Ethical issues and decision making related to resuscitation of severely injured patients: Perceptions of emergency department nurses

Nurses working in emergency departments (EDs) of trauma centers are integral members of the trauma team during the initial resuscitation of severely injured patients. Decisions regarding these resuscitations are made in high stress environments and are inevitably rife with ethical issues due to the high frequency and severity of injury and its exorbitant costs to society. These decisions are made with little background knowledge about the patients during a complex process of rapid assessment of physiological status overlaid by ethical principles, societal norms and expectations, and legal mandates. The purpose of this study was to assess the specific ethical issues that ED nurses encounter and their effects during the resuscitation of severely injured patients, the factors contributing to the decisions made during resuscitation, and how nurses are involved in these decisions. A qualitative descriptive design using semi-structured interviews of 22 ED nurses who participated in the resuscitation of severely injured patients was used. Data were analyzed using content analysis. The findings suggest that nurses experience many ethical issues related to the resuscitation of severely injured patients including: respect for persons, justice-related concerns, patient care issues, and job and role tensions. These issues had many effects on participants including threats to their being (ontological) with emotional, physical, life, and professional role consequences. Participants also experienced epistemological threats or threats to their knowing including realizations about insurance, life, and the healthcare system, and authoritative and cognitive dissonance. Findings reveal multiple factors considered when making decisions during a resuscitation ranging from the more physiologic or concrete protocol-driven factors to those that were perceived as intangible. Additionally, participants' cited various levels of involvement: some felt involved, some not involved, and some believed involvement was more situational based. Findings highlight nurses' thoughts about their role in emergency medicine and the resuscitation of severely injured patients, when they feel comfortable bringing forward their ethical concerns, and with whom they can discuss these issues. These findings underscore the ethical challenges that nurses face every day in clinical practice steps are needed to address organizational aspects of care and the retention of nurses caring for injured patients.