Running head: ETHICAL ISSUES REGARDING DNR IN ONCOLOGY PATIENTS

Ethical Issues for Nurses Regarding DNR Orders in Late-Stage Oncology Patients
Shawnee Cuthbert
Cedar Crest College

ETHICAL ISSUES REGARDING DNR IN ONCOLOGY PATIENTS

Abstract
The purpose of this paper is to discuss the ethical issues for nurses regarding Do Not Resuscitate
orders in late-stage oncology patients, specifically, in regards to surgical procedures to treat
symptoms and promote comfort care. The American Nurses Association takes a stance and
position statement on Nursing Care and Do Not Resuscitate and Allow Natural Death Decisions.
This stance is utilized in this paper to address standpoints used to develop an understanding of
the importance of providing ethical care and abiding to a DNR order of an oncology patient in
the perioperative setting. The significance of the problem is explained, and how the problem
relates to nursing is explained using pros and cons with arguments for and against. The paper
also includes the personal view of the author.
Keywords: oncology, do-not-resuscitate, palliative care, surgery, end-of-life,
perioperative, nursing ethics, advance directive.

ETHICAL ISSUES REGARDING DNR IN ONCOLOGY PATIENTS

Ethical Issues for Nurses Regarding DNR Orders in Late-Stage Oncology Patients
It is critical to the nursing profession to follow institutional policies and promote patient
advocacy in the palliative setting to uphold a patients ethical rights. The Patient SelfDetermination Act allows patients the right to determine their code status and direct the course of
their healthcare. The patient entering in the final stages of cancer who chooses to have surgery,
with a do not resuscitate order, can create confusion and ethical dilemmas among nurses caring
for them. An advance directive allows patients to have their wishes of their end-of-life care put
into written instruction (Marquis & Houston, 2012). This includes the patients decision of
initiating do not resuscitate (DNR) or do not intubate (DNI) orders as their advance directive.
Advance directives allow the patient to determine exactly what interventions are used and not
used in the event of needed life-sustaining interventions. Most patients that do wish to institute
these orders elect to do so in the event of end-of-life situations.
The option of initiating advance directives, including the implementation of a DNR or
DNI was not always a right held by patients. Yang, Kwee, and Krishna (2012) explain that
throughout the 1980s, physicians determined these end-of-life decisions for patients. Physicians
and anesthesiologists were the deciding factor of whether or not a DNR order could be removed.
Physicians, likewise, were the only individuals who could remove these orders from a patients
chart. This action on the physicians part was questioned that it violated patient ethics. This issue
led to the recognition that there was a need to institute a process for circumstances in which the
patient does not wish to have cardiopulmonary resuscitation. In 1974, the American Medical
Association recommended that DNR orders be clearly expressed and communicated among
healthcare providers (Zinn, 2012).

ETHICAL ISSUES REGARDING DNR IN ONCOLOGY PATIENTS

The right to have a DNR order was rightfully given back to the patients by the
implementation of the Patient Self-Determination Act of 1991. This act provides patients with
the rights to determine the course and outcome of their healthcare, including what interventions
are taken or not taken. Jackson (2015) explains that the Patient Self-Determination Act of 1991
allowed patients to have the opportunity to make educated decisions in terms of their medical
care. This act included giving patients the right to refuse any course of medical treatment they
did not wish to receive, including orders to resuscitate them in times of cardiac arrest.
In 2003, the American Nurses Association (ANA) created a position statement regarding
Nursing Care and DNR Orders. The ANA (2012) declares that nurses should have an awareness
of DNR orders and take an active part in the development of policies related to DNR orders
within their workplaces. Clear guidelines with respect to DNR orders should be identified within
health care organizations, which will give nurses the ability to successfully take part in this vital
characteristic of their patients care. A dying patients distress can be adequately prevented and
comfort can be enhanced in times of cardiopulmonary arrest when DNR orders are used
appropriately in conjunction with comfort care at the end of a patients life. The ANA (2012)
believes that it is important for nurses to take part in planning and implementing the wishes
regarding a patients end of life care, including having the decision to initiate DNR orders.
Significance of the problem
The patient entering into the final stages of cancer with a DNR order, who elects to have
surgery, can create confusion among those nurses caring for that patient. According to Zinn
(2012), an ethical predicament can be generated and it may be unclear of how to appropriately
care for a patient when a DNR order is in place. This confusion is created with regards of how

