Case Study 20 : BENEFICENCE AND NON-MALEFICENCE
Challenges
A 62-year old female is admitted for the sixth time in the hospital because of difficulty in breathing. She is diagnosed with Chronic Obstructive Pulmonary Disease and maintained regularly on anticholinergics and beta-2-agonist nebulizations. Her condition progressively deteriorates.
On the fifth hospital day, the patient goes into cardiorespiratory arrest. The chief resident recalls the attending physician saying three days earlier that he was going to put her on a No-CPR status after obtaining the family’s approval. The patient’s charts, however, indicate nothing to this effect, and attempts to reach and consult the attending physician and the patient’s relatives (none of whom was around at that time) prove unsuccessful.
Question
Should the chief resident initiate CPR?
Solutions
The principle of beneficence calls for physicians to always do what is best for the patient. Not only should they do no harmful action (the principle of non-maleficence, or the Hippocratic Oath’s “primum non nocere” or “First, do no harm”), but all actions that would prove beneficial to the patient, to the extent possible, should be performed.
It is true that there in some situations the No-CPR order is acceptable. This applies, for example, in terminal cases, when too little hope for recovery persists or if the burden for the patient, the family or society is too much. In the case presented, such criteria possibly exist, since at one point the attending physician even verbally expressed his preference for the No-CPR.
However, given that the No-CPR order has not been put into writing, the better course of action for the chief resident is to initiate CPR. In other words, he should opt to risk error by trying to do what might prove beneficial, rather than by omitting it. Besides, being under training, he does not really have the same decision-making authority as the attending physician, who did not indicated in writing such a significant decision as a No-CPR. Another consideration is that the attending physician could have changed his mind during the previous days, prompting him not to write down the No-CPR order.
