Why is dnr an ethical dilemma

In the more recent era, the world had witnessed many disease outbreaks, some of which were declared worldwide pandemics. These include, but are not limited to, the Asian flu in , Severe acute respiratory syndrome SARS in , Ebola in , and lastly Zika in However, in the case of commencement with CPR, only chest compressions should be started; mouth-to-mouth ventilation should be avoided.

Recently, an article on the American Heart Associations' guidance for CPR amid the COVID pandemic reiterated the aforementioned H1N1 guidelines, and also 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 virus to reduce the risk of aerosol generation The current pandemic, owing to the pervasive COVID virus, with up to million cases worldwide and 2,, deaths January 27, , advocates for upfront implementation of the DNR order to COVID infected patients; especially the elderly or those deemed associated with poor prognosis as per the physician's assessment The inquiry here is multifaceted.

How ethical is it to consider unilateral i. What are the potential consequences for other patients suffering from acute heart conditions, respiratory conditions, or road traffic accidents who might be competing with COVID infected patients for the limited ventilators?

Can we deny pre-planned treatment management to certain groups of patients like for example new and on-treatment cancer patients to preserve needed ICU rooms and ventilators if unilateral DNR orders for COVID infected cases could not be made? And essentially, what are the moral consequences for the healthcare providers HCPs making these tough decisions? How might these measures interject with the four major principles of medical ethics; autonomy, beneficence, non-maleficence, and justice?

What would be a plausible approach to this ethical dilemma? To address these questions, an exhaustive literature review using PubMed, Medline, Science Direct, and online news sites was undertaken to gather evidence and summarize the local, regional, and international recommendations.

The answer to this question might not be straight forward. On a global level, the issue is; what happens if HCPs who are at the frontline in our battle against COVID get infected with the virus in an attempt to resuscitate a patient with a very low probability of survival, i.

Moreover, most patients who are successfully resuscitated will need a ventilator, further contributing to the scarcity of resources amidst the COVID pandemic, and possibly depriving other patients with a greater probability of survival from using these resources. In light of these debatable questions, DNR seems to be an immensely valid option.

An article by Curtis et al. It also saves ICU resources to allow for the accommodation of patients with a better chance of recovery. In the case that such protocols are implemented, all patients and family members should be knowledgeable about and adhere to the healthcare unit's wishes. A study in that addressed the ethicality of allocating scarce medical resources by HCPs explored the views of general practitioner GP , medical students, and lay people This clearly addressed the potential controversy that might arise among HCPs and patients during health crises like pandemics and that should be addressed in anticipation of any.

Whether patients infected with COVID can be considered as a vulnerable population people in need of special care, support, or protection because of age, disability, or risk of abuse or neglect warrants further consideration while addressing the issue of DNR. Age was among the discriminator to triage patients; patients older than 80 years were offered DNR because of the futility of treatment and co-morbidities Patients and families of patients diagnosed with COVID disease have been stigmatized in some communities, which further adds to the vulnerability of COVID patients personal communication.

What are the potential consequences for other patients suffering from acute heart conditions, respiratory conditions, or road traffic accidents who might be competing with COVID patients for the limited resources? Triaging patients including COVID patients, those with acute conditions like cardiopulmonary cases, those with emergency surgical intervention as well as cancer patients planned for elective surgeries which can be postponed for a maximum of a few weeks, but no longer, would be an important ethical consideration when addressing the potential of limited resources should ICUs and ventilators be needed.

As a consequence, elective surgeries have been canceled, semi-elective procedures postponed, and operating rooms turned into makeshift ICUs The practice of dealing with DNR is sub-optimal even in the luxury of the routine practice outside pandemics. Within the setting of oncology practice in particular, Pettersson et al. Importantly, Bovman argues that reversing a DNR code if elective surgery is warranted is associated with a dismal day mortality One important limitation is that patients treated for other conditions might end up infected with COVID once admitted to the hospital During the months of March, April, and May, all elective surgeries, clinical appointments, and procedures were canceled, and chemotherapy and radiotherapy were canceled for the first two weeks and then started to build up gradually during the third week in anticipation of a potential surge of COVID infected cases.

In addition, patients were instructed to call a designated hotline if needed instead of in-person arrival to KHCC. All non-frontline employees were asked to stay at home, and a minimal number of HCPs were scheduled to cover the needs.

