Using the ethical decision-making framework of the Moral-Based Reasoning Model for the case study provided. How does each component of the framework was put into action to resolve the dilemma in the case study. What is the resolution in the case study?
Case Study 1
DNR on a healthy patient
Tina is a 37-year-old woman who is employed at an unspecified type of healthcare facility. She arrives at the hospital’s operating department to have a gynecological procedure done laparoscopically. This procedure requires general anesthesia with an endotracheal tube. Tina’s medical history is simple. She has a history of asthma as a child with no recurrences in many years, takes only oral contraceptives and multivitamins, and has never received general anesthesia before. Tina has a DNR order signed by her and her primary care doctor, which lists the prohibition of cardiopulmonary resuscitation (CPR), vasoactive drugs, and airway intubation in the event of a cardiopulmonary arrest. Tina has no known cardiac abnormalities and has never had a cardiac event. There seems to be no medical data to support her decision to be a DNR patient. Karen is the nurse anesthetist assigned to this case and she discusses this DNR order with Tina prior to surgery. Tina requests that Karen perform some form of anesthesia other than general anesthesia with an endotracheal tube because she “under no circumstances wants to be intubated.” Karen instructs Tina that general anesthesia with an endotracheal tube is the common and accepted practice for delivering a safe anesthetic during a laparoscopic procedure and, although it is possible to perform the procedure under spinal or epidural anesthesia, purely regional techniques are uncommon and typically utilized only with patients who are unfit to receive general anesthesia. Tina reluctantly agrees to be intubated for her surgery but insists on not changing any of the conditions of her DNR order, stating that she does not want to spend the rest of her life “on a breathing machine.” Efforts by Karen to discuss the use of resuscitative drugs and other measures during the unlikely event of a cardiopulmonary arrest are unsuccessful in persuading Tina to amend her DNR status for her surgery. Karen tries to differentiate between vasoactive medications used for treating transient hypotension during anesthesia and the drugs and doses that are used during a cardiac arrest, with the intention of being clear about what Tina’s requests are for her anesthesia care. Tina insists that she sees no difference and repeats her demand that her DNR be honored as it is. Karen is unable to resolve this conflict between honoring Tina’s request and her duty as a CRNA to provide safe anesthesia. Karen declines to participate in Tina’s surgery, and it is ultimately canceled.
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