DNR: LEGAL AND

MORAL
CHALLENGES TO
HEALTH
PROFESSIONALS
PREPARED BY: HYDE BACALUCOS,
MARISSA ASIM, ROSA MAE
GUMILAO, ROSE LAIN FERNANDEZ,
SHALAMAE SALIALAM, RHIDAB
TUTI, LESLIE PALACIO, VHINCE
PISCO
 INTRODUCTION

Do- Not- Resuscitate Order

is an advance directives that

requests health care providers
particularly doctors and nurses,
not to attempt cardiopulmonary
resuscitation (CPR) if patient’s
heart and breathing stops.
History

In 1976 the first hospital policies on orders not to resuscitate were

published in the medical literature. These policies mandated a formal
process of advance planning with the patient or patient’s surrogate on
the decision of whether to attempt resuscitation, and also stipulated
formal documentation of the rationale for this decision in the medical
record. In 1974 the American Heart Association (AHA) became the first
professional organization to propose that decisions not to resuscitate be
formally documented in progress notes and communicated to the
clinical staff.
 Does a DNR expire?

▪ DNR orders must be dated. Depending on the state, orders may

expire after a certain amount of time or there may be a deadline
for the physician to follow up.
 LEARNING OBJECTIVES

▪ At the end of the discussion, the students will be able to;

▪ Understand the principles, concepts and moral challenges of DNR to Health Professionals.
▪ Recognize the ethical complication of DNR orders.
▪ Recognize patients who are candidate for DNR.
 How is it Legal?

▪ The 1990 PSDA- Patient Self-determination Act

▪ Is a federal law, regarding advance directives. The purpose of PSDA is to ensure that a
patient’s rights to Self-determination in health care decision be communicated and protected.
▪ The advance directives go into effect if a patient is terminally ill and death is imminent.
▪ Legal aspects: The American Heart Association announced that CPR was not indicated for all
patients. An individual with a terminal, irreversible illness, where death is the expected
outcome does not necessarily deserve CPR. Originally, it was referred to the medical system.
▪ Finally, they conclude that the health care providers who attempt to resuscitate patients
against their wishes they violate the patients legal right to self-determination. The DNR order
is the legal and medical document that reflects the patient’s decision and desire to avoid life
sustaining interventions.
 MORAL CHALLLENGES OF DNR TO HEALTH
CARE PROFESSIONALS

▪ According to American Association of College Nurses (2004) Moral courage enables nurses to
face up steadfastly and self-confidently to ethical dilemmas surrounding the late timing of
DNR discussions and the poor communication by physicians of the bad news about prognosis.
▪ Fallahi et.al there are many differences among different societies in terms of performance,
morality, legality, and appropriate medical guidance of DNR. Medical staff consider a variety
of factors for making end of life decisions such as: probability of survival, patient’s desire,
previous quality of life and anticipated quality of life afterwards.
▪ One of the most important elements that influences the decision-making process for DNR
orders is religion. Many Muslims choose CPR despite the disease's poor prognosis in the faith
that God would eventually heal the sufferer. The major grounds for the Middle East nations'
refusal to legitimize DNR directives are religious and moral convictions.
 MORAL CHALLLENGES OF DNR TO HEALTH CARE
PROFESSIONALS

▪ When a patient's heart appears to be on the verge of stopping, it is commonly assumed

that the ethically best course of action is to try a new intervention. In contrary to popular
belief.
▪ Welie and Have argue that in most cases, the DNR is the ethically safer option. Only if
both of the following required conditions are satisfied is such intervention morally
justifiable: the treatment must be medically futile and there must be consent to the DNR.
▪ The DNR is still considered as a difficult and extraneous concept according to Audai
Nader Sa'id, in spite of health care providers' efforts to help patients and families to make
informed choices.
 DO NOT RESUSCITATE

▪ Do not resuscitate order (DNR order), an advance medical directive

that requests that doctors do not attempt cardiopulmonary resuscitation
(CPR) if a person’s heart or breathing stops.
▪ Emergency care and other health care providers may still continue to
administer oxygen therapy, control bleeding, position for comfort, and
provide pain medication and emotional support.
▪ If individuals are considered rational and able to communicate their
wishes in a clear manner, they may write their own advance directives
indicating a desire for a DNR order.
 (INSTANCES/CONDITIONS WHERE DNR IS
APPLIED)
Patients with multiple chronic illnesses

Patients with history of chronic disease such as heart, lung, liver or kidney
disease

Patients with terminal disease (severe dementia,progressing chronic condition,

advanced cancer)

Are in coma

Are seriously injured

High risk for stroke, cardiac arrest and respiratory arrest

 DNR FORM SAMPLE AND DNR WRISTBANDS

▪
DID YOU KNOW?

