Do not resuscitate: A different caring
As stated by Fields, “Do not resuscitate does not mean no care; it means a different kind of care that can be best achieved through end-of-life protocols and education” (2007, p. 294). According to Lachman (2010), do- not-resuscitate orders, or DNRs, are not being initiated early enough in their hospital stay for identified terminal patients. The purpose of this paper is to investigate and focus on a few reasons why this is happening, as well as to provide a few solutions. The terminal patients are the patients with chronic diseases such as end-stage renal disease, congestive heart failure, and diabetes, who have had an exacerbation in their symptoms which has now rendered them terminal. Prognostic tools and evidence-based predictor tools are being implemented more frequently to define these critical, “terminal” patients (Papadimos, 2011). These tools are especially important, because they apply mainly to non-cancer patients, whose terminal prognoses often overlooked. DNRs are not being initiated earlier in the hospital due to barriers such as the semantics of a DNR, doctors not setting the time to have the conversation with the family early enough in the hospital stay, and the miscommunication between healthcare providers, patients, and family members. The first advance directive, called a living will, was proposed by the Euthanasia Society of America in 1967 (Glick, 1991). On December 1st 1991, the Patient Self Determination Act (PSDA) came into effect (Glick, 1991). This is a federal law that requires all hospitals, nursing facilities, home health agencies, home health care providers, and hospices to provide patients with written information about advance directives (Glick, 1991). As Glick (1991) states, the PSDA was an amendment to federal Medicare and Medicaid laws, with the idea that it would impact how people plan for their future healthcare. Glick emphasizes that he PSDA acts as an information and education directive; therefore, it does not create or change any substantive right to health care decision making, but rather requires all Medicare and Medicaid provider organizations to fulfill five requirements: 1. provide written information to patients at the time of admission concerning an individual's right under state, including the right to accept or refuse medical or surgical treatment and the right to formulate advance directives; 2. maintain written policies and procedures,
3. document in the individual's medical record whether or not the individual has executed an advance directive, 4. ensure compliance with the requirements of state law respecting advance directives at facilities of the provider or organization, 5. Provide (individually or with others) for education for staff and the community on issues concerning advance directives (p. 287). In addition, as Glick (1991) writes, the PSDA required that the U.S. Department of Health and Human Services (HHS) begin a public education campaign on the topic of advanced directives, which included “developing or approving national educational materials, assisting states in developing state-specific documents, and mailing information to Social Security recipients” (p. 297). However, it should be noted that health care providers are not mandated to carry out advance directives if it is dilemma of one’s conscience (Glick, 1991), so the state law had to adjust to create that flexibility and possibility.
The Joint Commission (JC) currently does not provide specific guidelines for DNR discussions. Yeon & Fetters (2011) write that currently, the JC standards regarding hospital DNR policies are limited to “providing mechanisms for reaching decisions and resolving conflicts, describing the role of physicians, other staff and family members in the decision, as well as requiring the DNR order to be written by the attending physician” (p. 792). There is no requirement to ensure that a qualified...
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