Letting the nurse perform CPR? Against our policy

by Walter Olson on March 5, 2013

After all, what if something should go wrong? Following a resident’s death, a California senior facility defends its “protocol” of ordering nurses to stand by for rescue personnel rather than perform CPR themselves [L.A. Times]

More: Plenty of pushback from readers, including warnings that CPR is not necessarily an appropriate or desired intervention in the resident’s situation, even in an independent-living arrangement in the absence of a DNR (do not resuscitate) order. The resident’s family has expressed satisfaction with the senior facility’s actions and says it has no plans to sue. More: ABA Journal, White Coat.

{ 34 comments }

1 MattS 03.05.13 at 11:01 am

Given what I have read elsewhere on this story I suspect that the assisted living facility in question was employing people as nurses who were not actually qualified as nurses. I suspect that the anti-CPR policy was not about civil liability but to avoid getting caught employing unqualified “nurses”. Given the publicity this event has gotten and the investigations that are being done, that policy will be a total fail.

2 Jim 03.05.13 at 11:06 am

Frankly, the cause of death that should appear on the death certificate is “rational fear of litigation”.

This is the natural end result of a culture of after-the-fact micro second guessing by the litigious. It appears the poor woman’s daughter isn’t actually one of those, so I guess this is a case of second-hand litigation fears.

I don’t blame the nurse or the home. Blame the lawsuit happy culture.

3 Steve Parker, M.D. 03.05.13 at 11:25 am

I would think the nurse has an ethical duty to perform CPR. Some states might revoke her license for not doing so.

-Steve

4 Mike Z 03.05.13 at 12:20 pm

Actually I would blame the nurse here. If you click the link in the article to the 911 tape, the dispatcher states “The dispatcher assured the nurse Glenwood couldn’t be sued if anything went wrong with CPR. The lcoal emegency medical system “Takes the liability for this call,” the dispatcher said. ”

Assuming the nurse in question was actually a certified nurse, I’d assume they should already know this. At the very least the Home should know this when it was writing its policy.

5 Suki 03.05.13 at 1:03 pm

This is so ridiculous, I don’t even know how to respond to it. In most states it is illegal to call oneself a “nurse” unless you are truly a nurse. To not give CPR to an individual is just plain not right. Unless you are physically unable to do so yourself (then you should not work in such a facility) or the patient was considered a DNR person? No one has mentioned her status with records to this.

6 Mark Hartzler 03.05.13 at 1:25 pm

I agree with Jim’s comment. If she violates her employer’s policy, she may be out of work. If she violates her employer’s policy, she may not be covered by her employer’s insurance. If she acted “for compensation” or medical care is “usually offered” at her place of employment, she might not be shielded by California’s Good Samaritan law. This is the perfect article for Overlawyered. Trying to figure out her rights under the competing ethical rules, employer polices, and legal statutes would have any sane person pulling out their hair. You may argue she should have risked her livelihood and done the “right thing,” but I hate it when the law makes doing the right thing the wrong thing. Plus, it’s a tough time to be out of work if your family depends on you.

7 Andy 03.05.13 at 1:29 pm

the nurse was probably a caretaker rather than an RN. the woman who passed was 87. An untrained person doing CPR on her probably would’ve just crushed her brittle ribs and sped up her demise.

8 L Nettles 03.05.13 at 1:31 pm

This was an independent living facility, not assisted living or skilled care. Independent living means meals and transportation are available to someone otherwise able to live on their own.

9 MattS 03.05.13 at 1:46 pm

Dr Parker,

See my prior comment. I would not be at all surprised to find out that the “nurse” involved is not licensed in the first place.

10 John David Galt 03.05.13 at 1:58 pm

Because of the way the courts have been known to make things up in “emergency” situations, no “good samaritan law” is ever going to be able to relieve the nursing home of the fear-of-liability that provoked this policy.

Therefore it seems to me that the law needs to make this nurse override them. Threaten the next one like her with jail for manslaughter, or threaten the home with a suit for wrongful death (which should be tried anyway), or both. Because this outcome is worse than unnecessary, it’s just plain stupid.

11 Anonymous Nicholas 03.05.13 at 2:06 pm

Next thing, you’ll want to force laypeople to perform tubal ligation whenever someone chokes.

No, sorry, this policy is there to prevent greater tragedies. If you aren’t qualified to perform tubal ligation, you shouldn’t perform tubal ligation. If you aren’t qualified to perform CPR, you shouldn’t be performing CPR. Clearly the “nurse” in this story was not qualified to perform CPR.

Stop trying to weigh down free people with the chains of expectation to perform medical interventions.

