Oral+Presentation+Case+18

= Oral Presentation Case 18 =

//As a pharmacist, you are also expected to be a trained First Aid Officer. While driving to work one day you witness an accident where a vehicle drives into a cyclist. You are first to the scene, and when you get to the cyclist you notice he is not breathing and doesn’t have a pulse. While checking the pulse you notice a ‘Medic Alert’ bracelet which states “Not For Resuscitation”.

How would you act in response to this?//

Background
DNRs are Do Not Resuscitate orders. A DNR order on a patient's file means that a doctor is not required to resuscitate a patient if their heart stops and is designed to prevent unnecessary suffering. The usual circumstances in which it is appropriate not to resuscitate are: Although DNRs can be regarded as a form of passive euthanasia, they are not controversial unless they are abused, since they are intended to prevent patients suffering pointlessly from the bad effects that resuscitation can cause: broken ribs, other fractures, ruptured spleen, brain damage.
 * when it will not restart the heart or breathing
 * when there is no benefit to the patient
 * when the benefits are outweighed by the burdens

An example of a DNR protocol as given [|here]:
 * **WILL suction the airway**, administer oxygen, position for comfort, splint or immobilize, control bleeding, provide pain medication, provide emotional support, and contact other appropriate health care providers, and
 * **WILL NOT** administer chest compressions, insert an artificial airway, administer resuscitative drugs, defibrillate or cardiovert, provide respiratory assistance (other than suctioning the airway and administering oxygen), initiate resuscitative IV, or initiate cardiac monitoring.

Consequentialism
- Only about 20% of patients are competent at the time a do-not-resuscitate order is considered - Experience of competent patients changing their minds when facing death’s door //(the patient told the doctor “if I lose consciousness, forget what’s written”)// - May lead to extension of life, even if for several months - Patients differ greatly in their understanding of the word resuscitation. (defibrillation, IV therapy, or anything that prolongs life and suffering - even food and water) (68% of written hospital policies did not have a definition of resuscitation) - Patient may not understand the benefit of resuscitation (may believe that a heart attack will lead to a vegetative state) - Patient may mistakenly believe that they will feel the same about quality of life issues when they are older and dying as they do when they are young and well - Cases of DNR that were done without consent of the patient - Circumstances change and there’s only so much that can be accurately anticipated in writing
 * To resuscitate**

- Damage from resuscitation: broken ribs, other fractures, ruptured spleen, brain damage. - Have to appreciate what is suffering for the pharmacist— watching and waiting for someone to die — compared with what suffering the dying person is actually experiencing (patient does not want resuscitation as this may prolong suffering) - They have consulted the doctor about treatment should a situation arise in which they are unable to make their wishes known (enabling better decisions to be made) - Patients have a right to refuse medical treatment - Successful resuscitation would not be in the patient's best interest because it would lead to a poor quality of life - The option to refuse cardiopulmonary resuscitation (CPR) exists because of resuscitation's dismal success rate: only 1-2 percent for out-of-hospital sudden cardiac death (which is for a typically healthy businessman who collapses on the subway platform from a heart attack) - Cardiopulmonary resuscitation is a rough, some would say abusive, intervention. Cardiac arrest normally precedes death and providers are appropriately disturbed when they perform CPR on people afflicted by advanced illness, the debilities of old age, or dementia etc.
 * To not resuscitate**

Example
[|Example Position Statement]

Resources
[|BBC Ethical Issues - DNR]: as part of the Religion & Ethics series, this article explains the background of DNRs [|News.com.au]: an article on a doctor who has a tattoo of 'Do not resuscitate' on his body [|Do Do-Not-Resuscitate orders endanger patients?]: found at EuthanasiaProCon.org, detailing both sides of the story [|Do Not Resuscitate]: a documentary that screened on SBS in 2006. Website posts stories of three people dealing with their own mortality. [|CPR Decision Making]: Journal article on improve patient involvement in the complex process of CPR [|Sample Form]: An example of a Do Not Resuscitate Order Form [|Cleveland Clinic - Policy on Do Not Resuscitate]: includes a protocol and types of DNR orders [|“Not-for-resuscitation” orders in Australian public hospitals]: looks at the policies, order forms and information leaflets