Who can initiate a referral to an ethics committee?

Do Not Resuscitate

Situation

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

patient.

• 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.

Discussion Questions

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?