DNR vs. Selective Euthanasia

Great Debates
1

DNR – Do Not Resituate - Basically a judgement call made by the Doctor and, in some cases the familywhere present, as to what a ‘heroic measure’ is and whether it should be administered.

Euthanasia – A decision made by the family to discontinue treatments or medication to a patient who requires it to continue living, or to administer medication in order to speed along the demise of the patient. (aka Assisted Suicide in the latter case)

Here’s the point. In the case of DNR…it’s up to the doctor and the family to decide how much effort should go into saving the life of the patient….in Euthanasia, it’s discontinuing an existing effort. There’s a fine line there… at what point does an existing effort go against the DNR’s Heroic Efforts clause and become stoppable?

Morally speaking…where would you draw the line between the two? One is a legal right and one is a legal conundrum, with a slippery slope attached to it for good measure.

2

In most cases, a DNR order is a product of a patient’s advance directive or that of the patient’s medical surrogate. Nearly all patients admitted to hospitals these days are encouraged to make advance directives and/or have a living will. These advance directives are usually checklists the patient fills out on admission stating what heroic measures, e.g., chest massage, defibrillation, artificial ventilation, medications, etc., the patient may or may not want to be subjected to.

OTOH, euthanasia IMO is not the discontinuance of life support, rather it is an active intervention that will result in a peaceful and dignified death. I’ve watched patients die as a result of turning off machines and stopping medications, and I can assure you that although the outcome is the same, it does nothing to make death any more peaceful or dignified.

We had our 13 year old cat euthanized last week. She had metastatic cancer. We decided not to put the poor creature through treatment because we were advised that it would only prolong her suffering. Watching her just lie there in one spot without treatment until she died would not have been considered euthanization. When she got to the point of not eating, as advised by her vet, I brought her in and they sedated her. While she was asleep, she was given a drug that stopped her heart. I hope I’m that lucky when my time comes. AFAIK Oregon is the only place where human beings are allowed that kind of dignity.

Perhaps a physician or nurse from a hospice can comment on the fine line between terminal care and euthanasia and the wonderful job they do in keeping our loved ones comfortable in their final days.

3

Emphasizing what has already been stated - DNR is not the MD’s call, but that of the patient and family. A good physician will present a realistic picture and options for care, but the decision lies elsewhere.

4

Ideally, those decisions are made by the patient before the situation becomes critical. I know that doesn’t always happen and in that case the decisions would be made by the patient’s next of kin and the doctors that are treating the patient.

In the case of a DNR, that would be filled out and signed by the patient or the patient’s proxy and their primary physician in advance. This form basically states that the patient refuses treatment if they experience cardiac or respiratory failure: i.e. external compression, defibrillation and intubation.

In the absence of a DNR, resuscitation is attempted until either the patient stabilizes or it becomes clear that the patient will not be revived. That is typically a judgement call on the part of the attending physician.

At any time, a patient has the right to “informed consent”. You can freely give or withhold consent to any medical proceedure, medication, etc. And that means that a person has the right to have all treatments stopped at any time. For example, if a patient were in renal failure and had started dialysis treatments, but later decided s/he didn’t want to go through that anymore, s/he could refuse dialysis. Or if a patient were on a ventilator and didn’t want to live like that, s/he could ask for the vent to be removed. Of course, that only deals with patients that are cognizant and lucid.

If a patient is unable to give or withhold consent, normally the next of kin (wife, husband, parent, guardian) would make those decisions based on what the patient’s wishes would be. Withholding treatment or stopping treatment based on the patient’s wishes and/or maximum medical benefit is called Passive Euthanasia. It’s a large part of what Hospice does. All curative treatments are halted and palliative treatments are the main focus.

Assisted suicide requires that the patient be lucid and able to participate in their own medical care. Bascially, a physician/care provider gives the patient the means and instructions on how to die quickly and painlessly. In the US, I think that this is only legal in Oregon.

Active euthanasia requires someone else to make the decision to actively end the patient’s life without the patient being able to participate in the decision. I am of two minds on the issue. While I do see where active euthanasia could lead to abuses, I can’t understand why we can’t offer a kindness to our family members that we afford to our pets.

Since I live in Florida, I really need to get off my butt and get an Advanced Medical Directive and a Durable Medical Power of Attorney. That way, my wishes are spelled out long before I would be in a critical medical situation.

5

Sorry, E72521. I got called away from the keyboard while I was posting to this thread and didn’t see your post before I hit submit. I am not with Hospice, but my husband is a BSN with a local organization. Did you have any specific questions? I will ask him when he gets home from work.

6

How about the people that aren’t on life support but have no expectation of recovery… they’re basically taken off IV and allowed to die of dehydration.

Very humane.

7

Artificial feeding is a form of life support and a patient can refuse that at any time. If the patient isn’t capable of making that medical decision for themselves, their next of kin can make that for them. Ideally, the next of kin would follow the patient’s wishes. This is why advanced medical directives are a really good idea.

Personally, if I were in the situation where I had no expectation of recovery, I would want artificial feeding withheld. Even if it meant that I would die of dehydration. I would not want to be kept alive under those circumstances, so I would consider it very humane.

8

It’s humane compared to keeping a piece of human shaped meat alive.

It’s not terribly humane to allow it to die of dehydration over the course of days or weeks vs. a morphine overdose.