1929-2019
DID YOU KNOW?
CASE ANALYSIS
 CASE ANALYSIS I

▪ Case Scenario
Mr. A. is a 46-year-old man with multiple myeloma began experiencing acute pain in his right lower
abdomen. At 2'o clock, Mr. A's wife took him to the emergency department for diagnosis and
treatment. Examination revealed lower right abdominal tenderness with rebound pain and lab results
confirm high white blood cell count. The physician diagnosed acute appendicitis. When Mr. A's old
chart was brought to the emergency department, the physician discovered a DNR order that was
placed there during Mr. A's last hospitalization for cancer treatment. The physician approached Mr.
A. to discuss this DNR order, particularly its applicability during surgery.

Mr. A. insisted that the DNR order must still be followed. The oncall surgical team was preparing
for the emergency appendectomy when the physician relayed Mr. A's wishes about the DNR order
during this surgery. The circulating nurse, whose father also had been diagnosed with multiple
myeloma, refused to follow the DNR order. She explained that she had noted from Mr. A's chart that
the patient had a wife and 2 small children, and she did not believe that Mr. A. understood how
important the remaining time of life would be for him in helping to prepare his family for his
impending death.
 CASE ANALYSIS II

Mrs. K was taken to Oak Grove Nursing Home by her daughter the other day. It’s Alzheimer's
disease has wreaked so much havoc on her that her daughter, can no longer care for her at
home. Oak Grove has a dedicated unit for Alzheimer's patients, and her daugther discovered it
during her investigation that friends who have used the facility for both long-term and short-
term automobile care have highly recommended it.
The move to the care facility had been planned for several weeks, but when the time arrived,
Her Daugther discovered that her mother was particularly frail. When they arrived at Oak
Grove, the staff made Mrs. K feel welcome and started working on the paperworks. Her
daugther soon excused herself, claiming exhaustion, and she left with only a few of the
paperwork signed.
 CONCLUSION

▪ DNR does not lead to cessation of appropriate medical care however, it aims to avoid non-beneficial
interventions.
▪ DNR does not mean that patients will die alone and uncared for; rather, when the end is near, the patient will
be placed under hospice care.
▪ The DNR order is the legal and medical document that reflects the patient’s decision and desire to avoid life
sustaining interventions.
▪ Discussion DNR with patients and family might be taken in consideration for the following patients: whom
CPR may not provide benefits to enhance quality of life and terminal, irreversible illness.
▪ Discussion of DNR with patients and family should be included in all treatment modalities and balancing
between risks and benefits of each treatment.
▪ The doctors are morally and ethically obliged to provide good prognostication and initiate discussions about
treatment options, benefits of the treatment, and resuscitation. Patients and relatives should be well informed
about realistic outcomes of a disease modifying treatment, withholding and withdrawing treatment.
 REFERENCES

▪ 
https://www.omicsonline.org/open-access/do-not-resuscitate-an-argumentative-essay-2165-73
86-1000254.php?aid=70041&fbclid=IwAR0M5noNhxJzm1i0T-Q-yeBv2R1oCGU9o2va_3vb
XjuZ8D_gIVALKaB4P8U
▪ Downar J, Luk T, Sibbald RW, Santini T, Mikhael J, et al. (2011)
 Why do patients agree to a do not resuscitate or full code order? Perspectives of medical inpa
tients. J Gen Intern Med 26: 582-587.
▪ Tierney E, Kauts V (2014)
 Do not resuscitate policies in the intensive care unit - the time has come for openness and cha
nge. Bahrain Medical Bulletin 36: 65.
▪ Journal of Palliative Care and Medicine
OPEN FORUM
THANK YOU!