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Introduction   

End-of-life issues are often full of emotion and difficult to deal with for all involved. Do-not-resuscitate (DNR) orders can present many moral and ethical dilemmas in nursing. It takes the entire healthcare team, including the patient and their family, to ensure that all final wishes for the patient are followed. In order to understand this ethical dilemma in nursing, we must first define what ethical dilemmas are and what a DNR order is.

Nursing Ethics/Ethical Dilemma

Ethics are a system of moral principles or rules of conduct recognized by a particular group. However, the American Nurses Association (ANA) has developed its own code of ethics. The ANA Code of Ethics with Interpretive Statements includes nine provisions that direct a nurse’s moral and ethical practice. It reads:

Provision 1: The nurse practices with compassion and respect for the inherent dignity, worth, and unique attributes of every person.

Provision 2: The nurse's primary commitment is to the patient, whether an individual, family, group, community, or population.

Provision 3: The nurse promotes, advocates for, and protects the rights, health, and safety of the patient.

Provision 4: The nurse has authority, accountability, and responsibility for nursing practice; makes decisions; and takes action consistent with the obligation to provide optimal patient care.

Provision 5: The nurse owes the same duties to self as to others, including the responsibility to promote health and safety, preserve wholeness of character and integrity, maintain competence, and continue personal and professional growth.

Provision 6: The nurse, through individual and collective effort, establishes, maintains, and improves the ethical environment of the work setting and conditions of employment that are conducive to safe, quality health care.

Provision 7: The nurse, in all roles and settings, advances the profession through research and scholarly inquiry, professional standards development, and the generation of both nursing and health policy.

Provision 8: The nurse collaborates with other health professionals and the public to protect human rights, promote health diplomacy, and reduce health disparities.

Provision 9: The profession of nursing, collectively through its professional organizations, must articulate nursing values, maintain the integrity of the profession, and integrate principles of social justice into nursing and health policy.

An ethical dilemma in nursing arises when decisions are made that go against the ANA Code of Ethics with Interpretive Statements.

It is important to note that the nurse's main duty is to be an advocate for their patient, meaning that all actions should be in the patient’s best interest. Adhering to this principle will ensure a clear moral path where ethical dilemmas in nursing can be avoided (1).

DNR 

A DNR order is a situation where, should the patient's health deteriorate and progress to cardiac arrest, the healthcare team will not provide cardiopulmonary resuscitation (CPR). The physician usually gives this order after consulting with the patient and family. Should the patient be unable to make decisions about their health, their designated power of attorney (POA) for healthcare decisions will be able to make that determination.

The DNR order is usually reserved for patients who are gravely or terminally ill and have a strong possibility of dying during their stay at the hospital. Once the DNR is ordered, it will stay in effect until the patient passes, leaves the hospital, or rescinds the order (3, 5).

Possible Ethical Dilemmas with a DNR

There are different situations where a DNR order could pose an ethical dilemma for the nurse. All of these examples involve the nurse's feelings, beliefs, or morals contrasting against the DNR order or the circumstances leading to the DNR order.

• Operating Room/Procedural Suite: In many facilities and healthcare systems, when a patient is undergoing surgical intervention, the DNR is suspended while the patient is in the surgical suite. The consent form for the procedure will indicate that the DNR order will be suspended, and the patient/family must agree to this to proceed with the operation.
  • Should something happen during the procedure/operation, is it right to suspend the patient's DNR wishes? The hospital has metrics, including operating room mortality, that they must keep low. Suspending the DNR gives the facility a better opportunity to meet these metrics. These metric results can be viewed and compared from hospital to hospital.
  • Further, a DNR order can create confusion among the surgical team. Each member may have a different idea of precisely what the DNR means. Some team members may not even believe surgery should occur, given that the patient has a DNR order. In particular, the anesthesiologist may face an ethical dilemma when providing anesthesia to a patient with a DNR order. The anesthesia can cause cardiopulmonary arrest; if the anesthesia causes such, does treating the anesthesia-induced arrest go against the DNR order (4)?

