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Do not resuscitate orders and iatrogenic arrest during dialysis: should "No" mean "No"?
1Department of Pediatrics and MacLean Center for Clinical Medical Ethics, University of Chicago, Chicago, Illinois 60637, USA. lross@uchicago.edu
Insights
Cardiopulmonary arrest during hemodialysis (HD) can be iatrogenic. This paper argues that do not resuscitate (DNR) orders must be honored, respecting patient autonomy, unless overriding aligns with patient goals.
Area of Science:
- Medical Ethics
- Nephrology
- Critical Care Medicine
Background:
- Cardiopulmonary arrest (CPA) during hemodialysis (HD) is often iatrogenic, stemming from therapeutic interventions.
- Do Not Resuscitate (DNR) orders present ethical challenges when CPA occurs during HD.
- Existing arguments for overriding DNR orders in this context are critically examined.
Purpose of the Study:
- To explore the ethical considerations of managing CPA in HD patients with existing DNR orders.
- To argue for the strict adherence to DNR orders based on patient autonomy and goals.
- To highlight the need for improved advance care planning and communication in nephrology.
Main Methods:
- Ethical analysis of arguments for overriding DNR orders.
- Review of principles including nonmaleficence, efficacy of resuscitation, proximate cause, and physician error.
- Philosophical argument centered on patient autonomy and goals.
Main Results:
- Four common arguments for overriding DNR orders during HD CPA were analyzed and rejected.
- The primary ethical imperative is to respect patient autonomy and stated goals.
- Physicians have a moral obligation to follow DNR orders literally in the absence of evidence aligning with patient goals.
Conclusions:
- Respect for patient autonomy mandates adherence to DNR orders during hemodialysis-associated CPA.
- Nephrologists require enhanced communication skills for advance care planning and documentation.
- Upholding DNR orders ensures alignment with patient values and medical ethics.
Abstract:
An iatrogenic arrest is a cardiopulmonary arrest induced by a therapeutic effort. Frequently cardiopulmonary arrests during hemodialysis (HD) are iatrogenic. In this article I consider the question of what to do when a cardiopulmonary arrest occurs during HD in a patient with a do not resuscitate (DNR) order. I consider and reject four arguments to override the DNR order: the principle of nonmaleficence, the efficacy of resuscitation, proximate cause, and physician error. Instead, I argue that respect for patient autonomy and patient goals means that DNR orders must be respected unless there is compelling evidence that overriding the DNR would be consistent with the patient's goals. If such evidence is lacking, the physician has no moral choice but to follow the DNR order literally. As such, nephrologists need better communication with their patients regarding advance care planning and better documentation of their communication once it has occurred.