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DMEJ

Duke Medical Ethics Journal

Navigating Crossroads: Beneficence as Autonomy’s Antithesis in DNR Decisions

By Moayad Shehadeh
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Introduction

A Do-Not-Resuscitate order (DNR) is a consequential choice for patients facing terminal illnesses or limited life expectancy. It signifies the patient's refusal of lifesaving procedures, wherein “neither basic nor advanced Coronary Pulmonary Rescue (CPR) should be performed to a patient,” [5]. The decision involves complex factors, including religious, psychosocial, and spiritual considerations, as well as potential risks of resuscitation worsening the patient's condition.  In this case, “some argue that CPR should not be performed if it is not expected to result in benefit to patients, or if it may prolong their suffering, and the physicians should accordingly write a unilateral DNR order,” [6]. This is also known as a UDNR, whereby the decision of the DNR is out of the patient’s hands. The interplay of three major ethical principles—justice, beneficence, and autonomy—guides DNR decisions. This discussion

focuses on the tension between beneficence and autonomy and examines how these factors constantly counter each other in the decision-making process for signing a DNR. Understanding this relationship can help solidify laws and protocols concerning DNR to ensure that the patient’s wishes are truly honored while following established medical ethical codes.

Clash of Ethical Principles

Two of the key ethical principles, beneficence and autonomy, drive DNR decisions based on the slippery slope of individual judgment. Beneficence in medicine aims to “maximize good consequences and limit harm,” [5]. Autonomy, on the other hand, emphasizes an individual's power to “make decisions for their own health care needs,” [3].  Beneficence begins to clash with the patient's right to self-determination because although DNR decisions are typically entrusted to the patient, external influences such as physicians' and family members' beliefs, can compromise true patient autonomy in favor of perceived beneficence. Additionally, environmental factors like time constraints can further erode autonomy. Such discordance between beneficence and autonomy in DNR decisions poses continuous challenges to decisions regarding patient well-being.

"In an effort to seek beneficence, families and physicians may, in turn, rob the patient of their autonomy to make the decision."

Case Studies

To fully understand the extent to which the paradoxical nature of beneficence and autonomy affects DNR decisions, a few case studies must be analyzed. Iserson and Rouse’s 1989 case study is a perfect example to illustrate a breakdown in patient autonomy. In this situation, a woman with pancreatic cancer signed a DNR with her family’s support. When the woman began facing respiratory issues and went into a coma, her husband was forced to turn to the police as he was unable to reach the physician. The EMS team of the police, however, disregarded the husband’s pleas to check her DNR status before resuscitation. In fact, “only after her identity could be confirmed and her medical records retrieved from the incomplete record files and interpreted by a physician…could intensive life-sustaining care be halted and the woman be allowed to die,” [2]. This case exemplifies how in emergencies, medical staff can undermine patient autonomy, prioritizing paternalistic assumptions over the patient's explicit wishes.

 

Stigmatization of DNR decisions by physicians or family members, as revealed in Marchette et al.'s (1993) study, further complicates matters. This study revealed that “physicians sometimes make the DNR decision without discussing it with the patient or family because the physicians may…have paternalistic attitudes and feel they should act in their patients’ best interests,” [4]. To further investigate this, the study used questionnaires in a qualitative research design to ask physicians about their experiences with specific DNR situations. They found that an overwhelming 82% of nurses from the sample responded ‘Yes’ to the question: “Has a patient’s family member ever told you that he/she did not want CPR performed on the patient?” [4]. In such cases, physicians, driven by a fixed mindset prioritizing beneficence, may face conflicts with families. This can lead physicians to take unilateral decisions to avoid disputes and do what they believe is best. Attempts to circumvent patients or families may arise, or families may sometimes make patients feel guilty about their decisions. Thus in seeking beneficence, families and physicians may unintentionally compromise the patient's autonomy. These case studies exemplify ongoing challenges and how the erosion of autonomy can detrimentally impact patients.

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Conclusion and Interventions

While patients ideally should have autonomy in DNR decisions, reality often sees family members or physicians making these choices. Stricter protocols for emergencies and laws mandating the on-call physician to be aware of the patient’s DNR status before treatment can enhance adherence. In case of failure, as seen in the prior case study, the EMS team must swiftly access the DNR file to honor the patient’s wishes [2]. While some patients use tattoos to convey their preference not to be resuscitated [1], these lack legal binding. Instead, technological solutions, such as a device or indicator akin to a Life Alert, can efficiently signal to emergency responders that the patient has signed a DNR. These measures would diminish the physician's influence on the DNR decision. Additionally, addressing DNR matters directly with the patient before involving the family can mitigate external influences on the patient's decision. These interventions aim to restore a semblance of autonomy in the DNR process while preserving beneficence. Striking a balance between these ethical principles empowers patients to make informed decisions, thus fostering better care.

Additionally, addressing DNR matters directly with the patient before involving the family can mitigate external influences on the patient's decision. These interventions aim to restore a semblance of autonomy in the DNR process while preserving beneficence. Striking a balance between these ethical principles empowers patients to make informed decisions, thus fostering better care.

Review Editor: Radhika Subramani
Design Editor: Allison Yang
References

[1] Gilbert, J., & Boag, J. (2018). Nonstandard advance health care directives in emergency departments: ethical and legal dilemma or reality: a narrative review. Advanced Emergency Nursing Journal, 40(4), 324-327.

[2] Iserson, K. V., & Rouse, F. (1989). Case studies: prehospital DNR orders. The Hastings Center Report, 19(6), 17-19.

[3] Keffer, M. J. (1990). Ethical decisions in nursing: The do-not-resuscitate decision (Order No. 9114990). Available from ProQuest Central; ProQuest Dissertations & Theses Global. (303904630). https://login.proxy.lib.duke.edu/login?url=https://www.proquest.com/dissertations-theses/ethical-decisions-nursing-do-not-resuscitate/docview/303904630/se-2

[4] Marchette, L., Martha, H., Monica, W., Barbara, A., Darlinda, C., & Habib, K. (1993). Nurses' perceptions of the support of patient autonomy in do-not-resuscitate (DNR) decisions. International journal of nursing studies, 30(1), 37-49.

[5] Pettersson, M., Hedström, M., & Höglund, A. T. (2020). The ethics of DNR-decisions in oncology and hematology care: a qualitative study. BMC Medical Ethics, 21(1), 1-9.

[6] Sultan, H., Mansour, R., Shamieh, O., Al-Tabba', A., & Al-Hussaini, M. (2021). DNR and COVID-19: The ethical dilemma and suggested solutions. Frontiers in Public Health, 9, 560405.

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