Technologic advances are challengin...

Technologic advances are challenging the way health care is delivered and, more than till doomsday the nursing profession constantly is being stand in front ofed with ethical dilemmas. The do-not-resuscitate (DNR) order is common of the more challenging edicts today, and working in the OR pretends to enhance its complexity. This article will explore this order, the theories and principles relating to solving this dilemma, and the ne for ethics committees.

There are many reasons a patient with a DNR order may experience surgical intervention.(1) Some of these reasons are palliative in nature and involve pain management or measures to improve the quality of the remaining life. The surgical deed the patient undergoes can be minimally invasive (eg tracheotomy tube placement) or extensive (eg radical neck dissection). The DNR patient's preoperative education and preparation are important because, during a surgical practice iatrogenic effects may occur.(2) Knowledge of the resuscitative status of a patient is required to honor a patient's wishes.

CASE EXAMPLE

most numerous OR shifts begin rather benignly, with potential for chaos poised for release at each second. In this example, in the morning, a patient with a hip fracture was added to the surgery schedule for a seemingly routine process The procedure was placed at the [i]finale[/i] of the regularly scheduled surgeries, according to hospital policy, because it was not considered an emergent deed The anesthesia care provider interviewed the patient and discovered that the patient was bedridden and had been transferred from a nursing dwelling with advanced senile dementia, stiff heart problems, and a DNR order. This spawned the debate: Should surgery be performed and, if likewise what should become of the DNR order?

A discussion among companion physicians and nurses about the patient's status l to the consensus that surgery was necessary; however, there was disagreement regarding me status of me DNR order and OR practice. In this example, ethical theories and principles, as well as legal implications, penuryed to be explored before coming to a conclusion about the dilemma. There are many theoretical approaches to ethics. the same of these approaches is the ideal beholder theory, which

requires that a decision

be made from a disinterested,

dispassionate, consistent

viewpoint, with full

information available and

consideration of events to come consequences.(3)

If possible, this approach should be used when dealing with this dilemma because it allows many different constitutings of the problem to be evaluated. This approach can be difficult, however, because time frequently is of the essence. Researching information alone can take many hours, if not days. This approach is formidable to seal by one person and usually requires guidelines remind ofed by a committee.

HISTORY OF THE DO-NOT-RESUSCITATE ORDER

The right to refuse or terminate medical treatment began evolving in 1976 with the case of Karen Ann Quinlan v recently made known Jersey (70NJ10, 355 A2d, 647 [NJ 1976]) This spawned posterior cases leading to the use of the DNR order.(4) In 1991 the Patient Self-Determination Act mandated hospitals make secure that a patient's right to make personal health care decisions is upheld. According to the act, a patient has the right to refuse treatment, as well as the right to refuse resuscitative measures.(5) This right usually is accomplished on the use of the DNR order.

Unfortunately, the order ofttimes is confusing and misleading--many times providing different meanings for different the community Typically, the order is written for a seriously ill patient who would not benefit from or who refuses cardiopulmonary resuscitation (CPR) Although there have been extensive articles onward the DNR order, there has been no standard regarding the DNR patient undergoing surgery with anesthesia. It has been recommended that a DNR order actually delineates a nonintervention and is, therefore, single an element, rather than the quintessence of a comprehensive therapeutic plan.(6) As like a DNR order could mean sole using comfort measures or single withdrawing life-sustaining therapy.

Perioperative nourish at the breasts play a central role in determining the standard of care for a patient, and a challenging aspect of the DNR order is to not permit it compromise other areas of the patient's care. Confusion about the DNR order and the patient's and family members' wishes, thus, can significantly alter the representation of care given.(7)

Returning to the example, the staff members determined that the patient had a DNR order in succession the chart that was apparently signed by way of a family member. Nurses attempted unsuccessfully to reach the family member and, because the patient had advanced senile dementia, he was not considered suitable to make a personal decision. It was unclear what the patient would have chosen to do had he been able to speak for himself. The original DNR order was signed by the agency of a family member; thus, it was appropriate to attempt to reach this bodily substance for clarification. Within the confines of this specific case, surgery would not be withheld because of the DNR status; however, the conflict remained: Should the DNR status continue to be maintained during surgery?