The Cons of a Do Not Resuscitate Order and Other Advance Medical Directives
Advance Medical Directives: The Cons of a DNR
Having an advance medical directive – typically called a “do not resuscitate” order or a DNR does not always alleviate the complex issues surrounding the termination of life-sustaining medical measures. In some instances, the presence of a DNR only serves to complicate matters. The presence of a DNR will frequently prohibit the family or doctors from interceding in any way on behalf of the individual.
A significant part of the problem is that medical science does not yet understand what happens to people when they enter a coma-persistent vegetative state. According to the Department of Neurology Columbia University Medical Center, a coma is general “brain failure” characterized by severe depression of level of consciousness. -Several popular anecdotal stories exist about patients who have recovered from a coma and describe experiencing sensations related to the world around them. Unfortunately, there is no hard science to objectively document what someone in a comatose condition is feeling or thinking, or if these processes are even occurring at all. The brain is still largely a mystery in its function and operation, and well-documented arguments can be made on both sides of this scientific and ethical debate regarding brain death.
Brain death is a clinical diagnosis of “permanent functional death of the brainstem” (Eynon, 2005). It is determined that a patient is legally and clinically dead, if they are “brain dead.” Note that in some states removal from a ventilator is determined by the diagnosis of brain death from two different doctors.
The American Academy of Neurology (AAN) guidelines for brain death and the 2010 update, provide an interpretation of brain death and ancillary tests that are available such as:
- The EEG
- Nuclear Scans
- Cerebral Angiography,
- TCD Trans-Cranial Doppler
The clinical evidenced-based assessment includes:
- No evidence of any form of responsiveness to stimulus, including brainstem reflexes, pupillary response to bright light, fixed pupils, ocular movements and reflex using ice water in each ear, cornel reflex by touching the cornea
- No eyelid movement
- No facial muscle movement to stimulus or grimacing, pharyngeal and tracheal reflex
- No cough response or gag reflex
- Absence of a breathing drive
- A neurologic examination, and use of ancillary tests to determine if the patient may be in a transitional conscious awareness comatose state
The 2010 AAN Neurology Evidence-based guideline update, says that current research shows no evidence for the minimal length of observation period to determine neurological functions have irreversibly ceased and that neurological function has permanently ended. However, some doctors recommend a time period based on the age of the patient and the tests utilized. It says that the discovery of this “novel brain state” represents the deepest form of coma and demonstrates that the brain “may remain operational beyond the EEG isoelectric line.”
Defining Brain Death
In a research article titled “Human Brain Activity Patterns beyond the Isoelectric Line of Extreme Deep Coma,” by Romanian doctors Daniel Kroeger, Bogdan Florea, and Florin Amzica they suggest that “depth recordings” should be considered as an additional assessment in brain death cases. If the brain’s neuronal elements remain preserved, then establishing clinical brain death becomes harder as the brain could possibly remain operationally functional, even when the EEG activity patterns are flat, thereby indicating irreversible brain damage, and might be measuring a point between “a living brain and a deceased brain.” Depth recordings would measure the reversible brain.
In another study, Neural Dynamic during Anoxia and the “Wave of Death”, researchers found that absence of significant EEG power after depolarization wave is caused by a block, “which by no means implies irreversibility or cell death,” and that in this experiment EEG activity could return, that irreversible damage came from damage to synapses not the death of the cells.Further, they took human brain slices hours after death, and found they can survive for in vitro for weeks. In fact they say the wave of death does not imply death for either brain neurons or human beings. It only reflects the occurrence of sudden change.
The medical records for brain death patients are documented at the time the arterial PCO2 reaches a target value. Time of death for patients who have had ancillary test with aborted Apnea testing is when the tests are officially interpreted. The definition for brain death was originally developed in 1968 by Harvard physicians that defined irreversible coma as a measure for brain death. The definition of a permanently non-functioning brain allowed for and insure the freshness of the recovery of harvested organs for transplant. In most cases harvesting of the donors organs at this stage requires the donor to be anesthetized for pain as the body still can experience pain during the harvesting and removal of donated organs.
The Default Response: Preserve Life and Do No Harm
The medical system contains a great deal of uncertainty. A doctor or family may have to act under the pressure of the moment to make a decision. In these cases, there is no clear guidance on the proper course of action. When faced with irrevocably terminating the life of a patient or sustaining the patient’s life, common sense dictates that the life sustainment continue in the pendency of legal issues surrounding the DNR. Hospital legal and ethics boards will err on the side of sustaining life and determining the legally “correct” response at a later time. Is this course of action wrong? Ethical and moral debates go either way. There is no contesting that terminating life support leads to death (in most circumstances).
In the Catholic guide to end-of-life decision-making titled “Now and at the Hour of Our Death,” euthanasia as defined by the Catholic Church “constitutes a grave moral evil, because the act of euthanasia is an action, or an omission which of itself or by intention causes death, in order that all suffering may in this way be eliminated.” They argue that applying the “quality of life” standard to medical decisions leads to the rejection of God’s plan and rejection of the very precious gift of life that is sacred and inviolable at every stage, and in every situation. They see it as a violation of the fifth commandment–you shall not kill–regardless of civil laws.
