CPR Denied

The national news story about a 87 year old in cardiac arrest and a bystanders refusal to perform CPR attracted my interest. The reported facts as follows. “The deceased, identified as Lorraine Bayless, collapsed in the dining room of the Glenwood Gardens independent senior living complex in Bakersfield on Tuesday. A staffer who identified herself as a nurse quickly called 911 from her cell phone, but refused to administer CPR, citing it was against company policy. Ms Bayless was later pronounced dead at a nearby hospital. ‘Is there anybody that’s willing to help this lady and not let her die,’ dispatcher Tracey Halvorson asked on a dramatic seven-minute 911 tape released by the Bakersfield Fire Department. ‘Not at this time,’ said the woman, who didn’t give her full name and said facility policy prevented her from giving the woman medical help.” At first glance this is a seemingly callous and foolish respect for a company policy by a “Nurse”. My initial response to the story was “Are you kidding me?”. Most of my colleagues found it surreal that a medical professional would withhold life saving help from someone, even though the 911 operator begged her to help.

Immediately the facility in question has begun “Damage Control”. “Christopher Finn, a spokesman for Brookdale Senior Living, which owns the Glenwood Gardens facility, told the Los Angeles Times that the unnamed caller was ‘serving in the capacity of a resident services director, not as a nurse.’ Finn would not say if the director was licensed as a nurse. It was later revealed that Ms Bayless had no Do Not Resuscitate form on file. However, it is against the policy of the retirement home to give CPR to residents of the independent living complex. The executive director at Glenwood, Jeffrey Toomer, said in a statement: ‘In the event of a health emergency at this independent living community, our practice is to immediately call emergency medical personnel for assistance and wait with the individual needing attention until such personnel arrives.” Often assisted living facilities have RN’s involved in management. It would be very unusual for a business director to identify themselves as a nurse unless they actually were a RN. It seems equally implausible to me that this person would bother to identify themselves as a nurse, only to then refuse to help. I know it sounds strange to lay people, but you have to know what to do, to then refuse doing it. A person who would falsely identify as a nurse would most likely volunteer to help. It is likely that she identified as a nurse to help the operator understand that this was a medical assessment. A non-medical person would have been panicky and attempted to follow instructions. So I will begin this discussion from the standpoint that this was a RN that refused to help.

The facts about CPR:

For this discussion, the facility is considered a community site. Meaning assisted living is not medical care and not a medical facility. From a CPR standpoint it is no different than your local mall.

Hospital CPR Success:
Literature
– Survival 6.5%-32% – average 15%
• At least 44% of survivors have significant
decline in functional status.

Overall CPR Success rate.
1. Average rate of success (overall) 15%
2. Ventricular fibrillation after myocardial 26-46%
infarction
3. Drug reaction or overdose 22-28%
4. Acute stroke 0-3%
5. Bedfast patients with metastatic cancer 0-3%
who are spending fifty percent of their
time in bed
6. End stage liver disease 0-3%
7. Dementia requiring long-term care 0-3%
8. Coma (traumatic or non-traumatic) 0-3%
9. Multiple (2 or more) organ system 0-3%
consecutive days in the ICU
10. Unsuccessful out-of-hospital CPR 0-3%
11. Acute and chronic renal failure 0-10%
12. Elderly patients Same as
general population
13. Chronically ill elderly 0-5%

The purpose of cardiopulmonary resuscitation is the prevention of sudden, unexpected death. Cardiopulmonary resuscitation is not indicated in cases of terminal irreversible illness where death is expected or where prolonged cardiac arrest dictates the futility of resuscitation efforts. For many people the last beat of their heart should be the last beat of their heart. These people simply have reached the end of their life. A disease process reaches the end of its clinical course and a human life stops. In these circumstances resuscitation is unwanted, unneeded and impossible. If started, resuscitative efforts for those people are inappropriate, futile and undignified.They are demeaning to both the patient and rescuers.

Public Misperception of CPR:
67% of resuscitations are successful on TV
Major study evaluating a patient’s desire for CPR.
– 371 patients, age >60yrs
– 41% wanted CPR
After learning the probability of survival only 22%
wanted CPR.

Realistically an 87 year old woman, with chronic illness, outside of a hospital has little chance of surviving even if CPR was done. It is not the same as zero chance.

In my opinion there are 3 pertinent questions in this situation.

1. Are you able to help? The medical maxim”You can only improve a dead person’s condition” does not mean try anything? You need some knowledge(not TV knowledge).
2. What are her wishes? You assume that everyone one wants to be resuscitated. Unless you have specific indications to the contrary.
3. Is it safe to help?  For example: You getting shot will not help someone, it will just add you to the body pile. Doing CPR in the middle of the highway is a “good” way to commit suicide.

