Running head: DNR AND MEDICAL FUTILITY

DNR and Medical Futility: A Person's Right to Die with Dignity Melissa DArpino Molloy College

DNR AND MEDICAL FUTILITY Abstract This paper will discuss some of the challenges facing healthcare decisions. It will explain the issues surrounding medical futility and Do Not Resuscitate orders.

DNR AND MEDICAL FUTILITY DNR and Medical Futility: A Person's Right to Die with Dignity

Although death is a part of life, it is still one of the most sensitive issues in the healthcare field. Medical futility and Do Not Resuscitate orders provide a great deal of moral confusion. Ultimately, each person has value and should be given the right to die with dignity. A persons health is very important, and the decisions surrounding it can be extremely stressful for all persons involved. Each person plays a unique role; the doctor, patient, family, nurse and many others contribute to the experience. There are many considerations when determining which treatment will be effective and be most suitable for the patient. The challenge arises when there are no further available options and the person has lost the battle with the illness. Many people, including both the patient and the doctor, have a difficult time accepting this information. It is complicated for the doctor, whose primary focus is to get the patient well again, to admit defeat to the disease. While explaining the circumstances to the patient and family, the doctor often feels like he or she has failed the patient. Patients rightfully have a hard time accepting that they are sick and that treatments have been unsuccessful. This forces them to face the reality of death and the fear of leaving their loved ones behind. The family of a patient wants nothing more than to be able to have that person well again and take him or her home. This situation becomes very emotional and creates barriers when trying to objectively decide what is best for the patient. Consider this example of a woman who has pancreatic cancer. Some initial tests are conducted to determine this diagnosis, and she starts receiving treatment. She first undergoes extensive surgery, and then has to endure chemotherapy and radiation. Although she and her family wish to try all measures to ensure she makes a full recovery, the doctor continues to present poor statistics, which state her chances are grim. While receiving treatment, she becomes

DNR AND MEDICAL FUTILITY increasingly weak from all the side effects of the therapies. Tests are continually performed to determine if the cancer has been defeated or taken over. It is discovered that the cancer has rapidly spread to the entire body and has metastasized. Should the doctor offer this patient further treatment, even if it will serve no medical benefit? Should the patient or family be allowed to demand further treatment? When a patients management is unsuccessful, it is important to determine if the various treatments are now becoming unnecessary suffering. If the detriment is greater than the benefit, the treatments should be considered medically futile. Medical futility is when a treatment is

medically useless or ineffective; the patient is suffering with no clinical improvement. Since such treatments offer no benefit or enhancement of life, they should not be considerable options for the patient. Wicclair (1993/2006) discusses three branches of futility: physiological futility, futility in relation to the patients goals, and futility in relation to standards of professional integrity (p. 346). Physiological futility relies on the physicians experience and knowledge to determine if there will be beneficial physiological effects from medical treatments, such as chemotherapy or cardiopulmonary resuscitation (CPR). Communication between the patient and doctor is emphasized when determining futility in relation to the patients goals. It is important for a patient to communicate his or her goals to the doctor, so that the doctor may determine what treatments will help achieve those goals; if the treatment will not help the patient reach the desired goal, it is considered futile and should not be offered. A doctors personal beliefs should not interfere with the upholding of standards of professional integrity; this describes futility in relation to standards of professional integrity. Each aspect of futility is used in order to determine whether or not a particular treatment should be recommended to a patient.

