- Case 21 re: change of DNR
Answer questions at end of case, using one of your theories. Let's cover all the theories, so just rotate to the next one on a first-come, first-serve basis. As the last 2 people post, there might be some repeat.
The theories: Kant, Utilitarianism, Virtue Ethics, Casuistry, Ethics of Care, Ross' Principles, Principles of Bioethics, Coherence theory.
Case 21. Question 1.
ReplyDeleteI feel that the patient has the right to change his mind regarding his DNR status. It is his life and for another to say that earlier when he made the decision FOR a DNR he was rational, and now, as he is weaker, he is NOT rational, puts the judgment in someone else's hands and not the patient's. I do believe that judging someone's lucidity can be tricky; other times it's very easy to see. There are certain ways of discussing that may help the physician come to the conclusion if the patient is rational or not. Were these ways explored? One may not agree with the patent's decision to 'do everything'; based on his advanced disease and prognosis, but none the less, it is still not our personal situation, only the patient's.
Question 2
The patient, in his weakened state, who makes a decision that seems at odds with a earlier more rational decision, is still within his realm of self rights and should be allowed this level of autonomy regarding what happens to him. As I mentioned earlier, I think this would warrant further investigation as to how lucid the patent is at this time. He may just be very frightened of the 'letting it go' decision, and feel that he has to give it one more round. He should be allowed to try this, then possibly his eventual demise would become more apparent to him.
I base my answers on Kant's theory based on the Categorical Imperative. Treat humanity as ends, never as a means only:- persons are intrinsically valuable. Because they have rationality they cause morality to exist. Kant states the Moral Law is universal and necessary. It is a categorical imperative; it must be obeyed, regardless of the circumstances.
I agree with you completely! I cannot believe a physician would stick to the patient saying he wanted to be a DNR, and apply it to an acute bleeding event that is reversible and not related to DNR criteria. Excellent use of Kant's theory.
Deletethis was my stance aswell. If it is unclear on the mental state I feel as we need to error on the side of saving the mans life.
DeleteAgree with you. No mater the circumstance the patient has the right to change their mind. We have a moral obligation to act accordingly!
DeleteQuestion 1) The most-appropriate response in this situation is the response Dr. R had, the need to "do something" for the patient who is asking his physician's to save his life in this acute situation, something they have taken a oath to do. John H. is certain to die from acute blood loss, this is not the same as he was likely thinking when he asked to be a DNR. A DNR classically does not mean to withhold treatment in the case of hemorrhage, this could be specified in a living will. A classic DNR is instituted with the thoughts that "if I stop breathing do not intubate and ventilate me", or "if my heart stops beating, do not do CPR/ give drugs or shock me", or outlines what of those measures you do or do not want done if you have respiratory or cardiac arrest.
ReplyDeleteQuestion 2) These cases are difficult because they do not outline heroics as we do and specify what the patient does or does not want. Controlling bleeding and getting blood has nothing to do with a "DNR" typically. To me, the request for them to do something and save his life in this acute bleeding event, has nothing to do with his request to be a DNR. It isn't at odds with his original request to me.
The theory I answer these questions with in mind is that of Utilitarianism: Do the greatest balance of good over evil. To me, the greatest balance of good is do follow your oath and save your patient who is begging you to save his life.
I agree, even if a patient comes in on admission with a DNR slapped on his chart, the patient has a right to change their mind. Now if the patient is deemed incompetent to make decisions then ethically we should be going to next of kin and or POA at that time to carry out the patients wishes.
Delete1. The most appropriate response to this situation is to take whatever measures to stop John H's bleeding. The bleeding may not be related to his cancer. John H requested the DNR knowing that he had cancer (a terminal illness), however, he requested the bleeding to be controlled which is a new "acute" illness.
ReplyDelete2. When a patient's current request is at odd's with his original request, his current request still needs to be considered and/or honored. He still has some autonomy and his wishes should be respected.
I base my answer on the Principles of Bioethics. Autonomy - respecting a person's ability to make reasonable choices and informed decisions. Beneficence - Do good. Balancing the benefit of treatment against the risks of treatment. Benefit the patient. Non-maleficence - Do no harm. Avoid causing harm to patient. Treatment should cause minimal harm and provide a benefit to the patient. Justice - Be fair. All patients in the same situation should be treated fairly and in a similar manner.