I think it is safe to assume that the person was capable of providing CPR or at least taking direction from 911 operator. A cardiac arrest in the dining room of a assisted living facility does not usually constitute a safety issue. I think that it is also reasonable to exclude criminal, or sadistic motive given the 911 call. You are left with two realistic reasons. You have a person who is ethically challenged, and places work policies above human life. The second option is grim but plausible. Residents may have made tacit agreement to a DNR or Do Not Resuscitate order by living there. Specifically residents know that there is no regular staff trained in CPR and medical care will have to wait for the ambulance to arrive. In this situation a person may want to live there so that the will not receive unwanted life saving measures. This fits with the available facts. Today the family has made a public statement indicating that this policy is one of the reasons she chose this facility. Given the fact that the family has come out in support of the workers actions I tend to believe that the deceased may have not wanted to be resuscitated.

Nothing illegal has been done. First of all California is a Good Samaritan law state. It does not require that you help. Rather the law prevents you from being sued unless your are really outside of what is reasonable. Secondly the facility policy is not “Let Them Die.”. In fact the policy is reasonable. It requires that someone calls for help and stays by the person until help arrives. This policy makes a great deal of sense, if the majority of your staff is non-medical, and they are not trained for CPR. From a litigation standpoint, if this resident received CPR, it may set a precedent requiring future CPR for residents. Or worse one CPR event may open them up to litigation from previously deceased resident’s family. Not being a lawyer in California I am not certain about this. It is a plausible reason to have the policy. Ultimately legal standing does not say anything about the ethical decision to follow this policy to the letter.

I do not agree with the decision. Unless I knew personally that this woman did not want CPR it should have been done. My opinion. This may have been a person who had had been indoctrinated in this policy, and decided to follow it to the letter. Maybe this person may have been involved with drafting this policy and the reasons for it. She did not make a thoughtful decision but I find it hard to believe that this was laziness, or malice. Given the national attention I suspect she will be disciplined for this. Especially given the sensational nature and the negative coverage. Unless there are major details that are different than reported. She should be disciplined.

For the larger issue of elderly life saving procedures I also have a few opinions.  If you are a provider always err on the side of life. If there are clear wishes given by the patient they must be honored. Policies are irrelevant you can always get new job, you can’t bring someone back. If you are elderly or terminal and your wish is no heroic measures, make sure you are clear about that to everyone.

I have personally performed CPR on elderly women, it is not a pleasant experience for the patient. If they survive initially, they frequently do not make it out of the hospital. They end up with fractured ribs(among other injuries). Commonly CPR is not a single event and has to be done several times. If you have ever performed CPR on someone you quickly recognize why people have Do Not Resuscitate orders. Over age 80, even in the statistically “best situation”(the hospital ICU), only 1 in 5 survive. Ultimately the nurse’s decision may have not done anything to shorten that woman’s life.

Based on her family’s reaction, I think it reasonable to conclude that what happened is what she wanted. A”DNR” is all well and good legally, and would exonerate the nurse’s behavior. Still in reality if her wishes weren’t clear to her family. I am sure they would have voiced outrage over the refusal.

To end on a personal note. I think it is unconscionable that the fire department released the emotional 911 tapes to the media. No crime was committed. The only reason for this was to have the facility and worker publicly vilified. This was done without understanding the details of the case or speaking to the family. Not fair to the woman, her family, or their privacy.

References:

http://www.dailymail.co.uk/news/article-2288562/Officials-senior-living-facility-87-year-old-woman-died-say-staffer-denied-CPR-NOT-nurse-revealed-deceased-DNR-file.html

http://www.compassionandsupport.org/pdfs/professionals/training/111205MythsTruthsCPR.pdf

http://www.compassionandsupport.org/index.php/for_professionals/molst_training_center/cpr

