Health, Spirituality and Medical Ethics

Introduction

Cardiopulmonary arrest is a common cause of death that can occur suddenly and unexpectedly at any time or place [1, 2]. Cardiopulmonary resuscitation (CPR) is a process aimed at restoring the vital functions of important organs of the body, especially the heart and brain, in patients who have suffered cardiac arrest, in which an attempt is made to establish blood flow and respiration, which has specific instructions and steps that must be carried out carefully to have the necessary efficiency and productivity [3]. In-hospital cardiac arrest is a common and dangerous problem; approximately 370-750 thousand patients in hospitals in the United States of America suffer cardiac arrest and undergo resuscitation annually [4]. In CPR, the first 4-6 minutes after cardiac arrest are considered the golden time, and for every minute delay in defibrillation within 3-5 minutes, the patient’s survival rate decreases by about 70% [5]. Research has shown that various factors affect resuscitation outcomes, including age, underlying diseases, reason for referral, time from cardiopulmonary arrest to resuscitation initiation, and defibrillation use [6]. Some of these factors, such as age and gender, cannot be changed, but others, such as rapid initiation of resuscitation, timely use of shock, drug interventions, and the level of experience and knowledge of the resuscitation team, can be intervened in and can increase patient survival [7]. Although different members of the resuscitation team perform resuscitation of patients with different specialties, the important role and position of nurses and physicians in performing resuscitation, identifying patients with critical conditions, preventing cardiac arrest, performing resuscitation operations in a timely and systematic manner, and providing aftercare to improve outcomes from resuscitation in hospitalized patients is undeniable. Nurses are part of the first resuscitation team that encounters patients in need of CPR in the early stages and play a very sensitive role in the patient’s life [8].

The care team plays a crucial role in the patient’s life until death, and this impact will continue to be felt by survivors at the time of death and in the memories of death [9]. The way in which people are cared for at the end of their lives, and the services related to the dying process, are considered indicators of the way in which patients and vulnerable people are cared for; therefore, it makes sense that this type of care should be recognized as a core activity and as crucial as other areas of health and social care. How a patient dies will remain in the minds of many relatives, health workers, and social care workers; therefore, it is vital to recognize the serious responsibility of care team members to provide the best possible services in the last days of a patient’s life [10]. On the other hand, the routine use of CPR for all patients who experience cardiorespiratory arrest has led to problems. In fact, performing CPR in some patients only temporarily maintains physiological stability, continues the patient’s suffering, and postpones the natural process of death [11]. CPR has complications, such as bloating, gastric rupture, rib fractures, rib separation from the sternum, pulmonary contusion, pneumothorax, myocardial contusion, hemorrhagic pericardial effusion, splenic rupture, or liver rupture, which can lead to many problems for the survivor [12]. Nurses’ conflicts arise between protocols and perceived futility [13]. A review of studies shows that caring for patients in the last days and hours of their lives has always been a problem for healthcare professionals, including doctors and nurses [14]. In dying patients, due to the severe nature of the disease and severe physical disorders, CPR is often of no benefit and is often performed under the influence of factors such as legal issues, hospital policies, prevailing culture of the community, religion, and family requests [15]. Many experts believe that CPR is a double-edged sword that can be life-saving or prolong the process of death and pain, and affect the quality of life of the individual [16]. Despite extensive research on CPR outcomes and do not resuscitate (DNR) policies, few qualitative studies have explored how nurses navigate the ethical tensions between clinical guidelines, patient/family expectations, and personal moral beliefs in diverse cultural contexts.

Therefore, addressing this issue in different regions, with specific cultural and religious contexts, can help clarify more aspects of this issue. Despite numerous studies on the do-not-resuscitate order worldwide, physicians and medical teams still face challenges in this area, and this order is not considered an obstacle to performing medical interventions and nursing care services [17, 18].

To gain a deeper understanding of the ethical challenges, this study employs a qualitative approach to explore the lived experiences of nurses who perform CPR on patients. Focusing on lived experiences allows us to understand the hidden and unspoken dimensions of these challenges from the perspective of nurses directly involved in this process. By examining nurses’ ethical challenges, this study aimed to inform policies that support ethical decision-making, reduce moral distress, and align resuscitation practices with patient-centered care.

Methods

This qualitative study used a phenomenological approach with nurses experienced in CPR to identify and analyze their ethical challenges. Phenomenology explores how individuals ascribe meaning to their lived experiences, focusing on the subjective perceptions of ethical challenges during CPR. Instead of focusing on the objective and apparent indicators of a situation or phenomenon, phenomenology emphasizes the individual’s subjective and personal perspective on what is currently happening by delving into the phenomenon’s existential depth.

