When a patient is admitted into hospital they are sometimes accompanied by a sheet of paper containing directives that go against doctors usual instinct to save lives at all costs. “Do Not Resuscitate” (DNR), sometimes known as ‘no code’ or ‘allow natural death’, are legal orders to withhold CPR or advanced cardiac life support if a patient’s heart stops or they stop breathing independently.
DNR forms apply only to those two specific scenarios – other medical treatment including chemotherapy, antibiotics and dialysis, would not be automatically stopped as well. There has been movement towards using the term ‘allow natural death’ in recent years, as it focuses on what is being done rather than what is being withheld, and puts a more positive light on what is a natural thing.
There are various ethical dilemmas associated with DNR – not least due to evidence that when individuals have more in-depth discussions with healthcare professionals about the excluded interventions, they often feel differently or don’t want to have a blanket decision. For example, in cardiac arrests, a fifth of DNR patients would want resuscitation but to have care withdrawn after a week.
In England, if someone presents with a cardiac arrest then CPR will be carried out unless a DNR order is in place. If an individual has capacity in accordance with the Mental Capacity Act of 2005 then a patient can decline resuscitation. Sometimes DNR orders exist but the form doesn’t come with the patient and so doctors have to assume that they should resuscitate the patient, rather than make a horrible irreversible decision that could be wrong.
In Miami recently, a 70 year old man was brought in to the Emergency Room, unconscious and with ‘Do Not Resuscitate’ tattooed on his chest, with his signature below. The placement of the tattoo and the fact his signature accompanied it suggested the man had some understanding of the medical system – it was exactly where you would have to do chest compressions.
There are two main considerations here – legality and ethics. Legally it is clear – a tattoo is not a binding legal document, and wouldn’t meet many of the requirements (such as a doctor’s signature, or being on coloured paper) that exist for DNR forms.
Ethically it is less clear. There are two major ethical principles to be considered – autonomy, the patient’s right to make their own information-based decisions regarding their health care, and beneficence, that procedures are carried out with the intention of doing the best for the patient. In this case there was a chance that the patient truly did not wish to be resuscitated and live whatever quality of life existed for him afterwards, and his autonomy to choose this should be respected. Equally, in the lack of confirmed knowledge that this was what he wanted they should do what was considered as best for the patient which was seemingly to resuscitate them, as this was the impermanent choice.
Ultimately, the doctors concluded the man should be resuscitated because the legal situation was clear and they also felt that the thought of making such a huge and permanent mistake was too great of a risk. The man was resuscitated but two hours later the correct documentation was found confirming he had a DNR order in place. The patient took another turn for the worse and was allowed a natural death.
Whilst to some this may have seemed like prolonging a man’s suffering, particularly when it could have just been seen as a clear way of making his end of life wishes known, there are other ways of looking at it. Another man presented with a ‘Do Not Resuscitate’ tattoo in a situation where it wasn’t a necessary consideration and the doctor treating him asked him about it. He said that the tattoo was the result of a bet many years ago and did not reflect his wishes in the slightest, showing this was not always the sign it could be seen as.
Dr Holt, the attending Physician on the original case, claimed the case had been a ‘wake-up call’ to him, and had made him questions the validity of DNR orders. Just as the man who had been tattooed could have changed his mind after getting the tattoo about his resuscitation status, so could patients who have the forms and who haven’t had the opportunity to change it.
‘It’s a concern for both physicians and patients because you want to do right by someone and if you don’t know, you do everything you can think of because we always pick the reversible choice, not the one you can’t take back when faced with uncertainty,’ he says.