ETHICAL ISSUES REGARDING DNR IN ONCOLOGY PATIENTS

nurses should be carrying out proper healthcare decisions according to a patients desired wishes
throughout their treatment plan, including surgical procedures during the late-stages of cancer.
It is estimated that as many as 15% of patients with a current DNR order will be
scheduled to undergo surgical interventions for palliative care (Remesh, Boase, & Audisio,
2006). While this number is low, it still presents a population that will be seen in healthcare
institutions by nurses. Nurses in all areas providing care to this population need to be cognizant
of their patients wishes and code status at all times when care is being provided.
Even when advance directives are in put into place by patients, they are not always
abided by. The action of not abiding by a DNR order creates ethical dilemmas for patients and
nurses alike. A loophole that exists in the Patient Self Determination Act of 1991, in that it does
not address the surgical patient in the operating room. This loophole creates confusion among the
role that nurses are to take in the event of a needed resuscitation in this setting. This is especially
significant since an assumption exists that if patients are healthy enough to be cleared for
surgery, then they will also survive that operation (Jackson, 2015). Additionally, the ANA (2012)
explains that it was assumed that the Patient Self-Determination Act (PSDA) would encourage
discussions of advance directives and DNR orders between patients and physicians.
Unfortunately, the PSDA did not have this intended effect as expected.
In the past, DNR orders have been temporarily suspended during the perioperative period
of care. DNR orders were suspended because these orders were viewed as being contraindicated
with the administration of anesthesia and surgical intervention (Zinn, 2012). As history tends to
repeat itself and practice can become a routine, health care professionals will often take a
perspective of doing what has always been done in the past. This thought process leads to the
automatic implementation of CPR when it is needed. This thought process also contributes to

ETHICAL ISSUES REGARDING DNR IN ONCOLOGY PATIENTS

misunderstandings and misconceptions of appropriate actions that are to be taken by nurses in

these circumstances, particularly in cases where patients are in the late stages of cancer.
According to Guarisco (2004), some institutions still mandate that the DNR orders be
suspended in the perioperative setting as current practice. The suspension and disobedience to a
patients advance directive can create a significant ethical dilemma. Guarisco (2004) also
explains that not many hospitals will cater to specific advance directives in the perioperative
setting and that many opinions differentiate exist among healthcare providers on the management
of such patients. Another significant issue that is presented with the patient with a DNR order in
the operating room is that many of the healthcare providers within professional health care
organizations are not knowledgeable in regards to the policies within their profession or
institution (Byrne, Mulcahy, Torres & Catlin, 2014).
Significance of the problem to the nursing profession
Cheon, Coyle, Wiegand, and Welsh (2015), conducted a survey of nurses within the
hospice and palliative care setting. One part of this survey was aimed at determining what ethical
dilemmas nurses encountered in their clinical practice. The question Please describe the most
recent ethical dilemma that you have encountered was asked. Several examples were given
which involved nurses being asked to provide treatments that they perceived as being
nonbeneficial or futile (p. 8). As part of the survey, nurses reported that they struggle with what
care is most appropriate for the older population of patients.
Increasing elderly population
According to Ramesh et al., (2006), population of the elderly, or those 65 and older, is
increasing. With this increasing population, the number of patients with cancer is increasing, and
ways to help these patients are increasing. Surgical procedures to help with symptoms of cancer

ETHICAL ISSUES REGARDING DNR IN ONCOLOGY PATIENTS

in this population, are one of these ways that will be increased, becoming routine and seen by
nurses in the perioperative setting. Most of the surgical procedures undergone by patients facing
end-of-life issues are not performed with the intent of treating the disease process, but rather
provided to, improve the patients functionality, enhance comfort and possibly increase
continued existence (Byrne et al., 2014).
Advocacy
The statement of ANA position is that nurses must advocate for and play an active role in
initiating discussions about DNR with patients, families, and members of the health care team.
Provision 1.3 of the ANA Code of Ethics for Nurses states that:
Nursing care is directed toward meeting the comprehensive needs of patients and their families
across the continuum of care. This is particularly vital in the care of patients and families at the
end of life to prevent and relieve the cascade of symptoms and suffering that are commonly
associated with dying. Nurses are leaders and vigilant advocates for the delivery of dignified and
humane care. Nurses actively participate in assessing and assuring the responsible and
appropriate use of interventions in order to minimize unwarranted or unwanted treatment and
patient suffering. (ANA, 2012)
Nurses must be advocates for their patients and play an active part in commencing
discussions about DNR orders with not only patients and their families, but participants of the
health care team as well. Godden (2012) explains how nurses have one of the greatest influences
in the outcome of a patients care. The nursing profession continues to be one of the most valued
professions within the health care community. Nurses have a vital part in providing protection of
the patient against harm throughout the patients cancer process. This includes the palliative care
setting, and the perioperative period, which can be a very vulnerable times for patients. The