12 Bobbye 03.05.13 at 2:43 pm

This 85y/o lady was living in an assisted living facility that had a policy of DNR which she was well aware of. She was probably there insteed of in a facility that would do CPR because THAT was her choice. Regardless of this lady’s and her family’s wishes, almost everyone on every website wanted her rescusitated because a low level government employee thought she should be. This website shows me that there is no such thing as a libertarian, just people who tent toward totaltarianism.

13 No Name Guy 03.05.13 at 2:43 pm

Andy: Actually, breaking ribs is STANDARD in any CPR situation. My instructor indicated that it was normal and expected to hear the cracking sound for the first several compressions if you’re doing ‘em right.

Galt: Manslaughter? Wrongful death? Do you even KNOW what percentage of CPR actions actually revive the deceased? (Yes, deceased – they’re already DEAD at the point CPR is started, you know, a non-functional heart. CPR is just there to keep semi-oxygenated blood flowing to the brain to slow it’s death, hopefully until real medical care can get there.) Again, my instructor emphasized that if the spaghetti hits the fan and we actually need to do CPR, do it and do it well, but in the end the odds of survival aren’t all that great so don’t get into the “what-if-I-had-done-it better” guilt trip. At best you’re throwing the dice and hoping double sixes come up. Google “odds of CPR working”, read the first half dozen and please re-evaluate “manslaughter” and “wrongful death”.

14 Bumper 03.05.13 at 3:16 pm

MattS wins. Fox is reporting that the attendant was not a nurse. That is however irrelevant as lay people of all types take classes in and perform CPR all the time. However, the success stories when out in the wild are far and few in between. That said the women was 87 and probably would have died anyway, but you never know. Not having been there I can only surmise that based on the stories she was in respiratory distress, in which case a nasal catheter and a shot of oxygen just might have done the trick. As always there are more questions than answers, for one what was her quality of life before this event?

15 MattS 03.05.13 at 4:08 pm

The facility where this happened is now claiming the woman who refused to do CPR was not working as a nurse. I think my original speculation is correct that they had unqualified people working as nurses and are now trying to avoid liability for that.

http://www.foxnews.com/us/2013/03/05/spokesman-says-woman-who-refused-to-give-cpr-to-dying-87-year-old-wasnt-nurse/?test=latestnews

16 Bumper 03.05.13 at 4:10 pm

Anonymous Nicholas did you intubation? I really don’t think that a tubal ligation would be of much value when the person is choking, perhaps a better choice would be to do the “Heineken maneuver.”

True story, when I was at a family gathering some two decades ago my sister got a piece of food caught in her windpipe and I performed a Heimlich maneuver and quickly dispatched the offending piece of lettuce. Her then husband, a man not know for his eruditeness,, came up to me afterwards and thanked me for doing the Heineken on her. Had he known then what he knows now he might have preferred I hadn’t been in attendance.

17 coop 03.05.13 at 4:21 pm

@Anonymous Nicholas
I’m confused –

“Next thing, you’ll want to force laypeople to perform tubal ligation whenever someone chokes.”

How would that help? ;-)

Personally, I’m not in favour of forcing anyone, lay or otherwise, to perform a tubal ligation on a choking person…. what tubes are you talking about, fallopian, vas deferens, or esophagus?

18 gitarcarver 03.05.13 at 4:57 pm

The FoxNews report only says that she was not working as a nurse, not that she was not a nurse. It makes no sense to me to be on the phone with a 911 dispatcher and identify yourself as a nurse if you are not one instead of identifying yourself as the “resident services director.”

Secondly, not only did this woman not perform CPR, she and her boss prevented others from doing so. She would not allow other residents to try even after being informed there would be no liability.

It seems that this woman, her boss and the firm for which she works were so worried about legal repercussions that she forgot to be a moral, ethical and caring human being.

19 Anonymous Nicholas 03.05.13 at 5:09 pm

LOL@coop. I’m talking about the fallopian tubes, obviously. You know, the ones that carry the fallopiates into the guggenheim.

See? That’s why we don’t have rules forcing people to perform medical procedures. Because we don’t know what the hell we are doing and too often get it wrong!

20 coop 03.05.13 at 8:17 pm

@Anonymous Nicholas

Sorry, I couldn’t resist! Thanks for taking the comment in the lighthearted vein it was intended.

;-)

21 david7134 03.05.13 at 8:18 pm

Ok, I actually work with nursing homes daily. Therefore, my comments are not uniformed speculation. At first this seemed alarming until I thought it out. Most nursing homes have only one or two actual RN’s, especially resident homes such as this. Now, the attendant would not be qualified to do CPR in a medical facility as she is not ACLS qualified. Therefore, if she attempted anything in the setting, she could be prosecuted. The firemen are ACLS qualified. For that matter, as a cardiologist, I refuse to do basic life support or ACLS as I don’t think the AHA is a qualified educational or academic authority and my training included all the necessary information about sustaining life or reviving patients without the permission of the AHA. So the real culprit here is actually the American Heart Association. They have taken the postion of authorizing people and this is recognized in all courts. In fact, it is so bad that most people will avoid a code in a hospital due to liability issues and the bunk fostered by the AHA.

