Not for resuscitation: two decades of challenge for nursing ethics and practice

Since the 1970s, the designation of some patients as 'not for resuscitation' (NFR) has become standard practice in many health care facilities. Considerable disquiet has subsequently arisen about the way these decisions are implemented in practice. Nurses, in particular, often find themselves initiating or withholding cardiopulmonary resuscitation (CPR) in situations characterized by verbal orders, euphemistic documentation and poor communication, and when consultations with patients about their CPR choices often do not take place. These practices have developed in large part because a clear legal foundation for withdrawal of treatment decisions such as NFR is still lacking in many countries. The problems with NFR were identified in the 1970s and 1980s and are not new, but, as yet, we have not been able to bring about the necessary changes, in effect to translate broadly accepted ethical principles into clinical practice. This paper explores some of the reasons for this and provides a review and analysis of the main issues, including NFR guidelines and the nursing role in NFR decision-making.