I agree, Tracy. I think by making intervention of John H's acute bleeding part of his DNR he involed for his terminal cancer violates all of the principles of bioethics. It does not allow autonomy, it would do harm (death) to the patient, it would not do good for the patient and it is not fair to hold him to DNR when this isn't a DNR/ cancer treatment issue to him and he is asking for you to help him.
DeleteThis just goes to my original post, DNR does not mean do not treat, we send people home with hospice all the time and it doesn't mean that we are taking all of their oxygen, and antibiotics away. People don't just die the next day or that day all the time. You can go home with hospice and be a DNR and still be on Bipap and still have antibiotics for infections, because these are still comfort measures. I think a lot of people get mixed up and don't understand the nature of it.
DeleteI just had a patient a few nights ago and she was incompetent to make decisions (an overdose, intubated, sedated) and next of kin were her parents, they did not understand the DNR they wanted us to make her one if her condition gets worse. It doesn't work that way, it is an all or nothing (or with exceptions) type of deal. Even explaining to them we will still treat her, but in the event her heart were to stop would they want us to do CPR and shock because she was already intubated. Its really honestly a sticky topic that people thing is so easy and it in reality is not.
I agree. If the patient is alert and still about to have self determination, he has every right to ask for the physicians to stop his bleeding. If he is coherent I would suggest that the physicians clarify prior to surgery if he still wishes to not be resuscitated should he go into cardiac arrest during the procedure.
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DeleteI agree with you. Granted stabilizing his acute bleeding may not change the outcome as he is faced with terminal cancer. However, we do have an obligation to his request.
DeleteI am basing my answers to this case on using Casuistry, case based reasoning. This takes into account specific rules learned in a case study which can be applied to other situations from which refinements can be made.
ReplyDelete1. I believe the most appropriate response to this case is to look back at other cases in which someone with this type of cancer has experienced internal bleeding like that of John H. Were these operation successful in saving the patient? Did they cause further harm? Did the quality of life increase or decrease for those patients? If there has been success then I believe that Dr. R is correct in seeing the patients request "to do something" is a valid one. John H requested that he not be resuscitated if he goes into cardiac arrest and that he receives no more treatment for the cancer. If he is alert and oriented and able to make the request for treatment, the doctors should allow it.
2. If a patient is requesting something that contradicts his/her earlier wishes, and may be swayed by pain, weakness, and approaching death then previous cases would need to be examined. In the past have there been cases that dealt with this very topic? Is there any case law or classic cases that have the same set of variables? Casuistry reasoning has no single, simple ethical theory and relies on case history. It asserts practice over theory. So upon review of previous cases Dr.'s will need to determine what the outcomes were and decide if they fit the present case to help guide care for John H.
Just some thoughts, and you know I mean the most respect. I think that physicians already do too much under the influence of what is "going to get me sued." Secondly, patients elect for treatment all the time that may not result in a life saving outcome. I think if the patient is able to make the call then we need to save his life despite the outcomes of prior attempts at the same life saving efforts.
DeleteBased on Rosss' theory of fidelity, upholding your promise to your patient, Exactly what promise are we to uphold?
ReplyDeleteI feel like the most important response to the situation is "what does the patient want?" I think in this moment that the patient has gotten scared and is not ready to die. In my opinion, the physician should stop the source of the bleeding.
When John said he didnt want any more measures taken to sustain life, I don't feel as though he anticipated bleeding to death. I suppose it would depend on the action s needing to be taken to fix the bleeding. major surgery that would most likely result with him on a ventilator would be overstepping the promise previously given. However, if the fix was more simple, I do feel as though the patient deserves the right to change his mind. After all, we are not sure if he is in his right mind or not. This would be a good situation to have the family step in. I would not feel good about just standing back and letting this man die when he is asking for help.
Exactly, Jessica. In my mind, the promise the physician made to this patient is to take care of him through this illness. It's not about what cancer treatment they were going to not do, it's not about not putting a breathing tube in or not shocking him in cardiac arrest... It's about "You are in good hands, I will take care of you". Taking care of your patient isn't letting them exsanguinate when you can treat that for them.
DeleteThis is a interesting view point. You are right he never thought he was going to bleed to death so maybe it would be best to treat him.
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ReplyDeleteI think that the appropriate response is that we take a look at the whole situation going on. DNR means do not resuscitate, it does not mean do not treat. If the patients living will states that he is a DNR, that only covers if in the event he was to go into cardiac arrest, or respiratory distress then we would not do live saving measures such as intubation and or CPR, shock and medications. Also I agree with everyone else, even if the patient is "declared" a DNR on admission and he changes his mind throughout the stay it is our duty as healthcare professionals to respect his decision and his wishes.
