Do Not Resuscitate Orders (DNR Orders)
Rev. Robert Fleischmann, National Director, Christian Life Resources
A number of years ago a woman for whom I was a legal guardian was placed in a nursing home. Among the many questions I was asked, one caught me unprepared. Specifically, the nursing home wanted to know whether I wanted aggressive resuscitation measures to be taken in the event she suffered a serious organ failure. I knew I wanted to be sure the staff cared for her properly. I knew I wanted her regularly fed and to receive water, even through artificial methods. But I wasn’t prepared to consider the question of resuscitating her.
From my conversations with others, I discovered my experience is hardly unique. The American Medical Association had already recommended that decisions not to resuscitate a patient be formally entered into the patient’s medical record. By that time it was already a widespread practice. Do-Not-Resuscitate (DNR) orders are now a consideration for nearly every applicant for admission into the nursing home and for many admissions to the hospital. This article will attempt to wade through some of the confusing information by providing some guidelines to follow when asked to decide on a DNR order.
Pertinent Biblical Principles
There are three main Biblical principles to be considered. The first principle addresses the question of authority over life and death. That principle is: God alone has the right to initiate and terminate life. In this context, we are particularly concerned about God’s authority to take human life. God’s position on this matter is clearly stated in Scripture. In Deuteronomy 32:39 God says, “I put to death and I bring to life.” Consistent with that position God strictly limits our jurisdiction in this matter. In Genesis 9:6 he tells us, “Whoever sheds human blood, by humans shall their blood be shed; for in the image of God has God made mankind”. This latter point was well summed up in the commandment, “You shall not murder.”
A second principle addresses the controversial topic of “quality of life. That principle is: While God demonstrates in his word that there may be different qualities of life, he extends to all human life an absolute value. In other words, God does not play favorites, and neither should we.
When Peter encountered Cornelius he acknowledged, “I now realize how true it is that God does not show favoritism” (Acts 10:34). While recognizing there were vast differences in the quality of people’s lives, God nevertheless so loved the “world,” healthy and unhealthy, lame and whole, that he sent his Son, Jesus, as their Savior (John 3:16).
A third principle is: A Christian both accepts and perhaps even longs for death and the heavenly victory that comes with it, but at the same time will seek to retain life as a time of service to God. In other words, a Christian’s reason for living life is to serve God. Such service is God’s purpose for life. That is why the Apostle Paul, when considering the question of life and death, said, “I am torn between the two: I desire to depart and be with Christ, which is by better far; but it is more necessary for you that I remain in the body” (Philippians 1:23-24).
Paul characterized the greater sacrifice to be that of continued life for he knew what living meant. It meant a lot of personal labor and hardship, but it was for the greatest of causes: the nurturing and salvation of souls.
Paul also acknowledges that death does not come with fear for the Christian. When he wrote to the Thessalonians, who apparently mourned the death or deaths of fellow believers, he said, “Brothers, we do not want you to be ignorant about those who fall asleep, or to grieve like the rest of men, who have no hope. We believe that Jesus died and rose again and so we believe that God will bring with Jesus those who have fallen asleep in him.”
Before authorizing a DNR order for oneself or a loved one, a Christian will want to ask himself or herself some important, yet practical, questions: How do I feel about authorizing a DNR order? Do I see it as a way for me to bring about or encourage the end of life? Am I presuming authority over life and death, or am I surrendering to God’s authority?
How do I feel about the role a person’s quality of life should play in the decision? To what degree is my decision to authorize a DNR order based on a fear that the surviving person creates more of a burden for me or others that is not wanted? Would God approve of me taking action or authorizing an action to preserve a life based on a diminished quality? Why would I refuse to issue a DNR order? Am I unwilling to die or let a loved one die? Does God want us to fight against death as though it is the worst thing to happen for a Christian?
These questions are merely to get you thinking. Other factors are to be considered, not the least of which is the important understanding of what resuscitation is and how effective it is. Consider the following information:
Cardiopulmonary resuscitation (CPR) is a mechanical method of assisting the body in two of its vital functions: pumping blood and supplying oxygen to its parts. CPR therapies are employed when there are inadequate functioning of the person’s heart and lungs to maintain life.
There are four types of CPR functions designed to support a failing heart and circulation. They are: (1) mechanically pumping the blood by pressing the chest wall; (2) defibrillation, which is the electrical shocking of the heart to return it to a normal rhythm; (3) medication to sustain the blood pressure and correct acidity in the blood; (4) pacemakers, which stimulate the heart to beat regularly.
There are also four CPR functions designed to help the lungs oxygenate the blood. They are (1) artificial respiration, accomplished by another person breathing into the patient’s mouth or by using a mechanical balloon device; (2) intubation, or insertion of a tube into the mouth, to better supply oxygen to the lungs; (3) suction or manual removal of fluid or objects from the airway; (4) use of air mixtures with increased oxygen content.
