🙂
Explanation: The scenario describes a patient who presents to the emergency department with sudden cardiac arrest. The medical team quickly assesses the patient and initiates CPR, but during the resuscitation efforts, the team discovers a Do Not Resuscitate (DNR) order in the patient's medical chart. In this situation, the medical team should stop the CPR immediately and honor the patient's DNR request [13:3]. This is because a DNR order is a legal document that expresses a patient's wishes for end-of-life care [13:1], and it is the medical team's responsibility to honor the patient's wishes [13:3]. Continuing with CPR despite a DNR order is considered a violation of the patient's autonomy and can be considered medical malpractice [13:3]. The option of consulting with the patient's family before making a decision, is not appropriate in this situation as the DNR order is a legal document that expresses the patient's wishes and does not require input from the patient's family [13:2]. The option of obtaining a second opinion from another medical team before making a decision, is not appropriate in this situation as the DNR order is a legal document and does not require input from another medical team [13:1].
Wrong 😕
Explanation: The scenario describes a patient who presents to the emergency department with sudden cardiac arrest. The medical team quickly assesses the patient and initiates CPR, but during the resuscitation efforts, the team discovers a Do Not Resuscitate (DNR) order in the patient's medical chart. In this situation, the medical team should stop the CPR immediately and honor the patient's DNR request [13:3]. This is because a DNR order is a legal document that expresses a patient's wishes for end-of-life care [13:1], and it is the medical team's responsibility to honor the patient's wishes [13:3]. Continuing with CPR despite a DNR order is considered a violation of the patient's autonomy and can be considered medical malpractice [13:3]. The option of consulting with the patient's family before making a decision, is not appropriate in this situation as the DNR order is a legal document that expresses the patient's wishes and does not require input from the patient's family [13:2]. The option of obtaining a second opinion from another medical team before making a decision, is not appropriate in this situation as the DNR order is a legal document and does not require input from another medical team [13:1].
CORRECT! 🙂
Explanation: The scenario describes a patient who has designated a surrogate decision-maker through a power of attorney (POA), does not have decisional capacity, and is not expected to recover. The healthcare team is considering a do not resuscitate (DNR) order [13:1]. In this situation, the surrogate decision-maker should make the decision based on the patient's reasonable goals, values, and priorities [13:3], and if those are not known, then based on the patient's best interests [13:4]. This is because the surrogate decision-maker is responsible for making decisions that are consistent with the patient's values and preferences, and if those are not known, then decisions should be based on the patient's best interests [13:4]. The option of the surrogate decision-maker making the decision based solely on their own beliefs and values, is not appropriate as it does not take into account the patient's wishes and preferences [13:3]. The option of the healthcare team making the decision based on their clinical judgment and expertise, is not appropriate as it does not take into account the patient's wishes and preferences or the role of the surrogate decision-maker [13:3]. The option of the patient deciding if they can communicate and participate in the decision-making process, is not appropriate as the scenario describes a patient who does not have decisional capacity [13:2].
Wrong 😕
Explanation: The scenario describes a patient who has designated a surrogate decision-maker through a power of attorney (POA), does not have decisional capacity, and is not expected to recover. The healthcare team is considering a do not resuscitate (DNR) order [13:1]. In this situation, the surrogate decision-maker should make the decision based on the patient's reasonable goals, values, and priorities [13:3], and if those are not known, then based on the patient's best interests [13:4]. This is because the surrogate decision-maker is responsible for making decisions that are consistent with the patient's values and preferences, and if those are not known, then decisions should be based on the patient's best interests [13:4]. The option of the surrogate decision-maker making the decision based solely on their own beliefs and values, is not appropriate as it does not take into account the patient's wishes and preferences [13:3]. The option of the healthcare team making the decision based on their clinical judgment and expertise, is not appropriate as it does not take into account the patient's wishes and preferences or the role of the surrogate decision-maker [13:3]. The option of the patient deciding if they can communicate and participate in the decision-making process, is not appropriate as the scenario describes a patient who does not have decisional capacity [13:2].