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When a patient is terminally ill and death is inevitable, should that patient have the choice to receive CPR? Consider the prior example of the woman who now has metastatic cancer, CPR would not cure her illness or return her to normal health. Ditillo (2002) observes, Resuscitative measures on terminal patients will, at best, return them to the dying state (p. 108). CPR will have no benefit for the dying patient and should be considered medically futile. Ditillo further discusses, Resuscitation of the dying patient with irreparable damage to the heart, lungs, brain, or any other vital system of the body has no medical, ethical, or moral justification (p. 108). There is no justification for a doctor offering CPR to the dying patient and his or her family. In fact, this may cause great confusion for the patient and family. They may gain false hope with CPR as an option or be uncomfortable with making the decision to withdraw that option. In order to take the burden from the family and patient, the doctor should lead this discussion and ultimately make the decision. The decision to not do CPR is commonly known as Do Not Resuscitate or DNR. Regardless of the situation, there remains a great deal of controversy surrounding DNR orders. If, as Ditillo mentions, the patient will simply be returned to the dying state, there should be no reason to perform CPR and the patient should, in fact, be considered a DNR. There are many suggested reasons for a DNR order. Tomlinson and Brody (1988/2006) discuss three rationales for DNR: no medical benefit, poor quality of life after CPR, and poor quality of life before CPR. The first rationale for DNR, no medical benefit, is that which revolves around medical futility. As previously mentioned, CPR should not be performed on a patient for which it would have no benefit. Poor quality of life after CPR is an interesting second rationale. Many people are uneducated on the recovery percentage after CPR. This recovery includes not only immediate return of breathing and circulation, but also when and if the patient will be discharged from the hospital. For example, CPR can result in a permanent state of

DNR AND MEDICAL FUTILITY unconsciousness or continuous ventilator support; patients and families should be informed on these possibilities in order to make a proper decision. Poor quality of life before CPR is a valid concern and certainly a justifiable rationale for DNR. Tomlinson and Brody support, This

rationale might be applied to a patient who was severely incapacitated, mentally or physically, or who suffered intolerably from a terminal or chronic disease (p. 341). Some examples may include patients who suffer from cancer, Parkinsons or Alzheimers disease, congestive heart failure or chronic renal failure. Each of the rationales for DNR can be morally acceptable reasons for allowing a natural death to take place. Although the DNR order is ultimately given by the doctor, communication with the patient and family is essential. Firstly, the doctor should be aware of the goals set out by the patient. The patients wishes should be made known, therefore, making clear to the doctor to pursue or not pursue certain treatments. Secondly, the doctor should be honest with the patient and family regarding the circumstances of the situation. If the patient and family have a full understanding of the patients condition and a chance to ask questions, then an informed, educated decision can be made. This honesty also eliminates some of the confusion on the subject of futile care. If the patient and family can understand that certain treatments would not be medically beneficial, then perhaps they would not be so reluctant to agree to a DNR. Communication should also be clear on a patients rights and autonomy. When concerning his or her health, a patient does have a great deal of autonomy in the decision-making process. Wicclair (1993/2006) argues: However, a right to accept or refuse treatments if they are offered by physicians does not entail a right to demand or receive treatments that physicians are unwilling to offer. In fact, there is increasing support for the position that physicians are not obligated to give

DNR AND MEDICAL FUTILITY patients or their surrogates an opportunity to accept or refuse medically futile treatments. (p. 346) The patient is entitled to decide in the realm of what is offered by the doctor and that which can provide medical benefit. It is not justifiable for a patient or family to have this sense of

entitlement when demanding treatments that offer no benefit. The doctor should not compromise his or her standards of professional integrity in order to satisfy the patient and familys requests. There is often a question of justice. At times, the patient or family will suggest a similar scenario in which another patient received certain treatment. Based on another persons experience, they believe justice would be impeded if the same treatment were not offered in their situation. The distinction needs to be made that justice is not the same as equality. Maguire and Fargnoli (1999) state, Justice is fairness and it means giving others their rightful due as persons (p. 29). What is right for one person may not be for another, and each circumstance is unique and needs to be modified accordingly. In order to facilitate the decision-making process, regarding medical futility and DNR, underlying issues must be examined. When a patient is debilitated and unable to make his or her own medical decisions, a surrogate or health care proxy will then become responsible for making these decisions. This surrogate is often a family member or friend who has a close relationship with the patient. If the patient has previously filled out a proxy form or a living will, then the surrogate will be better able to follow the patients wishes. Many times, a person procrastinates making medical decisions until actually being faced by them, thus leaving the surrogate guessing what the patient would have wanted. Feelings of guilt can often affect the surrogate and the decision to be made. Maguire and Fargnoli (1999) describe three different views of guilt: taboo, egotistic, and realistic. Taboo guilt is when something is viewed as wrong, not for the harm it

