Running head: DO NOT RESUSCITATE ORDERS IN PEDIATRIC PATIENTS

Ethical Dilemma in Pediatric Patients

Olukemi Adekunle
Chamberlain College of Nursing

Running head: DO NOT RESUSCITATE ORDERS IN PEDIATRIC PATIENTS

Ethical Dilemma in Pediatric Patients

The purpose of this paper is to discuss ethical dilemma in pediatric patients and
how these dilemmas affect their caregivers. Children in the entire United States are
diagnosed with terminal diseases everyday. Once medical treatments begin and no
improvement is seen in the quality of life of the child, family would be advised to
consider a do not resuscitate order. According to Baker et al, A do not resuscitate order
is intended to protect the patient from resuscitative efforts that are not wanted by the
patient and family (2013). As a program director at an Intermediate Care facility (ICF)
pediatric unit, do not resuscitate status often come into discussion, and it is an
uncomfortable topic to discuss for some of the nurses at the unit. A do not resuscitate
order on a child can sometimes cause an internal ethical dilemma for some nurses.
Children are seen as lively individuals, and are supposed to outlive their elders. Also
there are many myths surrounding do not resuscitate orders with both family members
and members of the healthcare team. Some people believe that do not resuscitate orders
mean do not treat, when in actuality do not resuscitate orders only describe resuscitation
wishes. Do not resuscitate orders can in fact comply with all seven nursing ethical
principles. Ethical theory can be applied to a do not resuscitate order, and the ethical
dilemma of dealing with a child with a do not resuscitate order is discussed and how to
resolve it.
Beneficence and Nonmaleficence
One of the main nursing ethical principles is beneficence. Beneficence means to
act in the best interest of the patient (Burkhardt & Nathaniel, 2014). With a do not
resuscitate order, it is a common misperception that care is withheld from the patient. In

Running head: DO NOT RESUSCITATE ORDERS IN PEDIATRIC PATIENTS

actuality, the patient still receives appropriate medical and nursing interventions. While
the goals for the patient may change after a do not resuscitate order initiation, lifeprolonging measures still can be utilized (Baker et al., 2013). If the patient is at the end
stage of life, the care goals for the child have shifted towards an aim for a better quality
versus quantity of life. This entails making the patient comfortable and happy, versus
subjecting them to more procedures that will not prolong their life. The beneficence
principle can indeed be applied to a child with a do not resuscitate order, because in
certain situations, such as a child who is in pain and has been suffering, the act of not
resuscitating can be very much in the best interest of the child. Another nursing ethical
principle is nonmaleficence, which means to do no harm (Burkhardt & Nathaniel, 2014).
When a child has had all life prolonging treatments stopped, it is because the child will
not benefit from those measures. Decisions to limit interventions at end of life are based
on relieving suffering, and optimizing the quality of life the child has remaining (Lyon et
al., 2013). If the child is dying, resuscitation may not conform to the goal of a quality end
of life, thus having a do not resuscitate order can be considered a nonmaleficient act.
Autonomy and Justice
Autonomy is the ethical principle giving the patient the right to choose or deny
care (Burkhardt & Nathaniel, 2014). When a patient and family decide on a do not
resuscitate order, nurses need to understand that do not resuscitate is not the plan of care
(Murphy & Price, 2007). A do not resuscitate order only addresses whether or not to start
cardiopulmonary resuscitation. The patient and/or family have decided that being
resuscitated is not in the best interest of the child, but many other interventions are still
available to the patient. Nurses and other staff members have to respect the autonomous

Running head: DO NOT RESUSCITATE ORDERS IN PEDIATRIC PATIENTS

decision of the patient and family. The nursing ethical principle of justice involves giving
fair and equal care to all patients (Burkhardt & Nathaniel, 2014). A child with a do not
resuscitate order should be cared for comparatively like other children on the unit who
are a full code. Therapies, activities, and other nursing measures apply to the child with a
do not resuscitate order the same as a full code child (Burkhardt & Nathaniel, 2013).
Utilitarian Perspective with Do Not Resuscitate Orders
Patients, families, and health care providers choose to act in a way that increases
the overall good; act-utilitarianism can be defined the same as well. While assessing
whether a child should have a do not resuscitate order or not, many factors are involved.
The decision to withhold cardiopulmonary resuscitation is generally based on the
assumption that the child would suffer more if resuscitation occurred. The act of
withholding resuscitation to foster the overall good for the patient and family best fits
into the theory of act-utilitarianism since the end result derived from the do not
resuscitate order is beneficial (Burkhardt & Nathaniel, 2013). For example, if a child has
been in pain, suffering, and has a poor prognosis, allowing the child to pass comfortably
versus being intensively resuscitated is in the best interest of the child and family. Ruleutilitarianism theory also somewhat fits into a do not resuscitate order, rule-utilitarianism
theory describes following the rules that are in the best interest of everyone (Burkhardt &
Nathaniel, 2013). A do not resuscitate order can be said to be a rule to abide by that can
benefit the end of life comfort of the dying child and their family, compared to the
downfalls of attempting to resuscitate the child.