If any of you lawyers want to make a buck, start suing the AHA. They do not keep adequate reasons for there ACLS dictates and most of it is out of date. Many of the courses are taught by people that have never resucitated someone, even housewives.

Then we have the concept of the living will. How many people that are 87 years old want to continue to live under artifical circumstances? In my experience (copious) the number is close to zero. The only reason it is not zero is many have mental problems that prevent rational thoughts. Many elderly patients family desire for the people to live, no matter what, so frequently you have to intervene to stop them from being tortured by the family.

I think the attendant did the appropriate thing. And it was what is usually done. Get used to it under Obamacare.

22 Steve Stibbens 03.05.13 at 8:47 pm

“But I was just following orders…” It didn’t work at Nuremberg and it won’t work here.

23 OldNurse2 03.05.13 at 10:01 pm

As an RN for 40 years, I have to disagree with most of the above comments. We nurses aren’t just taught to give CPR – when justified, I might add. We’re also taught extensively about death with dignity.

This poor woman was 87 years old for goodness’ sake! The result of trying to do CPR on her if the procedure was successful, which is highly doubtful, may wel ahve caused extreme needless suffering.

CPR is nor just as matter of breathing in & pumping on their chest. First, the success rate is very low, especially for older adults. Second, should she have been miraculously revived, what extensive ICU medical care required afterwards, might well have been felt by her, and her family, to be nothing short of pure torture!

Would any of you really want to see an 80+ year old beloved relative put through all that pain, IV’s, hooked to a respirator – possibly for the rest of their life, etc., after they awoke? Especially, since they would, in all likelihood, die anyway, even if they did wake up?

I’m afraid the public still has a long way to go to really understanding, not only a nurse’s true role, but, at that advanced age, one’s mortality must be accepted, and the person allowed to die with dignity.

24 nevins 03.05.13 at 10:33 pm

” For that matter, as a cardiologist, I refuse to do basic life support or ACLS…” Yeah, I think David7134, if he really is a cardiologist, should keep a tight wrap on anonymity. This is not the kind of physician I want treating me.

25 gitarcarver 03.05.13 at 11:44 pm

The issue I have with both david;s and OldNurse’s comments is that they both are based on the premisw the woman was in a nursing home or assisted living facility. She was not. She was in an independant living facility which means she was self sufficient.

Any speculation as to what may have happened after the heart attck us just that – speculation. We’ll never know what would have happened because the nurse and her supervisors let her die in a dining roon.

26 MattS 03.05.13 at 11:58 pm

david7134,

The facility in question was assisted living, not a nursing home.

27 WhiteCoat 03.06.13 at 12:51 am

The degree of misinformation and possibly even disinformation in some of these comments me shake my head.

You lynch mobbers want to put down your torches and pitchforks, step back, and re-read the article MattS posted in comment 15?
The patient *didn’t want life-prolonging intervention*. That’s the definition of “DNR” although the article didn’t come right out and say it. Go ahead, Google the term “DNR order”. I’ll wait.

Now of course everyone knows that performing CPR on a patient with a DNR order would have been medically inappropriate and would have amounted to an unwanted touching which could result in criminal charges of assault and/or battery.
Ethical duty to perform CPR on a DNR patient? Manslaughter charges for allowing a patient to die peacefully? Meh. Who cares? Someone DIED, we don’t know all the facts and let’s just harangue this nurse so we can feel self-righteous! After that we can tell everybody involved to just SUE everyone else so we feel good about ourselves.

I’m betting that if the nurse performed CPR and some news report said that she didn’t do it correctly then everyone would pound their collective chests and write comments recommending that the nurse and her employer be SUED for misfeasance instead of nonfeasance … after filing reckless homicide charges against them. Maybe even elder abuse charges for good measure. Yeah!

For those of you who think every nurse should know CPR, I’ve got news for you. There are a *lot* of nurses and doctors who don’t know how to perform CPR and don’t *need* to know how to perform CPR. Administrators with medical degrees usually don’t keep up their clinical skills. Why would they?

Alleging that the nurse was an uncaring human and making Nazi references to this case? Unbelievable.

28 William Nuesslein 03.06.13 at 6:45 am

Kevin Pho has a great post on the humanity of CPR in situations like the one in the instant item.

http://www.kevinmd.com/blog/2013/02/physicians-tend-decline-cpr-heroic-measures.html

Withholding CPR quite probably was the right course of action.

