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WHAT DOES DNR REALLY MEAN? COMFORT MEASURES ONLY. C. Antonio Jesurun, MD Professor of Pediatrics Director of Neonatal Intensive Care June 29, 2005. Resuscitation or CPR.

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what does dnr really mean comfort measures only

WHAT DOES DNR REALLY MEAN?COMFORT MEASURES ONLY

C. Antonio Jesurun, MD

Professor of Pediatrics

Director of Neonatal Intensive Care

June 29, 2005

resuscitation or cpr
Resuscitation or CPR

Medical procedure which seeks to restore cardiac and/or respiratory function to individuals who have sustained a cardiac/respiratory arrest

why all the concern
Why All the Concern?
  • Withholding life-sustaining treatment
  • CMO-Does not mean abandoning the patient
  • 1983: The President’s Committee for the Study of Ethical Problems in Medicine
    • “Deciding to Forgo Life-Sustaining Treatment”
ethical principles
Ethical Principles
  • Autonomy
  • Beneficence
  • Nonmaleficence
  • Justice
  • Truth-telling
  • Promise-keeping
ethical issue analysis
Ethical Issue Analysis
  • Medical Indications
  • Patient preferences
  • Quality of life
  • Contextual features
quality of life
Quality of Life
  • Object of medical intervention is to restore, maintain, or improve quality of life
  • Whose quality is used for judgment?
  • Subject to bias & prejudice
  • General measures: mobility, performance of activities of daily living, absence of pain, social interaction, mental acuity
contextual issues
Contextual Issues
  • Should be evaluated in terms of their:
    • Psychological, emotional financial, legal, scientific, educational, religious impact on patient & others
paternalism
Paternalism
  • The days of the physician making independent decisions are gone.
  • Today’s standard—self-determinism
one ethical principle
One Ethical Principle
  • Respect for Autonomy means:
    • Self-determination to make choices based on one’s own values & belief system
    • Others refrain from interfering with choices
    • Patient free from coercion in deciding to act
    • True informed consent
    • One should tell the truth
    • Privacy and confidentiality respected
definition of death
Definition of Death
  • An Individual who has sustained either:

1. Irreversible cessation of circulatory and respiratory functions, OR

2. Irreversible cessation of all functions of the entire brain, including the brain stem

1980 Uniform Determination of Death Act

comfort measures only
Comfort Measures Only
  • Shift of goal from curative to palliative
  • Therapeutic measures directed towards comfort
  • Excludes specific interventions as listed on “Resuscitative Status Form”
resolution of conflicts
Resolution of Conflicts
  • If irreconcilable w/ moral view-withdraw & provide alternative care
  • If conflict with generally accepted standards or policies-concern should be voiced to appropriate institutional body
  • If this is not possible within time-frame then care should adhere to patient’s directives

ASA House of Delegates Oct. 1993. amended 2001

vegetative state
Vegetative State
  • Loss of cognitive neurological function and awareness of the environment. Retention of noncognitive function and a preserved sleep-wake cycle.
  • Sometimes described as when a person is technically alive, but his/her brain is dead. That description is not completely accurate. In a persistent vegetative state the individual loses the higher cerebral powers of the brain, but the functions of the brainstem, such as respiration (breathing) and circulation, remain relatively intact.

National Institute of Neurological Disorders and Stroke, National Institutes of Health

decision making
Decision-Making
  • Competent person
    • Family
    • Court
  • Substituted judgment (based on what the patient would have wanted)
  • Surrogate (based on what the surrogate believes is right)
surrogate decision making hierarchy
Surrogate Decision-Making Hierarchy
  • Legal guardian
  • Spouse
  • Adult children
  • Parents of patient
  • Adult siblings of patient
institutional or judicial review
Institutional or Judicial Review
  • No family member wants to be surrogate
  • Dispute among family members
  • Provider does not believe patient would have made specific decision
  • Provider does not believe decision could be reasonably judged in the patient’s best interest

AMA Code of Ethics, 150th edition

ethics committee
Ethics Committee
  • To act as a consultant in difficult medical/ethical cases
  • Forum for open and free discussion
  • Review of cases involving ethics
  • Education in Ethics
approach to patient
Approach to Patient
  • Discussion with patient regarding:
    • Quantitative likelihood of various outcomes
    • Qualitative aspects of outcomes and meaning to patient & family
    • Burden of reaching various quantitative and qualitative outcomes
dilemmas values in conflict
Dilemmas-Values in Conflict
  • Conflicting
    • Values
    • Rights
    • Duties
    • Ethical principles
ethical principles24
Ethical Principles
  • Autonomy
  • Beneficence
  • Nonmaleficence
  • Justice
  • Truth-telling
  • Promise-keeping
approach to comfort measures only
Approach to Comfort Measures Only
  • Sensitivity to the issues
  • Empathy
  • Founded in ethics
  • Familiarity with guidelines & protocols
  • Sound communication with patient, family, health-care team