Leigh's Policy

Background
Do-not-resuscitate (DNR) orders are a request by people to not have cardiopulmonary resuscitation (CPR) performed on them if their heart would stop or if they would stop breathing. If patients have previously stated that they did not want CPR if their heart would stop then they would not be administered it. Even if the doctors thought that the individual would survive, medical personnel have to follow the orders set earlier by the patient, and not perform CPR on such a patient. Patients’ rights to refuse resuscitation have long been recognized by the medical profession. As Smith writes,“Everyone has the right to decide about their own life-sustaining treatments and if they are not capable then they can appoint a surrogate” (Smith and Veatch 1988). Hoffman also writes that, “such an order is needed because it is counterintuitive: the assumption in health care is that everyone who goes into cardiac arrest would want to be revived” (Hoffman 2006).
All patients have the right to express their preferences of CPR if their hearts would suddenly stop. DNR orders are helpful, because it is almost impossible for the patient’s family members to know how to react in the case of deciding if a loved family member should be brought back to life or not (Jayes et al. 1993). Lately, more and more patients’ families have been setting limits of how far to go in the case of keeping a loved one alive. Schroeter writes “Many patients and their families fear abandonment when a DNR order is written. The patient and family must know from the outset that no code means, no care”(Schroeter et al. 2002). Hospitals prefer to have DNR orders in place for patients, because of the difficulty in communicating with family members during an emergency. For example if the patient suffered a cardiac arrest, doctors and nurses do not have enough time to go and ask the family what they want to happen to their loved one.
However, doctors sometimes make the mistake of ordering a patient to be resuscitated when his or her heart stops while the patient is in the hospital, even though the patient has a Do-Not-Resuscitate (DNR) order. This then causes problems between the patient and the doctor, for the patient may then have to suffer because of the doctor’s mistake.
Because of a doctor’s mistake some of the people who were resuscitated have had to suffer the rest of their lives, because CPR was performed on them when it was not in these patients’ best interest, and against the patients’ wishes. In one study of life after CPR “of 948 admissions during which CPR was performed, 61.2% of patients survived the arrest and 32.2% survived to hospital discharge. One year after hospital discharge, 24.5% of patients, regardless of age, had died” (Zoch et al. 2002). Another study found that “patients who have recovered from a circulatory arrest after CPR resuscitation find their capacity for resuming work diminished after discharge from the hospital, while they seem to experience a postponed negative effect on their mental functioning, especially the functions connected with the awareness of their environment” (Peterson et al. 1991).
This is especially a concern for VA hospitals because, the majority of the VA hospitals patients fall into the group where DNR orders are needed. The VA hospitals treat older, sick individuals, whereas community hospitals treat a larger proportion of younger individuals. This is why the policy to make DNR orders more visible is needed to help prevent individuals from being resuscitated against their will.
To help eliminate this problem, DNR order information must be more prominently displayed with bracelets, signs and notes in patients file so that the doctors will notice it in the patients file. Patients should have to wear a bright pink colored bracelet to identify them as being a do-not-resuscitate patient. There will also have to be a sign posted above the patients’ hospital bed stating that the patient wishes to not have their heart restarted if it would stop beating. This will make it easier for doctors to know that the patient wishes for their heart to not be restarted. A note will then also be made in the patients file allowing the doctors and nurses to be aware of the patient’s wants.
Policy
The policy to make DNR orders more visible to doctor and nurses to help prevent unwanted resuscitations should take place at all Veterans Administration (VA) hospitals and clinics, to make sure those individuals who wish to do not receive CPR do not. Individuals who are 65 or older and or have medical problems should consider getting a DNR. If the individual needs a proxy or someone to make a decision for them if they are unable, it should be a close family member or someone they trust to make life or death decisions.
At the current time “physicians are not required to discuss the procedure of CPR (Weissman 2003)” or an individuals’ other options with their patients. Doctors will have to fill out a paper stating that the patient or proxy read the information about DNR orders and they made a decision. The doctor, patient and head nurse for that area of the hospital will all have to see that the patient was explained their options and they decided yes or no. All three would then have to sign the paper and say that they were present for the decision. The paper would then be copied with one copy being placed in the patients file and the patient would then receive a bright pink bracelet identifying him or her as a DNR patient. The other copy would then be printed for the patient and their family to have to know that everyone signed the paper and it is official that they wish to not be resuscitated. A sign would also be posted above the patient’s hospital bed to let all doctors and nurses know that the patient wishes to not be resuscitated if his or her heart would stop.
A system similar to the one proposed here has been endorsed by others. M. Cantor, in Ethics Rounds a publication of The National Center for Ethics, writes, wristbands or other special identifiers that distinguish patients with do-not-resuscitate orders are intended to prevent unwanted resuscitation attempts by assuring that patient ‘code status’ is readily apparent in case of emergency (Cantor 2000). Writing this policy, keeping the patient in mind is very important, because the hospital has to respect the patients’ privacy and confidentiality. To make the policy work there needs to be a balance between making a patient feel like they are not going to have their privacy taken away but they will still have the benefit of the wristband to prevent unwanted CPR. There needs to be a policy in place to prevent unwanted CPR, for example, “in a recent study, 40% of hospital radiology departments reported resuscitating an inpatient who had a previously written DNR order” (Cantor 2000). In the policy patients will be given the opportunity to wear the wristbands, if they decide against it, the patient will be informed of the risk that DNR orders are not always noticed by hospitals nurses and doctors.
The VA hospitals for the United States will enforce that doctors look to see if a patient has a DNR order before they order resuscitation to be done on the patient. This would save a lot of confusion between the doctor and the patient. The VA should also enforce that the hospitals have the DNR patients wear bright pink colored bracelets to identify them as not wanting resuscitation to be done on them if they stop breathing.
According to Iowa and the U.S. Department of Veterans Affairs, the VA spent more than $673 million in Iowa in 2006 to serve more than 254,000 veterans who live in the state (Iowa and the U.S. Department of Veterans Affairs 2007). For the year 2009, President Bush is seeking a budget of $93.7 billion for the Department of Veterans Affairs (VA Request $94 Billion for Veterans in FY ’09 Budget, 2008). $2 million would be set aside for VA hospitals in each state to help pay for making patients’ DNR orders more known to hospital officials and workers. The money to pay for the policy would come from VA Iowa Budget that is part of the national budget that the Congress funds for the Department of VA. This money would help pay for individuals who fit the criteria of needing a DNR order to receive information about what a DNR order is and how it is helpful.
Conclusion
Hospitals should make it more visible that certain patients have DNR orders and wish to not be resuscitated if for some reason their heart would stop while they were receiving care at a medical facility. This would then lead to fewer patients being resuscitated against their previously stated wishes.
Although there is a need for this policy to be passed opponents of this policy might think that money does not need to be wasted on making it more visible that patients have DNR orders, and that this $2 million could go somewhere else and be better spent. They may already feel that doctors know if their patient has a DNR order or not by just looking at the patients file. But research shows that this is not the case (Weissman). Many hospitals do not spend the money to make it aware to its workers that certain patients wish to not have their hearts restarted if it stopped beating. This leads to some individuals being resuscitated who wished to not be and they may have to live a life in pain because someone did not follow their previously stated desire against resuscitation. Others might also disagree with this policy, because they do not exactly understand why DNR orders are so important. They might not be aware of how do-not-resuscitate orders have had such a big influence on people. But patients’ rights to determine whether they are resuscitated are important because many people will never return back to normal after they are resuscitated. DNR orders are put in place to help prevent doctors from performing CPR on a patient when the patient previously stated his or her wants for end of life care. Doctors are not always aware that their patients have DNR orders in place and they consequently order CPR to be done on the patient. If this policy was adopted, there would be less of a chance for doctors to order CPR against a patient’s previously stated wants.