CORRECT! 🙂
Explanation: A do not resuscitate (DNR) order is a medical order that indicates that cardiopulmonary resuscitation (CPR) should not be performed in the event of a cardiac or respiratory arrest [13:1]. However, a DNR order does not limit or affect the quality of medical treatment and care that a patient receives, except for the withholding of CPR. The patient should continue to receive all other necessary medical treatment and care that are indicated for their condition, and their care plan should be based on their individual needs and goals of care [13:1]. The option stating that DNR patients receive lower quality medical treatment and care compared to non-DNR patients, is not accurate as DNR status does not affect the quality of medical treatment and care a patient receives [13:4]. The option stating that DNR patients receive higher quality medical treatment and care compared to non-DNR patients, is also not accurate as DNR status does not affect the quality of medical treatment and care a patient receives [13:4]. The option stating that the quality of medical treatment and care a patient receives is related to their DNR status, is also not accurate as the quality of care a patient receives should be based on their individual needs and goals of care, regardless of their DNR status [13:1].
Wrong 😕
Explanation: A do not resuscitate (DNR) order is a medical order that indicates that cardiopulmonary resuscitation (CPR) should not be performed in the event of a cardiac or respiratory arrest [13:1]. However, a DNR order does not limit or affect the quality of medical treatment and care that a patient receives, except for the withholding of CPR. The patient should continue to receive all other necessary medical treatment and care that are indicated for their condition, and their care plan should be based on their individual needs and goals of care [13:1]. The option stating that DNR patients receive lower quality medical treatment and care compared to non-DNR patients, is not accurate as DNR status does not affect the quality of medical treatment and care a patient receives [13:4]. The option stating that DNR patients receive higher quality medical treatment and care compared to non-DNR patients, is also not accurate as DNR status does not affect the quality of medical treatment and care a patient receives [13:4]. The option stating that the quality of medical treatment and care a patient receives is related to their DNR status, is also not accurate as the quality of care a patient receives should be based on their individual needs and goals of care, regardless of their DNR status [13:1].
CORRECT! 🙂
Explanation: When a patient is unable to make decisions about their medical care, and there is no living will, durable power of attorney (POA), or any available surrogate to make decisions on their behalf, the practitioner should provide the medical standards of care, as it generally is in the patient's best interests [13:5]. This means that the practitioner should provide all necessary medical treatment and care that is indicated for the patient's condition, and that is consistent with the medical profession's code of ethics. The option stating that all medical treatment should be withheld until a surrogate or living will is located, is not accurate as it would be unethical to withhold necessary medical treatment and care from a patient, even if there is no surrogate or living will available. The option stating that only comfort measures should be provided, is also not accurate as the patient may require curative treatments, depending on their condition [13:1]. The option stating that experimental or non-standard treatments should be provided, is also not accurate as the practitioner should follow the medical standards of care that are indicated for the patient's condition [13:1].
Wrong 😕
Explanation: When a patient is unable to make decisions about their medical care, and there is no living will, durable power of attorney (POA), or any available surrogate to make decisions on their behalf, the practitioner should provide the medical standards of care, as it generally is in the patient's best interests [13:5]. This means that the practitioner should provide all necessary medical treatment and care that is indicated for the patient's condition, and that is consistent with the medical profession's code of ethics. The option stating that all medical treatment should be withheld until a surrogate or living will is located, is not accurate as it would be unethical to withhold necessary medical treatment and care from a patient, even if there is no surrogate or living will available. The option stating that only comfort measures should be provided, is also not accurate as the patient may require curative treatments, depending on their condition [13:1]. The option stating that experimental or non-standard treatments should be provided, is also not accurate as the practitioner should follow the medical standards of care that are indicated for the patient's condition [13:1].
