BIOM3200 Ethics essay Example #3 PDF

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Court-appointed legal guardians and their role in DNR authorisation News article citation: Cordiero, M 2019, ‘Man died after Orlando legal guardian filed ‘do not resuscitate’ order against his wishes, investigation finds’, Orlando Sentinel, 15 July, viewed 1 August 2019,

News article summary: 75-year-old Steven Stryker passed away in May 2019 after his court-appointed guardian, Rebecca Fierle, filed a “do not resuscitate” (DNR) order against his wishes. Fierle was appointed as Stryker’s guardian in August 2018 after AdventHealth Orlando deemed him unable to make reasonable decisions with regards to his care. However, a complaint filed by Stryker’s daughter expressing concerns over Fierle’s care for her father sparked investigations into the case. When questioned, Fierle claimed that the DNR order considered Stryker’s quality of life and insisted that he agreed with the decision. Further investigations found, however, that Steven had passed on his power of attorney to a friend, who stated that he had communicated a will for life-saving action. Additionally, Kirtikumar Pandya, a licensed psychiatrist, told investigators that Steven had expressed concerns over the DNR order and had vocalised a desire to live. As Stryker’s condition was not terminal and was one that he had been managing for many years, Dr. Pandya found Fierle’s reasons for filing the report irrational, requesting that the hospital remove the DNR order and arrange an ethics consult. However, the consult found that, as the court-appointed guardian, Fierle had authority over the decision and thus the DNR order remained. Stryker later died by asphyxiation, with hospital staff unable to perform lifesaving procedures to keep him alive. Postmortem investigations concluded that Fierle’s negligent actions had resulted in the unnecessary death of Steven Stryker and cited criminal statutes, however, Fierle is currently not facing any criminal charges for Stryker’s death.

Biomedical Ethics Essay: Question: Is it morally justified for a court-appointed legal guardian to sign a DNR order on behalf of someone else?

Discussion This essay aims to provide more insight into this issue by exploring the ethical arguments supporting or refuting this power of a court-appointed legal guardian (CALG). In this scenario, do-not-resuscitate (DNR) orders refer to any medical documentation stating that life-preserving aid or resuscitation cannot be performed on the patient if such a situation arises (Bedell et al. 1986, p. 233). Furthermore, a court-appointed legal guardian in this debate is a person who has been authorised by the court (either temporary or long-term) to make end of life decisions on behalf of a patient unable to make informed decisions (Bandy et al. 2010, p. 1003). This power granted to guardians has been heavily scrutinised, bringing into question the morality of such authority. Advocates for the power of such guardians raise the argument that CALGs provide an impartial body to gather all available information to make a beneficent decision on behalf of the patient. In most situations, DNR orders are authorised through the consensus between physician, patient and family following a discussion regarding their health status and personal views on the matter (Bedell et al. 1986, p. 233). However, when a patient is deemed incompetent to make their own decisions, how can we determine what is truly beneficent for the patient? Legal guardians exist to mediate conflicts between physicians and sources such as friends and others close to the patient (Bandy et al. 2010, p. 1003). Physicians often consider the patient’s health status and quality of life, and consequently make a judgement on whether resuscitation has

any medical benefit (Tomlinson & Brody 1988, p. 43). This information when merged with wishes of the patient and their family would allow for sound judgement regarding DNR approval. Another reason for legal guardian appointment is that family members can be unable or unwilling to make medical decisions for the patient. A retrospective cohort study found 67.2% of guardians appointed were non-family members, with the family being present but unwilling 50.2% of the time (Bandy et al. 2010, p. 1007). As a result of this, CALGs continue to be used as a tool to make the best possible decision for the good of the patient and their wishes, even with the limited information given. Whilst this is the case, increasing number of reports have surfaced regarding the disconnect between the intentions of the patient and the ultimate decision. Being one of the four key pillars of ethics, patient autonomy is key in allowing individuals to make informed decisions regarding the treatment they receive (Blackhall et al. 1995, p. 820). A nursing home study found that only 75% of pre-determined decisions by the patient and family were followed, with 24 cases of care inconsistent with the wishes of the patient (Danis et al. 1991, p. 884). When combined with hospital legal file findings that only 23 out of 71 patients had documentation suggesting contact between CALG and medical team, patient or patient’s family, these findings indicate that the wishes of the patient are often excluded from the decision regarding their own resuscitation (Bandy et al. 2010, p. 1008). Also, critics of DNR approval by court-appointed guardians argue that decisions made by physicians and legal guardians are predominantly based off medical prognoses such as age>75yrs, high disease severity and nonoperative diagnosis, whilst not considering the effectiveness of treatment and consequent improvements in future quality of life (Zimmerman et al. 1986, p. 355; Tomlinson & Brody 1988, p. 885-887). In the majority of situations, the patient’s life and livelihood are placed at paramount importance when considering DNR orders, however differing opinions blur the ultimate decision made. Currently, patient autonomy is an issue that complicates the dilemma greatly and is often disregarded by CALGs during the decision-making process. However, when consented to, DNRs serve an excellent purpose in preventing a deterioration in quality of life in a desperate attempt to slightly extend a patient’s lifespan at their last stages of life. Most parties would accept the concept of DNRs and allow CALG participation, if a consensus was achieved between the patient, their family, physician and legal guardian, and this decision was completely beneficent. Obviously, this will not always be the case, but the use of a CALG in tightly disputed situations is key to optimising an otherwise dire situation.