This regards not only to day-to-day practice, but also, and more importantly, for when they are needed most, such as in times of outbreaks. To HCPs, and in accordance with what their degrees encompass, universal DNR to COVID infected patients does not seem to be an option, adding to the ethical dilemma, self-blame, and burnout of the frontline decision makers.

In a study that addressed frontline vs. Italian physicians were reported to weep in hospital hallways because of the difficult decisions they had to make While this might be unreachable in the current condition, to understand the impact of the one-way tough decisions made by the physicians should be the subject of further research.

The dispute here is whether DNR codes, especially the unilateral DNR code, and resuscitation guidelines respect the four core medical ethics principles: autonomy, beneficence, non-maleficence, and justice 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.

An informed consent form signed by the patient or a surrogate might, however, falsely re-assure the HCPs of the patient's understanding and thus volunteerism and autonomy Also, making decisions on behalf of a competent patient exemplifies a paternalistic and professional nihilism that contradicts autonomy Additionally, weighing the risk-to-benefit ratio and prioritizing societal over individual benefit is another issue when considering DNR, especially amid the COVID pandemic.

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 Moreover, due to prolonged exposure, close contact, and lack of PPE, healthcare workers are at a significantly increased risk of acquiring infection 50 , and should be prioritized when providing critical care when it comes to advanced life support.

What medical and ethical decision should be made when all patients are equal in need and predicted outcome, but the resources are barely enough? Patients' characteristics were suggested to be entered into the system and a supervised random selection process should then take place to ensure fair and equity of distribution This could also apply to patients who are predicted to need CPR.

In healthcare, beneficence encompasses the idea that a physician's actions, decisions, and skills must always advocate for what is best for the patient. In this instance, CPR is advised to be performed on patients if apparent benefit was the expected result. However, some argue that CPR should not be performed if it is not expected to result in benefit to patients, or if it may prolong their suffering, and the physicians should accordingly write a unilateral DNR order The ethical and medical decision depends upon weighing therapeutic benefits against risks.

In a more conscious evaluation of the objective indications of DNR, Lipsky identified four core elements that can be assessed when deciding on DNR; futility of treatment, poor quality of life, patient refusal, and cost If these same elements are applied into the current condition, where societal benefit prevails over self-benefit, it would be logical to consider any of the aforementioned four elements as a justification for the universal or unilateral DNR code adopted by the health sector in some nations.

Along the same lines, Edwards B. Calls for a just allocation for the use of the already limited resources are in place despite potential adverse effects on patient's autonomy and beneficence. Additionally, an important argument would be that an early DNR code would save the patient and family futile interventions Triaging patients can be a multi-step and dynamic process that consists of three steps including 1 the application of exclusion criteria, 2 using the Sequential Organ Failure Assessment SOFA score to determine priority, and 3 repeated assessments to determine the futility of on-going ventilation We would suggest a fourth point for engaging and communicating with family members when possible Figure 1.

Curtis et al. Since not one single ethical consideration might be able to address how to allocate scarce resources, a multi-value ethical framework, where more than one factor is considered, might seem more ethical Maximizing benefits, i. Additional factors that we suggest based on this literature review to help align scarce resources include behavioral status; priority to those who did not engage in risky behaviors that caused their condition or affected it negatively, and reciprocity; priority to those who have voluntarily provided societal services in the past Figure 2.

Deployment of the medical workforce in areas in most need is an effective modality to support healthcare systems. This has been an effective strategy in Wuhan, China, where attempts to contain the spread of the pandemic was a wise decision In the US, due to the likelihood of a shortage of HCPs, many retired physicians and medical students volunteered to aid in the crisis.

Medical students have also aided, taking basic histories over phone calls and babysitting for HCPs overwhelmed in hospitals and other facilities. In Jordan, medical students were heavily engaged with surveillance activity for potentially infected persons, as well as volunteering to deliver prescribed drugs to patients personal communications.

The psychological impact on HCPs is of paramount importance 57 , and should be accounted for when nationwide decisions are put in place In addition, DNR needs to be disclosed by the more experienced members in the caring team KHCC has adopted a similar approach, where the decision on unilateral DNR has to be made by a committee composed of the primary physician and two other physicians for terminally ill patients if a shortage in ventilators occurs in the future in Jordan An often overlooked facet is the role religious scholars can play when a DNR order is made.

