International Journal of Nursing Studies 39 (2002) 71–77 Treatment refusal: the beliefs and experiences of Alberta nurses Ursula Dawe, Marja J. Verhoef *, Stacey A. Page Department of Community Health Sciences, Faculty of Medicine, University of Calgary, 3330 Hospital Drive NW, Calgary, AB, Canada T2N 4NI Received 27 July 2000; received in revised form 20 November 2000; accepted 6 December 2000 Abstract This study explored the beliefs and experiences of Alberta nurses concerning withholding and withdrawal of treatments from incurably or terminally ill patients. A mailed survey containing closed and open-ended questions was used to gather data. A response rate of 47% was achieved. The majority of respondents believed patients should legally be able to request that treatments be withheld (98%) or withdrawn (97%). More than half of the respondents had received requests from patients, families or physicians to withhold or withdraw treatments. Occasionally, nurses acted without physicians’ knowledge. Three different positions with respect to decision-making in withholding and withdrawing of care, ‘subordinate’, ‘collaborative’ and ‘independent’, emerged from nurses’ written comments on the questionnaire. Consensus among health care practitioners and consumers is critical to end-of-life decision-making. # 2001 Elsevier Science Ltd. All rights reserved. Keywords: Withholding/withdrawing treatment; Nursing ethics 1. Introduction Nurses are frequently the primary care givers to the terminally or incurably ill, providing constant care and attendance. Through this role, nurses often form close relationships with patients and their families, developing an intimate appreciation of their circumstances. On occasion, nurses may be confronted with situations where patients, families or physicians request that nurses withhold or withdraw life-sustaining treatments. These actions may be followed by the patient’s death as the underlying illness or condition is allowed to run its natural course. Treatments withheld or withdrawn range from basic interventions such as hydration and nutrition through to mechanical ventilation, renal dialysis or cardiopulmonary resuscitation. Requests for withhold- ing or withdrawing treatments may create conflict for nurses’ professional and personal values. Respect for patient autonomy is central in the Code of Ethics for Nursing (Canadian Nurses Association, 1997). Consistent with this principle, the Canadian Nurses Association (CNA) supports the rights of all competent persons to make informed decisions about their health care and treatment including the right to refuse or discontinue life-sustaining treatments. For nurses, this fundamental respect for autonomy guides patient advocacy and caring. At the same time, the CNA also supports nurses’ rights to decline participation in procedures that are contrary to their professional or personal moral values, in which case care of the patient would be transferred to another nurse who is comfor- table with the proposed course of action. In some cases, nurses and other health care profes- sionals may be asked to carry out decisions as written in personal directives. The Personal Directives Act, which came into effect in Alberta in 1997, requires that service providers follow any clear instructions in the personal directive or follow the instructions of a designate (e.g., family member) if one has been named. Health care decisions contained within personal directives, generally pertain to what type of treatment is to be used or discontinued and cannot contain instructions relating to aided suicide, euthanasia, or other actions prohibited by law. Similar to the CNA guidelines, the Act does not *Corresponding author. Tel.: +1-403-2207813; fax: +1-403- 2707307. E-mail address: mverhoef@ucalgary.ca (M.J. Verhoef). 0020-7489/01/$-see front matter # 2001 Elsevier Science Ltd. All rights reserved. PII:S0020-7489(01)00006-2