How long is long enough, and have we done everything we should?--Ethics of calling codes

Nurses' experiences of ethical and legal issues in post-resuscitation care: A qualitative content analysis

BACKGROUND

Cardiopulmonary resuscitation and subsequent care are subject to various ethical and legal issues. Few studies have addressed ethical and legal issues in post-resuscitation care.

OBJECTIVE

To explore nurses' experiences of ethical and legal issues in post-resuscitation care.

RESEARCH DESIGN

This qualitative study adopted an exploratory descriptive qualitative design using conventional content analysis.

PARTICIPANTS AND RESEARCH CONTEXT

In-depth, semi-structured interviews were conducted in three educational hospital centers in northwestern Iran. Using purposive sampling, 17 nurses participated. Data were analyzed by conventional content analysis.

ETHICAL CONSIDERATIONS

The study was approved by Research Ethics Committees at Tabriz University of Medical Sciences. Participation was voluntary and written informed consent was obtained. For each interview, the ethical principles including data confidentiality and social distance were respected.

FINDINGS

Five main categories emerged: Pressure to provide unprincipled care, unprofessional interactions, ignoring the patient, falsifying documents, and specific ethical challenges. Pressures in the post-resuscitation period can cause nurses to provide care that is not consistent with guidelines, and to avoid communicating with physicians, patients and their families. Patients can also be labeled negatively, with early judgments made about their condition. Medical records can be written in a way to indicate that all necessary care has been provided. Disclosure, withdrawing, and withholding of therapy were also specific important ethical challenges in the field of post-resuscitation care.

CONCLUSION

There are many ethical and legal issues in post-resuscitation care. Developing evidence-based guidelines and training staff to provide ethical care can help to reduce these challenges.

[Ethics of resuscitation and end of life decisions]

These European Resuscitation Council Ethics guidelines provide evidence-based recommendations for the ethical, routine practice of resuscitation and end-of-life care of adults and children. The guideline primarily focus on major ethical practice interventions (i.e. advance directives, advance care planning, and shared decision making), decision making regarding resuscitation, education, and research. These areas are tightly related to the application of the principles of bioethics in the practice of resuscitation and end-of-life care.

Nurses' Participation in Limited Resuscitation: Gray Areas in End of Life Decision-Making

Historically nurses have lacked significant input in end-of-life decision-making, despite being an integral part of care. Nurses experience negative feelings and moral conflict when forced to aggressively deliver care to patients at the EOL. As a result, nurses participate in slow codes, described as a limited resuscitation effort with no intended benefit of patient survival. The purpose of this study was to explore and understand the process nurses followed when making decisions about participation in limited resuscitation. Five core categories emerged that describe this theory: (1) recognition of patient and family values at the EOL; (2) stretching time and reluctance in decision-making; (3) harm and suffering caused by the physical components of CPR; (4) nurse's emotional and moral response to delivering aggressive care, and; (5) choosing limited resuscitation with or without a physician order. Several factors in end-of-life disputes contribute to negative feelings and moral distress driving some nurses to perform slow codes in order to preserve their own moral conflict, while other nurses refrain unless specifically ordered by physicians to provide limited care through tailored orders.

European Resuscitation Council Guidelines 2021: Ethics of resuscitation and end of life decisions

These European Resuscitation Council Ethics guidelines provide evidence-based recommendations for the ethical, routine practice of resuscitation and end-of-life care of adults and children. The guideline primarily focus on major ethical practice interventions (i.e. advance directives, advance care planning, and shared decision making), decision making regarding resuscitation, education, and research. These areas are tightly related to the application of the principles of bioethics in the practice of resuscitation and end-of-life care.

Usage of do-not-attempt-to-resuscitate orders in a Swedish community hospital - patient involvement, documentation and compliance

Background

To characterize patients dying in a community hospital with or without attempting cardiopulmonary resuscitation (CPR) and to describe patient involvement in, documentation of, and compliance with decisions on resuscitation (Do-not-attempt-to-resuscitate orders; DNAR).

Methods

All patients who died in Kalmar County Hospital during January 1, 2016 until December 31, 2016 were included. All information from the patients’ electronic chart was analysed.

Results

Of 660 patients (mean age 77.7 ± 12.1 years; range 21–101; median 79; 321 (48.6%) female), 30 (4.5%) were pronounced dead in the emergency department after out-of-hospital CPR. Of the remaining 630 patients a DNAR order had been documented in 558 patients (88.6%). Seventy had no DNAR order and 2 an explicit order to do CPR. In 43 of these 70 patients CPR was unsuccessfully attempted while the remaining 27 patients died without attempting CPR. In 2 of 558 (0.36%) patients CPR was attempted despite a DNAR order in place. In 412 patients (73.8%) the DNAR order had not been discussed with neither patient nor family/friends. Moreover, in 75 cases (13.4%) neither patient nor family/friends were even informed about the decision on code status.

Conclusions

In general, a large percentage of patients in our study had a DNAR order in place (88.6%). However, 27 patients (4.3%) died without CPR attempt or DNAR order. DNAR orders had not been discussed with the patient/surrogate in almost three fourths of the patients. Further work has to be done to elucidate the barriers to discussions of CPR decisions with the patient.

Factors influencing termination of resuscitation in children: a qualitative analysis

BACKGROUND

Pediatric Advanced Life Support provides guidelines for resuscitating children in cardiopulmonary arrest. However, the role physicians' attitudes and beliefs play in decision-making when terminating resuscitation has not been fully investigated. This study aims to identify and explore the vital "non-medical" considerations surrounding the decision to terminate efforts by U.S.-based Pediatric Emergency Medicine (PEM) physicians.