Religious scholars for different theistic groups should be made part of the clinical ethics committees in the hospitals, and in the case of the COVID pandemic, national committees that address the DNR issue in acutely diseased and admitted infected patients The presence of ethics-trained religious scholars can be of utmost importance especially when confronting national crises to ensure patient dignity, coping strategies for the family, and relief of the HCPs, with an ultimate goal to support family members as well as HCPs.

Eiott and Olver [ 14 ] believed that decision about DNR is equivalent to a choice between life and death. In contrast to this common practice, Welie and Have [ 15 ] argued that in most instances, the morally safer route is the DNR.

Such intervention is ethically justified only if both of the following necessary conditions have been met: the treatment must be medically futile and there must be consent to the DNR. An individual with a terminal, irreversible illness, where death is the expected outcome does not necessarily deserve CPR. Originally, it was referred to the medical system [ 16 ].

The American Nurse Association [ 17 ] and American Society of Anaesthesiologists [ 18 ] had a consensus about support the patients' rights to self-determination. This right includes that by law the competent patients can refuse life-saving procedures as long as they fully understand the implications of their decision and allow natural death without CPR efforts.

Finally, they conclude that the health care providers who attempt to resuscitate patients against their wishes they violate the patients legal right to self-determination. Downar [ 3 ] illustrated that DNR orders are legally acceptable, and should not be confused with euthanasia or assisted suicide. Welie and Have [ 14 ] stated that providing a treatment that is likely to be futile violates the bioethical principle of non mal-efficiency and may legally constitute battery if the foreseen harm actually occurs.

Ethical aspects: Aacharya [ 19 ] believed that end of life decisions by DNR are difficult emergency decisions, but ethical approach simplifies the complexities and facilitates shared decision making process. The CPR guidelines should not just be based on technical and legal issues but also need to encompass the ethical principles.

So that, due considerations are incorporated to respect the patients autonomy, without harm and additional sufferings and justifiable equal opportunities in a given context of the society.

Kasule [ 20 ] wrote that DNR order is permissible in Islam in cases of a high degree of certainty that resuscitation is futile and will not result in net and lasting benefit to the patient. In some cases, the decision not to attempt CPR is a clear clinical medical decision.

If the medical team believes that CPR will be failed, it should not be started. Decisional authority to use or withhold CPR must reside in providers who can use their training, skills and knowledge to provide the best available care [ 2 ]. Irrespective of international variation in decision-making, the DNR decisions form part of an essential framework to uninterrupted the dignified death by a futile resuscitation attempt [ 9 ]. In Judaism patients who are terminally ill may be withhold or refused the CPR.

Because it may prolonging the dying process and may increase suffering and pain for Jewish patients. Halachic authorities recommend a family to consult with their rabbi in situations involving the consideration of a DNR order [ 17 ]. In Catholic patients who are terminally ill permitted to withhold or refuse life-sustaining treatment like CPR if its judged to be extraordinary by the patient and family, and should always be respected and complied with that decision, unless it is contrary to Catholic moral teaching [ 21 ].

Finally, the DNR decision is a sophisticated bioethical discussion, although, the DNR orders have a wide cultural differences in their implementation. Taking in consideration according to King Hussein Cancer Center statistic that caring cancer patients on mechanical ventilator whose medically futile cost the center about JD daily, so many organization start to talk about DNR and introduce it to community to be familiar with this term and to differentiate between DNR and assist suicide.

The purpose of this literature review was to summarize the different ethical and legal aspects regarding the DNR code status which developed along the time according to different cultures including values, beliefs, and religious background. In this paper the researcher illustrated his agreement position from the DNR order supported by ethical and legal aspects. The current researcher is with DNR code status because some people at the end of life continuing of suffer may appear worse than death.

Watching a dying patient suffers can be nearly intolerable for loved ones. The DNR order does not mean patient will die alone and uncared, it means patient will be placed under hospice care when the end is near, and will not die with a tube in any site of body. The CPR might also seem to lack benefit when the patient's quality of life is so poor that no meaningful survival is expected even if CPR were successful at restoring circulatory stability.

