McErlean Gemma, Bowdler Suzanne, Cordina Joanne, Hui Heidi, Light Edwina, Lipworth Wendy, Maitland Susan, Merrick Eamon, Montgomery Amy, Preisz Anne, Sheahan Linda, Sheppard-Law Suzanne, Skowronski George, Stewart Cameron, Teus Judeil Krlan, Watts Michael, Zanotti Sahn, Kerridge Ian
George Hospital, South Eastern Sydney Local Health District, Gray Street, Kogarah, NSW, Australia.
University of Wollongong, Loftus, NSW, Australia.
BMC Med Ethics. 2025 May 20;26(1):65. doi: 10.1186/s12910-025-01224-2.
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.
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.
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'.
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.
在医院中，护士通常是最早识别出心脏呼吸骤停患者的人，并且必须决定是否呼叫“蓝色急救”并开始心肺复苏（CPR）。在澳大利亚，当出现明确的死亡迹象时，没有法律或政策义务开始进行心肺复苏。在对患者没有任何益处的情况下使用心肺复苏引发了关于决策和道德实践的深刻问题。这项实证伦理学研究的目的是描述医院护士在面对有明确死亡迹象但没有“不要复苏”（DNR）医嘱的住院患者时，进行心肺复苏的决策过程、观点和经历。
该研究是一项于2023年10月至2024年4月期间进行的多地点横断面描述性调查。向护士们呈现了两个临床场景，其中患者被发现没有生命迹象：D先生，一名84岁的癌症男性患者；G先生，一名35岁的机动车事故后男性患者。符合条件的参与者是所有在内科病房工作的护士。使用描述性统计、Pearson卡方检验或Fisher精确检验、McNemar检验和二项逻辑回归来分析数据。
531名护士完成了调查。对于D先生，61.5%（n = 324）会呼叫“蓝色急救”，24.1%（n = 127）会进行有限的心肺复苏。只有14.4%（n = 76）会确认死亡。对于G先生，93.9%（n = 492）会呼叫“蓝色急救”，4.4%（n = 23）会进行有限的心肺复苏，1.7%（n = 9）会确认死亡。护士发起“蓝色急救”的主要原因是“在没有DNR医嘱的情况下，别无选择只能开始心肺复苏”、“医院政策要求我这样做”、“法律要求我这样做”以及“这是我接受的培训内容”。
大多数护士会在没有DNR医嘱且有明确死亡迹象的患者中开始进行心肺复苏。这似乎最有可能与对法律、政策的无知或误解以及/或者专业规范的错误应用有关。这些结果引发了关于护士对心肺复苏的理解和参与的驱动因素的重要问题。这凸显了对临终患者护理和治疗的伦理关注，并强调需要审视伦理实践、机构和专业性，支持对关于临终决策和护理的伦理政策、实践和教育进行审查。