References
Cantor, M Wristbands for DNR? (September 2000). Ethics Rounds, The National Center for Ethics. (3)
Hoffman, J The last word on the last breath. (2006, October 10). The New York Times. F1
Iowa and the U.S. department of veterans affairs. (2007, October). Department of Veterans Affairs State Summary.
Jayes, R, Zimmerman, J, Wagner, D, Draper, E, & Knaus, W (1993). Do-not-resuscitate orders in intensive care units. Current practices and recent changes. The Journal of the American Medical Association. 270 (18): 2213-2217.
Peterson, M, Geist, L, Schwartz, D, Konicek, S, & Moseley, P (1991). Outcome after cardiopulmonary resuscitation in a medical intensive care unit. Chest. 100: 168-174.
Schroeter, K, Derse, A, Junkerman, C, & Schiedermayer, D (2002) Practical Ethics for Nurses and Nursing Students. Hagerstown, MD: University Publishing Group, Inc.
Smith, D, & Veatch, R (1988) Guidelines on the termination of life-sustaining treatment and the care of the dying. Briarcliff Manor, N.Y
VA Request $94 Billion for Veterans in FY '09 Budget. (2008, Feb, 4). Department of Veterans Affairs News Release. Department of Veterans’ Affairs.
Weissman, D (2003).Policy proposal: do not resuscitate Orders: a call for reform. American Medical Association Journal of Ethics. 5(1).
Zoch, T, Desbiens, M, DeStefano, F, Stueland, D, & Layde, P (2002). Long-term Survival After Cardiopulmonary Resuscitation. Archives of Internal Medicine. 160, 1969-1973.

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