Case Study – Alice’s Frail Mother

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What Part of DNR Don’t You Understand?

“Don’t Advance Directives mean anything around here?

Don’t DNR orders mean what they say?”

By Rosemary Flanigan, PhD

Yesterday, Martha T. was taken to Oak Grove Nursing Home by her daughter. The developing Alzheimer-type degeneration has caused such havoc in Martha that her daughter, Alice, is no longer able to care for her at home. Oak Grove has a special unit for Alzheimer patients and Alice found in her research that it is highly commended by friends who used the facility both for long-term and short-term care.

The move to the nursing facility has been in the making for several weeks, but when the day for the move came, Alice found that her mother was in an especially frail state. When they reached Oak Grove, the staff made Martha comfortable and began the paperwork with Alice. Before long, Alice pleaded weariness, and she left with only some of the forms signed. She had given Martha’s advance directive to the facility, and she discussed her mother’s wishes that, if her heart stopped beating, she did not want to have surgery, CPR, antibiotics, and so on. Alice had then signed the color-coded DNR order, but there was no discussion and other forms were left for another day.

This morning Alice is awakened by a call from Oak Grove informing her that her mother had had a “cardiac episode” and that the facility had called 911. Her mother, they said, was now at Community Hospital. Alice left immediately and found her mother in the Intensive Care Unit on a heart monitor, a ventilator, and an intravenous line. Alice sought out the patient representative at the hospital and asked how her mother’s worst nightmares could have come true.
“Don’t Advance Directives mean anything around here? Don’t DNR orders mean what they say?” she asked.

Questions for discussion
Using the following questions, discuss the ethical implications of Martha’s treatment.
• Is the relationship between DNR orders and advance directives is a confusing one? Discuss
• When are DNR orders operative? Why wasn’t the DNR order for Martha honored?
• Many people feel that to sign a DNR order is the same as condemning oneself or another to no care. Discuss.
• Does the DNR policy in your institution explain the meaning of “Do not resuscitate”? For example, does it mean: “If I’m dead, don’t bring me back to life” or “If I’m dying, don’t try to save me”?
• Communication, either with the patient or the surrogate and with the attending physician, is the only way one can clarify what DNR means in each situation and with each player. Such communication must include why it does or does not make sense to attempt resuscitation at a particular time with this particular patient. Has your ethics committee facilitated such meetings?
• Often long-term care facilities promise resuscitation when they actually do not have the crash carts and trained staff to do so. Examine the marketing materials for your organization to see whether the words it uses convey actual practice.
• Clinical directors of long-term care facilities need to clarify to the administration and staff their meaning/s of DNR orders so that there is no conflict between policy and practice. Has your ethics committee facilitated such clarification?
• Finally, ethics committees should present educational segments to explain DNR orders.

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