Ethical issues do not resuscitate orders

CASE 74

Ethical Issues Over DNR Orders

Dale Buchbinder

Mr. Warden, a 93-year-old white male, is admitted to Centerville Community Hospital from Centerville Estates Nursing Home. Mr. Warden has had multiple strokes and is only partially responsive to painful stimuli. He does not recognize or respond to nursing staff, physicians, or family members. In addition, he has flexion contractures and a large infected decubitus ulcer over his left sacral area. Further evaluation shows Mr. Warden has extremely poor heart function and is in congestive heart failure. The notes from Centerville Estates Nursing Home indicate Mr. Warden has had one visitor in the past six months;that visitor was not a family member.

As the physician in charge of this case, you have asked the Warden family to meet with you to decide what type of care should be provided to Mr. Warden. A 69-year-old daughter and a 64-year-old son with two grandchildren come to the meeting. After you introduce yourself and explain their father’s condition and poor prognosis, you recommend no further treatment be given. The daughter becomes hysterical. Weeping and shouting, she states she wants “everything”done for her father. The son, on the other hand, states he understands his father does not have a good quality of life and cannot communicate. “I don’t want him to suffer. Please give him comfort care only.”

The daughter becomes more hysterical and accuses her brother of being cruel.

The brother remains calm and repeats, “Comfort care only.”

While you attempt to address Mr. Warden’s quality-of-life issues and the limited powers that medical care has over the end of life, the daughter shakes her head and continues to be agitated. At length, you ask the daughter why she hasn’t visited her father in three years, despite the fact that she lives only a few miles away from the nursing home. The daughter ignores your question and continues to insist on a maximum level of medical care. She refuses to entertain the possibility of a do not resuscitate (DNR) order.

Her brother, however, agrees to the DNR and states, “It’s not as if he’s there, really. Our father died a long time ago.”Upon further questioning, the son reveals he has the father’s power of attorney, and therefore has the authority to make the DNR decision in this case.

Discussion Questions

1. What are the facts in this situation?

2. Autonomy, nonmaleficence, beneficence, and justice are the cornerstones of ethical decision making. What ethical dilemmas does this case illustrate?

3. Have any principles of ethical decision making been violated in this case? What ones have been supported? How might our cultural upbringing, personal assumptions, and opinions influence our decisions as health care managers? Provide rationales for your responses.

4. Based on what you know from this short case, why do you think Mr. Warden’s daughter is so insistent on wanting “everything”done for her father?

5. What if Mr. Warden was wealthy and had a large estate? Would that change your opinion of the son and his responses? Provide a rationale for your response.

6. If the son had no power of attorney, how could this issue be resolved? Can a physician decide to withdraw care without the consent of the family? Who has the final say in the care of a patient in this condition? Provide your reflections and personal opinions as well as your recommendations and rationale for your responses.

ADDITIONAL RESOURCES

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