Recommendation Due to the arguments previously discussed, I believe that CALGs should hold the power to make the final decision on whether or not a DNR order should be authorised, provided that this decision is based on all information available. In all scenarios, patient autonomy should remain paramount, despite their medical status and any physician recommendations. When the patient is unable to competently make decisions regarding their health, the authorisation of a DNR should fall to available and willing family members, prior to any other party. The patient’s family have the patient’s best interest at heart, possessing extensive knowledge on the patient’s wishes and opinions regarding issues such as DNR decisions. Even if the patient did not directly convey their choice concerning DNR orders to family members, having travelled alongside the patient throughout their medical journey, they would have the best indication of the patient’s wishes; being the closest thing to patient autonomy available. It is only when family members are unavailable or unwilling that a CALG should be appointed. From here, CALGs would serve to search through all available data –medical records, transcripts or medical letters – as well as discuss the issue with physicians and other sources close to the patient. This allows the legal guardian to better understand the thought processes of the patient, such that the decision maintains the patient’s right of self-determination and keeps patient beneficence at heart. Undoubtedly, there is no foolproof and conclusive method of ascertaining the true opinions of the patient, but CALGs aid in providing the best possible care for the patient given limited information.

When such power is imbued to an individual, there will certainly be cases where this power is abused or misused. At the current time, these regulations are weak, and allow for misinterpretation of what patient autonomy is and its influence in the final decision (Cherniack 2002, p. 303). As such, it is imperative that if CALGs continue to have the ability to decide lives of countless patients, clear laws and regulations must govern their actions to prevent unnecessary and potentially malicious decisions. When considering methods on how to regulate such decisions, it raises questions as to how we can standardise laws that apply to all, when each patient is a unique individual. How do we know whether the decision we make is one that the patient would have truly agreed with? How can one person with one set of criteria decide for countless patients all with differing ideologies, beliefs, morals and cultural backgrounds? I do not think that it is possible to definitively answer these questions, and that the true wishes of the patient will always remain hidden away. However, when critical, often time-sensitive decisions need to be made, CALGs are crucial in piecing parts of the puzzle together, culminating in a decision most representative of the patient’s wishes.

Reference list Bandy, RJ, Helft, PR, Bandy, RW & Torke, AM 2010, 'Medical decision-making during the guardianship process for incapacitated, hospitalized adults: a descriptive cohort study', Journal of General Internal Medicine, vol. 25, no. 10, pp. 1003-8. Bedell, SE, Pelle, D, Maher, PL & Cleary, PD 1986, 'Do-not-resuscitate orders for critically ill patients in the hospital. How are they used and what is their impact?', Journal of the American Medical Association , vol. 256, no. 2, pp. 233-7. Blackhall, LJ, Murphy, ST, Frank, G, Michel, V & Azen, S 1995, 'Ethnicity and attitudes toward patient autonomy', Journal of the American Medical Association, vol. 274, no. 10, pp. 820-5. Cherniack, EP 2002, 'Increasing use of DNR orders in the elderly worldwide: whose choice is it?', Journal of Medical Ethics, vol. 28, no. 5, pp. 303-7. Danis, M, Southerland, LI, Garrett, JM, Smith, JL, Hielema, F, Pickard, CG, Egner, DM & Patrick, DL 1991, 'A prospective study of advance directives for life-sustaining care', New England Journal of Medicine , vol. 324, no. 13, pp. 882-8. Tomlinson, T & Brody, H 1988, 'Ethics and communication in do-not-resuscitate orders', New England Journal of Medicine, vol. 318, no. 1, pp. 43-6. Zimmerman, JE, Knaus, WA, Sharpe, SM, Anderson, AS, Draper, EA & Wagner, DP 1986, 'The use and implications of do not resuscitate orders in intensive care units', Journal of the American Medical Association, vol. 255, no. 3, pp. 351-6....