1. Case Study: On the Permissibility of a DNR Order
for Patient with Dismal Prognosis
Nate Pilcher
Emily Hockett
Sam Kendrick
Lori Waldeck

2. OVERVIEW
• Patient is an 86-year old female
• Was living independently and in good health
• Had severe head injury
• Placed on ventilator in ICU

3. OVERVIEW
• Trauma team placed a DNR in patient’s chart
• Palliative Care team found her awake and communicative
• Ethics consultation was sought by palliative physician

4. OVERVIEW
Is it ethically legal to withdraw the patient from life
support without a living will or surrogate present?
Is it ethically legal to allow a patient to make decisions
without a surrogate present or without a family
member?

5. ETHICAL ISSUES
• Follow the family’s wishes and carry out the DNR
even though the patient is awake and coherent?
• If the patient is able to communicate, shouldn’t the
question be directed to her?
• Is it possible that the family may benefit from the
patient’s death
• Is it possible for her to make a full recovery?

6. PERSONAL VALUES
• Everyone deserves a chance to live and make a
full recovery, regardless of age
• This patient should be involved in decision-making
PROFESSIONAL VALUES
• Respect the patient’s wishes
• “Do no harm”
VALUES OF OTHERS INVOLVED
• Family Values

7. ENVIRONMENTAL FACTORS
• Patient’s age
• Patient’s mental state
BARRIERS
• Effects of the fall on the patient’s mental status
• Possible barrier to communicate with patient

8. STANDARDS OF PRACTICE
Administration level:
• Legal procedures (DNR)
• What if her wishes were to live even though there is
a DNR on her chart?
LEGAL GUIDELINES AND PRINCIPLES
• Legal rights of the patient
• Now that she is coherent, her wishes should be
taken into consideration.

9. ALTERNATIVES
Option 1: Remove the DNR from the patient’s chart
Arguments for:
• Improved state
• She was not involved in decisions concerning her own
treatment
Arguments against:
• Decision regarding DNR has already been made
• Her recovery is unlikely

10. ALTERNATIVES
Option 2: Leave DNR in place
Arguments for:
• Decision has already been made
• Prognosis is bleak/Waste of time and services to
continue life support
Arguments against:
• She is alert and awake, and she should be given a
chance to make her own decision

11. ALTERNATIVES
Option 3: Consult patient & get second opinion
Arguments for:
• She can understand her situation and make her
own decision
• Another physician may see possible recovery
Arguments against:
• DNR already in place

12. FINAL DECISION
The patient should choose whether or not to have a
DNR in place.
• She is awake and able to communicate
• She had not been asked to give consent

13. ACTION PLAN
1. The patient should be asked if she wants to know
her condition/prognosis
2. She should be asked if she wants to make
decisions about her care
3. Ask if she wants the DNR to be in place
4. If mental state declines, a surrogate should be
named (POA) and they shall make the decision

14. WHAT REALLY HAPPENED
• Patient was asked to be involved in decision-making;
she accepted
• She agreed to DNR order
• She developed pneumonia
• Began decline in health on third day
• Slipped into coma on day 4
• Was withdrawn from ventilator and expired (following
her wishes)

15. If you were that patient, what would
you want?