Reimagining resuscitation ethics: a narrative review and emergent ethical pathways model

Background: Decision-making surrounding cardiopulmonary resuscitation (CPR) presents persistent ethical challenges in acute and critical care. Existing evidence points to ambiguous do-not-resuscitate pathways, moral distress, family-driven demands, and systemic pressures, yet these influences are often examined separately. This review synthesizes current evidence to clarify the ethical, relational, and organizational dynamics that influence CPR-related decisions. Methods: We conducted a structured narrative review of four databases (Web of Science, PubMed, Scopus, Embase) for studies published between 2020 and 2025. Eligible studies included. Data was analyzed using reflexive thematic analysis. Results: Twenty-two studies were included. Seven interrelated themes emerged: (1) Futility, inappropriate and symbolic CPR; (2) Moral distress, emotional burden and moral residue; (3) Ethical ambiguity and unclear decision pathways; (4) Hierarchy, power and constrained nursing moral agency; (5) Family influence, cultural and religious norms, and truth-telling practices; (6) Systemic, legal and organizational drivers of ethically problematic practice; and (7) Ethical competence, moral sensitivity, advocacy and ethics support. Together, these findings informed the development of an Ethical Pathways Model (EPM) that conceptually depicts how contextual, relational, and individual determinants may converge to shape ethical decision trajectories in resuscitation and how conflicted pathways may contribute to symbolic or non-beneficial CPR and clinician moral distress. Conclusions: Ethical challenges in resuscitation are largely system-produced rather than individual failings. The EPM offers an integrative conceptual framework that may help inform clearer policies, strengthen communication, and guide the development of accessible ethics support to promote more value-concordant resuscitation care and reduce clinician moral distress.