Outstanding ethico-legal-fiqhi issues

ObjectiveTo examine the practical issues arising in implementation of DNR from the perspectives of maqasid al shari’at and qawa’id al shari’at.MethodsThe purposes and principles of the Law provided a conceptual framework for analyzing practical issues related to DNR orders. The issues were identified from a Pubmed literature search with the key word ‘DNR’ covering about 30 years and were analyzed as they related to the principles of intention, certainty and preventing harm and also to the purposes of preserving life and resources.ResultsIt is proposed that DNR orders be written for patients in an established death process, i.e. cardiorespiratory failure beyond Young’s point ‘z’. Patients with terminal incurable conditions who develop acute, reversible cardiorespiratory arrest should be resuscitated if the net benefit will last for a reasonable time. Five components of DNR (cardiopulmonary resuscitation involving chest compression and oxygenation, endotracheal intubation, mechanical ventilation, defibrillation and vasoactive or ionotropic medication) could be provided on a case-by-case basis. The interventions may or may not include renal dialysis, blood transfusion, parenteral nutrition, pulmonary hygiene and normal treatment such as antibiotics. All patients, irrespective of their DNR status, deserve supportive care.ConclusionTo improve DNR processes, training should be given on end-of-life ethical issues for physicians and nurses, DNR orders should specify interventions, the autonomy of physicians who have a conscientious objection to DNR should be respected, more psychosocial support should be given to the families of DNR patients, more empirical research is required on DNR, and DNR decisions should be audited regularly.