Professionals
Cardiopulmonary Resuscitation (CPR)
References
i
Tulsky JA, et al. How do medical residents discuss resuscitation with patients? JGIM, 1995;
10:436-442
ii Fischer GS, et al. Patient knowledge and physician predictions of treatment preferences after
discussion of advance directives. JGIM, 1998;13:447-454
iii Fairbanks, R.J., Shah, M.N., Lerner, E.B., Ilangovan, K., Pennington, E.C., Schneider, S.M.
(2007) Epidemiology and Outcomes of out-of-hospital cardiac arrest in Rochester, New York.
Resuscitation. 72, 415-424.
iv Miller DL, et al. Factors influencing physicians in recommending in-hospital cardiopulmonary
resuscitation. Arch Intern Med, 1993;153:1999-2003
v
Zoch TW, Desbians NA, et al. Short- and long-term survival after cardiopulmonary resuscitation.
Arch Intern Med, 2000; 160:1969-1973
vi Rabinstein AA, et al. Cardiopulmonary resuscitation in critically ill neurologic-neurosurgical
patients. Mayo Clin Proc, 2004;79(11):1391-5
vii Annals Int Med 1989; 111:199-205
viii JAMA 1990; 264:2109-2110
ix EPEC Project RWJ Foundation, 1999
x
Diem SJ, Lantos JD, Tulsky JA. Cardiopulmonary resuscitation on television: miracles and
misinformation. NEJM,1996:334:1578-1582
xi Jones GK, Brewer KL, Garrison HG. Public expectations of survival following cardiopulmonary
resuscitation. Acad Emer Med, 2000;7(1):48-53

About Stephen Propatier

Stephen Propatier is a board certified acute care nurse practitioner specializing in spine and sports medicine. He is a member of the Society for Science Based Medicine.
This entry was posted in Health, TV & Media. Bookmark the permalink.

24 Responses to CPR Denied

  1. James Beattie says:

    There was a goof Radiolab short about this topic: http://www.radiolab.org/blogs/radiolab-blog/2013/jan/15/bitter-end/

  2. gwen says:

    As a registered nurse ‘dinosaur’, that would be the kind of nursing home I would love to spend my last days in. Working in ICU settings from 1980 to 2005, I can verify I have seen no successful CPR community interventions of an elderly person, even in the ICU under optimal conditions, it is very dicey. It makes me sad to do futile CPR on someone who’s bones are cracking under my compressions, and I know suffered from end stage dementia even before the code, where the family told us to do EVERYTHING for dear old mom/dad…even after we tell them WHAT everything is. My mom gave me power of attorney for her health care, and I mad sure she was a Do not intubate and Do No Resuscitate and no tube feedings after losing her battle with cancer. IV fluid with omfort and pain relief measures only until she died peacefully.

  3. nat williams says:

    “To end on a personal note. I think it is unconscionable that the fire department released the emotional 911 tapes to the media. No crime was committed. The only reason for this was to have the facility and worker publicly vilified. This was done without understanding the details of the case or speaking to the family. Not fair to the woman, her family, or their privacy.”

    The biggest crime of the entire ordeal is the public release of that data. As I studied the matter earlier today I found the DNR and families reactions to all line up, and as a result I believe the rush to vilify the nurse is the most egregious offense committed in this media splash. A person acting on behalf of a terminal patient’s wishes should be rewarded. Thank you for your (as always) thoughtful article.

  4. Jordan says:

    This is coincidental timing with a recent radiolab episode, or a rip off…

  5. I know from first hand experience that CPR is not always successful. It seems to me that this was a story that was reported on for shock value in order to gain ratings. On the other hand, CPR training is a relatively quick and painless process. If your business involves caring for people who may need this, why not train the staff?

  6. Innominata says:

    Best part of the article is the last paragraph.
    Should have put that at the top.

  7. Jim Clewell says:

    this is definitely a must read!!! I unfortunately know colleague nurses who are CPR believers….

  8. David R. says:

    I was pleasantly surprised by the article, it seemed to be going a different way initially. Well done. The 911 recording was used on a radio show and provided fodder for an entire hour of vilifying and disparaging the ‘nurse’. In the recording the ‘nurse’ is calm and professional, the 911 person is emotional, paniced and unprofessional. She sounded like she had never taken a call on an elderly patient like this. She obviously had no concept of the ramifications.

  9. Justin Nnoix says:

    as someone who is planning to sue for my right to seek assistance to kill myself when i deem fit, i’m fully on the nursing homes side. DNR means DNR. and if the place specifically markets itself as a place where old people can go to die without worrying about bumbling buffoons breaking their chest and making their lives miserable for the short duration left, than thats the service they provide. Life is only worth living if you want to keep living. people who’s lives are not 24/7 agony have absolutely no concept of having a legitimate desire to die, while still not wanting to kill yourself, and i pray they never will.

  10. Tom Hodgson says:

    If I were 87, I’d have a DNR… As would any reasonable 87 year old with any knowledge of the likely outcomes of CPR… So I’d assume the person was reasonable, and not attempt to resuscitate. Should be a rule.
    Organ donation should be opt-out (donate all by default).
    Lots of reasonable actions are argued down by noisemakers in our culture. It’s a shame reason doesn’t win out.

  11. As a human being your first instinct should be to help. As a paramedic we/I know that the sooner CPR starts the higher the averages of success you used increase. Though I’m on the fence about whether the tapes should have been released, I’m hoping the outrage I hear from most people about this story makes them take a CPR course.