Some of these eight functions are more intrusive and demanding than others. Like most other forms of medical therapy, resuscitation is indicated in some situations but not in others. Generally, however, CPR is considered to be an emergency treatment that is aggressive, expensive, and of limited success.
There is a significant failure rate for CPR. One study indicates that CPR is attempted in approximately one-third of the two million patient deaths that occur each year in U.S. hospitals. Of that one-third receiving CPR, only about 33% survived. Of those who survived, only about a third survived to discharge. Of those discharged, about 80% are still alive six months later, generally without severe impairment.
The success rate of CPR is lower in the nursing home setting on patients over the age of 70. This is due to less medical equipment and medical training of the staff and the generally poor health of the elderly patient.
When should we employ CPR, and when should we issue a DNR order? It depends on the circumstance and the motive. In the late 1980s, the National Conference on Standards for Cardio-Pulmonary Resuscitation and Emergency Cardiac Care issued revised guidelines that stated: “When doubt exists…resuscitation should be instituted. One of the situations in which CPR is usually not indicated is in the case of the terminally ill patient for whom no further therapy for the underlying disease process remains available and for whom death appears imminent.” The document went to define “imminent death” as a situation in which death is most likely to occur in two weeks.
Statistically, CPR as a general form of medical therapy appears discouraging. But upon closer examination, it appears that the outcome of CPR efforts is more closely tied with a patient’s underlying condition, the prognosis for reasonable recovery, and the type of CPR therapy utilized. Most people would have little trouble with chemical attempts to elevate circulatory or respiratory functions. In fact, a close examination of the kinds of resuscitation would probably lead the average person to express comfort with some but not other forms of therapy. Therein lies the rub. While it would appear we would categorize CPR as extraordinary treatment the question might be asked, “When does and which extraordinary treatment becomes too much?” The answer rests not so much in a formula for the application of CPR and the justification for a DNR order. Rather, I suggest the answer lies more within the realm of God-fearing medical intuition and motive.
God-fearing medical intuition begins not with an analysis of the patient’s condition, but the motives of those making the decision about treatment. A doctor who evaluates the value of life subjectively and qualitatively is more likely to paint a dim picture of the outcome for CPR therapy. That doctor will be quick to recommend a DNR order rather than risk the survival of a patient whose quality of life is diminished. On the other hand, a doctor who sees life as having intrinsic value, who is rooted in Biblical principles, will be more inclined to advise CPR and DNR decisions from that perspective. Even though the ability of the medical community to accurately predict treatment outcome is scarcely better than a weatherman’s success at predicting the weather, a God-fearing doctor will advise with a backbone of Christian values about God and about human life.
When faced with the question as to whether or not to authorize a DNR order, the Christian will want to obtain the best available advice. The first step is to seek out a doctor who reflects the biblical value of human life. Look for a doctor who sees himself or herself as a caretaker of life in God’s kingdom, not as the great judge of valuable life versus a wasted life.
The key element when making this search is to listen to the language used by the doctor. If he or she talks about dying with “dignity,” be careful. A Christian doctor recognizes that death is a result of sin and that the word “dignity” may be inappropriate. Instead, a Christian doctor is more inclined to be concerned that the dying process is not artificially extended or suffering increased.
Also, talk frankly with the doctor about the value he/she places on human life. How does he feel about abortion? A doctor who would kill unborn children often has no trouble justifying the death of “useless” adults. Obtain a downloadable copy of your state’s Durable Power of Attorney for Health Care – Christian Version from the national office of Christian Life Resources and go through it with a doctor. Discuss it thoroughly with him or her and evaluate the reactions. Is the doctor supportive, or is he or she quick to muddy the waters in trying to confuse the issue, though being careful not to alarm you by outright rejection of the document?
Watch the way the doctor gets along with others who have a terminal condition. Is he or she compassionate and caring, or cold and mechanical? Listen to what is said in front of the patient and about the patient to the support staff. Ask the advice of your clergy, Christian friends, or family.
Finally, continue to run through a motive checklist of your own. Ask yourself the hard questions proposed earlier in this article. Probe your feelings on the tough subjects of burden-carrying, sacrifice, selfishness, and compassion. Determine whether your treasure lies in service to the Lord or service to yourself.
There is considerable room for Christian discretion in these issues. Two Christians, both evaluating the same information, may arrive at different, nevertheless, God-pleasing decisions on DNR orders and implementation of CPR therapy. It is important, however, to keep in mind God’s command which says, “So whether you eat or drink or whatever you do, do it all for the glory of God.” Never forget that the entire decision process falls under the broader umbrella which says, “Thy will be done.”
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