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Multicenter Study
. 2025 May 20;26(1):65.
doi: 10.1186/s12910-025-01224-2.

Ethics, orthodoxies and defensive practice: a cross-sectional survey of nurse's decision-making surrounding CPR in deceased inpatients without Do Not Resuscitate orders

Gemma McErlean  1   2 , Suzanne Bowdler  3 , Joanne Cordina  3 , Heidi Hui  4 , Edwina Light  5   6 , Wendy Lipworth  7 , Susan Maitland  8 , Eamon Merrick  9   10 , Amy Montgomery  3 , Anne Preisz  11   12 , Linda Sheahan  5   6 , Suzanne Sheppard-Law  9   13 , George Skowronski  4   5 , Cameron Stewart  5 , Judeil Krlan Teus  4 , Michael Watts  14 , Sahn Zanotti  13 , Ian Kerridge  5   10
Affiliations
Multicenter Study

Ethics, orthodoxies and defensive practice: a cross-sectional survey of nurse's decision-making surrounding CPR in deceased inpatients without Do Not Resuscitate orders

Gemma McErlean et al. BMC Med Ethics. .

Erratum in

Abstract

Background: In hospital, nurses are often the first to identify patients in cardiorespiratory arrest and must decide whether to call a CODE BLUE and commence cardiopulmonary resuscitation (CPR). In Australia, there are no legal or policy obligations to commence CPR when unequivocal signs of death are present. The use of CPR where it cannot provide any benefit to a patient raises profound questions about decision-making and ethical practice. The aim of this empirical ethics study was to describe hospital-based nurses' decision-making, perspectives, and experiences of initiating CPR in hospitalised patients who have unequivocal signs of death but lack a Do-Not-Resuscitate (DNR) order.

Methods: The study was a multisite cross-sectional descriptive survey conducted between October 2023-April 2024. Nurses were presented with two clinical scenarios in which patients were found to have no signs of life: Mr. D, an 84-year-old male with cancer, and Mr. G, a 35-year-old male post-motor vehicle accident. Eligible participants were all nurses working in in-patient units. Descriptive statistics, Pearson Chi-square or Fisher's exact tests, McNemar test, and binomial logistic regression were used to analyse the data.

Results: 531 nurses completed the survey. For Mr D, 61.5% (n = 324) would call a CODE BLUE, 24.1% (n = 127) would perform limited CPR. Only 14.4% (n = 76) would confirm death. For Mr G, 93.9% (n = 492) would call a CODE BLUE, 4.4% (n = 23) would perform limited CPR, and 1.7% (n = 9) would confirm death. The major reasons why nurses initiate a CODE BLUE were 'In the absence of an DNR order, there is no option but to begin CPR', 'I am required by hospital policy to do so', 'I am required by law to do so' and 'It is what I was trained to do'.

Conclusions: Most nurses would commence CPR in patients with clear signs of death in the absence of a DNR order. This seems most likely related to ignorance or misunderstanding of law, policy and/or the misapplication or professional norms. These results raise important questions about the drivers of nurses understanding of and engagement with CPR. This highlights ethical concerns for care and treatment of patients at the end of their life and underscores the need to examine ethical practice, agency, and professionalism and supports review of policy, practices and education regarding ethical end-of-life decision making and care.

Keywords: Cardiopulmonary resuscitation; Cross-Sectional studies; Decision making; Defensive medicine; Ethics; Nursing; Resuscitation orders.

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Conflict of interest statement

Declarations. Ethics approval and consent to participate: The study protocol was approved by the South Eastern Sydney Local Health District (SESLHD) Human Research Ethics Committee (HREC) (Reference: 2023_ETH01759) and was conducted in accordance with the Declaration of Helsinki. All participants were advised via the Participant Information Sheet (PIS) that completion of the survey constituted implied informed consent as per the ethics approval. Consent for publication: All participants gave implied informed consent for participation and for all data to be reported in publications as per the ethics approval. Competing interests: The authors declare no competing interests.

Figures

Fig. 1
Fig. 1
Study Flowchart
Fig. 2
Fig. 2
Responses to ‘What would you do?’ for both scenarios. Scenario 1 = Mr D, an 84 yo man, Scenario 2 = Mr G, a 35yo man, pt = patient, CPR = cardiopulmonary resuscitation
See this image and copyright information in PMC

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