The Ethics Team is prepared to meet to discuss specific clinical ethical issues. Hospital staff, patients and families who have concerns or need clarification about ethical aspects of patient care may consult the committee.
Dr. Jaro Kotalik
Email: jkotalik@tbaytel.net
S Hamilton
Email: hamiltos@tbh.net
(807) 684-6012
P Lee
Email: leep@tbh.net
(807) 684-6028
The following is a summary of the Roundtable Discussions held in October and November regarding Do Not Attempt Resuscitation. The participants discussed four fictional cases involving decision-making around DNAR. These scenarios were chosen because it is recognized that staff members encounter these types of cases fairly frequently, and also because some of the issues are challenging in practice.
A 92-year old man with mild dementia and end-stage congestive heart failure is admitted for minor surgery. There has been no previous discussion with his physician or family regarding end of life issues. The patient suffers a cardio-pulmonary arrest shortly after he returns to his bed.
Issues to Consider
- Resuscitate when in doubt.
- No predetermined prejudices or hasty personal judgment.
- No evidence of prior discussion on DNAR - must resuscitate.
This same patient is successfully resuscitated but later on that night becomes tearful and distressed and says to the nurse caring for him “I’m just so tired and I don’t want to live like this any longer.”
Issues to Consider
- Must have therapeutic discussion with patient – is he traumatized due to code or does he want to die? Does he need pastoral care or other help to discuss his spiritual/emotional distress?
- Never jump to conclusion that patients who verbalize these feelings always want to die.
- If further discussion reveals a true wish for DNAR, must assess capacity.
- Assess family situation as well.
- Consider all aspects of informed consent including what DNAR means, what comes next, etc.
This same patient’s chart now has a DNAR order - which he has requested and to which he has consented. A family member now objects to the DNAR order, and produces a document identifying him as Power of Attorney for Personal Care.
Issues to Consider
- DNAR order on chart means policy has been complied with including assessment of capacity.
- POA does not overrule a capable patient’s wishes.
- If conflict ensues (ie. Family believes patient not capable), options in case of conflict are covered in the policy and must be followed.
- Patient wishes and patient care are primary.
You admit a patient, who is 90 years old, has severe dementia, weighs 80 pounds, and who is now comatose. There is no DNAR order, and the person holding Power of Attorney for Personal Care wants full resuscitation carried out. Clinicians are distressed because they feel resuscitation would be inappropriate.
Issues to Consider
- Primary rule is patients with no DNAR order must be resuscitated.
- Exception – MD order of DNAR based on “medical futility” – legally and ethically defensible.
- Important to provide support for distressed clinicians.
- Also must recognize that as important as clinicians’ feelings and needs are, patients’ are more important.
- There is an extreme need for conference with all parties ASAP.
- Cannot withhold resuscitation on categories of patients – must be individually considered in a framework of ethical decision-making.
- Communication, communication, communication, with support of Ethics Team, Pastoral Care, Case Conferences, etc.
Centre for Health Care Ethics April 16, 2003
"Capacity for Decision Making among the Mentally Ill: Ethical Concerns"
Panel: Jane McKenzie: Psychiatric Patients Advocate Office;
Pauline Bodnar: Thunder Bay Regional Hospital; Psychiatrist in Chief, Lakehead Psychiatric Hospital
Facilitator: Louisa Pedri, MA, CHCE
:: back to top ::
|
