CLARIFICATION OF TERMS

What do “CPR” and “DNR” mean?

CPR (Cardiopulmonary Resuscitation) refers to the medical procedures used to revive a person’s heart and breathing when heart failure occurs. CPR may involve simple efforts such as mouth-to-mouth resuscitation and external chest compression. Advanced CPR may involve electric shock, insertion of a tube to open a person’s airway, injection of medication into the heart, and in extreme cases, open chest heart massage.

CPR, when successful, restores heartbeat and breathing and allows persons to resume their previous lifestyle. The success of CPR depends on a person’s overall medical condition. ^[1]

DNR (Do Not Resuscitate) Orders instruct medical professionals not to perform CPR. This means that doctors, nurses, emergency medical personnel, or other healthcare providers will not attempt emergency CPR if a person’s breathing or heartbeat stops.

DNR orders may be written for patients in a hospital or personal care home, or for persons at home. Hospital DNR Orders tell the medical staff not to revive the patient if cardiac arrest occurs. If a patient is in a personal care home or at home, a DNR Order tells the staff &/or medical emergency personnel not to perform emergency resuscitation and not to transfer the patient to a hospital for CPR. ^[2]

What are some of the similarities and differences between the terms “DNR,” “Euthanasia,” and “Assisted Suicide?” ^[3]

A DNR Order is a notation placed on a patient’s chart which states that if the patient should undergo respiratory or heart failure, no efforts should be made to resuscitate that individual. The placement of DNR Orders on patients’ charts in Manitoba can occur without the consultation or consent of the patient or someone acting on behalf of the patient’s best interests (sometimes known as a “patient surrogate,” a “proxy” or a “patient advocate.”) A distinction between DNR Orders and Euthanasia is that a death can occur because of a lack of action rather than the result of a deliberate action.

Euthanasia stems from the Greek term “euthanatos” which literally means “joyous” or “easy death.” Today’s euthanasia generally refers to mercy killing - the voluntary ending of the life of someone who is perceived as being terminally or “hopelessly” ill. Euthanasia has been defined in two ways:

	“Active Euthanasia” - whereby a healthcare provider takes a deliberate action that will induce death, such as administering morphine, insulin or barbiturates, followed by an injection of curare; and,
	“Passive Euthanasia” - which involves letting a patient die for lack of treatment or suspending treatment that has already begun. An example of this is the removal of a patient from a respirator or other life support system or stopping the food supply (usually intravenous feeding) to patients.

Euthanasia is a deliberate action resulting in death that can occur without the patient’s consent.

Assisted Suicide occurs when persons deemed as having terminal illness or a disability are aided in a deliberate act of ending their lives by physicians, loved ones or other care givers or acquaintances. The difference between euthanasia and assisted suicide occurs because the latter constitutes a joint action between the person wishing to die and another complying with those wishes.

These definitions show the distinctions between the terms DNR Order, euthanasia, and assisted suicide. Similarities exist because each of these terms deals with end of life issues, and, to a greater or lesser extent, undergoing the process of determining an individual’s “quality of life.” Currently in Canada it is illegal for someone to assist an individual in the act of suicide. However, there are many who support this action. (Derek Humphry’s book “Final Exit,” a guide for terminally ill people to commit suicide, became a bestseller in the United States in 1991.) Organizations such as the Hemlock Society offer encouragement and support for those who desire to take their own life with the help of others. Persons with disabilities have voiced repeatedly their concerns, expressing a sense of vulnerability because of a fear of not having the capacity to determine and/or have influence over a course of treatment. The devaluing of persons with disabilities which has existed historically and is still demonstrated in various situations today leaves persons with disabilities feeling more prone to such actions as the placement of DNR Orders without consent and the practice of euthanasia. It should be noted that may of the patients who’s suicides were assisted by Dr. Jack Kevorkian, a well-known American advocate of this practice, were not diagnosed with terminal illnesses but had acquired a physical disability which led them to the conclusion that their lives were no longer worth living.^[4]

There also exist organizations such as the American group “Not Dead Yet” who strongly oppose assisted suicide and have intervened in court cases where an appeal has been made to legalize assisted suicide.

What are “Advance Directives” and “Living Wills?” ^[5]

An Advance Directive (sometimes known as a “Healthcare Directive”) is a document which informs a doctor or other healthcare provider of the type of care a patient would like to have if he/she becomes unable to make medical decisions. Advance Directives can take many forms, and laws about advance directives vary from province to province.

A Living Will is one type of Advance Directive that usually only comes into effect when a person is deemed terminally ill. A Living Will is a legal document which states that the life of the person writing the will should not be prolonged under specified circumstances.

Currently in Manitoba, any requests within an Advance Directive for the cessation of treatment are honoured; however, if an Advance Directive states that there be the initiation or continuation of life-supporting treatment, this can be called into question by one’s attending physician or the hospital administration.

It is important to note that while an Advance Directive and a Living Will allow patients to select someone to make decisions on their behalf in a surrogate or advocate capacity, it is recommended that this naming of a proxy occur through a “Power of Attorney.”

What does “being competent” have to do with the placement of DNR Orders, and who determines if someone is competent?

“Competency” is a term which describes one’s mental ability to perform a particular task or grasp a concept. When we are able to exercise judgement in making valid decisions in our day-to-day living, we are demonstrating our competency.^[6]

Questions may arise in the course of health care as to a person’s capacity to make competent decisions, and if it is determined that a patient is no longer competent, the responsibility for making those decisions is placed with someone else. This transfer of decision making power can be made to a surrogate or proxy who is deemed as acting in the best interests of the patient, or to a medical facility itself.

