Exploring New Zealand Paramedic Attitudes Towards Advance Directives: An Ethical Analysis


Advance directives
ethical decisions-making
Values Exchange

How to Cite

Davey PJ, Lees AB, Godbold R. Exploring New Zealand Paramedic Attitudes Towards Advance Directives: An Ethical Analysis. Australasian Journal of Paramedicine [Internet]. 2016Nov.6 [cited 2023Jan.26];13(4). Available from: https://ajp.paramedics.org/index.php/ajp/article/view/241



Advance directives are known to present challenging ethical issues in health care practice, however there is a paucity of research paramedic perspectives. When a cardiac arrest occurs in the community, end of life provisions have often not been considered by patients or the patients are unable to communicate their wishes and these are not usually known to the attending paramedic crew. These factors contribute to an ethically complex decision-making environment. Ethical deliberation contributes to practitioners’ critical thinking skills and helps prepare them for decision-making under uncertainty. This research aims to highlight and explore underlying values present within practice-based decisions.


An exploratory, interpretive study, using the Values Exchange, a web-based ethical decision-making tool, explored eighteen urban-based New Zealand paramedics’ deliberative perspectives on an ethically controversial end of life scenario.


Thematic analysis of participants’ free text responses ascertained the breadth of views on advanced directives, with the emergence of three dominant themes; legal tensions, multiple constructs of dignity and seeking solutions that support clinical practice.


Findings revealed that when considering situations involving advance directives, participants regarded the duty to uphold patient dignity as paramount. There was a desire for greater legal guidance and a call for increased professional education in law and ethics. This study provides insight into New Zealand urban-based paramedics’ views and experiences of this ethically challenging aspect of patient care.



Ambulance New Zealand (2011). New Zealand Ambulance Major Incident and Emergency Plan: The Plan. Wellington, New Zealand. Available at: www.ambulancenz.co.nz/downloads/files/The_Overview.pdf

Statistics New Zealand (2013) Census QuickStats about national highlights. Available at: www.stats.govt.nz/Census/2013-census/profile-and-summary-reports/quickstats-about-national-highlights.aspx

St John (2013). Annual Report. Wellington, New Zealand. Available at: www.stjohn.org.nz/globalassets/.../annual-report/annualreport2013.pdf

Malpas P. Advance directives and older people: ethical challenges in the promotion of advance directives in New Zealand. J Med Ethics 2011;37:285–9.

New Zealand Medical Association. Advance directives. Wellington, New Zealand. Available at: www.nzma.org.nz/patients-guide/advance-directive

Bremer A, Dahlberg K, Sandman L. Balancing between closeness and distance: emergency medical services personnel’s experiences of caring for families at out-of- hospital cardiac arrest and sudden death. Prehosp Dis Med 2012;27:42–52.

Grudzen C, Timmermans S, Koenig W, et al. Paramedic and emergency medical technicians views on opportunities and challenges when forgoing and halting resuscitation in the field. Acad Emerg Med 2009;16:532–8.

Sherbino J, Guru V, Verbeek P, Morrison L. Prehospital emergency medical services’ ethical dilemma with do-not-resuscitate orders. CJEM 2000;2:246–51.

New Zealand Bill of Rights 1990. Available at: www.legislation.govt.nz/act/public/1990/0109/latest/DLM224792.html

Health and Disability Commissioner (Code of Health and Disability Services Consumers Rights) Regulation 1996. Available at: www.hdc.org.nz/the-act--code/the-code-of-rights

Protection of Personal and Property Rights Act 1998. Available at: www.legislation.govt.nz

Santonocito C, Ristagno G, Gullo A, Weil M. Do-not-resuscitate order: a view throughout the world. J Crit Care 2013;1:14–21.

Wareham P, McCallin A, Diesfeld K. Advance directives: the New Zealand context. Nurs Ethics 2005;4:349–59.

Skegg P, Paterson R, Manning J. Medical law in New Zealand. Wellington: Thomson Brookers; 2006.

New Zealand Crimes Act 1961. Available at: www.legislation.govt.nz/act/public/1961/0043/latest/whole.html

Fulford K, Dickenson D, Murray T. Healthcare ethics and human values: an introductory text with readings and case studies. Oxford: Blackwell; 2002.

Petrova M, Dale J, Fulford B. Values-based practice in primary care: easing the tensions between individual values, ethical principles and best evidence. Br J Gen Pract 2006;6:703–9.

Lees A, Godbold R. To tell or not to tell? Physiotherapy students responses to breaking patient confidentiality. N Z J Physiother 2012;40:59–63.

Godbold R, Lees A. Valuing values in health education: Can web based decision making technology help? NET NEP 2014 5th International Nurse Education Conference; Noordiwijkerhout, The Netherlands.

Godbold R, Lees A. Ethics education for health professionals: a values based approach. Nurse Educ Pract 2013;13:553–60.

Lees A. Learning about ethical decision making in health care using web-based technology a case study: a thesis submitted to Auckland University of Technology. 2001. Available at: http://hdl.handle.net/10292/1334

Seedhouse D. Values based decision making for the caring professions. Chichester, U.K.: Wiley-Blackwell; 2005.

Bremer A, Herrera MJ, Axelsson C, Marti DB, Sandman L, Casali GL. Ethical values in emergency medical services: a pilot study. Nurs Ethics 2015;22:928–42.

French E, Casali G. Ethics in emergency medical services – Who cares? An exploratory analysis from Australia. Journal of Business Ethics and Organizational Studies 2008;13:44–53.

Patton M. Qualitative research and evaluation methods. Thousand Oaks, CA: Sage; 2002.

Seedhouse D. Ethics: the heart of health care. 3rd edn. Chichester, U.K.: Wiley-Blackwell; 2009.

Vaismoradi M. Content analysis and thematic analysis: Implications for conducting a qualitative descriptive study. Nurs Health Sci 2013;15:398–405.

Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psych 2006;3:77–101.

Sandman L, Nordmark A. Ethical conflicts in prehospital emergency care. Nurs Ethics 2006;13:592–607.

Nordby H, Nøhr Ø. The ethics of resuscitation: How do paramedics experience ethical dilemmas when faced with cancer patients with cardiac arrest? Prehosp Disaster Med 2012;27:64–70.

Gillett G. Whose best interests? Advance directives and clinical discretion. J Law Med 2009;16:751–8.

Accident Compensation Act 2001. Available at: www.legislation.govt.nz/act/public/2001/0049/latest/DLM99494.html

Avery G. Law and ethics in nursing and healthcare: an introduction. London, Sage; 2013.

Rachels J, Rachels S. The elements of moral philosophy. 5th edn. Boston: McGraw-Hill; 2007.

Beauchamp T, Childress J. Principles of biomedical ethics. 5th edn. Oxford; 2001.

Moore M, Grundy K. CPR in New Zealand hospitals: an alternate perspective on lawfulness and ways to improve practice. N Z Med J 2011;124:72–9.

Foo A, Lee T, Soh C. Discrepancies in end-of-life decisions between elderly patients and their named surrogates. Ann Acad Med Singapore 2012;41:141–53.

Worthington R. Clinical issues on consent: some philosophical concerns. J Med Ethics 2002;28:377–80.

Sonnenblick M, Friedlander Y, Steinberg A. Dissociation between the wishes of terminally ill parents and decisions by their offspring. J Am Geriatr Soc 1992;41:599–604.

Marco C, Schears R. Societal opinions regarding CPR. Am J Emerg Med 2002;20:207–11.