Ross Lainie Friedman
Department of Pediatrics and MacLean Center for Clinical Medical Ethics, University of Chicago, Chicago, Illinois 60637, USA.
Semin Dial. 2003 Sep-Oct;16(5):395-8. doi: 10.1046/j.1525-139x.2003.16081.x.
An iatrogenic arrest is a cardiopulmonary arrest induced by a therapeutic effort. Frequently cardiopulmonary arrests during hemodialysis (HD) are iatrogenic. In this article I consider the question of what to do when a cardiopulmonary arrest occurs during HD in a patient with a do not resuscitate (DNR) order. I consider and reject four arguments to override the DNR order: the principle of nonmaleficence, the efficacy of resuscitation, proximate cause, and physician error. Instead, I argue that respect for patient autonomy and patient goals means that DNR orders must be respected unless there is compelling evidence that overriding the DNR would be consistent with the patient's goals. If such evidence is lacking, the physician has no moral choice but to follow the DNR order literally. As such, nephrologists need better communication with their patients regarding advance care planning and better documentation of their communication once it has occurred.
医源性心脏骤停是指由治疗行为引发的心肺骤停。血液透析（HD）过程中频繁出现的心肺骤停属于医源性。在本文中，我探讨了在下达了“不要复苏”（DNR）医嘱的患者进行血液透析期间发生心肺骤停时应如何应对的问题。我考量并驳斥了四种推翻DNR医嘱的观点：不伤害原则、复苏的有效性、近因以及医生失误。相反，我认为尊重患者自主权和患者目标意味着必须尊重DNR医嘱，除非有确凿证据表明推翻DNR医嘱符合患者目标。如果缺乏此类证据，医生在道德上别无选择，只能严格遵循DNR医嘱。因此，肾病学家需要就预先护理计划与患者进行更好的沟通，并在沟通发生后更好地记录沟通情况。
