Do-not-resuscitate status: Conflict and culture brokering in critical care units

Objective: To describe the conflict that occurs during the process of consenting to do-not-resuscitate (DNR) status and the strategies used by critical care nurses to attempt to prevent, minimize, and/or resolve these conflicts. Design: Grounded theory study. Subjects: Twenty-two critical care nurses practicing in upstate New York in urban and rural, profit and nonprofit hospitals. Method: Semi-structured, in-depth interviews were used to collect data. The interviews were audiotaped and transcribed. The transcribed data were analyzed with the continuous comparative method of grounded theory. Categories were identified and linked to a core category: conflict. Results: Conflict occurred during the process of consenting to DNR status. Two major categories of conflict were intrapersonal (inner conflict in coming to terms with a DNR-status decision) and interpersonal (conflict that took place between individuals involved in consenting to a DNR status). Intrapersonal conflict occurred while determining the appropriateness of DNR for the patient and coming to terms with the meaning of DNR status. Interpersonal conflict occurred between family members, patients, and staff. Nurses descriptions of their role were reflective of a culture broker framework incorporating advocacy, negotiation, mediation, and sensitivity to patients' and families' needs. Conclusions: Critical care nurses play an active role in assisting patients and families with DNR-status decisions. To better understand the process of consenting to DNR status, additional studies need to focus on the experiences of patients, families, and other health care providers.