DNR AND MEDICAL FUTILITY may cause, but simply because it is considered forbidden. DNR can often be viewed as taboo, discouraging many people from making that decision. Egotistic guilt can also affect the surrogates decision. People may not be able to live with themselves if they decide to not try everything for their loved one, even if it means that the patient will be suffering. Maguire and Fargnoli explain, In cases of terminal illness, for example, decisions are often made not according to the rights or wishes of the dying person but according to the guilt feelings other would have by allowing the person to die (p. 153). Permitting a patients suffering, in order to make the surrogate feel better, is not acceptable. Realistic guilt is present when actual harm is done to a person. This may coincide with the other examples of guilt without the person knowing. The surrogate may only see the taboo surrounding the DNR or the personal effects

from the medical decisions, but in fact, medical futility may simply be causing patient suffering. The harm caused to the patient from these treatments may be enough to cause realistic guilt. Medical decisions, including that of DNR, should be made according to the patients wishes and as objectively as possible. In order to examine medical futility and the decision of DNR, there are many moral questions that should be answered. Maguire and Fargnoli (1999) present a wheel model in order to question and evaluate moral reality. The questions in the hub of the wheel are used to assemble facts, and these questions include: what, why, how, who and foreseeable effects. Each of these questions should be applied to the situation which warrants a DNR and where medical futility is to be determined. The first reality revealing question to be posed is what. The question what can encompass many different answers. What fixes attention on the primary data (physical, psychological, systemic) by which we make our first cognitive contact with a subject or case (Maguire &

DNR AND MEDICAL FUTILITY Fargnoli, 1999, p. 50). It is important for all persons involved to gain knowledge on as much information as possible, in order to make an informed decision. When asking what, the disease,

treatment options, and the patients medical and personal information should be examined. Each of the answers to the question what should, in one way or another, influence the decision-making process. Also, definitions of medical futility and DNR should be provided to the patient and family, in order for their answers of what to be answered. The next reality revealing questions are why and how. These questions go hand in hand with each other when determining the ends and the means. The question why focuses on the goal; this is very important when making healthcare decisions. Why one is going to continue treatment is based on the specific goals which have been set forth. The doctor needs to be informed on the patients desired goals or ends in order to adjust care appropriately. The family also needs to know the patients goals. If cases arise where a surrogate is necessary, that person may make proper decisions based on the wants of the patient. Why also involves motives; the reason why a certain action is being taken is crucial. As previously discussed, if guilt is the reason for a treatment, then perhaps the decisions should be reexamined or be relinquished to someone else. A doctor may also continue medically futile treatments, in order to keep a person alive, so that statistics will not be affected; these ends do not justify the means and should be considered immoral. The means or mode in which the goal is achieved is known as the how. The how needs to be acknowledged in order to respect the patients wishes and fulfill the goals. The method by which a person may have a quick, painless death may be to avoid medically futile interventions and have a DNR order. Who is one of the most important reality revealing questions to be asked. Since there are many persons involved in making medical decisions, each one needs to be considered. The

DNR AND MEDICAL FUTILITY doctor, patient, and family each exist as separate beings and yet, are forced to come together during this difficult time to make medical and moral decisions. Persons become who they are over the course of their life and may experience many changes over that time. Influencing factors, such as culture and religion, alter the way in which a person grows. Maguire and Fargnoli (1999) refer to two different types of personal growth; psychologically and morally. They further explain: Moral growth presupposes some psychological growth but it refers specifically to the

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development of human values and character. Moral decisions make us virtuous, or heroic, or just or they make us exploiters, or liars, or villains, or a little bit of each. Moral decisions make us what we are as persons.(p. 61) Medical decisions, which are often moral ones as well, depend on who is making them. When making the moral decisions, one must remember the value of persons. When a surrogate is considering medical decisions for a patient, it is essential to keep in mind the value of that person, not only in their personal relationship, but as a human being. One of the most basic human rights should be to die with dignity; this should be strongly emphasized when discussing medical futility and the DNR order. One of the most misconstrued questions is foreseeable effects or consequences. Many times a person will only see how the situation will affect ones own future, as opposed to considering the patients. The future of the patient can be perceived in many different ways, depending on who is looking. As previously mentioned, when discussing the why question, a doctor may continue medically futile treatments in order to keep a person alive, so as not to affect the statistics. The doctor can only see the future from his perspective and is not acting in the best interest of the patient, which compromises his moral integrity. A surrogate can also have

