Do Not Resuscitate
J.L., a 68-yr-old man, is admitted for a second mitral valve surgery
and coronary artery bypass graft surgery. He did not adhere to the
treatment plan after his original surgery 7 years ago. You are worried
about his future adherence with drugs, diet, and exercise. His kidneys
are failing, and he is on dialysis, making him a high-risk surgical
patient. J.L. and his caregiver want all treatment and refuse to discuss
advance directives (ADs) or do-not-resuscitate (DNR) orders.
Ethical/Legal Points for Consideration
• Patient adherence with past treatment plans is not a factor when
considering DNR decisions. Many circumstances related to
nonadherence are outside the patient’s control, such as finances,
transportation, availability of help, and declining physical and
medical capabilities. Based on their expertise, HCPs have the
right to refuse to provide treatment that offers no benefit to the
• ADs do not include a DNR order. If the patient is unable to speak
for himself or herself, the HCP can start a DNR order only after
conversation with the health care proxy and/or nearest kin. The
decision usually depends on evidence of the patient’s preferences
(substituted judgment standard) or what is thought to be in the
best interest of the patient.
• If there is an AD refusing resuscitation, the HCP is required to act
accordingly but is not compelled to enact a DNR without clear
direction from the patient or proxy.
• If the involved parties disagree about the patient’s treatment
plan, a referral can be made to an ethics committee, they can seek
treatment from another HCP, or they may seek legal intervention
by way of a court order.
1. How can a lack of understanding or limited financial resources
contribute to nonadherence with the plan of care?
2. What type of information should be given to a patient and
caregiver in discussions about ADs and DNR orders? Who
should provide this information?
3. Who can initiate a referral to an ethics committee?
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