An 83-year-old woman acutely ill with congestive heart failure and a severe, probably end-stage respiratory attack was fading over the course of a slow-moving hour. Still clear and conscious, she repeated her wish to the nurse: "I don't want CPR." The patient's husband echoed his wife's request: "Please do what she says."

The nurse hurriedly phoned the attending physician, who refused to change the patient's code status and repeated his orders to administer CPR. The patient lapsed into unconsciousness, prompting a resuscitation effort which left the nurse feeling drained and guilty, and the patient dead after 30 minutes of futile effort.

The nurse's moral distress arose from an obvious conflict: on the one hand, as part of the CPR team, she had a duty to carry out the physician's orders; on the other hand, she and felt obligated to honor the patient's repeated requests.

What could or should she have done?

The attempted resuscitation of a competent, seriously ill patient against her and her husband's wishes arose from communication problems in the immediate situation and in a style of clinical practice that did not ensure timely access to patient information.

An attending physician should discuss a patient's wishes about resuscitation as soon as possible after her admission, and chart the conversation so all professionals involved in her care can access the information. Even better, the attending physician should encourage timely, multidisciplinary rounds to include respiratory therapists, nurses, dietary specialists, chaplains, ethicists, and other relevant professionals.

The nurse could have tried the following strategies, if time permitted:

1. Talking directly to the attending physician to find out his reasons for not permitting a DNR order, given the patient's refusal. Attempting to convince him otherwise if his reasons do not seem to be based on the patient's best interests.

2. Arranging for the patient and/or her husband to speak with the physician directly, and offering to assist them in signing a statement in the chart about their wishes.

3. Requesting that the physician's house staff come to the unit to help assess and witness the situation.

4. Contacting others—such as the director of respiratory therapy, unit medical director, unit nursing director, or ethicist—for backup.

The nurse's options are somewhat limited, however, by virtue of her status within the medical hierarchy. She could have refused to participate and taken whatever consequences might result from having others interpret her act of civil disobedience as willful insubordination. To do what she did, to participate against her better judgment in a resuscitation without medical warrant, seems to violate her moral integrity. Is there an option between disobedience and submission?

In hindsight, the nurse should have done exactly what she did in that situation: attempt to change the physician's mind and, failing that, to administer CPR. However, this was an ethical dilemma that could have been prevented with a little effort to communicate with the patient about what mattered to her as her life wound down.