The statistical population of this study included nurses with experience in CPR working in hospitals. The sample group was selected using a purposive sampling method from nurses in Mashhad and Gonbad Kavous who met the inclusion criteria and did not meet the exclusion criteria. The inclusion criteria included having a bachelor’s degree in nursing, experience in at least 10 CPRs, and being employed in a hospital at the time of the study. The exclusion criteria were also failure to respond to interview questions, and refusal to continue the interview before the end of the interview for any reason.

Sampling continued until thematic saturation was reached, defined as no new codes emerging across three consecutive interviews, resulting in 12 participants . The interviews were semi-structured and in-depth and were conducted face-to-face in Qaem, Imam Reza (AS), and Musa bin Jafar hospitals in Mashhad City, Iran, and Borzovieh Gonbad Kavous hospital, in a comfortable and private room. After explaining the purpose of the research and obtaining permission from the participant, all interviews were recorded.

After explaining the purpose of the study to the nurses, they were first asked to state their age, clinical work experience, and the approximate number of CPRs they had experienced. Then, as the first question, the participants were asked, “Can you describe a specific CPR case where you faced an ethical dilemma?” Then, two ethical challenges were raised to prompt the interviewees to express their concerns, feelings, actions, and thoughts. Also, as necessary, to clarify and resolve ambiguities and explore inner feelings, follow-up questions, such as “Please explain more”, “What do you mean?”, and the like were asked. In the following, the interviewees were asked whether they had any memories of CPR with a moral theme. To ensure clarity of the questions, the interview guide was pilot-tested with two nurses to refine the wording. Subsequent interviews were also structured and guided based on the concepts extracted from the previous interviews.

In addition to recording the interviews, which were conducted with a mobile phone, the interviewer also took field notes and notes during observation. Observations of the interviewees’ reactions while answering were written next to each question; these reactions included laughing, pausing, disgust, thinking, shaking hands, and frowning.

Each interview lasted an average of 13 minutes (10 to 20 minutes) (due to the nurses’ workload, interviews were concise but focused). The text of each interview was written down and coded verbatim after it was finished, and after analyzing each interview, the next interview was conducted. Data were analyzed using conventional content analysis. For the sake of trust and auditability, we maintained an audit trail of coding decisions, practiced reflexivity through researcher journals, and conducted peer debriefing with a qualitative methods expert. The transcripts were independently coded by two researchers using open coding, and discrepancies resolved through discussion. Emerging themes were validated via member checking with participants.

Results

Finally, 12 semi-structured interviews were conducted with nurses. Seven were male, and five were female. The age range of the study participants was 26-48 years with a mean age of 34.91 years. Ten nurses had a bachelor’s degree, and two had a master’s degree. The work experience of the study participants ranged from 3-22 years, with a mean of 8.5 years, and the number of CPRs performed ranged from 10 to over 400 (Table 1).

The theme of nurses’ ethical challenges was extracted in four themes: 1) Religious and cultural dimension with three subcategories: “Colleagues’ lack of awareness of the rules”, “patient’s lack of understanding of the world”, and “ignorance of the patient’s race and religion”; 2) patient and family dimension including three subcategories: “Patient’s conditions and situation”, “family feelings”, and “how to inform the family”; 3) personal and human dimension with two subcategories: “Negative effects on the individual’s morale” and “unpleasant experiences during CPR”, while ‘family feelings’ focuses on external interactions, ‘negative effects on morale’ captures nurses’ internalized stress; and 4) scientific, regulations, and treatment team dimension with two subcategories: “Physician’s orders as team leader”, and “attention to AHA reference and protocol” (Table 2). These categories are explained below.

Religious and cultural dimension

One of the ethical challenges for nurses in dealing with CPR patients is the issue of culture and religion, which has a special place in our country, based on being Muslim and the culture of altruism and respect for the deceased. The ethical challenges for nurses in this regard are ignoring the rules of dying and not respecting the patient’s privacy. In CPR patients, due to heart massage or shock, the patient’s body needs to be naked, which is unpleasant after the resuscitation operation is completed and the person has died, which is not a good thing. Considering the patient undergoing CPR as a person in the final stages of life, we must be aware of laughing, joking, or disrespect at the patient’s bedside and make every effort to bring the person back to life, regardless of the patient’s culture, ethnicity, and religion. In this regard, Code No. 9 said: “Ethically, my patient is a human being, whatever his religion... and if an hour is added to his life, maybe he will repent and change completely.”

