All of the scenarios in the Role 4 suit should be considered from the perspective of a health professional working in a military hospital receiving casualties from military operations with responsibility for the clinical care of patients and management of the facility. The primary supporting reference for this suit is the World Medical Association International Code of Medical Ethics (WMA Code) at: https://www.wma.net/policies-post/wma-international-code-of-medical-ethics/ supported by the WMA Declaration of Lisbon on the Rights of the Patient at: https://www.wma.net/policies-post/wma-declaration-of-lisbon-on-the-rights-of-the-patient/#:~:text=Every%20person%20is%20entitled%20without,with%20his%2Fher%20best%20interests. You should also consider your national professional ethical codes and relevant military law or guidance.

Step 1 – IDENTIFY THE PROBLEM(S)

Briefly state the Scenario: A badly injured patient has returned to the ward after their third admission to ITU. They are requesting not to be resuscitated in the future but the junior staff object. Should they be allowed to sign the document?

• List the Issues that arise from the scenario.
• Identify Critical Information required and Assumptions to be made:

This scenario covers the ethics and law regarding consent, autonomy regarding patient choice to refuse treatment in the face of a severe medical condition, and the concept of ‘Do Not Resuscitate’ orders.

Step 2 – ANALYSE

Patient: Patients have the right to refuse treatment. WMA Code Para 13 - In providing medical care, the physician must respect the dignity, autonomy, and rights of the patient. The physician must respect the patient’s right to freely accept or refuse care in keeping with the patient’s values and preferences.

Clinical: Clinical staff may have formed a close bond with the patient and may feel personally upset if the patient choses to not to be resuscitated in the future. The patient may also have psychological issues that prevent them accepting future opportunities for positive health.

Legal: there may be formal policies and procedures by which a patient can initiate a ‘do not resuscitate’ (DNR) instruction – these should be followed.

Societal/Military: there may be reputational risks if the patient is/is not allowed to exercise their autonomy to sign a DNR order. There may also be established moral or religious perspectives on DNR orders.

Step 3 – FUSE

• Summarise conclusions
• Insert citations to key reference sources for your analysis
• Determine the exact Decision(s) to be made

The patient’s autonomy must be respected. However, it might be appropriate to determine if they are competent to make the decision to sign a DNR order.

Step 4 – DECIDE

• What is your Decision?
• Why (can you justify it)?
• Residual uncertainly, need for review?

The patient’s wishes might be reviewed by a multi-disciplinary committee to determine if they had been fully informed and were competent to sign a DNR order. The nursing staff should be involved in the process and may need special support if the patient were to die as a result of refusing intensive treatment.  

Contributor – Group Captain (Rtd) Teresa Griffiths CBE ARRC. Military Chief Nurse, Royal Centre for Defence Medicine (2010 - 2013) and Commanding Officer Defence Medical Rehabilitation Centre Headley Court/Stanford Hall (2016-2018).