ReplyDeleteLooking at Virtue Ethics, it is an approach that emphasizes an individual's character as the key element of thinking, rather than the rules about the acts themselves. So I feel like the Doctor in this case would be the individual here, as his character with his profession he took an oath to do no harm. He respecting the patients wishes here and doing what he asked, is based off of the ethical thinking that he is probably doing. If he were to just ignore that the patient said "to do something" given his admission status of a DNR, then he would feel this could be unethical and if he does "do something" and even if it doesn't turn out a good outcome he would know that he had at least did everything he could and that was the last patients request, given if he was competent or not. If he wanted to be completely right, if he didn't feel that the patient at this time was competent in the matter of making decision he would have went to next of kin, explained the given situation and then he would have had to respect their wishes.
Kourtney,
DeleteI agree that the physician should perform the surgery. The patient states in his living will that he does not wish to be resuscitated should he go into cardiac arrest. I feel like fixing his internal bleeding does not go against his wishes, especially since he asked if there was anything they could do. Now, should he go into cardiac arrest during the surgery, then I feel as though the doctors would need to honor his wishes and not resuscitate him.
Exactly, Kourtney! The DNR has nothing to do with treating this patients bleeding. It's immaterial in this case. I agree, also, however, if the patient can talk and verbalizes they changed their mind about their DNR, you have to revoke the previous and go with what they want now. The thought that you wouldn't is completely unethical.
DeleteI agree, DNR does not mean "I don't want you to treat any other acute thing that comes up," It means if my heart stops or I stop breathing, don't resuscitate me. If I get the "flu", I want to be treated if I ask to be treated. It doesn't mean withhold treatment at all.
DeleteAccording to the theory of coherence where no level of reasoning should have priority over another, then I feel like the most appropriate response in this situation is to treat the patient's acute bleeding. Coherence consists of logical consistency, there are no obvious contradictions in this scenario. It also consists of argumentative support, there are reasons that plausibly support the argument to treat this patient's bleeding.
ReplyDeleteEven though the patient's request seemed to be at odds with his prior decision, he is still giving consent to be treated. I would assume that the doctor would be able to determine if the man is alert and oriented at the time by doing a quick simple assessment. DNR does not necessarily mean do not treat. If the patient was obviously not alert and oriented then I feel like his original request should be honored.
The only thing I would say is it did say it was unclear if the patient was coherent and if he wasn't you couldn't obtain a proper consent. If he was coherent I agree he should be treated even if it doesn't match up with his prior request.
DeleteUsing the Kant theory I believe they shouldn't do anything to fix the bleeding but instead provide comfort measures. The reason is because Kant's theory is you should do what is morally right with no bearing on what the consequences will be. So imminent death at this point is irrelevant to this case. Additionally weather he is coherent is unclear and if he wasn't in a right state of mind it wouldn't be prudent to proceed.
ReplyDelete2. Although my above point would be contrary to what I'm going to say I do believe if you have a coherent patient they should be able to guide there own care along the way. DNR doesn't mean don't treat so you can fix the internal bleeding and it will ensure he doesn't die in the next day or so but that doesn't necessarily fall under a DNR because he hasn't stopped breathing or went into cardiac arrest.
That is an interesting viewpoint related to Kant's theory. I wish the case would have specified whether or not the patient was oriented, that would weight very heavily on the outcome of this scenario. I feel like if I was physically present in that situation, a simple neurological assessment could be done to make that determination, however, I realize these questions are designed to challenge us to think ethically.
Delete1) I think that the most appropriate response for this situation is to comply with patient request to do something. Even though he is DNR he is asking for you to do something. As others have said, and I agree with the saying-DNR does not mean do not treat. It is morally right to help the patient upon request. They have the right to change their mind about decisions made. Using the utilitarian theory, this would be the best moral action to maximize utility.
ReplyDelete2) It may be viewed as an odd request, but if someone is mentally competent then that is their wish. If they were not mentally competent or oriented, consultation should be made with the POA or next of kin. If they decide that they want nothing done, then it is our duty to keep him comfortable as possible and help him die with dignity.
I think that is a very good point. The patient does have the right to change their mind about decisions made, including DNR status. I wish the case was more specific in stating whether or not the patient was coherent or not, that would make a huge difference in the outcome. I feel like if I was placed in that situation and could physically lay eyes on the patient a quick neurological assessment could be done to determine if he was oriented or not.
ReplyDelete