Evidenced-based practice concerning the DNR advanced directive

The DNR Directive

The do not resuscitate (DNR) directive is a standard medical order issued by a practitioner that includes instructions for resuscitating the patient, in this example, Mr. Miles, a 70-year-old patient. If the patient has life-threatening, fatal, or chronic diseases and does not want to prolong their life in a possible profound handicap or coma, the practitioner will issue a DNR order after counseling. The doctor can also issue the order if the patient requests it. Following agreement between the patient and the physician, the patient signs the order. The clinician formally notes the order in the patient's medical record. Unlike other advanced directives, the DNR order is a crucial and severe document that requires the formal prescription of the patient. From time to time, enforcing the DNR order can be tricky for the reason that the severity and the nature of a potential life threatening event, which can turn out to be a subjective issue. For instance, in the course of an emergency, well-trained and well-meaning physicians may automatically seek to offer CPR since they may not be aware of the DNR order (Blackburn & Dulmus, 2007).

The Implications of Not Honoring DNR Orders

When the patient’s wishes or advanced directive, in this case, the DNR are not honored for the reason that a health care provider or caregiver disagrees with the wishes of the patient, it can lead to a set of an ethical, legal, and clinical dilemma. For this reason, as a nurse, it is imperative to discuss the DNR order with the patient and then documents based on their stated preferences. Additionally, the DNR can lead errors of offering all-encompassing treatments, such as resuscitation and intubation that are not consistent with the preferences of the patient. This, in turn, can cause considerable suffering to the family and the patient (Blackburn & Dulmus, 2007).

The Nurse's Moral Responsibility

1. The nurse’s responsibility to the patient in the scenario

There is a wide-ranging accord concerning the right of a competent individual to refuse therapies that can sustain life, whereby in this situation, the patient refuses DNR and dialysis. The legal as well as the ethical argument that upholds the concept is based on the right of one to be left alone, the right to privacy, and the right to determine what is done to one’s body. For this reason, the responsibility of the nurse would be to respect the autonomy of Mr. Miles. The nurse also has an obligation to guarantee that the patient had the ability to make the decision and he was not unduly inhibited in the expression of his autonomy. The nurse also has the responsibility of ensuring that the refusal by Mr. Miles was informed whereby the nurse made him aware of the possible alternatives for the treatment, the likely benefits and risks, and the consequences of refusal. The nurse is obligated to respect this autonomy approach since it is consistent with the ethical and legal standards that permit the denial of treatment by qualified patients (Karnik & Kanekar, 2016).

(a) The potential moral dilemma

In this scenario, the nurse has found themselves in a situation that is ethically questionable since it conflicts with their professional and personal morals. Mr. Miles has the right to put forward his preference when it comes to the end of life treatment. Nonetheless, the resolution strategy in this scenario will involve the nurse having to consider the choices and the perspective of the patient. Additionally, the healthcare provider will have to work for the good of the patient by working against the egoistic theory. They need to apply the virtue theory of ethics by acting towards attaining the greatest good for Mr. Miles by collaborating with the family members. The nurse can judge the situation and present suitable prognosis for treatment so that the family of the patient can make choices for them. This will ensure that they work toward the beneficence act for the patient (Karnik & Kanekar, 2016).

2. The advanced directive DNR impact on the stakeholders in the scenario

This order will spell out what Mr. Miles wants in regards to resuscitation in various cases. This includes when the patient is being seen as an outpatient at another physician office or hospital or when being transported from one facility to another. Furthermore, this concept impacts the stakeholders since unlike years ago where most deaths occurred at home, in the present day, there is a greater chance of dying in nursing homes or hospitals. The impact here is that sometimes the stakeholders may be required to come up decisions concerning the care of the patient at a time when they can no longer put forward their wishes. The two categories of the advanced directive are the proxy and instructional, which allows the patient to specify their wishes to families or providers in case they are unable to make end-of-life decisions in the future due to disability (Karnik & Kanekar, 2016).

The American Nurses Association (ANA) Code of Ethics

1. How the provision applies to the scenario

The ANA Code of Ethics offers the highest desire when it comes to professional nursing ethical practice. They allow a nurse to achieve their daily practice because they represent the ideal action that needs to be considered by the nurse. The first provision is crucial in this scenario because it asserts that in all professional associations, the nurse needs to carry out their duties with respect and compassion. They are required to achieve this by inherent uniqueness, worth, and dignity of each patient unrestricted by the consideration of the nature of health problems, personal attributes, and the economic or social status (Bosek & Savage, 2007).

2. Importance of patient autonomy

The significance of autonomy is based on the assertion that every individual has the right to shape their life based on their preference and this right is extended to comprise the right of a patient to choose the manner in which they wish to die. Therefore, the concept is vital for the reason that it has a pivotal role in one’s decision making to their end-of-life (Cholbi & Varelius, 2015).

Legal Implication

1. Potential legal conflicts among organization, nurse, family, and patient

Each day, nurses are required to come up with decisions that adhere to ethical standards and stipulated laws. For this reason, the healthcare providers need to understand nursing, ethics, and law's interface so as to come up with appropriate decisions. In the case of Mr. Miles, conflict may arise among the institution, the nurse, the patient, and the family based on their views on what makes up good care for the patient considering the patient refused the advanced directive. Practitioners should have the familiarity with the possible legal issues that apply to practicing nursing (Brooker & Waugh, 2013).

2. How the potential legal conflict influences the role of the nurses

The legitimate concern that may transpire in this scenario may shape the environment in which decision making by the nurses based on advanced directive is made. The legal likely legal conflict will as well impact the practice of nursing, which means that the nurses should be familiar with the regulations and statutes concerning the delivery of patient care. This will help them to avoid the potential sanctions, criminal as well as civil liability in regards to healthcare. The healthcare providers must consider how the law affects their role and pay attention to it each day when they are working (Brooker & Waugh, 2013).

3. Potential nursing actions to prevent conflicts

The potential healing act that would be crucial for helping to prevent the possible conflict involves the healthcare providers adhering to the law and upholding knowledge. This is essential to the anticipation of the public well-being, patient and client outcome, appropriate nursing practice, and for the standard of care. The ethical and legal issues are concerned with this, which means that it is crucial for the healthcare providers to consider the effects on decision-making and practice.


Although close attention to advance care planning is crucial in nursing practice, the preference of the patient, particularly in regards to advanced directive, must be followed, documented, and ascertained. Poor communication or documentation concerning these preferences can result in errors in code situations, miscommunication with families, and the staff. This, in turn, can cause considerable suffering to the family and the patient (Blackburn & Dulmus, 2007).


Blackburn, J., & Dulmus, C. (2007). Handbook of Gerontology: Evidence-Based Approaches to Theory, Practice, and Policy. John Wiley & Sons.

Bosek, M. S., & Savage, T. A. (2007). The ethical component of nursing education: integrating ethics into clinical experience. Philadephia: Lippincott Williams and Wilkins.

Brooker, C., & Waugh, A. (2013). Foundations of Nursing Practice E-Book: Fundamentals of Holistic Care. Elsevier Health Sciences.

Cholbi, M., & Varelius, J. (2015). New Directions in the Ethics of Assisted Suicide and Euthanasia. Cham: Springer International Publishing.

Karnik, S., & Kanekar, A. (2016). Ethical Issues Surrounding End-of-Life Care: A Narrative Review. In Healthcare (Vol. 4, No. 2, p. 24). Multidisciplinary Digital Publishing Institute.

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