Problem
To resuscitate or not resuscitate is one of the most prevalent problems affecting today’s health care systems. The case of Mrs. Nickleby illustrates the difficulties associated with making and implementing do-not-resuscitate decisions. Mrs. Nickleby is in her mid-forties, but she has multiple sclerosis and resides in the Hightower Nursing Home. Her husband divorced her 5 years ago, but her daughters visit her frequently. The woman has frequent asthma attacks and, until today, she has been lucky to be saved by the nursing staff. However, because Mrs. Nickleby’s physical state quickly deteriorates, her physician has issued a no-code-order in case of a cardiac arrest. In other words, she will not be resuscitated. The case demonstrates several ethical problems. First, the decision not to resuscitate Mrs. Nickleby was taken without any prior consultation with the woman’s family. Second, Mrs. Nickleby herself never expressed any wish to leave this life for good. Third, nurses working in the Hightower Nursing Home are not involved in the end-of-life decisions affecting nursing home residents. Simultaneously, the circumstances of health make Mrs. Nickleby’s life virtually intolerable.
Options
Despite the difficulties associated with this case, nursing home staff can follow several ethical paths. First, they can silently comply with the physician’s decision not to resuscitate Mrs. Nickleby in case of a cardiac arrest. Second, nurses may approach the physician with questions concerning Mrs. Nickleby’s physical state and the importance of holding ethical consultations with her family. Third, nurses may contact Mrs. Nickleby’s family, namely, her daughters, for a consultation. Fourth, nurses can approach Mrs. Nickleby directly and initiate a conversation regarding her future. They may ask Mrs. Nickleby to express her wishes concerning her health state in emergency situations.
Arguments for each option
All four ethical options have their pros and cons. To begin with, nurses can simply choose to comply with the physician’s decision not to resuscitate Mrs. Nickleby in case of a cardiac arrest. From the legal standpoint, “doctors can choose not to treat and that while such choices may get them into trouble with their employers or the GMC, they would not get into trouble with the law of tort” (Makin, 2005). On the ethical side, nurses feel that such decision goes against their intrinsic ethical values, but Makin (2005) is confident that whether or not nurses feel comfortable with physician orders is a secondary matter. Moreover, by giving a no-code order, Mrs. Nickleby’s physician also avoids unnecessary conflicts with her family, who may wish to insist on providing continuous life support in the best interest of their mother. The physician also wants to avoid possible difficulties obtaining patient consent.
Despite considerable legal and ethical benefits offered by this option, nurses can resolve the dilemma in a different way. They may approach the physician with questions concerning Mrs. Nickleby’s health state and resuscitation perspectives. Nurses can assume a proactive position and participate in the end-of-life decisions affecting nursing home residents. On the other hand, nurses can help the physician to better understand the seriousness of the problem and its potential implications for the nursing home. As a person caring for dying patients, Mrs. Nickleby’s physician may experience stress, burnout, and compassion deficits (Kearney, Weininger, Vachon, Harrison & Mount, 2009). All these issues could have affected physician’s decision not to resuscitate Mrs. Nickleby in case of a cardiac arrest. In collaboration with nurses, the physician may find another, better way of dealing with the problem.
Third, nurses may choose to contact Mrs. Nickleby’s family and discuss the issue of no-code orders with them. Because Mrs. Nickleby’s daughters visit their mother regularly, nurses may expect that their communication will be productive and benefit the patient. However, nurses cannot be confident that Mrs. Nickleby’s children have an objective picture of their mother’s health and can act for her benefit. As a result, they may also initiate a conversation with Mrs. Nickleby, to understand what she wants to do with her life, if she faces a cardiac arrest.
Making a decision
The best way to handle the situation is to approach Mrs. Nickleby and her family directly and ask their opinion on the no-code order made by the physician. Reasons why this decision is the best are numerous. First, by asking Mrs. Nickleby and her daughters to express their opinions, the nursing home will actually defend the rights of the patient and promote the fundamental principles of ethical medical care. The latter include life prolongation irrespective of its quality, symptom palliation and comfort provision, and aggressive attempts to restore life by all possible means (American Nurses Association, 2004). According to ANA (2004), whenever possible, the do-not-resuscitate decision should be taken in a discussion between the patient and the family. This is how nurses, physicians and family members will protect themselves from unnecessary legal and ethical attacks and will act according to the patient’s known and, preferably, documented wishes (Makin, 2005).
Certainly, in case of Mrs. Nickleby, providing resuscitation in a cardiac arrest seems unnecessary and futile. The quality of Mrs. Nickleby’s life is so poor that even in case resuscitation is successful, there is hardly any hope for meaningful survival (Braddock, 1998). This is also why the nurse sometimes thinks that, if she were Mrs. Nickleby, she would not want to continue her life. Even then, there is no ethical right to deny Mrs. Nickleby a voice in the decision that affects her life. She never expressed any wish to die, and it is imperative that her wishes and priorities are considered. ANA (2004) recommends that the values and choices of the patient are given the highest priority, and as long as Mrs. Nickleby is competent, she has the right to make orders regarding her health.
In this case, nurses also deserve to participate in the end-of-life decisions with physicians on equal terms. Nurses should also participate in the development and implementation of do-not-resuscitate policies in the nursing home. This is how the nursing home can have its do-not-resuscitate policies communicated effectively among the staff and between the staff and nursing home residents (ANA, 2004). Certainly, nurses may face serious barriers when dealing with this issue. Mrs. Nickleby’s physician may object to nurses’ participation in the discussion. However, the physician should also understand the legal and ethical ramifications of issuing the no-code order without Mrs. Nickleby’s consent. Nurses can help the physician to achieve the desired agreement with Mrs. Nickleby and her family members.
References
ANA. (2004). Position statement on nursing care and do-not-resuscitate (DNR) decisions. American Nurses Association. Web.
Braddock, C.H. (1998). Do not resuscitate orders. University of Washington School of Medicine. Web.
Braddock, C.H., Fihn, S.D., Levinson, W., Jonsen, A.R. & Pearlman, R.A. (1997). How doctors and patients discuss routine clinical decisions. Journal of General Internal Medicine, 12(6), 339-345.
Kearney, M.K., Weininger, R.B., Vachon, M.L., Harrison, R.I. & Mount, B.M. (2009). Self-care of physicians caring for patients at the end of life. Journal of American Medical Association, 301(11), 1155-1164.
Lewis, J. (n.d.). Surgical instruments left inside patients can cause serious injuries. Shapiro, Lewis & Appleton. Web.
Lincourt, A.E., Harrell, A., Cristiano, J., Sechrist, C., Kercher, K. & Heniford, B.T. (2007). Retained foreign bodies after surgery. Journal of Surgical Research, 138, 170-174.
Makin, A. (2005). Taking resuscitation decisions in the nursing home setting. Nursing Times, 101(41), 28. Web.
Science Daily. (2007). Surgical objects accidentally left inside about 1,500 patients in US each year. Science Daily. Web.