**
13. Reflective Vignettes
1. The attending physician, Dr. James, was caring for Mr. Robert, a 65-year-old man who had been admitted to the hospital with severe pneumonia. Mr. Robert had a history of heart disease, and his condition had worsened, with respiratory distress and sepsis. Dr. James reviewed Mr. Robert's medical records and noted that he had a DNR order in his chart. During his rounds, Dr. James explained the DNR order to Mr. Robert, informing him that if his heart stopped, they would not perform CPR to revive him. Mr. Robert listened carefully and nodded his head in agreement, indicating that he understood what the DNR order meant. However, shortly after Dr. James left, Mr. Robert's wife, Mrs. Robert, arrived at the hospital. Mrs. Robert informed the nursing staff that Mr. Robert had changed his mind about the DNR order and wanted everything to be done if his heart stopped. She mentioned that Mr. Robert had been adamant about having a DNR in his medical records to avoid becoming a vegetable. However, after further discussion with Mrs. Robert, it became clear that Mr. Robert had not understood the implications of the DNR order and had agreed to it without fully comprehending its meaning. Later that day, Mr. Robert's condition deteriorated rapidly, and he went into cardiac arrest. The medical team was notified, and they rushed to his bedside. The nursing staff informed Dr. James that Mr. Robert's wife had requested that everything be done to save her husband's life. Dr. James spoke with Mrs. Robert and explained that the DNR order was in Mr. Robert's medical records and that they could not perform CPR without violating the order. Mrs. Robert became emotional, stating that Mr. Robert had not fully understood the implications of the DNR order and had agreed to it without knowing what he was agreeing to.
Think
Assess
Patient: Autonomy
Practitioner: Beneficence & Nonmaleficence
Public Policy: Justice
Conclude
2. The patient in question is a 68-year-old man with a history of coronary artery disease, hypertension, and type 2 diabetes. He has been admitted to the hospital for treatment of an exacerbation of his heart failure. His medical record includes a Do-Not-Resuscitate (DNR) order, which was discussed and signed by the patient and his family members during a previous hospitalization. During this hospitalization, the patient's care team has been managing his heart failure with diuretics, ACE inhibitors, and beta-blockers. However, due to a medication error, the patient received an incorrect dose of his beta-blocker medication, which caused his heart rate to drop rapidly. This led to the patient going into cardiac arrest. The attending practitioner, Dr. Austin Meyers, was called to the patient's bedside when the code blue was announced. Upon arrival, he reviewed the patient's medical record and noted that the patient had a DNR order. Dr. Meyers communicated this information to the team.
Think
Assess
Patient: Autonomy
Practitioner: Beneficence & Nonmaleficence
Public Policy: Justice
Conclude
**
Scenario 1
3. Dr. Rachel, an emergency medicine physician, was working in the emergency department when a patient was brought in by ambulance in cardiac arrest. The patient, an elderly man, was unconscious and had no pulse. Dr. Rachel and her team immediately began resuscitation efforts, performing chest compressions and administering medications. As they worked to stabilize the patient, they noticed a tattoo across the patient's chest that read: "Do Not Resuscitate.” Dr. Rachel paused and assessed the situation. The medical team had not seen a case like this before, where a patient had a DNR tattoo on their chest without any living will or durable power of attorney on record, and no surrogates were available. Dr. Rachel knew that it was essential to respect the patient's autonomy and end-of-life wishes but also understood the importance of legal documentation in such cases.
Think
Assess
Patient: Autonomy
Practitioner: Beneficence & Nonmaleficence
Public Policy: Justice
Conclude
**
Scenario 2:
4. Dr. Michael, an emergency medicine physician, was working in the emergency department when an unconscious patient was brought in by ambulance in cardiac arrest. The patient, a young adult, had attempted suicide, and it was unclear what had caused the cardiac arrest. As the medical team worked to stabilize the patient, they noticed that the patient's body was covered in writing, including the phrase "Do Not Resuscitate" written in Sharpie all over their body. Dr. Michael immediately assessed the situation and consulted with his colleagues to understand the legal and ethical implications of the patient's situation. They discovered that there was no living will or durable power of attorney on record and that no surrogates were available to make medical decisions for the patient. Dr. Michael knew that it was important to respect the patient's autonomy and end-of-life wishes but also understood the need for legal documentation in such cases. He also recognized that the patient's mental state at the time of writing the DNR message was unclear, and that the patient may have lacked the capacity to make such decisions.. What does the practitioner do?
A. Comply with the patient’s wishes and do not provide CPR.
B. Get a court order.
C. Get an ethics consultation.
D. Provide CPR.
Think
Assess
Patient: Autonomy
Practitioner: Beneficence & Nonmaleficence
Public Policy: Justice
Conclude
**
