Ethics review: Perioperative do-not-resuscitate orders – doing 'nothing' when 'something' can be done

Cardiopulmonary resuscitation (CPR) has the ability to reverse premature death. It can also prolong terminal illness, increase discomfort and consume enormous resources. Despite the desire to respect patient autonomy, there are many reasons why withholding CPR may be complicated in the perioperative setting. This review outlines these factors in order to offer practical suggestions and to provoke discussion among perioperative care providers. Although originally described for witnessed intraoperative arrests, closed chest cardiac massage quickly became universal practice, and a legal imperative in many hospitals. Concerns were raised by both health care workers and patient groups; this eventually led to the creation of the do-not-resuscitate (DNR) order. However, legal precedents and ethical interpretations dictated that patients were expected to receive full resuscitation unless there was explicit documentation to the contrary. In short, CPR became the only medical intervention that required an order to prevent it from being performed. Before the 1990s, patients routinely had pre-existing DNR orders suspended during the perioperative period. Several articles criticized this widespread practice, and the policy of 'required reconsideration' was proposed. Despite this, many practical issues have hindered widespread observance of DNR orders for surgical patients, including concerns related to the DNR order itself and difficulties related to the nature of the operating room environment. This review outlines the origins of the DNR order, and how it currently affects the patient presenting for surgery with a pre-existing DNR order. There are many obstacles yet to overcome, but several practical strategies exist to aid health care workers and patients alike.     

Ethics review: Perioperative do-not-resuscitate orders – doing 'nothing' when 'something' can be done

Cardiopulmonary resuscitation (CPR) has the ability to reverse premature death. It can also prolong terminal illness, increase discomfort and consume enormous resources. Despite the desire to respect patient autonomy, there are many reasons why withholding CPR may be complicated in the perioperative setting. This review outlines these factors in order to offer practical suggestions and to provoke discussion among perioperative care providers. Although originally described for witnessed intraoperative arrests, closed chest cardiac massage quickly became universal practice, and a legal imperative in many hospitals. Concerns were raised by both health care workers and patient groups; this eventually led to the creation of the do-not-resuscitate (DNR) order. However, legal precedents and ethical interpretations dictated that patients were expected to receive full resuscitation unless there was explicit documentation to the contrary. In short, CPR became the only medical intervention that required an order to prevent it from being performed. Before the 1990s, patients routinely had pre-existing DNR orders suspended during the perioperative period. Several articles criticized this widespread practice, and the policy of 'required reconsideration' was proposed. Despite this, many practical issues have hindered widespread observance of DNR orders for surgical patients, including concerns related to the DNR order itself and difficulties related to the nature of the operating room environment. This review outlines the origins of the DNR order, and how it currently affects the patient presenting for surgery with a pre-existing DNR order. There are many obstacles yet to overcome, but several practical strategies exist to aid health care workers and patients alike.     

Teaching student nurses to be culturally safe: can it be done?

From the perspective of a third-year student nurse about to graduate in New Zealand, this article discusses the complexities of teaching and learning the concept of cultural safety for educators and student nurses. The background of the implementation of cultural safety content into New Zealand nursing curriculum is briefly discussed, and the evolution of cultural safety and its diverse meanings that has led to some confusion among student nurses. How is cultural safety taught and what are the surrounding barriers? Also, where does the student nurse fit into this process? Recommendations are then made to improve the teaching of cultural safety in the New Zealand nursing curriculum.     

Neonatal loss. What can be done to ease parents' grief

Healthcare professionals have an important role in helping grieving parents cope with a neonatal loss. Physicians need to be professionally prepared to deal with such a situation, which includes knowing how to refer the parents to community support systems and anticipating and being prepared for a variety of emotional responses. Suggestions based on personal experience are offered for dealing with bereaved parents during this complex and difficult time.     

Releasing restraints in the nursing home: it can be done.

1. The value of physical restraints for nursing home residents has not been documented, yet they have been used almost universally for at least 50 years. 2. The use of physical restraints for confused patients produces numerous negative outcomes. 3. Nursing homes can create environments that are restraint-free for all residents, and demonstration trials have proven the feasibility of restraint-free care. 4. A restraint-free environment produces a dramatic decrease in agitation and mobility problems.