Healthcare, ethics and resuscitation

Cardiopulmonary rescue (CPR) should be initiated within 60 seconds of discovering a patient with cardiac arrest. In some cases, when patients are severely ill, their physicians decide not to resuscitate them if their heart stops. These decisions must be communicated to the medical staff closest to the patient at the time of cardiac arrest. According to Mona Pettersson, do not resuscitate (DNR) orders are issued too late, they are unclear and they are not documented in a uniform manner. This is ethically problematic.

Mona Pettersson, PhD Student & Lecturer

Mona Pettersson is a lecturer in the Nursing Programme and a PhD student at the Centre for Research Ethics & Bioethics (CRB). At 15 years old, she started working as a care assistant. She went on to become a nurse. In 2003, she started teaching.

While reading a student paper on Do Not Resuscitate orders (DNR orders) in hematology and oncology, she realized more people shared her experiences of them. Because there were ethical questions that needed answers, she decided to start her PhD studies – after 19 years as a nurse.

"The nurses I interviewed want patients and next-of-kin to be informed about DNR orders issued. Thus makes it possible for them to provide additional support and care in dialogue with the family. Several of the physicians I interviewed have ethical considerations behind not informing about DNR orders. When informing could do more harm than good, for example by depriving patients and next-of-kin of their hope, they avoid it," says Mona Pettersson.

When patients and next-of-kin are not informed, there is a risk they find out through other channels. For example by accessing medical records online.

As a nurse, Mona Pettersson thought DNR orders were issued too late. The orders were often issued on the same day the patient died. Particularly in hematology, where the worsening of  the disease progresses for a long time before it is clear whether they will recover. Backed by her own experience, Mona Pettersson disagrees with media descriptions of DNR decisions. She dies not believe they issued on insufficient grounds. She does not agree DNR orders deny patients care that could save them. Or that they determine who should live or die. She believes some clarification is needed:

Mona Pettersson"Physicians are not making decisions on whether to revive healthy people. They issue DNR orders for patients that have a poor prognosis for surviving their disease, or a very little chance of surviving CPR with retained quality of life," says Mona Pettersson.

The same thing goes for other treatments, such as dialysis or ventilators. Patients should not have to suffer through painful treatments that cannot help them.

Mona Pettersson describes cardiopulmonary rescue as a violent process. Physical complications are common even for healthy patients. Performing CPR on a patient in the terminal phases of cancer can be perceived as the opposite of good nursing care. This can cause moral distress among the staff. It is important to remember that for a severely cancerous patient, CPR can significantly impair quality of life. For these patients, it is a balancing act to do all you can without causing harm.

According to Mona Pettersson, the phrase "allow for natural death" is sometimes used. This another way of saying the disease cannot be cured, and that focus should move from life sustaining measures to providing good care and pain release.

Nurses are often first to arrive when a patient whose heart has stopped is discovered. Many nurses participating in Mona Pettersson’s research experience distress in connection to cardiac arrests. When DNR orders are issued the day of, are unclear and poorly documented, the patient can be deprived of their right to a dignified death. This occurs because it is impossible to communicate the DNR order before the 60 second count-down begins. 

Mona Pettersson’s research have proven communication is crucial. Her own experiences as a nurse have been confirmed, but she has also seen another side of the decisions. She has gained the perspectives if the decision-maker: the physician.

"Physicians’ experiences differ from nurses’. Physicians follow the patient from early on in their disease, until its' end. They also get to see survivors. Nurses are close to the patients when they are at their worst. This could explain the differences between nurses’ and physicians’ opinions of the timing of DNR orders. Their perspectives are different," says Mona Pettersson.

Mona Pettersson

Mona Pettersson has interviewed 15 nurses and 16 physicians at 7 hematology and oncology departments in Central Sweden. Many of them have experienced moral dilemma in relation to DNR orders. Additionally, a survey has been performed. 216 nurses and physicians, from 16 hematology and oncology departments in Central Sweden participated. Results will be published in scientific journals.

"We want to share results with the departments that participated. They may not have access to subscriptions to scientific journals and we want to make sure the results are returned to them. We hope we will be able to print a brochure describing the results, and send to the departments. My research is for them. To open up a conversation on the ethics of DNR orders in hematology and oncology," says Mona Pettersson.

Mona Pettersson defends her dissertation in the fall of 2018. But the results raises new questions. Her research clarifies nurses' and pysicians' clinical and ethical perspectives on DNR orders. What remains to investigate is the perspectives of patients and next-of-kin. They have very different starting points than medical staff. Are their åerspectives similar to the perspectives of medical staff? Are they different? How? These are questions Mona Pettersson hopes she will have the opportunity to investigate in the future.

Swedish law & DNR orders

The Patient Act clearly states that patients should take part and be informed, possible alongside their next-of-kin. The National Board of Health and Welfare (Socialstyrelsen) have regulations describing what should be documented in patients’ medical records. But they both agree the information should be adapted to the individual receiving it. Guidelines from the Swedish Society of Medicine, the Swedish Society of Nursing and the Swedish Resuscitation Council underline the responsibility of physicians and nurses to handle decisions and information with the patients’ best interests in mind. For example that not informing the patient and/or next-of-kin if it could do more harm than good.