Do-not-resuscitate orders: nurse's role requires moral courage.

The Truth About CPR All Patients and Families Need to Know CPR stands alone as the only intervention the patient must state explicitly that he or she does not want. Today, every patient is a “full code” unless a DNR order is documented clearly in the medical record. However, the probability of success of CPR varies based on the cause of the arrest, the patient’s health status, and the availability of a trained first responder (Cooper, Cooper, & Cooper, 2006). Although the right to patient autonomy was expressed in 1914 and informed consent became a catch phrase in 1957, not until 1985 did polices to limit medical care became explicit, in part due to the data on the outcomes of CPR. Discharge from the hospital (definition of long-term survival) after CPR originally was reported as 70%, but this conclusion was based on a select group of patients resuscitated in the operating room and recovery room (Layon & Dirk, 1994). Most current rates of survival are recorded to hospital discharge at 1%-25% for outpatients and 029% for inpatients (Cooper et al., 2006). The summary of results from the four large studies of arrest survival demonstrates increased probability of survival for all rhythms when the arrest happens in the hospital (6.4% vs. 17.6%). Patients with ventricular fibrillation fare markedly better than patients in asystole. Current statistics fail to match modern television dramas, however, where 75% of the patients survive in programs such as “ER” (Diem, Lantos, & Tulsky, 1996). The disparity between these statistics and those of the 1950s is attributed to today’s higher level of patient acuity as well as non-cardiac causes of arrest. Also, this cohort of 50 years ago was primarily surgical patients who benefited from intense monitoring. This cohort also did not demonstrate the brain damage that is a frequent cause of death after cardiac arrest (Safar & Kochanek, 2002). Perhaps these poor outcomes are also the result of CPR being performed In the past, the moral command was to choose life. The contemporary moral dilemma is to choose life under what circumstances. “Now, the emerging trend is to cede moral authority – and with it, responsibility – to patients and families (what ought to be done), while scientific authority (what can be done) remains with the professional” (Curtin, 2010, p. 1). This shift is far too simplistic; instead the public and professionals must determine the separation of what ought to be done from what can be done. Do-not-resuscitate (DNR) orders were initiated as a method to give competent patients the chance to determine under what circumstances they still choose life. Unfortunately, the discussion usually occurs between the surrogate decision maker and the physician, because the discussion has waited too long and the patient now lacks the mental capacity to decide. The focus of this article is the ethical obligation nurses have to support families and patients in making a DNR decision. Initially, a brief review of the statistics on cardiopulmonary resuscitation (CPR), ethical issues surrounding partial do-not-resuscitate (DNR) orders, and the present timing of DNR discussions will be presented. It will be followed by a discussion of the results of Sulmasy, He, McAuley, and Ury’s (2008) study on the difference between nurses’ and physicians’ beliefs and attitudes on DNR. Though this study points to the acceptance of the majority of attendings for nurses to initiate DNR discussions, in reality nurses often are not included in the preparation or implementation of these discussions. Interwoven throughout this article will be ideas about what nurses can do to facilitate more open DNR discussions. Moral courage will be needed to overcome fear and stand up for the core values surrounding compassionate end-of-life decision making. Nurses need to put ethical principles, such as veracity, fidelity, and autonomy, into action for end of life (American