This week we wrap up our discussion of advance directives as they relate to hospice social work. No discussion of advance directives, or of hospice social work, would be complete without discussing the DNR (do-not-resuscitate orders). And no discussion of DNRs should begin without clarity on how they relate to the social work value of “dignity and worth of the person” (NASW, 2017).
With DNRs come an ethical dilemma that social workers are responsible to navigate assertively. Some patients will not want a DNR. They will assert that everything that can be done to restart their hearts must be done. Some family members take this stance for their loved ones. As social workers, we respect the dignity and worth of patients by protecting their right to self-determination. If they don’t want a DNR, they don’t have to have one.
The other side of the dilemma is that DNRs can be really good. They can reduce the likelihood of some suffering. When a terminally ill patient is passing away, CPR can be traumatic and unlikely to succeed.
“The first time I saw a patient who had received CPR, the experience wasn’t what I expected,” wrote Dhruv Khullar, M.D. in his New York Times blog article “The CPR We Don’t See on TV” (2017).
“I wasn’t prepared for the scene before me: a frail woman in her mid-80s, barely conscious, vomiting, with broken ribs and a bruised lung. Her stomach was bloated and her chest was bleeding. She looked more like a survivor of CPR than of cardiac arrest, I thought to myself. When she died a few days later, I couldn’t help wondering if she really knew what she was getting herself into.”
The social worker’s role relating to DNRs
Dr. Khullar’s question speaks to the second of two responsibilities a social worker has in terms of DNRs. The first responsibility is promoting the patient’s wishes. The second is to ensure that patients and family members realistically understand the choice they’re making. We can communicate two important ideas:
- CPR can be traumatic. The chest is repeatedly compressed at least 2 inches deep. Ribs are likely to break.
- CPR is unlikely to lead to a meaningful recovery for people with advanced illnesses. “Patients whose hearts stop and who are revived through cardiopulmonary resuscitation (CPR) are unlikely to live for a long period of time if they are in very poor health prior to receiving CPR” (Professional Heart Daily, 2017).
We are not responsible to convince anyone that CPR is a bad idea, but to help them understand the reason it might be. Once they’re aware, their decision is an informed one, and the social worker’s job is to defend it.
The DNR boundary violation in hospice
Once in an interdisciplinary meeting, the DON asked why a patient didn’t have a DNR. I explained that I educated the patient’s family about DNRs and CPR, and after verbalizing understanding, they said they still did not want a DNR.
The DON asked me to demonstrate to her how I discuss DNRs with patients. I didn’t feel it was necessary to let her scrutinize my approach, but I also detected the frame from which she was communicating: she believed it was our job to excel at persuading patients to choose DNRs.
She was wrong. It is our job to respect viewpoints, starting the viewpoints of patients and family members. Respecting a viewpoint means we do not need to try to change it. When it comes to DNRs, it’s our job to listen, educate, listen more, and then support the wishes we hear expressed.
Check back on Thursday for a a number of strategies for supporting your agency with managing DNRs, or use the form below to receive upcoming articles in your email.
Khullar, D., M.D. (2014, July 17). The CPR We Don’t See on TV. Retrieved June 20, 2017, from https://well.blogs.nytimes.com/2014/07/17/the-cpr-we-dont-see-on-tv/
NASW. (2017). Code of Ethics of the National Association of Social Workers. Retrieved June 20, 2017, from http://www.socialworkers.org/pubs/Code/code.asp
Professional Heart Daily/Part 2: Ethical Aspects of CPR and ECC. (2000, August 22). Retrieved June 20, 2017, from http://circ.ahajournals.org/content/102/suppl_1/I-12