信義區英文口語讀書會

Source: https://depts.washington.edu/bioethx/topics/dnr.html

Q1: What do you think about patient autonomy and DNAR?
Q2: Do you have any friend/relative who knows about DNAR in Taiwan? What is his/her opinion?

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(The article is very long. I only pastes some paragraphs here.)

What is a Do Not Attempt Resuscitation (DNAR) Order?

A Do Not Attempt Resuscitation (DNAR) Order, also known as a do not resuscitate (DNR) order, is written by a licensed physician in consultation with a patient or surrogate decision maker that indicates whether or not the patient will receive cardiopulmonary resuscitation (CPR) in the setting of cardiac and/or respiratory arrest. CPR is a series of specific medical procedures that attempt to maintain perfusion to vital organs while efforts are made to reverse the underlying cause for the cardiopulmonary arrest. Although a DNAR order may be a component of an advance directive or indicated through advance care planning, it is valid without an advance directive. (See Advance Care Planning and Advance Directives)

History of Cardiopulmonary Resuscitation and Do Not Attempt Resuscitation Orders

The history of CPR and DNAR orders is extensively reviewed in the literature (Bishop et al., 2010; Burns et al., 2003). In the 1960s, CPR was initially performed by anesthesiologists on adults and children who suffered from witnessed cardiac arrest following reversible illnesses and injuries. Based on the success of this intervention, CPR became the standard of care for all etiologies of cardiopulmonary arrest and the universal presumptive consent to resuscitation evolved (Burns et al., 2003). However, in 1974, the American Heart Association (AHA) recognized that many patients who received CPR survived with significant morbidities and recommended that physicians document in the chart when CPR is not indicated after obtaining patient or surrogate consent (ibid). This documentation formally became known as the DNR order. Recent medical literature encourages reference to this documentation as do-not-attempt-resuscitation (DNAR) and allow a natural death (AND) based on the practical reality that performing CPR is an attempt to save life rather than a guarantee (Venneman et al., 2008).

The Role of Patient Autonomy

Since the original inception of DNAR orders, respecting the rights of adult patients and their surrogates to make medical decisions, otherwise known as respect for autonomy or respect for persons, has been emphasized. This concept is reinforced legally in the Patient Self Determination Act of 1991, which requires hospitals to respect the adult patient’s right to make an advanced care directive and clarify wishes for end-of-life care. In general, an emphasis on improving communication with patients and families is preferred over physicians making unilateral decisions based on appeals to medical futility regarding the resuscitation status of their patients. See below.

What if patients are unable to express what their wishes are?

In some cases, patients are unable to participate in decision-making, and hence cannot voice their preferences regarding cardiopulmonary resuscitation. Under these circumstances, two approaches are used to ensure that the best attempt is made to provide the patient with the medical care they would desire if they were able to express their voice. These approaches include Advance Care Planning and the use of surrogate decision makers. (See Advance Care Planning and Advance Directives , and Surrogate Decision Makers)

Not all patients have Advance Care Plans. Under these circumstances, a surrogate decision maker who is close to the patient and familiar with the patient’s wishes may be identified. Washington state recognizes a legal hierarchy of surrogate decision-makers, though generally close family members and significant others should be involved in the discussion and ideally reach some consensus. Not all states specify a hierarchy, so check your state law. Washington’s hierarchy is as follows:

1. Legal guardian with health care decision-making authority
2. Individual given durable power of attorney for health care decisions
3. Spouse
4. Adult children of patient (all in agreement)
5. Parents of patient
6. Adult siblings of patient (all in agreement)

The surrogate decision maker is expected to make decisions using a substituted judgment standard, which is based on what the patient would want if she could express her wishes. In certain circumstances, such as in children who have not yet developed decisional capacity, parents are expected to make decisions based on the best of the patient, called a best interest standard.