ETHICAL ISSUES REGARDING DNR IN ONCOLOGY PATIENTS

importance of implementing and discussing such directives that guide a patients healthcare is a
critical role that a nurse must perform in order to advocate for their patients properly and in
accordance with the ANA and professional practice.
The Association of Operating Room Registered Nurses (AORN) also takes a stance on
patient advocacy in the patient with a DNR status in the operating room. AORN explains that the
perioperative nurse is an advocate for the patient and has ethical and moral responsibilities when
giving patient care. AORN also believes that a patients rights can be undermined when a DNR
order is automatically suspended during the perioperative period. A discussion in regards to the
DNR order should take place before the perioperative period to further evaluate and form and
understanding between the patient and the operative staff. This discussion should not only be
documented but communicated to the entire health care team taking part in the patients care
(Byrne et al., 2014).
Moral distress
Moral distress can often be seen in all types of healthcare institutions. Weigand and Funk
(2012) explain that a multitude of circumstances can be the causative factor of a nurse going
through emotions of moral distress, including excessive aggression in a patients care plan and
when a patients desires are overlooked. In the event that a patients code status of DNR is
dismissed, disobeyed, or suspended, nurses can be impacted by this, resulting in moral distress.
The impact of moral distress can influence nurses to avoid patients that have moral distressing
circumstances, the amount of time that they work, and even in their own personal lives (Weigand
& Funk, 2012).
Unclear definition of perioperative time frame

ETHICAL ISSUES REGARDING DNR IN ONCOLOGY PATIENTS

Often, oncology patients with DNR orders consent to surgery to alleviate symptoms and
promote comfort care. In doing this, patients allow for the suspension of their code status in the
perioperative setting. However, research suggests that a knowledge gap exists in the clear
definition of when the perioperative time frame begins and when it ends. This can create
confusion and misunderstanding for the patients involved, as well as to the nurses caring for
them. More importantly, this issue can change and delay when the suspension of the DNR is
lifted (Byrne et al., 2014). If the DNR is not suspended and the patient experiences cardiac arrest,
interventions to resuscitate the patient will be implemented, disregarding the patients wishes.
Pros to abiding to a DNR/DNI
Respecting patient autonomy
The automatic suspension of a DNR order in the perioperative setting goes against a
patients rights (Byrne et al., 2014). When faced with this situation the nurse providing care for
the perioperative patient with a suspended DNR order can be contributing to the disregard of the
patients autonomy. This proposes the argument that DNR orders should be abided to by ceasing
automatic suspensions in the operating room. Abiding to a patients DNR code in the
perioperative setting also corresponds the ANAs code of ethics which explains how a competent
patients wishes with regards to their health care decisions should have the greatest priority, even
if these decisions are in direct conflict with the opinions of the patients family members and
members of their health care team (ANA, 2012). In doing this, a patients autonomy can be
promoted and abided by members of the health care team providing care to the patient.
Nonmaleficence and beneficence
The concepts of nonmaleficence and beneficence state, that if one cannot do good, in
regards to the patient, then one should at least not harm the patient (Marquis & Houston, 2012).

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To follow these ethical concepts, nurses and other practitioners should not participate in
resuscitation efforts that contradict DNR orders. Acts of successful resuscitation efforts are not
viewed by all in the same manner. Guarisco (2004) explains that patients facing end-of-life
situations may view successful resuscitation efforts as negatively impacting them by continuing
to prolong their lives. Resuscitation does not add quality to life, it only revives it.
Therefore, since no good has come from the efforts of resuscitation, then the efforts should be
withheld.
Cons to abiding to a DNR/DNI
Not many cons exist in abiding to a DNR order for the late-stage oncology patient in the
perioperative setting. Abiding to a patients DNR order complies with ethical stances. However,
one issue is found that presents a con in abiding to a DNR in the operating room. This issue is
due to the fact that the administration of anesthesia suppresses regular body functioning and
causes depression of the respiratory system (Byrne et al., 2014). When functions vital to a
patients survival are intentionally depressed (as happens under anesthesia), multiple
interventions are regularly used that are also used during resuscitation efforts, such as employing
the use of vasopressors and mechanical ventilation. The anesthesia team may have to withhold
care with these interventions in a patient with a DNR order, and potentially even make a
reduction in the amount of anesthesia given to ensure the stability of vital life functions, which
can compromise the outcomes of surgery (Girard, 2011).
Personal views
Every patient has the right to determine the care that is provided to them in the healthcare
setting. A patients wishes should be respected and upheld by all healthcare personnel. This
moral obligation is especially important to the nursing profession. It is every nurses ethical and

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moral obligation to provide patients with the respect and dignity, not just because the ANA says
we should, but because it is just the right thing to do. Nurses need to recognize that death and
medical interventions are not viewed the same by all. This idea should be understood by nurses
that an open mindset, and open opinions are critical in caring for the patients in end-of-life
situations ethically.
Conclusion
In accordance with the Patient Self-Determination Act, patients are given the right to
determining the course and outcome of their healthcare, including what interventions are taken or
not taken. A significant ethical problem exists when this right is disregarded by not abiding to a
patients DNR order. Nurses should advocate and uphold all moral and ethical obligations to the
patients that they are caring for oncology patients intraoperatively with a DNR order in place.
Nurses should promote the continuity of care of these directives among other healthcare
professionals through constant education on institution policies, good communication and
thorough documentation. By following these principles, nurses can be ensured that they are
providing the most ethical care to their patients.

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