Literature review: decision-making regarding slow resuscitation

[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.

Perceptions of slow codes by nurses working on internal medicine wards

Background:

Cardio-pulmonary resuscitation is the default procedure during cardio-pulmonary arrest. If a patient does not want cardio-pulmonary resuscitation, then a do not attempt resuscitation order must be documented. Often, this order is not given; even if thought to be appropriate. This situation can lead to a slow code, defined as an ineffective resuscitation, where all resuscitation procedures are not performed or done slowly.

Research objectives:

To describe the perceptions of nurses working on internal medicine wards of slow codes, including the factors associated with its implementation.

Research design:

This was a cross-sectional, descriptive study. Participants completed a personal characteristics questionnaire and the Perceptions and Factors of Slow Codes questionnaire designed for this study.

Participants and research context:

The sample was a convenience sample of nurses working on internal medicine wards in two Israeli hospitals.

Ethical considerations:

The study received ethical approval from both institutions, where data were collected and stored according to institutional policy.

Findings:

Most reported that resuscitations were conducted according to protocol (n = 90, 76.2%). Some took their time calling the code (n = 22, 18.3%), or waited by the bedside and did not perform cardio-pulmonary resuscitation (n = 45, 37.5%). Factors most associated with slow codes were poor patient prognosis (mean = 3.52/5, standard deviation = 1.27) and a low chance of patient survival (mean = 3.37/5, standard deviation = 1.21). Two-thirds (n = 76, 66.8%) reported that slow codes were done on their unit and the majority (n = 80, 69%) perceived slow codes as ethical.

Discussion:

This study confirms that slow codes are part of medical care on internal medicine wards, where most nurses perceive them as an ethical alternative. These perceptions are in contrast to most legal and ethical opinions expressed in the literature.

Conclusion:

Nurses should be educated about the legal and ethical implications of slow codes, and qualitative and quantitative studies should be conducted that further investigate its implementation.

The family surrogates' psychological experience of making a do-not-resuscitate decision for older relatives: a qualitative study

BACKGROUND

Many nursing home residents lack autonomous decision-making capacity and rely on family members to make do-not-resuscitate (DNR) decisions. Making DNR decisions can be difficult and complicated for surrogates. However, surrogates' psychological experience in making these decisions for older relatives is not well studied.

AIM

To understand the surrogates' psychological experience of making DNR decisions for older relatives in a nursing home.

METHODS

The study subjects of this qualitative study were family surrogates of older residents in a nursing home of Taiwan. A self-constructed, semi-structured interview guided in-depth interviews, which were recorded. Content analysis was used to discover themes from verbatim record.

RESULTS

Four themes were revealed: lack of psychological preparation, considering issues when making a decision, ambivalent emotional responses and impact of cultural factors. Fifteen subthemes were also found.

CONCLUSIONS

Surrogates who must decide whether to make a DNR decision for older relatives experience great emotional conflict. Understanding surrogates' struggles may assist nursing and care staff in managing this difficult situation.