Posted: May 12th, 2015

Topic: nursing -Activity homework‎

Imagine caring for a person who do not wish to the ‘rescued’. Ethical dilemmas are encountered by nurses every day in practice. ‘Failure to rescue’ can happen when nurses miss vial cues and fail to detect patient deterioration. But sometimes the opposite occurs. That is, cues that patients are trying to refuse treatment might also be overlooked. Not all attempts at ‘rescue’ are appropriate, particularly if the treatment is futile and burdensome, is not in the person’s best interests, or is not in accordance with the person’s wishes (Levett-Jones 2013).

Whatever the reasons, decisions to withhold potentially life-saving treatments—not to rescue—are among the most frequent and difficult moral problems that nursed encounter in practice (Johnstone, DaCosta&Turale 2004). They require excellent clinical reasoning and decision-making skills and a sound understanding of the relevant legislation and case law. The clinical reasoning cycle can be used to assist in the moral reasoning process associated with a situation involving the withholding of CPR for example.



Suggested readings

Readings (ethics)

Forrester, K & Griffiths, D 2010, chapter 7 ‘Refusal of treatment’, in Essentials of law for health professionals, 3rd edn, Elsevier, Sydney, Australia.

Johnstone, M-J 2009, chapter 12 ‘End-of-life decision-making and the nursing profession’, in Bioethics: a nursing perspective, 5th edn, Elsevier, Sydney, Australia.

Kerridge, I, Lowe, M & Stewart, C 2009, chapter 18 ‘CPR and no-CPR orders’, in Ethics and law for the health professions, 4th edn, Federation Press, Sydney, Australia.









Online exercises

All answers to these online exercises must be entered into the Module 13 Online learning module drop box.

Activity 1

Access the Australian Institute of Health and Welfare (AIHW) website to find out more about the incidence, prevalence, morbidity and mortality risks associated with the four conditions: myocardial infarction, prostate cancer, stroke and type 2 diabetes.

Australian Institute of Health and Welfare, ‘Risk factors, diseases and death’,

Discuss this in 400 words.


Activity 2

A patient’s personal values underpin his beliefs and guide his decisions. The nurse caring for such a patient is guided by the values of his profession, which are expressed in the ANMC Code of Ethics for Nurses in Australia.

  • What values from the Code do you think are most relevant here?

Australian Nursing & Midwifery Council, Code of Ethics for Nurses in Australia,,d.dGY

(Relevant provisions)

Section 7: Nurses value ethical management of information.

Nurses are aware of, and comply with, the conditions under which information about individuals – including children, people who are incapacitated or disabled or who do not speak or read English – may or may not be shared with others. Nurses respect each person’s wishes about with whom information may be shared and preserve each person’s privacy to the extent this does not significantly compromise or disadvantage the health or safety of the person or others. Nurses comply with mandated reporting requirements and conform to relevant privacy and other legislation.

Note: this Code of Ethics is supported by, and should be read in conjunction with, the Code of Conduct for Nurses in Australia and the Australian Nursing and Midwifery Council National Competency Standards for the Registered Nurse, National Competency Standards for the Enrolled Nurse and National Competency Standards for the Nurse Practitioner.

Patients’ personal information is mostly unknown to the doctors and nurses who have cared for them during their contact with the health system. One reason for this is that most health assessments do not entail asking patients about their values and beliefs, or their wishes about the limits to continued treatment, such as CPR. Read ‘The value of taking an ‘ethics history’ by Sayers et al. (2001), and discuss what taking an ’ethics history’ might entail in 400 words.

Sayers, G, Barratt, D, Gothard, C, Onnie, C, Perera, S & Schulman, D 2001, “The value of taking an ‘ethics history’”, Journal of Medical Ethics, vol. 27, no. 2, pp. 114-117,


Activity 3

A study by Tulsky, Chesney and Lo (2005) found that conversations between doctors and patients about CPR preferences and options took about ten minutes and missed key information such as the likelihood of surviving CPR. Visit the website Respecting Patients Choices (supported by the Department of Health and Ageing). It has excellent state-based information and resources on advanced care planning: and so does the SA Health website:

  • How do you explain the findings of Tulsky Chesney and Lo (2005)?
  • Do you think that nurses should be involved in making CPR decisions, or is this outside the scope of nursing practice? Explain.


Activity 4

In Victoria, patients can fill out a refusal of treatment certificate (see
This option is not available in New South Wales. New South Wales has three relevant policy documents:

    1. Using Advance Directives
    2. End-of-life Care and Decision-making
    3. CPR-Decisions Relating to No Cardiopulmonary Resuscitation Orders.
  • Identify what laws and policies apply in South Australia.

The NSW Ministry of Health policy on Using Advance Care Directives lists (on p. six barriers to advance care planning. What are they?
This document also identifies (on pp. 6 and 7) a number of best practice recommendations pertaining to advance care directives. Which are most relevant to patients’ situations?
What does the law say about the need for refusal of treatment decisions to be informed?
Assuming a patient does have decision-specific capacity, does he then have the legal right to refuse CPR?