To that end, the current researcher strives to assist the individual in taking decision in terminally ill and hopeless cases to use the DNR order. The DNR still consider a difficult and extraneous concept, in spite of health care providers' efforts to help patients and families to make informed choices.

The life of human being in Islam is sacred and wealthy and nobody on earth can end it, so; there is a value and great respect to human life and the exciting civil forbids euthanasia or assisted suicide, in regards to other issues like brain death and DNR, the verdicts of the Islamic been facilitating easy courses medical futility prescribed by specialist doctors.

So, the DNR order is permissible in cases of a high degree of certainty that resuscitation is not feasible and will not lead to a net and lasting benefit to the patients permanently. Focusing on survival after CPR among patients with cancer according to Ehlenbach et al. Accordingly, the current researcher with DNR order because the patients' chances of surviving until discharge could not be improved by CPR.

Although, there are many risks involved in performing CPR, including the decrease level of consciousness and chronic coma which sometimes is worse than death, or survival after CPR then death occurring after a long time stay in the intensive care unit.

For that choice is clear between deaths on the oncology ward, surrounded by loved family members, nurses and doctors who knew the patient or death in the intensive care unit after multiple attempt of invasive, painful, and dehumanizing procedures but if the patient's heart stopped to work, the family heart will stop at the same. In order to protect the autonomy right of the patient to make health care decisions, certain measures need to be taken to ensure that the potential harm to patients is minimized, in addition legislate law to protect DNR policy and procedure is essential, also, the ethics committee needs to be involved more in such situations.

The current researcher articulates the following fundamental principles to guide action on the DNR issue:. Discussion DNR with patients and family might be taken in consider for the following patients: whom CPR may not provide benefits to enhance quality of life and terminal, irreversible illness where death is expected.

One model of ethical competence for healthcare staff includes three main aspects: being, doing and knowing, suggesting that ethical competence requires abilities of character, action and knowledge.

Ethical competence can be developed through experience, communication and education, and a supportive environment is necessary for maintaining a high ethical competence. The aim of the present study was to investigate how nurses and physicians in oncology and hematology care understand the concept of ethical competence in order to make, or be involved in, DNR decisions and how such skills can be learned and developed.

A further aim was to investigate the role of guidelines in relation to the development of ethical competence in DNR decisions.

Individual interviews were conducted with fifteen nurses and sixteen physicians. The interviews were analyzed using thematic content analysis. Physicians and nurses in the study reflected on their ethical competence in relation to DNR decisions, on what it should comprise and how it could be developed.

The ethical competence described by the respondents related to the concepts being, doing and knowing. In order to make ethically sound DNR decisions in oncology and hematology care, physicians and nurses need to develop appropriate virtues, improve their knowledge of ethical theories and relevant clinical guidelines. Ethical competence also includes the ability to act upon ethical judgements. Continued ethical education and discussions for further development of a common ethical language and a good ethical working climate can improve ethical competence and help nurses and physicians cooperate better with regard to patients in relation to DNR decisions, in their efforts to act in the best interest of the patient.

Peer Review reports. In almost every kind of care, patients can sometimes be considered to have such a poor prognosis that they would not survive cardiopulmonary resuscitation CPR for cardiac arrest, or would survive with poor function and quality of life.

A do-not-resuscitate DNR order can then be made by the responsible physician. The meaning of DNR is that neither basic heart compressions and ventilation nor advanced defibrillator or medicines CPR should be performed. In oncology and hematology care, decisions on DNR are made regularly, but the context of these decisions can differ between the specialties. In oncology, a patient with metastases can be incurable, but still have a long time left to live with a good quality of life, and in these cases the palliative phase can thus be quite long.

In hematology, on the other hand, a patient can be severely and life-threateningly ill due to treatment, but remain in the curable phase until all available treatments have been given. In those cases the palliative phase can be short, sometimes only a few days.

Due to the severity, and often also stigmatization, of a cancer diagnosis, and the occasionally long curative treatment periods, patients and their families might be vulnerable in these situations. This imposes major ethical demands on making decisions regarding DNR, and the information given must be clear and adapted to the situation at hand.

