Perception of "No Code" and the Role of the Nurse

Do not resuscitate: an ethical dilemma for the decision-maker

Since its introduction in the 1960s, cardiopulmonary resuscitation (CPR) has been universally available to all hospital patients unless the consultant in charge has specified a 'do not resuscitate' (DNR) order. The public perception of CPR has tended to be one of overoptimism, but this is not matched by the low survival to discharge ratio of approximately 1:10. In addition, there is the risk of prolonging suffering, compared with the quick and relatively painfree alternative offered by cardiac arrest. Decisions about resuscitation pose many ethical dilemmas for those involved and should take into consideration the patient's wishes, prognosis and quality of life.

Ethical decision-making by staff nurses

Ethical decision-making is inherent in nursing practice. Although a definite portion of the nursing literature is devoted to ethics and ethical decision-making, the profession is just beginning to ground its ethics research in the actual experience of nurses. Therefore, the purpose of this phenomenological study was to examine the experience of staff nurses as they engage in ethical decision-making. Interview data were collected from 19 staff nurses in a large, midwestern American metropolitan hospital. Interviews were subsequently transcribed and Giorgi's method of data analysis applied. The emerging description revealed four common aspects of ethical decision-making among staff nurses: context, trigger, ethical decision-making process (i.e. deliberation and integration), and outcomes. This description provides a foundation for future research regarding a descriptive theory of ethical decision-making in nursing.

Critical care nurses' perceptions of appropriate care of the patient with orders not to resuscitate

OBJECTIVE

To determine critical care nurses' perceptions of appropriate care of patients with and without do-not-resuscitate (DNR) orders.

DESIGN

Descriptive, cross-sectional.

SETTING

Large, northeastern, metropolitan teaching hospital.

SAMPLE

Eighty-seven staff nurses divided into DNR and non-DNR groups whose demographic characteristics were coincidentally similar.

MEASURE

Responses to an original questionnaire. Questionnaires describing one of two hypothetical patients (DNR or non-DNR) were distributed to all available staff nurses working in adult intensive care units.

RESULTS

After construct validity and internal consistency reliability were established (Cronbach's coefficient alpha = 0.84 for the physical subscale, 0.79 for the psychosocial), analysis of variance was used in the data analysis. Mean total scores were 60.7 for the DNR group and 69.6 for the non-DNR group (p = 0.0031). Mean scores on the physical subscale were 33.6 and 41.9 for the DNR and the non-DNR groups, respectively (p = 0.0032). Results on the psychosocial subscale showed no significant differences between the groups. Item analysis showed significant differences on weighing the patient (p = 0.0002), monitoring neurologic status (p = 0.0082), drawing blood cultures (p = 0.0094), checking vital signs (p = 0.0071), performing complete nursing assessments (p = 0.0179), and treating the patient in an intensive care unit (p = 0.0001).

CONCLUSIONS

Compared with the patient without a DNR order, significantly lower levels of agreement were expressed with interventions involving monitoring for the patient with the DNR order. Agreement with placement of the patient with the DNR order in an intensive care unit may be seen to follow the same pattern. Education of caregivers and communication among them might help to clarify what may be ambiguous policies and orders.

Ethical dilemmas in the delivery of intensive care to critically ill oncology patients

Caring for the critically ill oncology patient presents ethical dilemmas with which the critical care oncology nurse may need assistance. Understanding how values can be in conflict encourages exploration of alternatives. As health care professionals, one of our missions is to learn to make decisions using current knowledge about clinical problems and expected outcomes, value systems that affect our decisions, and systematic approaches to problem solving. Our challenge is well-defined.