• Suffering: Another dilemma regarding a DNR order is the idea of patient suffering. It is tough to quantify and qualify suffering. That being said, one of the nurse's prime responsibilities regarding their patients is to relieve suffering. No nurse anywhere likes to see their patient in pain and suffering. In their attempts to help reduce that suffering, the nurse may push the patient or the patient's family into considering a DNR order even when it may be inappropriate given the patient's diagnosis and prognosis.
  • This thought could extend to the nurse asking the physician to consult hospice services. It must be clear that not every patient who is suffering should have a DNR order; unfortunately, pain and suffering sometimes go hand-in-hand with recovery.
  • There are also many different types of suffering: physical, emotional, mental, spiritual, etc. Is it right to initiate a DNR order based on these types of suffering alone? Who can say what suffering is, especially when it can't be seen (6)?

• Religion: Another factor that can impact the ethics of a DNR is the religious beliefs of the patient/family as well as the beliefs of the nurse.
  • Some religions do not condone the idea of a DNR. This may stem from an erroneous understanding that the DNR is somehow assisting or facilitating death. This is not the case. A DNR means that no heroic measures will be taken should the patient stop breathing or should their heart stop beating.
  • Yet, the stigma remains. There have also been cases where, when the prognosis was poor and the patient had deteriorated, a DNR was put into place. Later, the family reversed the DNR as they believed a miracle could happen and wanted to give time for their deity to move. Now, the family may be at odds with the healthcare team.  One knows that God can perform a miracle and save the patient, and the other knows that the end is inevitable.
  • The nurse's religious beliefs can also play a part. The nurse may believe that the DNR is premature and that the patient should still fight for life. Maybe the patient is a young one or someone who seems to have much to live for and should not give up. This nurse may find it hard just to let the patient go and could call a Code Blue despite the DNR order (2, 6).

• Capacity: The nurse needs to assess the patient's ability to make decisions for themselves, especially when a patient's faculties may come into question at the end of life. The decision for DNR is not one to be taken lightly; it is a life-or-death decision. The patient must understand what it means to be DNR, how it will affect the care plan, and what it means for their family and loved ones. Allowing the patient to make such a decision based on their condition, though their faculties may be compromised, could become an ethical dilemma (6).

• Effects on treatment: It must be noted that DNR means do not renew, not do not treat. That being said, the perception of the care that should be provided to a patient with a DNR order decreases dramatically. The idea that a DNR patient should have any procedure or operation is often scoffed at. This is especially evident when it comes to procedures meant to provide comfort but also have life-prolonging results.
  • Procedures such as placing a gastrostomy tube to deliver parenteral nutrition may be needed for patient comfort and health but could be perceived as contrary to the DNR order. Also, nurses are far less likely to call a "rapid response" on a DNR patient if their condition begins to deteriorate; the nurse may not even call the physician until the patient passes because the DNR was in place. The patient should be treated as any other patient until the parameters of the DNR order are met. Nurses need to be aware of their own biases regarding DNR. Treatment should not be withheld or altered because of the DNR (2, 5, 6).

How to Avoid Ethical Dilemmas with DNR

All parties agree that the best way to avoid any ethical dilemma regarding a DNR order is to have clear communication. Patients need to communicate their wishes to all their immediate family members. This will keep everyone on the same page and inform them about the patient's desires. Their end-of-life wishes need to be clear and without any confusion. In this way, the patient's wishes can be met despite what the family may believe.

It would be well advised for patients approaching the end of life to appoint a medical power of attorney who will ensure that all their expectations are followed. The decision for a DNR order must also be communicated to the healthcare team. It may not be enough to speak about the desire for the DNR, but also the expectations of their healthcare needs leading up to death as well.

The patient, their family, and the healthcare team must all understand what DNR means when it comes into play and how it will impact their care. Everyone involved in the patient's care must agree with the care plan, including the DNR. The patient and family should be educated about their diagnosis, disease process, prognosis, and treatments. In other words, a decision to have a DNR order must be made in advance.

If nurses are unable to reconcile the DNR decision within themselves even after discussing the issues with the healthcare team, they may need to step away from the situation (5).

Conclusion

End-of-life issues are always challenging to deal with; they are often less complicated to discuss. Most ethical dilemmas regarding a DNR order arise due to a lack of communication or miscommunication between the patient, family, and the healthcare team. When the nurse openly communicates with the patient and their family and follows the Nursing Code of Ethics, the chances of facing a DNR-related dilemma will significantly decrease. The nurse must always be ready to discuss the situation and, if necessary, remove themselves from the equation.

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