DNR AND MEDICAL FUTILITY distorted views when looking to the future, as mentioned with egotistic guilt. Surrogates may

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make medical decisions for the patient by simply thinking of their own future regarding the loss of their loved one. The patients foreseeable effects should be the focus, regarding the medical decisions being made. If the patient is going to die, then that person should be allowed limited suffering and be able to die with dignity. Maguire and Fargnoli (1999) use the spokes of the wheel model to evaluate moral reality. Some of the concepts used in the spokes of the wheel are: affectivity, authority, and group experience. Each of these concepts can affect how a person reaches a decision. In order to make a suitable decision, one needs to use not only the mind, but the heart as well; this brings in the idea of affectivity. Maguire and Fargnoli (1999) explain, Affectivity, in many morally informative ways, is our rapport with the ethical world. Feeling is not totally separate from intelligence or affectivity from knowledge. Feeling is a knowing experience (p. 89). Since medical decisions are surrounded by stress and emotion for the patient and family, they should be encouraged to consider their feelings when making their conclusions. If done unselfishly, affectivity can help a loved one decide what is best for the patient. The next spoke to evaluate is authority. The authority can be held by many different persons when making medical decisions. Patients have autonomy and authority in making their own healthcare decisions, but can often relinquish that power to those around them. Doctors have a special sense of authority because they have the advantage of holding the scientific knowledge in order to make the decisions. Families often gain authority when the patient is no longer able to make the decisions, and the surrogate may have some difficulty with this. Maguire and Fargnoli (1999) state, Authority must be open to moral growth. . . . Because authority can be wrong, it

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should be open to change when new moral insights emerge (p. 103). The person with authority may have grown up believing in one thing, but should stay open-minded to different options. Group experience can have a great impact on the way a person makes decisions regarding healthcare. Each person is shaped by the traditions learned from the family, religion, culture, and society. Maguire and Fargnoli (1999) explain the following: Some group experiences may affirm or correct our value positions; others, through detailed analysis and comparison, may need to be rejected as morally unfit. But in both cases, group experience is a critical resource that is meant to expand our moral awareness. (p. 125) It is important for one to compare different views and follow what is best for that individual. Group experience can alter ones healthcare decisions. For example, DNR orders may be frowned upon depending on a persons religious or cultural traditions, making it taboo. Doctors may also be influenced by group experience, but they should objectively maintain moral integrity and not let learned practices poorly influence the care for their patients. It is important for the doctor to respect the patients group influence and to modify care accordingly. There are many controversial issues surrounding medical futility and DNR. The patients wishes and future should be the main focus for all persons involved. The doctor, patient, and family need to maintain open communication in order to properly decide what is best for the patient.

DNR AND MEDICAL FUTILITY References Ditillo, B. (2002). Should there be a choice for cardiopulmonary resuscitation when death is expected? Revisiting an old idea whose time is yet to come. Journal Of Palliative Medicine, 5(1), 107-116. Retrieved from MEDLINE with Full Text database. Maguire, D. C., & Fargnoli, A. N. (1999). On moral grounds: The art/science of ethics. New York: McGraw-Hill.

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Tomlinson, T., & Brody, H. (2006). Ethics and communication in do-not-resuscitate orders. In T. A. Mappes & D. DeGrazia (Eds.), Biomedical ethics (pp. 340-345). Boston: McGrawHill. (Reprinted from New England Journal of Medicine, 8[January 7, 1988], 43-46.) Wicclair, M. R. (2006). Medical futility: A conceptual and ethical analysis. In T. A. Mappes & D. DeGrazia (Eds.), Biomedical ethics (pp. 345-349). Boston: McGraw-Hill. (Reprinted from Ethics and the Elderly, by Oxford University Press, 1993.)