Our previous research has revealed ethical dilemmas, which physicians and nurses may face in relation to DNR decisions in oncology and hematology care [ 2 ]. Ethical dilemmas are situations in which a person must choose between actions that are apprehended as equally correct ethically.

The choice renders one action deselected, and it is therefore impossible to perform all ethically important actions [ 3 , 4 , 5 ]. When ethical dilemmas occur, different values, norms or interests must be weighed against each other. Different models have been developed for such moral judgements and there are well-established examples of theories that judge ethical dilemmas based on consequences e. These traditions are mirrored in the four well-known ethical principles of autonomy, non-maleficence, beneficence and justice [ 7 ].

The principles of autonomy and justice are derived from deontological reasoning, meaning that we have a duty to respect human dignity in every person and treat everyone as equals, regardless of consequences. The principles of non-maleficence and beneficence are utilitarian in character, as they prescribe maximizing the well-being of others by promoting good consequences and limiting harm.

Apart from utilitarianism and deontology the ethics of virtue is another well-established theory in medical ethics. Here, the character of the agent is at the fore. As ethics is considered a basic competence in health care, ethics is part of the curriculum in the training for both nurses and physicians in Swedish education system.

Since training for physicians is longer than for nurses, the amount of ethics education is a bit larger for physicians than for nurses. Further, ethical guidelines have been developed for different staff categories, e. But ethical guidelines have also been developed in relation to certain diagnoses or decisions, for example DNR. These guidelines state, among other things, that there is no ethical difference between refraining from CPR and starting CPR and then withholding it. As guidelines, they are advisory, unlike laws, which are compulsory.

It is reasonable to argue that since ethical dilemmas do occur in relation to DNR decisions in oncology and hematology care, staff involved in these decisions need adequate competence to handle these dilemmas. In the literature, such competence is often referred to as ethical competence.

In short, ethical competence can be defined as a capacity to handle a task that involves an ethical dilemma in an adequate, ethically responsible manner [ 15 ]. The Commission stresses that such competence is essential for the development of responsibility and autonomy in an individual. Ethical competence has been studied in settings other than health care, for example in research with possible dual use [ 17 ] and in management [ 15 ].

In health care the concept has been defined in many ways, and as Kulju et al. In the review of Lechasseur et al. A slightly different approach is suggested by Eriksson et al.

Their model of ethical competence for healthcare staff includes three main aspects: being, doing and knowing. In short, this means that ethical competence requires abilities of character, action and knowledge. The ethics of doing, on the other hand, are concerned with how we should act in ethically challenging situations. Models of weighing consequences or following duties, as for example in utilitarianism and deontology, are typical examples of such an ethics of doing , since they are primarily concerned with how to act.

However, Eriksson et al. A communicative model is suggested in which the work organization should provide opportunities for regular ethical discussions in which all aspects of ethical competence can be alerted.

In this article, the model suggested by Eriksson et al. Kulju et al. Furthermore, they emphasize the importance of a supportive environment and organization. Research has also suggested that in order to develop and maintain a high level of ethical competence in health care, ethical deliberation, in the form of regular ethical discussion forums, is required [ 22 ].

In sum, one can state that decisions on DNR are frequently made in oncology and hematology care and that ethical dilemmas are likely to arise in relation to these decisions. The study was conducted in hematology and oncology departments in central Sweden.

Fifteen nurses from four hospitals and sixteen physicians from seven hospitals participated. Nursing unit managers and heads of the departments introduced the study to eligible nurses and physicians and asked for interest in participation. The first author contacted some of the suggested participants and was contacted by some. All individuals with whom initial contact was taken were included in the study, except one nurse, who was then replaced by another nurse from the same department.

After receiving written and oral information, all respondents agreed to participation by signing an informed consent form. Characteristics of the participants are presented in Table 1. Portions of the data, collected through interviews, have been published previously [ 2 ]. While those studies focused on the clinical parts of perceptions on and experiences with DNR decisions, the data on ethical competence and guidelines were saved to be presented separately. Hence, the main topics of the interviews that are presented in this paper are: Knowledge of guidelines, Content of guidelines, Understanding of ethical competence, and Need for ethical competence in DNR decisions.

Some nurses mentioned the development of ethical competence during their interviews. Thus, the topic Development of ethical competence was added to the interviews with the physicians. All interviews were performed by the first author and lasted between 23 and 67 min. The interviews were recorded and transcribed verbatim.