Patient and family dimension

Sometimes the patient’s condition is such that trying to bring the patient back is useless, and the patient will die after a few hours or days in the intensive care unit. This situation is one of the most significant ethical challenges for nurses to continue resuscitation operations and do nothing to achieve results, or to not cause further suffering to the patient, knowing that the patient will not return; as code number 8 stated: “The patient was completely cachectic and all the ribs were broken... He was very old (silence and pause), indeed, he came back, but two days later he died in the intensive care unit (ICU), and an additional expense was added to the family».

On the other hand, one must put oneself in the place of the patient’s family, what feelings and hopes they have, and one must try for the wife, daughter or son who are waiting behind the door of the CPR room; this issue has also been observed in situations where the end of CPR has been announced and the rhythm is pulseless electrical activity (PEA) and not asystole, when after the child is present at the mother’s bedside and kisses the forehead and holds the mother’s hand, the rhythm becomes completely asystole.

In addition, informing the family of the patient’s death is another challenge they face, “who to tell” or “how to tell”. One nurse noted, “Following the AHA guidelines is morally clear, but the family’s begging makes it harder” (code 6).

Personal and human dimension

The first experiences of CPR for nurses are accompanied by feelings of fear and anxiety, and can cause mental turmoil and mental disorders. Although with increasing experience and being in a similar situation, the anxiety and turmoil of nurses decreases, it remains an important factor in secondary traumatic stress disorder. Secondary traumatic stress disorder occurs when nurses, in addition to the psychological pressure caused by work, also share in suffering in some way; in fact, it is the same mental anguish caused by compassion. This condition was more common in women than in men, so that code number 3 stated during the interview with stress and turmoil that “because women do not feel comfortable and have more fear and anxiety, it is better not to interfere in chest massage and shock and take over the task of giving medication”.

The nurses’ unpleasant experiences are consistent with Jameton’s (1984) theory of moral distress, where institutional constraints conflict with individual morality.

Scientific dimension, regulations, and treatment team

Given the team-oriented nature of CPR and the physician as the team leader, sometimes the end of CPR may be announced less than 20 minutes after the start of the resuscitation operation, in which case nurses are faced with an ethical challenge between conscience and following the team leader’s orders. Continuing resuscitation even after the physician leaves, informing the clinical supervisor, considering the patient’s condition, and talking to the physician to continue CPR were among the actions that nurses raised in this ethical challenge.

In contrast, some nurses believed that the AHA protocol should be followed and ethical and emotional issues should not be addressed. These nurses believe that one should complete the CPR cycle and act according to the laws and regulations.

Nonverbal data

“Pauses during interviews often accompanied descriptions of futile CPR, suggesting unresolved grief or moral residue.”

Hand movements, facial discoloration, or a trembling voice indicate stress and the nurse’s inexperience with CPR.

Missing contrasts

Religious/cultural: “Whatever his religion... if an hour is added to his life, maybe he will repent” → Highlights spiritual hope vs. futility. Futility: “All ribs were broken... he came back but died in ICU” → Illustrates moral distress over futile care. Gender: “Women do not feel comfortable... take over medication” → Suggests role tensions in CPR teams. Education/experience: Colleagues who work in special and emergency departments or have a high level of experience are less likely to experience ethical tensions than novice nurses. For example, a nurse with 10 years of experience and 100 CPR experiences (code 9) pays attention to all aspects of treatment, care, culture, religion, and family during CPR and even performs post-mortem care. Also, master’s-trained nurses more frequently cited protocol adherence.

Discussion

This study aimed to explain the ethical challenges faced by nurses caring for CPR patients. This phenomenological study revealed four ethical challenges faced by nurses during CPR: Religious/cultural conflicts, patient/family tensions, personal moral distress, and team/protocol dilemmas. These findings underscore the need for context-aware ethical frameworks in resuscitation.

In this study, the religious and cultural dimension was raised as one of the main themes, and attention to the dying decrees, respecting the privacy of the deceased, and observing ethical principles at the patient’s bedside were identified as ethical challenges for nurses. In all religions, the decrees regarding the dying person are fully stated, which shows the importance of this issue.

