THE COMPETENT PATIENT'S REFUSAL PREVAILS OVER FAMILY'S WISHES
Mrs. Jones, a 45-year-old wife and mother suffering from the advanced stages of
terminal leukemia, was nearing death. She was tired of the normal and experimental
treatments she had undergone over the preceding year. The only thing she wanted
now was to be made comfortable and sleepy. On the hospital admission form, she
refused all further routine treatment and supportive measures (antibiotics, blood
transfusions, and so forth). She also indicated that she did not wish to be
resuscitated in the event of cardiac arrest. The physician complied, ordering only an
IV morphine drip "until the patient becomes lethargic." But, Mrs. Jones' husband and
child, unwilling to let go and still hoping for a miracle, demanded continued
aggressive treatment. (Does the family have the right to overrule the patient's
refusal? No. As long as the patient is competent the patient remains the primary
health care decision maker). Once the patient lapsed into unconsciousness, the
physician continued to comply. This is as it should be. To begin aggressive
treatment once the patient had become unconscious would have violated the
d. Confidential Do Not Resuscitate Orders. If the patient chooses not to
inform his or her family of the DNR decision, the patient should be made aware of the
problems that can result. If, for example, the family should demand resuscitation, the
physician would then be placed in the difficult position of having to deal with the family's
demands, while still trying to honor the patient's desire for confidentiality.
e. Surrogate Do Not Resuscitate Orders. When no prior decision has been
made and the patient is incompetent, the next of kin (generally the spouse or competent
adult child) may choose to exercise the DNR option for the patient.
Without a DNR order, CPR is obligatory.
Reviewed every 72 hours.
Affects CPR only. Other treatments continue.
Can be made confidential by the patient.
Figure 2-7. A Do Not Resuscitate order suspends the otherwise automatic
initiation of CPR.