The transcribed interviews were analyzed using thematic content analysis [ 23 ]. The process was initially done by the first author, who read the transcripts and made notes in the margins as a first open coding.

In the second stage, all margin notes were listed. The list was examined for overlaps and similarities, and used for sorting the meaning units under appropriate codes, creating subcategories which were grouped together in categories and a theme Table 2. The co-authors listened to random selections of recordings, read selections of transcripts and participated in the analysis process, including creating categories.

The final version of the analysis was approved in consensus with all authors. The research followed international guidelines for empirical research, as outlined in the Helsinki Declaration [ 24 ], and national regulations and guidelines [ 25 , 26 ]. According to Swedish legislation [ 26 ], no approval from the Regional Ethical Review Board was needed for the study. Permission for the interviews for each study was given by the head of the departments.

Each participant received written and verbal information before signing the informed consent form, including information on voluntary participation, on the fact that the data would be kept confidential, and that they could terminate their participation at any time. In order to enhance dependability, the interview guide for each group of respondents was the same. One researcher performed all interviews with both groups [ 27 ].

Since the participants had no difficulty understanding and answering the questions during the interviews, credibility was strengthened [ 28 ]. As a nurse who has worked in the same specialty as the respondents, the interviewer was aware that her pre-understanding could be a bias.

This awareness enhanced confirmability [ 28 ]. The credibility was further strengthened by the fact that all co-authors cooperated on the analysis process, through identifying and formulating the theme, categories and subcategories.

The analysis resulted in an overall theme, related to the aim and the interview questions: Ethical competence in relation to DNR decisions. Under this theme, several subcategories were grouped together into three categories: Understandings of ethical competence, Learning and developing ethical competence, and The role of guidelines.

Theme, categories and subcategories are presented in Fig. In the following sections, each category is illustrated by quotes. The sign [ Applying knowledge describes the importance of formal medical knowledge related to the context, as well as ethical competence comprising the ability to apply ethical models, to weigh ethical values against each other and to be aware of different perspectives in a situation.

Several respondents emphasized that ethical competence was always necessary in their work, not only in DNR or other decisions concerning prolonging life or not.

However, several physicians expressed that medical knowledge was a prerequisite for ethical competence regarding DNR decisions. All respondents, both nurses and physicians, mentioned several aspects of ethical competence which they regarded as necessary for making or participating in DNR decisions.

You have to be interested in the person you have in front of you and understand that person. And you need to have medical skills, to know That is also a kind of ethics.

The respondents also mentioned the importance of knowledge about ethics and the ability to identify value conflicts as a part of ethical competence. Some of the ethical values the respondents mentioned were primarily directed at the patient, such as providing the best possible care to the right patient; seeing and understanding the person as well as the patient; and respecting patient integrity. They also mentioned the importance of seeing patients as the different individuals they are.

There can be two people who look the same and have the same diagnosis, but it can still be different in so many ways. In one case it might be ethically right to do this and in another case it can be ethically right to do that, because people are different. Other aspects mentioned as components of ethical competence were knowledge of ethical theories and principles, such as utilitarianism and the principle of human dignity.

It would be good for one person, but not for others. So, which principle are we to support? They are all pretty good, because You might have prejudices and so on But if you think ethically … I believe you can reason in another way. Some respondents described ethical competence as the ability to weigh ethical values against each other, e. Can this cause harm, or can this be beneficial? And how great is the harm and how great are the benefits?

Am I causing suffering now? Things like that. Ethical competence was also expressed as perceiving where in the process the patient and family members were, and being able to meet them on their different levels. Both physicians and nurses mentioned the value of listening and being able to respect different opinions and interests. Also, how they perceive the situation in end of life, both patients and family members.

In addition to referring to ethical competence as knowledge of ethics, the respondents also referred to ethical competence as characteristics in the individual caregiver. In line with the theoretical perspective described above, this could be described as a form of virtue ethics.

The respondents expressed how virtues could make the caregiver a better person and also a better physician or nurse. The virtues were described as character traits, such as empathy, respect, compassion, openness, courage and humbleness. Some physicians expressed humbleness with regard to being the one who made the decision. And knowledge. To see the person as well as the patient.