When Orders and Ethics Collide

As self-regulated professionals, respiratory therapists have a responsibility to be guided as much by orders and best practice guidelines as their own ethics. Take, for example, this case study:

A 21-year-old male with severe cerebral palsy, who has been in a near vegetative state for the last 5 years, was admitted to the neurologic in-patient ward. The patient’s power of care indicated that the patient’s code status was full care but no CPR, so orders were written that “patient is not to receive CPR.”

At 9 a.m., the respiratory therapist was paged on an urgent basis because the patient’s respiratory rate was 8 bpm and shallow. The patient was on a tracheostomy hood receiving oxygen by cool mist at 28 percent. The patient’s SpO2 was at 90 percent with a pulse of 120 bpm. The attending nurse reported that the patient’s mother had just left and the father was not due in for 30 minutes. (The father and mother were estranged because of the high emotional turmoil caused by caring for the patient on a 24-hour basis.)

The patient’s respiratory rate continued to fall and was now at 6 bpm. The therapist asked the RN to page the parents to return immediately and he initiated manual ventilation (BVM) with air. The therapist sustained the patient’s ventilation until the parents arrived approximately 45 minutes later.

The patient still had a pulse and weak respiratory efforts. No supplementary oxygen was used. On the parents’ return, they consented to cessation of ventilatory efforts after they both had the opportunity to say goodbye. They remained at his bedside until he passed on.

ethics booksDoes initiating manual ventilation violate the order of “not receiving CPR”? Ethically, was it correct to sustain the patient’s respirations until the parents returned? Does the written order’s literal meaning have an unwritten implied meaning?

Often, professional practice guidelines are written based on a standard as it relates to a normally encountered set of clinical situations. When something out of the norm is encountered, best practice guidelines may fall short.

In teaching hospitals, resident physicians cross-cover for other physicians on the service which reduces their familiarity with the patients they are responsible for. This can result in medically reasonable orders that conflict with the wishes of the patient and family and create an ethical dilemma.

When conflict with written orders arises, the therapist must seek clarification from the author of the orders and document the communication and the author’s concerns. If the author cannot be reached because they are off-site and no longer on-call, the therapist can seek clarification from the relieving physician on the service. If he cannot clarify the order, the therapist must be guided by past practice (experience), departmental policies, direction from supervisors or clinical experts and ultimately, their own ethics.

In the case study above, the clinical intent of the written orders was to prevent the initiation of chest compressions in the event of a cardiac or respiratory arrest. In a medically futile clinical situation, this is a reasonable order and complies with the caregivers wishes. However, in this situation, the patient had not reached a state where the circumstances specified by the order had been reached. The therapist on scene determined that manually assisting ventilation would slow but not stop the patient’s imminent death. Given the parent’s emotional attachment to the patient and that they were only a short drive away, the therapist determined that starting manual ventilation with air was a reasonable, compassionate and ethical decision to make. Both parents were able to return to their son’s bedside in time to share his final moments of life.

Following the patient’s death, a clinical colleague filed a complaint that the initiation of manual ventilation contravened the intent of the order. This clinician’s understanding was that the patient was known to be dying and that the implied intent of the orders was to ensure that no unreasonable action was initiated that would prevent the patient’s death.

Given the circumstances, how would you proceed? Did the therapist’s actions to slow the patient’s death and allow the family to reach the patient’s bedside contravene the orders? If a patient is still breathing and has a pulse, does that mean they have not reached the criteria where the order for “not receiving CPR” would be activated?

In this case, the facility’s leadership determined that the respiratory therapist’s decision was ethical, reasonable and compassionate. However, they also identified the need to ensure that written medical orders reflect the medical decisions surrounding end of life decisions and provide clear that can be applied to clinical changes.

When orders and ethics collide, clinicians must be guided by clinical experience and professional ethics to determine a reasonable course of action.

Dave Swift, RRT, is campus coordinator, professional practice respiratory therapy, at Ottawa Hospital – Civic Campus, Ottawa, Ontario, Canada. He is also respiratory therapy lead/subject matter expert, for the National Office of the Healthcare Emergency Response Team, Public Health Canada.

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