Melissa Morris
Level III Project
Lit Review DNAR Lock-and-Key Language
Literature Review: DNAR Lock-and-Key Language
Title of Article
And Citation
Conflicting Perspectives
Compromising
Discussions On
Cardiopulmonary
Resuscitation (Groark,
Gallagher, & McGovern,
2010).
LOE
6
Take Away Points and Quotations
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Groarke, J., Gallagher, J.,
& McGovern, R. (2010).
Conflicting perspectives
compromising discussions
on cardiopulmonary
resuscitation. The Irish
Medical Journal 103(8),
233-235. LOE 6.
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Nurses’ perceptions of
attempting
cardiopulmonary
resuscitation
on oldest old patients
(Sævareid & Balandin,
2011)
Sævareid, J.T. & Balandin,
S. (2011). Nurses’
perceptions of attempting
cardiopulmonary
resuscitation
on oldest old patients.
6
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
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Only 16% of patient will survive to discharge following an
in-hospital resuscitation from cardiopulmonary arrest.
“An observational study was carried out to examine the
knowledge and opinions of doctors, nurses and the general
public on various aspects of resuscitation”.
“70% of doctors, only 24% of nurses and no person from
the general public group correctly estimated survival to
discharge after in-hospital cardiopulmonary resuscitation
attempts at less than 20%”.
Of questions answered by the general public, 67%
incorrectly equated cardiopulmonary arrest to a heart
attack; 42% did not think drugs or intubation were used in
resuscitation attempts; and 58% cited TV medical dramas
as their primary source of information regarding
resuscitation attempts.
“The general public significantly overestimate the success
of CPR attempts while nurses and doctors also do so, but to
a lesser extent”.
“Doctors and nurses must be definite on the ethics
involved before embarking on resuscitation discussions.
Doctors can be deficient in initiating resuscitation
discussions and decisions. Training in areas such as
survival, ethics, and communication is needed. Failure to
address these deficiencies will violate an ethical and legal
responsibility to ensure patients a dignified and
comfortable death”.
Usually, nurses are the healthcare professionals who find
patients in cardiac arrest, and are the ones who start CPR,
but physicians are responsible for writing DNAR orders.
Because nurses want to participate in DNAR decisionmaking, but do not want to take full responsibility in the
decision-making process, interdisciplinary collaboration
should be used for decisions about end-of-life treatment.
Laws about DNAR status vary from country to country.
The Norwegian Nurses Organization states that nurses are
responsible for providing care that alleviates suffering and
contributes to ensuring a dignified death. Because of this,
many nurses experience ethical dilemmas if no DNAR is in
place, but the patient is perceived to be suffering or at risk
of an undignified death.
Melissa Morris
Level III Project
Lit Review DNAR Lock-and-Key Language
Journal of Advanced
Nursing 67(8), 1739-1748.
LOE 6.
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http://www.colorado.gov/ 8
cs/Satellite/CDPHEEM/CBON/125158973863
6 (LOE 8)
6
Do not attempt
resuscitation: the
importance of consensual
decisions (Imhofa, MahrerImhofa, Janischb,
Kesselringc, & Zuercher
Zenklusend, 2011).




Imhofa, L., Mahrer-Imhofa,
R., Janischb, Kesselringc,
A., & Zuercher
Zenklusend, R. (2011). Do
not attempt resuscitation:
the importance of
consensual decisions. Swiss
Medical Weekly, 141,
w13157. LOE 6.

Junior physicians also experience stress while attending
cardiac arrests.
“Slow codes” can occur because of pressure by patients’
families, failure to have a written DNAR order, fear of
litigation, and fear of harming patients by discussing code
status; this may increase nurses’ anxiety about end-of-life
decisions.
“Physicians may follow a disease-centered method of
treating patients and experience more difficulty in adapting
to a palliative or patient-centered approach than nurses.”
“The aim of the study was to explore nurses’ thoughts and
attitudes about CPR of the oldest old patients”.
“The participants perceived that the amount and quality of
information given to patients and family [caregivers] about
CPR and DNAR varied across different physicians”.
“All participants stressed that they wanted to respect their
patients’ wishes. When reflecting on what is important in
determining DNAR, nine of the ten participants mentioned
autonomy and noted that often the patients would not want
to be resuscitated… Nevertheless, respect for patient
autonomy was one reason for not wanting an age limit for
CPR”.
Limitation to study was that it was conducted in Norway,
where patients cannot decide against CPR unless they are
dying.
Information from the Colorado Department of Public
Health and Environment: Emergency Medical and Trauma
Services (CPR Directives)
“Yet, in daily clinical practice, patient involvement,
specific professional responsibilities and communication
between professionals regarding DNAR orders remain a
major challenge”.
DNAR discussions can be difficult because everything is
based on hypothetical facts and scenarios; informed
consent for DNAR orders can be difficult.
“International guidelines further state that DNAR orders
should include the coordinated expertise of
interdisciplinary teams. Observations by nurses may be
crucial and the importance of their input in the decisionmaking process is increasingly recognized. However,
nurses still report frequent exclusion from CPR decisions”.
Participant physicians reported DNAR discussions should
be held by chief physicians; and participant nurses reported
that nurses should be able to participate, but a lot of
clinical experience would be required to do so.
Melissa Morris
Level III Project
Lit Review DNAR Lock-and-Key Language
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“The descriptions by the participants showed that
CPR/DNAR decisions are the product of three distinct
decisional phases: 1) the phase of implicit decision, 2) the
phase of explicit decision, and 3) the phase of
reconsidering decisions”.
“Whereas CPR/DNAR orders were discussed on a daily
basis in most intensive care units, reluctance to consider
new orders was remarkable on surgical wards”
“Well-accepted decisions typically combined profound,
mutually respected medical and nursing expertise,
communication and negotiation skills, common sense and
life experience coupled with empathy for patients and
colleagues”.
“A consensus did not mean that all team members had to
share the same opinion, but that the expertise and
perspectives of different members of the team had become
part of the decision”.
References
Groarke, J., Gallagher, J., & McGovern, R. (2010). Conflicting perspectives compromising
discussions on cardiopulmonary resuscitation. The Irish Medical Journal 103(8), 233-235. LOE
6.
http://www.colorado.gov/cs/Satellite/CDPHE-EM/CBON/1251589738636. LOE 8
Imhofa, L., Mahrer-Imhofa, R., Janischb, Kesselringc, A., & Zuercher Zenklusend, R. (2011).
Do not attempt resuscitation: the importance of consensual decisions . Swiss Medical Weekly,
141, w13157. LOE 6.
Sævareid, J.T. & Balandin, S. (2011). Nurses’ perceptions of attempting cardiopulmonary
resuscitation on oldest old patients. Journal of Advanced Nursing 67(8), 1739-1748. LOE 6.