Winifred Badaiki explores ethical issues that arise due to the absence of DNR databases in Canada and the possible benefits of such databases.
Advance care directives are means to express one’s healthcare wishes when one is incapable of doing so. These directives cover decisions on artificial nutrition, ventilator use, comfort care, and emergency resuscitation. A “Do Not Resuscitate” (DNR) order stipulates that a competent individual has requested not to be resuscitated if they stop breathing or do not have a heartbeat. Although resuscitation can sometimes be effective, it is often futile and might lead to more pain and suffering or a worse quality of life even if successful.
Like other advance directives, DNR orders are more likely to be followed in a health care institution where care professionals are familiar with the patient’s wishes. This might not be the case outside of an institutional setting. Paramedics, for instance, often do not have access to advance care planning documents like DNR orders, and even when they have access, there might be issues identifying the patient to confirm their resuscitation order. Unlike most of the decisions delineated in an advance directive, the decision to resuscitate must be made within minutes of contact with a person that requires it. This means people who have declared their desire not to be resuscitated are at risk of being revived if they lose consciousness and their DNR forms are not presented quickly to the paramedic.
One solution to this problem would be a database of DNR orders that is accessible by health care providers outside of hospitals, such as paramedics. Most provinces in Canada do not have databases like these. Quebec has a database that includes patient preferences about CPR. But paramedics in Quebec have complained that they do not have access.
There are other ways of making DNR preferences known when outside of the hospital. These include informing family members and substitute decision-makers of this order, wearing special bracelets or keeping a copy in an easily accessible place such as on the refrigerator or by the bedside. However, some people might refuse to comply with these measures for several reasons, such as privacy. While suggestions to wear bracelets, or place advance directive forms in open spaces in one’s house are not unreasonable, some patients might not be comfortable sharing this information with others who might see their bracelet or enter their house.
End-of-life wishes made by patients to die on their terms must be respected and carried out to the best of a health care provider’s ability and within reason. Unconscious patients cannot advocate for themselves, particularly if family members or assigned substitute decision-makers are absent. A DNR database could help mitigate this issue.
In the event of an emergency outside of the hospital or one’s home, well-meaning bystanders might decide to provide CPR. DNR databases would not help prevent CPR in such situations. Databases have some limitations, but would nonetheless be helpful in many scenarios outside of hospitals.
For a DNR database to function effectively, several potential issues must be addressed before implementing one. The first is the question of who gets access to the database. For a DNR database to fulfill its objectives, various healthcare professionals, especially those involved in emergency patient care, must be able to access it. Second, some people might express concern about the privacy of their information on a widely-accessible database. To calm these fears, health information collecting bodies of various provinces must employ measures to ensure that this sensitive information is only accessible by qualified personnel. Third, to avoid communication challenges, the database across departments and institutions in a province must follow an identical protocol of implementation and usage. The last issue is flexibility. Patients with information on a DNR database should have the ability to change their information by themselves or through a primary care physician. This will enable people who have changed their minds about their advance directives to receive their preferred method of care.
A general DNR database will not only benefit patients who do not want to be resuscitated but will also guide health care professionals and minimize the ethical dilemmas surrounding this decision. A DNR database might be ineffectual in provinces where advanced directives are not generally accepted or in cases where patients cannot be identified before resuscitation is commenced. These limitations could be improved with further policy review and consultations. Finally, databases could perhaps shed light on how extensively DNR orders are used, which could induce policy change when necessary.
Winifred Badaiki is a graduate of the Master of Health Ethics program at Memorial University and is a member of the MUN Centre for Bioethics. @WinnieOmo.