Ethics of DNR Orders and End-of-Life Care Decisions

Introduction

When a family has to decide how much is too much, as Plakovic (2016) puts it during end-of-life care, a clear ethical dilemma emerges for both family members and care providers. That dilemma is related to the question of how to approach end-of-life treatment. For instance, some individuals have strict preferences regarding whether or not they want to be resuscitated or kept alive by a machine. Others have left no instructions for care providers and family members to follow. The ethical dilemma is further complicated by the fact that care providers take an oath to care for all life — but at the end of life, where is the line between postponing the inevitable inhumanely and providing the most humane care possible? That blurred line is a difficult one to walk.

The two major points this paper addresses in relation to end-of-life care and the do-not-resuscitate (DNR) clause concern the principles of nonmaleficence and autonomy. The ethical theory discussed in relation to this issue is deontology, also known as duty ethics.

What Is the Ethical Dilemma?

The ethical dilemma associated with end-of-life care and the DNR clause is whether a patient's life should be prolonged simply because it is mechanically possible to do so, even when there is no hope for improvement and the patient will have an extremely low quality of life — essentially remaining unresponsive or in a terminal state. Should the care provider continue to recommend that the patient's life be prolonged? What should the care provider advise to the patient's family? How should the issue of DNR be approached?

The example of Mary attempting to ensure that the best care is provided to her father CJ — whom the health care team believes to be in a terminal state — illustrates the complexity of such ethical situations (Plakovic, 2016). On the one hand, it is understandable that the daughter wants to see her father improve; on the other, it is equally understandable that the son sees the reality of the situation and does not want to prolong his father's suffering unnecessarily. Yet health care providers must respect the family's wishes, and when conflict arises — with the son stepping back and the daughter taking charge — the providers must continue to deliver care even though, as the case demonstrates, the patient would have died within days regardless. It is sometimes difficult to communicate that reality to a patient's family. Emotions cloud reason, and loved ones do not want to say goodbye without first exhausting every possible option.

As Yuen, Reid, and Fetters (2011) explain, even in cases where DNR orders exist — as with Mary's father — ethical issues remain, because it is not always clear-cut that a patient requires resuscitation. Weissman (1999) notes that DNR orders are in need of reform because there is no clear framework for navigating the subject. As one participant in Weissman's (1999) study stated: "We know it's required under hospital policy to ask patients their preference about resuscitation, but these cancer patients . . . well . . . you know . . . they're dying . . . it doesn't make sense" (p. 149). This admission from a health care professional illustrates the extent to which the issue can become complicated.

Main Moral Issues

The main moral issue in end-of-life care is that health care providers who attempt to inform a patient's family about the realities of terminal decline can come across as seeming uncaring, insensitive, or unwilling to do everything possible to save a life. The exact opposite is typically true: the health care professional understands everything that could and will go wrong as the patient deteriorates, and delaying the end of life simply to allow a family member to feel that every opportunity was given can cause significant stress — to other family members, to health care professionals, and to the patient. This unnecessary stress runs counter to the goals of quality care, yet the health care professional must abide by the wishes of the patient's family if there are no clear DNR instructions that explicitly express the patient's own preferences.

From a deontological perspective, the health care provider has a duty to abide by the patient's DNR instructions. However, in the absence of such instructions, the provider must defer to what the patient's family wants — even if this conflicts with what the provider believes to be in the best interests of all stakeholders. Defining what is right in every instance is neither easy nor universally agreed upon, which makes the moral issues in such cases all the more difficult to understand and even to define (Karnik & Kanekar, 2016; Sen, 1983).

Conclusion

The ethics involved in end-of-life care and how to address that situation can be complex, particularly for family members who disagree about the best course of action when a loved one does not have a clear DNR on file. Care providers should strive to communicate the situation to the patient's loved ones in an effective yet respectful way. However, if loved ones cannot accept the reality and wish to hold out hope for improvement, care providers may continue to deliver treatment. It is in everyone's best interests, nonetheless, for care providers to maintain ongoing, honest conversations with family members — helping them understand why prolonging the inevitable may ultimately cause more pain than comfort.