Running head: DO NOT RESUSCITATE ORDERS IN PEDIATRIC PATIENTS

The Dilemma
When children and their family start discussion on a do not resuscitate order it is
sometimes assumed that the family and health care team have given up on the child.
(Burkhardt & Nathaniel, 2013). Nurses can question themselves and coworkers about the
do not resuscitate order, and upon applying it to their personal morals and the nursing
principles of beneficence and nonmaleficence, have internal strife. Since the patient is a
child, many health care providers are uncomfortable about the fact that if the child were
to stop breathing, or code, the act of withholding care may be difficult to faced. If the
do not resuscitate order is confusing, then these feelings are compounded. Nurses, who
are not sure what to do in an urgent situation, will likely agonize over taking that patient,
and feelings of awkwardness with the patient and the care they require may lead to
suboptimal care.
Resolving the Dilemma
Having understanding of the goals for the child helps nursing and other staff members
feel more comfortable with a do not resuscitate order. Making the do not resuscitate order
as readily understood as possible clears up any confusion of what to do if an event occurs
(Murphy & Price, 2007). When staff members or family seem unclear as to what the do
not resuscitate order entails, management can approach them and promptly address any
clarifications needed. Also a do not resuscitate order can be adjusted or removed at any
time. Patients conditions do change, and if modification is desired, a do not resuscitate
order is not set in stone. Nurses comfortable with do not resuscitate orders should be
given the chance to in-service other staff members on the details of do not resuscitate
orders and what they require. According to the American Nursing Association (ANA),

Running head: DO NOT RESUSCITATE ORDERS IN PEDIATRIC PATIENTS

Nurses should advocate for and play a major role in initiating discussions about DNR
with patients, families, and members of the health care team. Provision 1.3 of the ANA
Code of Ethics for Nurses (2001).
Conclusion
Do not resuscitate order in the pediatric patient can be a difficult subject matter for nurses
and other health care professionals. Children are expected to outlive adults, and when a
do not resuscitate order is in place, staff members are confronted with the reality of death
of a child. Having straightforward language in each do not resuscitate order will assist
staff members in understanding what is asked of them in a code situation. Knowing what
goals are wanted in the childs care helps staff be aware of how the do not resuscitate
order fits in the overall plan of care for the child. Ethical theory can apply to a do not
resuscitate order. It can be an ethical decision and fit into the seven nursing ethical
principles. Miscommunications about do not resuscitate orders can cause ethical
dilemmas in nurses and other health care professionals, but with proper training and clear
guidelines, nurses can succeed in coping with do not resuscitate orders in the pediatric
patient.

Running head: DO NOT RESUSCITATE ORDERS IN PEDIATRIC PATIENTS

References
ANA. (2001, January 12). Nursing Care and Do Not Resuscitate (DNR) and Allow
Natural Death (AND) Decisions. Retrieved from
http://www.nursingworld.org/MainMenuCategories/EthicsStandards/EthicsPosition-Statements/Nursing-Care-and-Do-Not-Resuscitate-DNR-and-AllowNatural-Death-Decisions.pdf
Baker, J., Kane, J., Rai, S., Howard, S., PCS Research Working Group, & Hinds, P.
(2013). Changes in medical care at a pediatric oncology referral center after
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Burkhardt, M. A., & Nathaniel, A. K. (2014). Ethics and issues in contemporary nursing
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Lyon, M., Williams, P., Woods, E., Hutton, N., Butler, A., Sibinga, E., & ... Oleske, J.
(2013). Do-not-resuscitate orders and/or hospice care, psychological health, and
quality of life among children/adolescents with acquired immune deficiency
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