  • What might the potential legal consequences be of instigating CPR knowing a patient has refused it, but in the absence of any documentation?


Activity 5

Patients and the general public considerably overestimate their chances of surviving a cardiac arrest. One of the reasons for this might lie in the findings of a famous study of the depiction of CPR in movies and television. A study found that CPR was shown as being successful over 75% of the time, many times greater than happens in reality. A study by Kaldjian et al. (2009) found that patients think that the probabilities of surviving a cardiac arrest is 60%, whereas actual rates are closer to 17-20%, or even lower depending on age, co-morbidities, peri-arrest variables such as time taken to initiate CPR and other risks such as surviving with permanent neurological damage, and/or needing nursing home care rather than being able to be discharge home. Studies of the morbidity and mortality of in-hospital cardiac arrest show some interesting findings, some of which may surprise you. For example, post-arrest survival-to-discharge rates have not improved very much over the past 40 years, despite changes in technology and practice (Alabi& Haines 2009).

For more details on the epidemiology of CPR, browse the following website.

Consultant 360, ‘Geriactrics’, com/articles/Predicting-Survival-From-In-Hospital-CPR“>

  • How does this information affect your assessment of whether CPR is in a patient’s best interest?


Activity 6

Interpretation can be difficult when the information that you are working with is subjective and not in the form of quantifiable and objective data, such as that derived from physiological signs and symptoms, for example.

This stage of interpretation will also be filtered through the person doing the interpreting; and we know that human beings are not value-neutral when they make interpretations. Each person has had past experiences, both personal and professional, of situations such as this. Each person has personal beliefs and opinions about such matters, perhaps informed by a religion or perhaps not. These past experiences and personal values will affect how the nurse feels about what a patient is requesting. Some nurses may interpret what a patient is requesting as irrational, a product of fear or stress or depression, and call into question his capacity to make such a decision. Others may interpret his/her refusal of treatment as synonymous with a wish to die. The nurse’s interpretation of these complex factors will have a significant impact on the outcome. Another nurse may interpret things differently and come to a quite different conclusion. This is yet one more way in which a patient is vulnerable in this situation. He is, to a considerable extent, dependent not only on the way others see him but also on their preparedness to act (or not) based on their interpretations.

According to the moral psychologist Jonathan Haidt (2000), human beings do not make moral judgments judicially and reasonably; rather, they do so quickly and instinctively, relying on innate intuitions, emotions, and socially and culturally derived perceptions and values. For Haidt, reason comes into play only after we have already made a judgment, and it is used mainly to rationalise or justify the judgment to ourselves and to others. Haidt’s challenging ideas provide a fascinating insight into the ways in which a reasoning process may be far less rational that we realise.

This situation potentially involves a clash of differing values and moral views. We are often well aware of patient’s values, but those of the nurse and Drs are much less visible. How might they affect the situation?

  • What values do you hold that would influence your interpretation of the information that you have about this situation?



  1. What are three of the most important things that you have learnt from this week’s tasks?
  2. Identify the full range of specific nursing actions that may have prevented a patient from having CPR against his wishes.
  3. Considering your answer to the above, what would you have done in this situation and why?
  4. If what you would do is different from what you think you should do, explain why this is the case.
  5. What specific further knowledge do you think you need in order to be able to practise ethically and legally in situations involving refusal of treatment?


















Alaibi, TO & Haines, CA 2009, ‘Predicting survival from in-hospital CPR’, Clinical Geriatrics, vol. 17, no. 12, pp. 34-36.

Haidt, J 2000, ‘The emotional dog and its rational tail: a social intuitionist approach to moral judgement’, Psychological Review, vol. 108, pp. 814-834.

Levett-Jones, T & Newby, D 2013, ‘Clinical reasoning—learning to think like a nurse’, ed. T Levett-Jones, Pearson Australia, Frenchs Forest Australia.

Jonhstone, M-J, Da Costa, C &Turale, S 2004, ‘Registered and enrolled nurses’ experiences of ethical issues in nursing practice’, Australian Journal of Advanced Nursing, vol. 22, no. 1, pp. 24-30.

Tulsky, JA, Chesney, MA & Lo, B 2005, ‘How do medical residents discuss resuscitation with patients?’, Journal of General Internal Medicine, vol. 10, no. 8, pp. 436-442.



Suggested readings

Readings (ethics)

Forrester, K & Griffiths, D 2010, chapter 7 ‘Refusal of treatment’, in Essentials of law for health professionals, 3rd edn, Elsevier, Sydney, Australia.

Johnstone, M-J 2009, chapter 12 ‘End-of-life decision-making and the nursing profession’, in Bioethics: a nursing perspective, 5th edn, Elsevier, Sydney, Australia.

Kerridge, I, Lowe, M & Stewart, C 2009, chapter 18 ‘CPR and no-CPR orders’, in Ethics and law for the health professions, 4th edn, Federation Press, Sydney, Australia.



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