Scenario: The Patient with a “Do Not Resuscitate” Order and Family Conflict
Imagine a situation in a busy hospital in Nairobi, Kenya. Mrs. A, a 78-year-old woman with advanced heart failure and multiple comorbidities, has been admitted with a severe exacerbation. After extensive discussions with her physician and in accordance with her wishes and Kenyan law, a valid “Do Not Resuscitate” (DNR) order is in place, clearly documented in her chart. Mrs. A is conscious but frail, and her condition is deteriorating.
Her adult children, who live in different parts of the country and were not all present for the initial DNR discussion, arrive at the hospital. Upon learning about the DNR order, a significant conflict arises. One daughter strongly believes that “everything possible” should be done to save her mother’s life, citing cultural beliefs about respecting elders and fighting until the very end. She expresses anger and disbelief that the medical team and her mother would “give up.” The other children, while saddened, acknowledge their mother’s wishes and the physician’s assessment of her poor prognosis.
The nurse on duty, Sister Beatrice, finds herself in a difficult ethical situation:
- Respect for Patient Autonomy: The DNR order reflects Mrs. A’s informed decision about her end-of-life care, a cornerstone of ethical nursing practice.
- Beneficence: Sister Beatrice has a duty to act in Mrs. A’s best interest, which, based on the DNR, is to allow a natural death without aggressive interventions.
- Non-Maleficence: Resuscitating Mrs. A against her wishes could cause her further suffering and violate her autonomy.
- Justice: Treating all patients fairly includes respecting their legal and ethical rights, including the right to make decisions about their own care.
- Family Involvement and Cultural Sensitivity: Kenyan culture often places a strong emphasis on family involvement in healthcare decisions and respecting the wishes of elders. The daughter’s distress and cultural perspective cannot be dismissed.
Resolution Process (Hypothetical):
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Initial Assessment and Communication: Sister Beatrice would first calmly and empathetically listen to the concerned daughter’s perspective, acknowledging her emotions and cultural beliefs. She would gently explain the purpose of a DNR order and confirm that Mrs. A had been involved in the decision-making process with her physician.
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Review Documentation: Sister Beatrice would carefully review Mrs. A’s medical chart to ensure the DNR order is valid, properly documented, and reflects informed consent. She would also note any previous discussions about end-of-life care.
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Involve the Physician: Sister Beatrice would immediately inform the attending physician about the family conflict. The physician has the primary responsibility for explaining the medical prognosis and the implications of the DNR order to the family in a clear and sensitive manner. The physician can reiterate the medical rationale behind the DNR and address any medical misunderstandings.
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Facilitate Family Meeting: With the physician’s involvement, Sister Beatrice would advocate for a family meeting to discuss the situation openly. This meeting would provide a platform for all family members to express their concerns, share their perspectives, and ask questions. A social worker or a trained counselor, if available within the Kenyan healthcare setting, could be invaluable in facilitating this emotionally charged discussion and mediating differing viewpoints, while being mindful of cultural nuances around death and dying.
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Re-engage with the Patient (if possible): If Mrs. A’s condition allows and she is still capable of expressing her wishes, the medical team, including Sister Beatrice, would gently re-engage with her to reaffirm her understanding and decision regarding the DNR. Her direct input would be paramount in resolving the conflict.
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Cultural Considerations: Sister Beatrice, being aware of the strong cultural emphasis on family and respect for elders in Kenya, would ensure that the discussions are conducted in a culturally sensitive manner. This might involve allowing more time for family members to process the information, involving respected family elders in the conversation (if appropriate and desired by the patient), and framing the DNR not as “giving up” but as respecting the patient’s wishes for a peaceful and dignified end of life, consistent with her values.
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Ethical Consultation (if necessary): If the conflict remains unresolved and poses a significant ethical challenge for the healthcare team, Sister Beatrice would advocate for an ethical consultation. An ethics committee (if available within the institution) or a senior nurse with expertise in ethical issues could provide guidance and support in navigating the situation while upholding ethical principles and legal requirements within the Kenyan context.
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Documentation: Throughout the process, Sister Beatrice would meticulously document all discussions with the patient, family members, and the healthcare team, including the resolution reached and the rationale behind it.
Resolution:
Ideally, through open communication, empathetic listening, and the involvement of the physician and potentially a social worker or counselor, the family would come to a better understanding of Mrs. A’s wishes and the medical reality of her condition. While the dissenting daughter might still experience grief and disagreement, the process would aim to honor the patient’s autonomy while acknowledging and addressing the family’s emotional and cultural needs. The healthcare team would continue to provide compassionate and supportive care to Mrs. A in accordance with her DNR order, ensuring a peaceful and dignified end of life
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