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Advance Directives: Implications for Dialysis Professionals (1 credit hours)
Modern medical technology has created a need for patients to prepare treatment directives in advance, indicating desired medical care in the event of becoming incapacitated. This module offers a historical overview of CPR and its relationship to the concept of advance directives. Also addressed are the concepts of Euthanasia, and "Do Not Resuscitate" orders. Types of advance directives are delineated to include a discussion of the Living Wills as well as the ethical considerations of autonomy, fairness, non-maleficence and beneficence. The module concludes by describing issues associated with application of advance directives in dialysis units.

Planners, content specialists and feedback personnel have declared that there is no conflict of interest in the preparation and content of this module. There is no commercial support for or endorsement of products in this module.

Wanda Jelus, RN, MS, CEN
Wanda Jelus holds a masters degree in nursing and is professor of Nursing at Sinclair Community College (Dayton, OH). Professor Jelus has extensive experience in critical care/emergency nursing, and has over 15 years experience teaching nursing, both in the clinical area and in the classroom. Her multiple professional presentations have covered such topics as shock, using technology for effective teaching, creative clinical teaching, and ethical considerations of Do Not Resuscitate orders.
After studying the information presented here, the learner will be able to:
  • Discuss the history of CPR.
  • Identify the types of advance directives.
  • Recognize the ethical issues involved in honoring advance directives.
  • Summarize the implications of DNR orders in the dialysis unit.
  • Describe important legislative considerations regarding advance directives.

Bibliography
Applebaum GE, King JE, Finucane TE. The outcome of CPR initiated in nursing homes. Journal of the American Geriatrics Society. 1990;38 (2):197-200.

Asch DA. The role of critical care nurses in euthanasia and assisted suicide. New England Journal of Medicine. 1996;334 (21):1274-9.

Casarett D, Ross LF. Overriding a patient’s refusal of treatment after an iatrogenic complication. New England Journal of Medicine. 1997;336 (26):1908-9.

Clemency MV, Thompson NJ. Do not resuscitate (DNR) orders and the anesthesiologist: a survey. Anesthesia and Analgesia. 1993;76 (2):394-9.

DeBard ML. Cardiopulmonary resuscitation: analysis of six years experience and review of the literature. Annals of Emergency Medicine. 1981; 10:408-415.

Hall JK. Nursing Ethics and Law. Philadelphia, Pa: W.B. Saunders Co; 1996.

Heffner JE, Barbieri C. Compliance with do-not-resuscitate orders for hospitalized patients transported to radiology departments. Annals of Internal Medicine. 1998;129 (10): 801-5.

Heffner JE, Barbieri C, Casey K. Procedure-specific do-not- resuscitate orders. Archives of Internal Medicine. 1996;156 (7):793-7.

Jacobsen JA, Gully JE, Mann H. “Do not resuscitate” orders in the radiology department: an interpretation. Radiology. 1996;198 (1):21-4.

Jordens C, Little M, Kerridge I, McPhee J. Ethics in Medicine, from advance directives to advance care planning: current legal status, ethical rationales and a new research agenda. Internal Medicine Journal, 35 (9): 563-566.

Kiely DK, Mitchell SL, Marlow A, Murphy KM, Morris JN. Racial and state differences in the designation of advance directives in nursing home residents. Journal of the American Geriatrics Society, 49 (10): 1346-1352.

Lequn C, Wei S. Do-Not-Resuscitate Orders in Critical Care Elderly: No Age Discrimination Against Elderly in a Community Hospital. Archives of Internal Medicine, May 1998; 158: 1154.

McDermott VG. Resuscitation and the radiologist. Annals of Internal Medicine. 1998;129 (10):831-3.

Messert B, Quaglieri CE. Cardiopulmonary resuscitation: perspectives and problems. Lancet. 1976;2:410-2.

Miranda DR. Quality of life after cardiopulmonary resuscitation. Chest. 1994; 106 (2):524-9.

Moseley R, Dobalian A, Hatch R. The problem with advance directives: Maybe it is the medium, not the message. Archives of Gerontology and Geriatrics, 41 (2): 211-219.

Nolan MT. Could lack of clarity in written advance directives contribute to their ineffectiveness? A study of the content of written advance directives. Applied Nursing Research, 16 (1): 65-69.

Peterson MW, Schwartz DA, Moseley PL. Outcome of cardiopulmonary resuscitation in a medical intensive care unit. Chest. 1991:100 (1):168-174.

Taffet GE, Teasdale TA, Luchi RJ. In-hospital cardiopulmonary resuscitation. JAMA. 1998;260:2069-72,

Terry PB. Resuscitation and radiology. Radiology. 1996;198 (1):17-18.

Zimring SK. Multi-cultural issues in advance directives. Journal of the American Medical Directors Association, 2 (5): 241-245.

Zucker MB, Zucker HD. Medical Futility. New York, NY: Cambridge University Press;1997.

Webliography
American Academy of Pediatrics. Do Not Resuscitate Orders in Schools -- Committee on School Health and Committee on Bioethics. 2000. Available at: http://www.aap.org/policy/re9842.html. Accessed March 28, 2007.

American Nurses Association. NursingWorld: Reading Room: Position Statement: Nursing Care and Do-Not-Resuscitate (DNR) Decisions. 2007. Available at: http://www.aap.org/policy/re9842.html. Accessed March 28, 2007.

CNN online. Study: Many 'do not resuscitate' patients change their minds. Available at: http://www.cnn.com/HEALTH/9808/24/end.of.life/. Accessed March 28, 2007.

Euthanasia ProCon.org. Should euthenasia be legal? Available at: http://www.euthanasiaprocon.org/?OVRAW=The%20Medical%20Ethics%20Advisor&OVKEY=medical%20ethics&OVMTC=advanced. Accessed March 28, 2007.

Legal Eagle Eye Newsletter for the Nursing Profession. Do Not Resuscitate Order for Profoundly Retarded Patient Thrown Out by Court. 1995. Available at: http://www.nursinglaw.com/dnrretarded.htm. Accessed March 28, 2007.

NYS Department of Health. DNR-guidebook for patients and families -- Deciding about CPR. Available at: http://wings.buffalo.edu/faculty/research/bioethics/dnr-p.html. Accessed March 28, 2007.


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