Iranian Critical Care Nurses' Experiences With Slow Codes in the Absence of Formal ‘Do‐Not‐Resuscitate’ Orders: A Qualitative Study

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BACKGROUND: Sudden cardiac death remains a critical global health issue, with cardiopulmonary resuscitation serving as a vital life-saving intervention. However, ethical dilemmas emerge when cardiopulmonary resuscitation is unlikely to benefit the patient, particularly in settings lacking formal Do-Not-Resuscitate orders. This situation often leads to ambiguous practices such as 'slow codes', raising complex challenges for critical care nurses involved in end-of-life decision-making. AIM: This study aims to explore the experiences of Iranian critical care nurses with slow code practices in the absence of formal Do-Not-Resuscitate orders. STUDY DESIGN: This qualitative study employed semi-structured interviews with purposively sampled nurses from diverse intensive care units (medical, pulmonary, poisoning, surgical and cardiac) across three teaching hospitals. Data were analysed using Braun and Clarke's thematic analysis framework. RESULTS: Sixteen participants took part in the study. They had a mean age of 36.8 years (SD = 5.9) and professional experience ranging from 6 to 23 years (M = 13 years), with 2-15 years in intensive care (M = 8.5 years). Most were female (75%), married (75%) and held a bachelor's degree (68.8%). Six key themes emerged influencing slow code practices: fear of litigation and criticism, stretching and buying time, post-resuscitation care and quality of life, opportunities for gaining resuscitation expertise, emotional struggles and moral disengagement. These findings highlight the complex ethical and practical dilemmas nurses face, where legal ambiguities and resource constraints significantly affect end-of-life care decisions. CONCLUSIONS: Nurses often initiate slow codes due to fear of litigation and the desire to support families, while confronting moral dilemmas and concerns about patient outcomes. These findings highlight the urgent need for formal legal frameworks on Do-Not-Resuscitate orders and enhanced nurse training to effectively address the ethical complexities of end-of-life care. RELEVANCE TO CLINICAL PRACTICE: Resuscitation decisions must align with updated clinical guidelines, underscoring the need for formal national and local frameworks on Do-Not-Resuscitate orders in Iran. Legislation that reduces nurses' fear of litigation is essential to promote confident, ethically grounded decision-making. Furthermore, enhancing healthcare professionals' communication skills is critical to improving patients' and families' understanding of cardiopulmonary resuscitation.

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