Decisions regarding resuscitation and do not attempt resuscitation (DNAR): nurses' and junior doctors' perspectives

Abstract

Cardiopulmonary resuscitation (CPR) has been an accepted part of emergency medicine since the middle of the 20th century but its success rate for in-hospital cardiac arrest in terms of survival to discharge from hospital remains at 10 - 15% (Bedell, Delbanco, Cook & Epstein, 1983; Ballew, 1997; Ebell, Becker, Barry & Hagan, 1998; Tunstall-Pedoe, Bailey, Chamberlain, Marsden, Ward & Ziderman, 1992). In recognition that most people will not benefit from this potentially life-saving procedure, 'do not attempt resuscitation' (DNAR) orders have been developed. However, published research shows that there are many difficulties associated with these orders for the patient, family and health care team involved (Bedell, Pelle, Maher & Cleary, 1986; Taylor, Parker, Ramsay & Peart, 1996). The aim of this qualitative study was to explore decision making around both resuscitation and DNAR orders from the perspective of nurses and junior doctors. This is the group of health care professionals most likely to be 'on the spot' in the event of a cardiac arrest and are therefore the group most likely to have to make a decision when there is lack of clarity or doubt surrounding the patient's resuscitation status. Four nurses and two house surgeons working within a regional hospital in New Zealand were interviewed. Scenarios were utilised to explore what this group of staff would do and why, if forced into making a decision when the patient's resuscitation status is unclear. Through the process of thematic content analysis some key themes emerged. These themes were divided into two sections. The first focussed on the shared views of doctors and nurses in regards to resuscitation and decision making including making decisions in times of pressure and how good decision making is achieved. The second section focused on the perspectives the nurses and doctors had not only on their own roles and responsibilities but also on each other's in the decision making process. This thesis concludes with recommendations for on-going research, for improving decision making and for improved preparation of the public as well as health care professionals in order to deal with these difficult decisions.