Wesleyan University-Philippines

Cushman Campus, Mabini Ext., Cabanatuan City

College of Nursing
 COVID-19 tormented a lot of people in the world especially in the healthcare sector.
Recorded death toll is more than 6 million as to date globally with more than 750,000
cases confirmed. Another factor worth mentioning is here in the Philippines wherein
hospitals couldn’t admit all of COVID-19 positive patients due to scarcity of hospital beds,
oxygen tanks, healthcare staff and professionals. Other than that, countries like Italy also
suffered to a great extent with the situation similar with our country. This article begs the
question, is DNR necessary in these conditions? If so, is by considering unilateral DNR
ordain for COVID-19 patients on account of limited resources deemed as ethical?

This conversation is needed because it introduces a lot of moral and ethical inquiries.
Such as how could this provide patient’s autonomy by having to decide for them, is it fair
to prioritize those that has the higher chance of survival (younger people, patients that do
not present any comorbidities, abled-bodied patients, etc.) and contradicts the purpose
of beneficence as well as non-maleficence by not having to perform CPR to those that
have a less probability of remaining alive.

Autonomy
Autonomy and non-maleficence were reported by nurses and physicians, respectively,
as the most important ethical values when dealing with the DNR status. Deciding on DNR
on behalf of patients, i.e., unilateral DNR to save others with a higher probability of survival
and to protect HCPs may serve the principles of equity and not equality, and seems to
violate the principle of autonomy, which honors the patients' preference and wishes
regarding any decision for their medical care.
 Justice
The principle of justice entails “fair adjudication between conflicting claims,” as well as
treating patients with fairness, and to do so equally and equitably. Concerning the COVID-
19 pandemic and DNR, the term “distributive justice” resurfaces, which considers fair
allocation of resources, treatments, and benefits during a time of medical resource
scarcity. Physicians started treating patients equitably but not equally, and other factors
entered the equation when it came to providing care, as patients with the best chance of
recovery were prioritized over others.

Beneficence and Non-maleficence

Beneficence is defined as “an act of charity, mercy, and kindness with a strong
connotation of doing good to others including moral obligation”. In healthcare,
beneficence encompasses the idea that a physician's actions, decisions, and skills must
always advocate for what is best for the patient. Physicians must apply the principle of
beneficence while causing no harm to patients, a term referred to as non-maleficence
(“above all do no harm”)

A do-not-resuscitate order, or DNR order, is a medical order written by a doctor. It

instructs health care providers not to do cardiopulmonary resuscitation (CPR) if a patient's
breathing stops or if the patient's heart stops beating. DNR orders resulted in lower
hospitalization and hospital-based mortality incidences suggesting that even in the
absence of outbreaks and pandemics, planning and implementing DNR would save
resources which can then be re-directed. Resources become especially scarce during a
pandemic. The World Health Organization (WHO) defines a pandemic as “the worldwide
spread of a new disease” where the R0, a term that reflects “how infectious a disease is,”
is.

In of the COVID-19 pandemic the news emphasized the use of airborne infection
isolation rooms especially when there is a risk of dissemination of virus droplets, such as
endoscopies, and bronchoscopy procedures, as well as respiratory protection; most
importantly an N95 mask. More importantly, physicians are recommended to intubate
patients with respiratory failure owing to the COVID-19 virus to reduce the risk of aerosol
generation.

The government's response on this issue is they planned and implement the isolation
room for the patient who have COVID-19 and also the lockdown thing which results on
lowering the hospitalization and the cases of COVID-19
 We all know that the Covid-19 virus was very dangerous, it affects a lot of things
especially in our society and of course our industry. Many people died, many things were
perverted and some of us are hopeless when they had infected by Covid-19 virus.
Because the situation before when the covid-19 came, was very deadly and there was no
effective medicine to cure those infected patients that’s why other facilities decide to do
the DNR but it is against the patients' right because they have their right to live longer and
to survive any illness. The reason why they went to the hospital is that the doctor can cure
them of the pain they are feeling. Since the Covid-19 started many people alarmed about
the disease spreading around the world because many countries are infected. Day by day,
more and more people are getting sick, all the facilities are full and the Doctors and
Nurses become sick too that’s why many people are afraid of the spreading virus.

According to the article their way to those Covid-19 patients that are in the chronic
conditions implement the DNR which means Do Not Resuscitate. Because of the
spreading virus, they don’t want to infect others that’s why they decided to do the DNR.
The reason for the DNR is we lack vaccines to cure and fight the virus. The reaction of the
agencies/ institution/ government to this news was they suggested something that can
help reduce the cases of Covid-19 and later on implemented isolation areas for those
covid-19 patients to lower the risk of covid-19 patients. Because isolation areas are the
state of being separated from others. Isolation is used to prevent the disease from
spreading. It is good to know that their response was very effective because as time pass
by Covid-19 cases are decreasing and because they found the perfect formula for the
covid-19 virus that’s why the descend continued. Also they implement lockdown in every
country so as not to infect others because people that is not infected was not allowed to
get out to protect them from the virus. In this way, covid-19 cases did not increase. So the
responses of institution, agencies and government become successful because it lowers
the cases of covid-19, and as the time pass by the cases continued to decrease and
became better and better.
 Long-standing medical ethics principles must direct the line of work, individual
clinicians, healthcare systems, and our community. They must continually be reinforced in
the face of healthcare system disasters, wherein one‘s practice may change, although not
the concepts themselves. These fundamentals involve righteousness, fairness, and, most
importantly, the physician's or health worker's responsibility to think for all patients without
discrimination.

First and foremost, these orders are pivotal for terminally ill local citizens or any
patients who want only comfort care and no resuscitation and medical intervention to be
given the moment that their heart or breathing stops.

According to current data, there were over 672 million Covid-19 cases worldwide,
with a total of 6.84 million deaths. In response to the DNR order and Covid-19 controversy,
we believe it should no longer be an option for individuals or patients unless they also
have other chronic conditions. If exposure to Covid-19 is bothersome before, which could
potentially be one of the reasons for DNR, then as of today, healthcare workers are now
equipped not only with their personal protective equipment but also with complete
vaccines to add to their protection. Given that vaccines are now widely available, as of
December 7, 2022, 81% of patients are experiencing mild symptoms, with severe cases
ranging from 12 to 14%. Compared to when there was no known medication, the chances
of patients becoming terminally ill due to Covid-19 are extremely low, resulting in the
discontinuation or non-necessity of DNR.

In conclusion, given the percentage of Covid-19 cases and the fact that it is no
longer as mysterious as it once was, we genuinely think it should no longer be an ethical
issue. Medically, Covid-19 is still a virus with no known cure to end its existence; however,
we all want to save lives and provide our patients with the best care possible to help them
cope, recover, and be themselves again. As future nurses, we always believe that each
and every single life, matters.

Reference Article:
Sultan H, Mansour R, Shamieh O, Al-Tabba' A and Al-Hussaini M (2021) DNR and
COVID-19: The Ethical Dilemma and Suggested Solutions. Front. Public Health
9:560405. doi: 10.3389/fpubh.2021.560405