The quality of life argument for euthanasia, active or passive euthanasia as a basis for those who are sick, dying, despairing or disabled then, is the “temptation to judge the quality of our own life and the lives of others … to use this ‘quality of life’ standard to guide medical decisions” wherein, it becomes a termination of life for convenience, in order to escape pain and difficulty by withholding “ordinary medical means which is a moral obligation to all life.” Extraordinary means however, are not morally obligatory. Allowing natural death to occur is not the same as killing.
With regard to brain death the Catholic Church recognizes the right of a person to die a dignify death. That one is not bound to “prolong the dying process by using every medical treatment available.” Is it better to sustain life in a state of what is thought to be pain and discomfort for the patient, or should the patient be allowed to pass away quietly? Because medical intervention can be both obligatory, or extraordinary-morally optional, every case just like people are unique. No clear answers exist. However, the Catholic Church has a Catholic education resource center of guidelines, for the families and patient in this position. This article discusses scientists recognizing brain death if it includes brain stem death that includes the “irreversible cessation of the brain, respiratory and cardiovascular systems.”
What Does the DNR State?
In absence of legal direction we turn to the intent of the executor of the document. In the end, we want to know what the patient intended when they still had legal capacity to make such choices. Determining intent is not always possible.
In some cases, particularly those in which a DNR is vague or contains a set of boilerplate clauses and medical professionals may be ethically motivated to ignore the black and white of the document. It is often unclear what an individual’s quality of life will be like if his/her life is sustained. Driven by ethical quandaries, such as the Hippocratic Oath, medical practitioners may override portions of a patient’s written wishes or the entire document altogether with an optimistic outlook. Even the most specific legal document will contain gaps. There are always areas where a particular medical eventuality was not contemplated, or where the document is silent on the topic. DNR’s are inherently vague and often clumsy documents. They are rarely state-specific and, even when they are, state laws do not have codified patient right-to-life provisions, or interpretive case law to draw more clear answers.
Quality of Life – Those Left Behind
Another significant negative impact of a DNR is the effect it has on family members and friends who are left behind. Many times, the DNR will impact the lives of those who are left behind as much, or more, than those in the persistent vegetative state. An order from a guardian that is directing doctors to remove life-sustaining support can create an emotionally eviscerating feeling for those who love and care for the unconscious individual. Feelings of guilt or responsibility often affect the quality of life of survivors.
The presence of a DNR will frequently prohibit the family or doctors from interceding in any way on behalf of the individual. Lawsuits have been filed in cases where doctors saved a patient and were subsequently sued. Fear of legal reprisal can cause medical staff to enforce a DNR over the wishes of loved ones who seek to sustain the patient’s life in efforts to revive them. The DNR order by law actually authorizes the withholding of medical treatment for CPR cardiopulmonary resuscitation, as well as, other medical care. The diagnosis of Brain Death does play a role in deciding whether withdrawal of ventilator treatment is appropriate if doctors are convinced continued treatment and care is futile and the care will not alter what is the expected outcome. An August 2013 survey shows substantial variability in interpretation of DNR order. The DNR interpretation among medical professionals is “substantial variability,” and sometimes influence care for medical issues unrelated to the do- not-attempt-cardiopulmonary resuscitation, changing the broader treatment directives to more comfort care and clinician attentiveness to less aggressive care in general.
There are no easy answers. If you are making decisions for a loved one, then there are three questions you need to ask, in order to be fully informed when making decisions.
1. Have the doctors told you everything? Ask questions on behalf of the patient for anything you need to know.
2. Have the doctors performed all the tests required under the AAN Guidelines to determine “Brain Death” including performing MRI/MRA, and depth recordings to look for consciousness and the reversible brain that exists past the “Flat Brain Wave”.
3. Ask yourself, who is this expedient for? For this, if the answer you get – is for anyone other than or in addition to the patient, then termination, and removal off the ventilator is probably the wrong answer.
Your actions should only benefit the patient, and honor the patient’s beliefs as they are the only person who matters. There is no hurry to make a decision, most doctors will wait. You can also, ask for the hospital’s right to life advocate, and ask your attorney for advice, or seek religious council to aid you in making a decision. Even on a ventilator, without any intervention on your part, the body will cease when there is no life.
Ultimately, the decision to continue life-supporting assistance is an intimate one and life changing event, driven by integrity, and deeply personal mental, physical and spiritual motives. When making decisions for your loved one on spiritual matters, make sure to involve your spiritual counselor at the beginning, before testing if you can. Be mindful of the order in which you make them when testing is preformed, as respiratory failure, and end of life can occur during testing.
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- Circulation ECC Guidelines Part 2: Ethical Aspects of CPR and ECC, by American Heart Journal
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- Neural Dynamics during Anoxia and “Wave of Death,” by Bas-Jan Zandt, Bennie ten Haken, J. Gert van Dijk, Michel J.A.M. van Putten, PLOS ONE
- Reversible Brain Death: Failure of Test or Technique?, by Professor Julian Bion, 1st Annual Organ Donation Congress, London, March 8th, 2012
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- Nutrition Support at End of Life: A Critical Decision, by M. Patricia Fuhrman, MS, RD,LD, FADA, CNSD, Today’s Dietitian
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- Brain Death – A Reappraisal, by Machado, C. , Springer.com, ISBN# 978-0-387-38977-6