DNR Orders and Living Wills: Ethics, Law, and Patient Rights

Introduction to Advance Directives

This paper examines do not resuscitate (DNR) orders and living wills, also known as advance directives. Specifically, it discusses the ethics of these orders and how they relate to medical law and professional ethics. Living wills and DNR orders are common methods for patients and their families to indicate their wishes during times of hospitalization and treatment. However, the many exceptional cases and circumstances surrounding these issues make them continually controversial, testing the bioethical standards of both the medical and legal communities. Where do patient rights and medical ethics blend, and where do they diverge? These are not simple questions to answer, as the research shows.

Living wills and do not resuscitate orders are usually created by patients and their families as a means to ensure their lives are not prolonged if they are suffering from a debilitating or terminal illness and require life support or resuscitation. They are simple legal documents that individuals can write and create in a matter of minutes. Many online locations offer generic and state-specific forms, and there is also a national living wills registry online where living wills can be posted, giving healthcare professionals access to personal wishes. In addition, living wills and other forms of advance directives are becoming increasingly popular. A Washington, D.C. reporter notes, "the American Medical Association estimates that 15% of the population has filled out some type of advance directive specifying what medical treatment they should be given if they are unable to offer guidance, or who will decide for them" (Moran 10). The process sounds simple and painless, but in reality, many questions still surround living wills and advance directives, and it is the healthcare professional who usually has to make quick judgment calls — or seek legal advice — when living wills become complicated.

Ethical Complexity in Contested Cases

To a family member or patient, a living will or do not resuscitate order may seem binding and unquestionable. However, many circumstances challenge these orders, and the ethics of carrying them out are sometimes convoluted. For example, one cited case involved a 21-year-old pregnant female diagnosed with "PCP (pneumocystis carinii pneumonia), right parietal infarct (a blood clot in her brain) with left hemiplegia, and CMV (cytomegalovirus, an infection similar to mononucleosis)" (Kuczewski and Pinkus 73). It was also discovered that the woman was HIV-positive, and there was a strong possibility her unborn child was as well.

The woman, also the mother of a 4-year-old, was placed on a ventilator, but no improvement was seen. After three weeks, her husband issued a palliative care sheet asking that the medical team not perform CPR and, additionally, that if the child were delivered, it not be resuscitated. Normally, these orders would have been carried out, but some members of the team felt that because the directive involved a pregnant woman and her unborn child, other ethical issues were at play. The hospital attorney agreed, noting that if the woman's child were allowed to die, the hospital and medical staff could face serious reprisals. The woman's social worker and primary care nurse did not agree; they felt the additional child would be a burden on the grieving husband and a major economic hurdle for the family. Furthermore, the fetus was not yet viable on its own, and the mother would need to be sustained for four to five more weeks for viability to occur.

Ultimately, the woman's condition deteriorated, and she died within 24 hours of the first legal and medical meeting regarding her case. The situation nonetheless raises important ethical questions. Who is ultimately responsible for carrying out advance directive orders? In this case, the woman could not speak for herself, and the closest relative — her husband — had made his wishes clearly known. However, the rights of the fetus also had to be considered. As the authors of the case study note, "the rights of the unborn are still widely debated, and it is far less obvious that they can outweigh the well-established right of competent adults to be free of unwanted and burdensome medical treatment" (Kuczewski and Pinkus 77). This ethical question is difficult to decide and even more difficult to implement. In this case, the physician felt that performing CPR on the woman would only prolong her life by perhaps minutes or hours and would do little to greatly extend the lives of either mother or child. Had the gestational age of the fetus been different, this case would likely have ended up in the courts. As it stands, it is only one of many ethical issues that medical professionals face every day. Clearly, today's medical professional must consider not only the health implications of a given treatment, but also its ethical implications across a range of difficult and demanding situations.

Conclusion: Balancing Patient Rights and Medical Ethics

Advance directives are extremely popular with the American public and can pose significant ethical dilemmas for healthcare personnel. Patients should have the right to determine their own medical preferences and the conditions of their own survival. At the same time, medical professionals should retain the right to intervene when their professional knowledge outweighs that of the patient or family, or when extenuating circumstances arise. Even so, the ethics of "playing God" — whether by family or physician — will always be emotionally charged and open to debate.