METHODS

A phenomenological qualitative study was conducted using PEM physician experiences in terminating resuscitation within a large freestanding children's hospital. Semi-structured interviews were conducted with 17 physicians, sampled purposively for their relevant content experience, and continued until the point of content saturation. Resulting data were coded using conventional content analysis by 2 coders; intercoder reliability was calculated as κ of 0.91. Coding disagreements were resolved through consultation with other authors.

RESULTS

Coding yielded 5 broad categories of "non-medical" factors that influenced physicians' decision to terminate resuscitation: legal and financial, parent-related, patient-related, physician-related, and resuscitation. When relevant, each factor was assigned a directionality tag indicating whether the factor influenced physicians to terminate a resuscitation, prolong a resuscitation, or not consider resuscitation. Seventy-eight unique factors were identified, 49 of which were defined by the research team as notable due to the frequency of their mention or novelty of concept.

CONCLUSION

Physicians consider numerous "non-medical" factors when terminating pediatric resuscitative efforts. Factors are tied largely to individual beliefs, attitudes, and values, and likely contribute to variability in practice. An increased understanding of the uncertainty that exists around termination of resuscitation may help physicians in objective clinical decision-making in similar situations.

Is There Ever a Role for the Unilateral Do Not Attempt Resuscitation Order in Pediatric Care?

Care for children as they near the end of life is difficult and very complex. More difficult still are the decisions regarding what interventions are and are not indicated during these trying times. Occasionally, families of children who are nearing the end of life disagree with the assessment of the medical team regarding these interventions. In rare cases, the medical team can be moved to enact a do not attempt resuscitation order against the wishes of the patient's parents. This article presents one such illustrative case and discusses the ethical issues relevant to such challenging clinical scenarios. The authors posit that such a unilateral do not attempt resuscitation order is only appropriate in very limited circumstances in pediatric care. Instead, focus should be placed on open discussion between parents and members of the clinical team, shared decision making, and maintenance of the clinician-parent relationship while simultaneously supporting members of the clinical team who express discomfort with parental decisions. The authors propose an alternative framework for approaching such a conflict based on clinician-parent collaboration and open communication.

An Ethical Justification for Termination of Resuscitation Protocols for Pediatric Patients

OBJECTIVE

The aim of this article was to compare specific characteristics and outcomes among adult and pediatric out-of-hospital cardiac arrest (OHCA) patients to show that the existing literature warrants the design and implementation of pediatric studies that would specifically evaluate termination of resuscitation protocols. We also address the emotional and practical concerns associated with ceasing resuscitation efforts on scene when treating pediatric patients.

METHODS

Relevant prospective and retrospective studies were used to compare characteristics and outcomes between adult and pediatric OHCA patients. Characteristics analyzed were nonwitnessed arrests, absence of shockable rhythm, no return of spontaneous circulation, and survival to hospital discharge.

RESULTS

Cases of unwitnessed arrests by emergency medical services providers are substantially the same in pediatric patients (41.0%-96.3%) compared with their adult counterparts (47.4%-97.7%). The adult studies revealed 57.6% to 92.2% of patients without an initial shockable rhythm. The pediatric studies showed a range of 64.0% to 98.0%. The range of adult patients without return of spontaneous circulation was 54.8% to 95.4%, and the range in pediatric patients was 68.2% to 95.6%. Survival rates among the adult studies ranged from 0.8% to 9.3% (mean, 5.0%; median, 5.2%), and in the pediatric studies they were 2.0% to 26.2% (mean, 9.2%; median, 7.7%).

CONCLUSIONS

The data compared demonstrate that characteristics and outcomes are virtually identical between adult and pediatric OHCA patients. We also found the 3 chief barriers hindering further research to be invalid impediments to moving forward. This review warrants designing pediatric studies that would specifically correlate termination of resuscitation protocols with patient survival and include predictive values.

When Terminal Illness Is Worse Than Death: A Multicenter Study of Health-Care Providers' Resuscitation Desires

PURPOSE

To investigate how a terminal illness may affect the health-care providers' resuscitation preferences.

METHODS

We conducted a cross-sectional survey in 9 health-care institutions located in 4 geographical regions in North and Central America, investigating attitudes toward end-of-life practices in health-care providers. Statistical analysis included descriptive statistics and χ² test for the presence of associations ( P < 0.05 being significant) and Cramer V for the strength of the association. The main outcome measured the correlation between the respondents' present code status and their preference for cardiopulmonary resuscitation (CPR) in case of terminal illness.

RESULTS

A total of 852 surveys were completed. Among the respondents, 21% (n = 180) were physicians, 36.9% (n = 317) were nurses, 10.5% (n = 90) were medical students, and 265 participants were other staff members of the institutions. Most respondents (58.3%; n = 500) desired "definitely full code" (physicians 73.2%; n = 131), only 13.8% of the respondents (physicians 8.33%; n = 15) desired "definitely no code" or "partial support," and 20.9% of the respondents (n = 179; among physicians 18.4%; n = 33) had never considered their code status. There was an association between current code status and resuscitation preference in case of terminal illness ( P < .001), but this association was overall quite weak (Cramer V = 0.180). Subgroup analysis revealed no association between current code status and terminal illness code preference among physicians ( P = .290) and nurses ( P = .316), whereupon other hospital workers were more consistent ( P < .01, Cramer V = .291).

CONCLUSION

Doctors and nurses have different end-of-life preferences than other hospital workers. Their desire to undergo CPR may change when facing a terminal illness.