The patient and family dimension was the second central theme of the present study, in which not performing CPR for patients with multiple problems or fatal diseases that the person has been suffering from for some time and has no hope of recovery, was an important challenge in the professional ethics of nurses, in which issues, such as “there is no point in the person’s survival” or “it is better not to bother him” were raised. Asadi-Lari et al. [19] also, in their study of patients with terminal and progressive diseases or in the final stages of the disease, where the choice between life and death is not an issue and the individual must choose between death and prolonging the process of death, stated that, provided the physician makes the right judgment and the patient’s family agrees, there is no need to perform resuscitation. This issue can also be referred to as passive euthanasia, which means that not performing life-saving measures for the patient, called No CPR, prevents further harm to the patient. Our participants’ struggles with futile CPR mirror global debates on DNR orders, suggesting a universal need for more explicit criteria to define ‘medical futility. This study also discusses the presence of the family at the bedside of the deceased, which can be coordinated and maintained by a first-degree relative of the patient, who also supports the family’s presence during resuscitation in Spiros et al. [20].

In the personal and human dimension, feelings of guilt after the patient’s death, feelings of fear and anxiety during the first few CPR sessions, and adverse effects on the morale of nurses are among the issues that the individual faces and most often requests to be transferred from the emergency and intensive care units. These issues are especially evident in female nurses due to their more gentle and emotional nature. In Soleimani’s study, one of the most crucial stressors that causes nurses’ burnout is seeing and performing therapeutic and care interventions in unpleasant scenes, such as resuscitation operations [21]. In the present study, in the scientific dimension, the treatment team, and regulations, the importance of following the doctor’s orders and performing the correct CPR protocol based on sources and references was stated, and it seems that this will not be achieved except by increasing the awareness and skills of the CPR team personnel, as well as their experience, which has been indicated in various studies on this subject [22, 23]. Also, when the physician announces the end of CPR before 45 minutes or without a scientific reason, this study discussed informing the supervisor, continuing the CPR protocol, and attempting to revive the patient.

The strengths of the present study were its qualitative nature and the use of all nurses’ opinions. In addition, no qualitative study has been conducted to date on the ethical challenges faced by nurses in caring for CPR patients, underscoring the importance of the present study. Among the limitations of this study was the nurses’ fear of telling the truth, which was partially overcome by assuring them that the interviews would be anonymous and that the material expressed would not be used elsewhere except in this study, as well as the interviewer’s attention to nonverbal communication.

Conclusion

Paying attention to the ethical challenges that nurses face during CPR can reduce the psychological harm to nurses, prevent legal problems, and increase the satisfaction of companions. Also, developing ethical guidelines based on culture and religious beliefs is essential to respond to the ethical challenges facing medical staff during CPR.

Future research should evaluate interventions, such as ethics debriefings or nurse-led DNR discussions, to mitigate these challenges.

Policy recommendations

“Hospitals should implement:

1. Debriefing sessions post-CPR to address moral distress. 2. Interdisciplinary ethics committees to review futile cases. 3. Training modules on cultural/religious sensitivity in end-of-life care.” 4. Gender dynamics

“Gender differences in stress may reflect societal expectations or unequal task distribution (e.g. women more often tasked with family communication).”

Research limitations

Findings may not generalize to non-Muslim contexts or settings with limited resources where CPR outcomes differ.

Ethical Considerations

Compliance with ethical guidelines

This study was conducted in accordance with the ethical principles of the Declaration of Helsinki (2013) and was approved by the Ethics Committee of Islamic Azad University, Mashhad Medical Sciences Branch, Mashhad, Iran (Code: IR.IAU.MSHD.REC.1403.135).

Prior to data collection, participants received comprehensive information about the study’s aims, procedures, risks, and benefits. Written informed consent was obtained from all participants. To ensure confidentiality, all identifying details were removed or coded, and data were stored securely and used only for research purposes.

Participation was voluntary, and participants had the right to withdraw from the study at any stage without any consequences. The research team maintained professional integrity, ensured respect for participants’ autonomy, and upheld the principles of beneficence, nonmaleficence, and justice throughout the study.

Funding

This research did not receive any grant from funding agencies in the public, commercial, or non-profit sectors.

Authors' contributions

Conceptualization: Mohadeseh Shahrodi and Atiyeh Okhli; Methodology, software, formal analysis, visualization, and project administration: Mohammadreza Yousefi; Validation: Maryam Jafarnejad, Mohammadreza Yousefi, and Elahe Dolati; Investigation: Mohadeseh Shahrodi; Resources: Mohammadreza Yousefi and Atiyeh Okhli; Data curation: Elahe Dolati; Supervision and writing: Maryam Jafarnejad.

Conflict of interest

The authors declared no conflict of interest.

Acknowledgments

The authors would like to express their gratitude to all nursing colleagues who collaborated with the researchers.