  12. Compression-only CPR has a significantly higher success rate, though it’s likely that is a function of age as well.

    • Stephen Propatier says:

      I am not knocking what you are saying. But here is the truth about compression only CPR. The statistical improvement in compression only CPR, stems from the fact that people are hesitant to do mouth to mouth. So there was a lot of hesitation in doing CPR with mouth to mouth. The AHA studies done in hospital settings( where there is AMBU bag ventilation), show equivocal statistical findings with and without ventilation. AHA decided to advise compression only because more people were willing to do it. Compression only CPR does not have better outcomes, just better rescuer compliance.

      • gymgoki says:

        I concur 100%. Mouth to mouth is gross under the best of circumstances. When people collapse and need CPR it means they have a really low blood pressure or no blood pressure. Both of these situations tends to make people vomit.

  13. Todd says:

    Thank you very much for this analysis. I find it very hard not to be outraged by the story, even after reading your analysis but you’ve definitely helped me to put it into broader perspective with your analysis. In general we admonish each other to help those who can’t help themselves, even against our initial hesitation, and this is a very central principle of civilized society, and I think a good impulse to cultivate. There are still specific situations where active intervention isn’t neccessarily the best course of action though upon reflection, and our evaluation should consider people’s practical understanding of the situation, not just its idealized principles and our impulse of outrage.

  14. gymgoki says:

    All was appropriate except the tape release. The only benefit of this was to serve the political agenda of the news outlet….unconscionable IS the word.

    I’m a physician and I thought the above mentioned Radiolab piece was spot-on. See: “The Bitter End”

    In talking to my family (including in-laws) about end of life concerns, I tell them that specific scenarios of acute onset of “ill health” will be unpredictable. And given this, I will have a strong tendency to let you die, meaning an early DNR order and probable withdrawal of support. I’ve done it with my grandma and my mom and I sleep really well.

    I can only remember one “field” CPR resulting in a good quality outcome. That case was a SAVE. (The first responder was a doctor…so I don’t know if that helped….I really don’t). Based on this one case….I guess I support community CPR, but bear in mind that the vast majority of these cases don’t survive and if so with a horrible outcome….. I would like to hear other’s views.

    Last month: (CNN) — Comatose for seven years, Israel’s iconic former Prime Minister Ariel Sharon is showing “significant brain activity.” He can’t communicate, has a feeding tube and has been on a ventilator for seven years………………should we be happy about the brain activity? ….I recoil in horror.

  15. Anonymous says:

    Good article. As for the 911 tape release, 911 tapes are public record. In criminal cases release of 911 tapes can be delayed by the police if they believe they interfere with a investigation. Otherwise, they can’t be kept private. They can be edited (bleeped, redacted) to protect identities, addresses, phone numbers, etc.
    ES

    • Stephen Propatier says:

      I understand what you are saying. It is a good point. My question is how did the news media outlet find out about it? I am doubtful that they routinely check all 911 calls. Someone had to bring this to their attention. I find it hard to believe that the facility or the family contacted the media about this.

      • Anonymous says:

        That’s a good question. Without more information we can only speculate. Could have been the 911 operator; someone in that department; a family member; an employee of the facility who doesn’t like the policy; an enterprising reporter who noticed an unusually long call in the log. Your guess is as good as any.

        Also the laws governing the release of tapes varies from state to state. In California they are public record. Your milage may vary.

        http://www.firstamendmentcenter.org/911-recordings-transcripts-state-statutes

        ES

  16. Jon Richfield says:

    A good, thoughtful discussion, both the article and the responses. Well done all round.

  17. Robert Hale says:

    great blog, Brian. I appreciate how you walk through each element. This teaches all of us rational thinking.
    BTW Typo here?
    “so that the [they?] will not receive”

  18. Myfanwy Coghill says:

    I have to say, after the Radiolab episode examining physicians own wishes for end-of-life care ( http://www.radiolab.org/blogs/radiolab-blog/2013/jan/15/bitter-end/ ) I am seriously inclined to reject medical interventions in the case of my own unrecoverable brain injury or terminal illness. The aggressive attempt to prolong life robs us of a dignified end.
    In the case of the incident examined in the article, I feel strongly that unless some wrongdoing or criminal behaviour has taken place, it’s none of anyone else’s business and is entirely between the family and the care facility. We can debate the issues all we like, but I know that I would not want my final moments to become a major scandal potentially costing someone their job.

  19. Stephanie C. says:

    Good article. Sometimes I think our society has become addicted to “public outrage”. May common sense rule.

Leave a Reply

Your email address will not be published. Required fields are marked *