Unfortunately plaintiffs’ lawyers have you coming and going. Apply CPR and get sued when it doesn’t work right. Withhold the CPR and get sued. What drives me nuts is the claim “if I only I new” to justify payments while people fight to be included in experiments to establish what it is to be known.

29 asdfasdf 03.06.13 at 7:29 am

The family of the dead woman supported the decision not to perform CPR.

They state “it was our beloved mother and grandmother’s wish to die naturally and without any kind of life-prolonging intervention. Our family respects the right of all people to make their own life choices in such cases”. See http://www.bakersfieldcalifornian.com/local/x837006764/Family-We-dont-intend-to-sue-Glenwood-Gardens .

One of the remarkable things about the family’s comments is that they are voluntarily foregoing the right to sue, simply because they knew the facility was acting in the best interest of their relative. This is the precise opposite of most stories on this blog, which involve people violating moral precepts to make a buck: here the family is doing the right thing and foregoing the cash. Why this blog implicitly seems to be second-guessing their reasonable and ethical approach is one of those enigmatic editorial decisions that I find difficult to reconcile with its nominal conservative stance.

30 Jim 03.06.13 at 10:01 am

I saw my own mother after one of those “medical interventions”.

A sight that remains with me a decade later, and one I’d have spared her from.

My regards to a decent family raised by a decent woman, now sadly beyond us.

31 MikeZ 03.06.13 at 10:35 am

WhiteCoat,
I’d suggest whether or not there was a DNR in place isn’t a clear issue. From the below link, when EMTs arrived on the scene they couldn’t find any evidence of a DNR and attempted CPR. If they couldn’t find the DNR then the ‘Nurse’ didn’t have access to it either. As for getting sued taking blame for incorrectly performing CPR, that was handled in the 911 call. The dispatcher made it clear they were giving instructions and assuming responsibility.

http://www.bakersfieldcalifornian.com/local/x738926924/Police-probe-Glenwood-Gardens-death?utm_source=widget_63&utm_medium=latest_entries_widget&utm_campaign=synapse

Now there are articles that show the daughter ‘believed’ the mother had a DNR, and this outcome may have been for the best. However the daughter’s belief may have no basis in reality. I’d give more weight to the fact that the EMTs didn’t find a DNR than any belief with no evidence.

32 Liz 03.06.13 at 2:28 pm

Personally, I suspect that there is a different reason for the company policy. Assisted living facilities provide medical services and have to be licensed and meet a lot of regulatory requirements. Independent living facilities do not provide medical services, so they do not have to go through all of that. If employees perform CPR on residents whenever one of them has a cardiac or respiratory event, that could be construed as providing medical services. The next time a resident died after being given CPR you can bet their family’s lawyer would claim they were operating an unlicensed assisted living facility and use previous cpr attempts to prove that the facility provided illegal unlicensed medical services. The state could also come after them. Frankly, I am surprised that no one is looking at that angle.

33 OldNurse2 03.07.13 at 2:08 am

Gitarcarver, my post was not based on the fact that she was in a facility. I don’t care if she was in one or not. If you knew what really happens to a person after receiving CPR, you might re-think you position too. CPR is not a cake walk. You don’t just breathe into someone’s mouth, pump on their chest, and that’s it. Far from it!

First, even in younger people, CPR done at the scene is usually not successful. Even CPR done at the hospital, with a full ICU response team, and all the drugs, and IV’s is not always successful.

Second, you’re talking about an 87 year old woman who would have very brittle, easily cracked, chest ribs, which could puncture her heart or lungs. Very dangerous, especially in someone her age.

All this is moot anyway, as it’s been reported twice now that the woman was still breathing. And it was reported by a nurse that she had a pulse too. In other words, she was unconscious. You don’t do CPR on someone who is breathing and has a pulse! Give oxygen in the ambo, yes. CPR? No. What would be the point?

And as far as the facility comments? It appears like they’re trying to throw the nurse under the bus, which is very typical of these kinds of facilities.

34 Bumper 03.08.13 at 4:20 am

I would hope that the readers of this thread would not let some of the comments of some of medical professionals posting here deter them from learning CPR and being prepared to use it the time ever comes. It is not that difficult a procedure and while the success ratio may not be over whelming CPR can and does work. I know, I’ve been resuscitating people for over 50 years, my first was as a teen age lifeguard and my last was a year and a half ago at a board meeting for a non-profit I sit on, and there were more than I can ever remember during my clinical days.

The event that led to this discussion were unique and many of the points made are appropriate only to this specific event and certainly the nature of this blog influenced the context of the discussion. But this event was an outlier and should be taken as such and while the odds of survival are slim when attempting CPR if nobody does anything they are zero.

So take a class and be prepared, I hope you never have to use your new skills, but if you do the life you save may be your spouse, your child or a total stranger. Regardless of the outcome you will rest better knowing that you did everything in your power to help.

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