Issues around competency have already risen with respect to the placements of DNR Orders in Manitoba. In cases such as the situation with the Sawatzkys, where patients have refused to consent to a DNR Order, the placement occurred against their wishes because they were deemed incompetent. When a family member objected to the placement of a DNR Order, she was deemed incompetent and the care of the patient was placed under the control of the Public Trustee. This decision was later reversed in the Manitoba Court of Appeal.

What does it mean to be in a “persistent vegetative state?” When is one “permanently unconscious?” What does it mean to be “brain dead?”

The American Academy of Neurology defines a Persistent Vegetative State as:

“A form of eyes-open permanent unconsciousness in which the patient has periods of wakefulness and physiological sleep/wake cycles, but at no time is the patient aware of him or her self or the environment. Neurologically, being awake but unaware as the result of a functioning brainstem and the total loss of cerebral cortical functioning.” [7]

A Persistent Vegetative State (PVS) may be caused by a variety of injuries to the brain through accident or illness. Studies conducted on patients with PVS have led to the following conclusions:

“All voluntary reactions or behavioral responses reflecting consciousness, volition or emotion at the cerebral cortex level are absent...there is no observable experience of pain or suffering...they remain permanently unaware.” [8]

However, it is important to note that some of these same researchers state that although there is no observable experience of pain or suffering, they do not mean that there is nothing to observe.

“The PVS patient may ‘react’ to painful stimuli, but does not ‘feel’ pain in the sense of conscious discomfort..” [9]

Permanent Unconsciousness is a deep, prolonged unconsciousness in which a person cannot be aroused. This is usually a result of head injury, neurological disease, acute hydrocephaly, intoxication or metabolic derangement. Persons in this state may be able to maintain respiratory functions, but require maintenance of basic bodily functions. ^[10]

Brain Death is a definition that carries much controversy with it. ^[11] No organism dies all at once. Major vital organs such as the brain, the heart, and the lungs can experience failure that can occur at different times from each other. Because of modern resuscitation techniques, failure of the heart or lungs does not necessarily mean the end of one’s life. If, however, the heart or lungs cannot be revived and cease to operate, the brain will die of lack of oxygen. Conversely, if the brain dies, the heart and lungs will soon fail to function unless regulated by a respirator.

The failure of the heart or lungs is fairly easy to determine, but discerning brain death is more difficult, and is established by examining a combination of life signs. These include responses to stimulation; the ability to breathe; eye movement, swallowing or coughing; and evidence of electrical activity or blood flow in the brain. Negative responses to all of these indicate brain death, but no single sign is enough to warrant such an assumption.

What does the term “futility of treatment” mean and how is it applied to DNR Order placement?

When a person is deemed as no longer having the quality of life which would warrant treatment (in other words, any efforts made to prolong life would be seen as “futile,”) the application of a DNR Order has seemed, to some, to be ethical and reasonable. Often a determination is made by the physician in attendance or by hospital policy based on medical considerations. These considerations then establish the extent of the futileness of treatment. If, in medical terms, there is no purpose for providing treatment, a DNR Order is applied.

“Futility of Treatment” is a term often used by medical practitioners when they assess that a patient would have no direct benefit from being resuscitated or given intervening medical treatment because the patient’s condition will not improve following intervention, and will only prolong an inevitable organ failure and death.

The objections to applying this term to a patient’s medical chart stem from ethical and moral debates around the quality of life and the right to self-determination. The controversy over the concept of “futility of treatment” is based on several factors, namely:

	who makes the decision? Historically, patients and their families have been left out of this process and feel voiceless and powerless in determining the outcome;
	the decision to determine that treatment is futile and a DNR Order is appropriate has been argued to rest on a subjective evaluation of anticipated benefits and harms. Any outcomes are influenced by a number of probabilities; and,
	physicians have medical expertise, but are no more “moral agents” than many others in determining a direct course in the ending of a life.

---

1	This definition is drawn from guidelines issued by the Canadian Medical Association (1995).
2	IBid.
3	These definitions are drawn from a discourse regarding these definitions and their implications written by Anne Mullens in Timely Death: What We Can Expect And What We Need To Know. Toronto: Random House, 1997. See 25-26, 89-90, 94, 224-25.
4	There is extensive coverage in the Detroit Free Press of Dr. Kevorkian and his involvement in assisted suicide. References to the deaths of persons with disabilities can be found in the series "Suicide Machine." See the Detroit Free Press website for the entry August 30, 1996.
5	Edmund D. Pellegrino, "Decisions to Withdraw Life-Sustaining Treatment: A Moral Algorithm." Journal of American Medical Association. Vol. 283, No. 8, February 23, 2000. 1-7.
6	This definition is drawn from guidelines issued by the Canadian Medical Association (1995).
7	Daniel E. Deaton, "Questions Surrounding the Withdrawal of Artificial Hydration and Nutrition from Patients in a Persistent Vegetative State," Journal of Biblical Ethics in Medicine, Summer 1992.
8	K. Mitchell, I. Kerridge, & T. Lovat, 1993, "Medical Futility, Treatment Withdrawal, and the Persistent Vegetative State," Journal of Medical Ethics, 19, 71-76.
9	IBid.
10	This definition is taken from the "Medical-Links" web page created by the Pharmacy Association of Nova Scotia. Yarmouth: Electronic Publications. 2000.
11	Further information regarding issues around medical understandings of brain death can be found in the abstracts of the 2nd INTERNATIONAL SYMPOSIUM ON BRAIN DEATH (Havana, Cuba, 1996), in particular the submission of Julius Korein Entitled "Brain Ontogenesis, The Life and Death of the Human Being and Person."

Our Last Rights - Contents