Nurse refuses to perform CPR on elderly woman

[mycrofft]

Assitsed living facility with policy residents sign for if they sign in that says they do'y do codes.
I've seen some nurses back away from doing codes where they are expected to.
I've seen responders and nurses who shoulda.

 

[ExpatMedic0]

This sounds like an assisted living facility and not a skilled nursing home. The nurse is most likely an lpn.

I do not think it matters. I do not understand how someone with a medical licence, on duty, working under that medical licence, does not have a "duty to act"? The woman had no DNR or advance directives from what we can see.

From a legal perspective does anyone know any type of business, or agency that can mandate their medical employees not do CPR? Would this not interfere with the Nurses licence?

 

[firecoins]

Assisted living does not provide services a skilled nursing facility brings.

2nd the nurses work under someone else's license and that person does not permit them to do CPR. They lose their job if they do. They do not have a duty to act.

 

[ExpatMedic0]

The living facility issued this statment:

“In the event of a health emergency at this independent living community, our practice is to immediately call emergency medical personnel for assistance and to wait with the individual needing attention until such personnel arrives. That is the protocol we followed,” the statement said.

However, a Nurse holds a licence not a certification. Licensure is the state’s grant of legal authority, pursuant to the state’s police powers, to practice a profession within a designated scope of practice.

According to Texas(just using this as a quick google search example) The say the following for their nurses.

"Two of the main rules that relate to nursing practice are Rules 217.11 Standards of Nursing Practice, and 217.12 Unprofessional Conduct. The standard that serves as the foundation for all other standards is rule 217.11(1) (B)"...maintain a safe environment for clients and others." This standard supersedes any physician order, facility policy, or administrative directive."

If the person was hired under the title and licence of "nurse" I do not see how a facility, company, nursing home, taco truck, super market, whatever, can prevent a nurse from doing CPR? how on earth is this legal?

 

[WTEngel]

Fascinating how the facility thinks that policy supersedes common sense. Common sense would dictate to even the average person, if they are unconscious and not breathing normally, at the very least open the airway, and most likely begin compressions.

Haven't we been pushing this into the community ad nauseum for years now...hopefully it will reach the directors of this facility soon enough.

Again, I think this outcome was most likely with or without CPR, and this probably limited the patient suffering...but those decisions are not for anyone other than the patient and family to make with the guidance of a physician. No nurse, medic, RT, or otherwise gets to decide on the fly when they do and do not do CPR in the absence of an advanced directive.

 

[Veneficus]

The living facility issued this statment:

“In the event of a health emergency at this independent living community, our practice is to immediately call emergency medical personnel for assistance and to wait with the individual needing attention until such personnel arrives. That is the protocol we followed,” the statement said.

However, a Nurse holds a licence not a certification. Licensure is the state’s grant of legal authority, pursuant to the state’s police powers, to practice a profession within a designated scope of practice.

According to Texas(just using this as a quick google search example) The say the following for their nurses.

"Two of the main rules that relate to nursing practice are Rules 217.11 Standards of Nursing Practice, and 217.12 Unprofessional Conduct. The standard that serves as the foundation for all other standards is rule 217.11(1) (B)"...maintain a safe environment for clients and others." This standard supersedes any physician order, facility policy, or administrative directive."

If the person was hired under the title and licence of "nurse" I do not see how a facility, company, nursing home, taco truck, super market, whatever, can prevent a nurse from doing CPR? how on earth is this legal?

I am not a lawyer, I didn't play one on TV, and I didn't stay in a holiday inn express last night, but I am not sure how this relates to what happened.

CPR or any resuscitation procedure is not a matter of safety, it is a medical intervention.

There is a lot of uproar over this in many medical circles.

The EM physicians I know seem to think the outrage is a policy against CPR, not that this particular patient should have received CPR.

But it brings us to an interesting question...

Should we withold resuscitative intervention in populations that are not likely to benefit from them or be reduced to requiring constant medical and nursing care to even survive?

In EMS is often said "that is not my call" but somebody has to make the call, and since most physicians are not going to drive out to the scene, read through the chart, consult, and then make a prognosis before deciding whether to procede with resuscitation, it seems logical somebody on scene should be doing that.

Not the dispatcher over the phone, not calling medical control to force a doctor to make a decision over the phone, etc.

Whether it is a company policy or a medical protocol, it would probably be a good idea to have some kind of guidline on the matter.

Let us remember, death is a part of life, we are not in some existential battle against death.

I think the outrage over this is being perpetuated by people who still think we should always go all out to resuscitate every terminal patient encountered.

Professional healthcare providers need to look past the emotion of this and start thinking about it logically.

What I find truly outrageous about the event is that the dispatcher expects everyone to be a cog in the machine of her standard procedures and expectations.

It is no different than EMTs getting upset because their protocol says every patient gets 15L of NRB and a backboard and everybody doesn't play along.

 

[WTEngel]

I agree that not every patient should be resuscitated, and I also agree that EMS, nurses, and other healthcare professionals need to use discretion and common sense when doing any intervention, CPR included. Lastly, I agree that death is a part of the life cycle, and this is where my main sticking point comes.

The time for end of life counseling, especially in demographics which include the patient in this situation, is not when they arrest. It is at their yearly, is semi-yearly appointment with a PCP.

Unfortunately, end of life counseling, and reimbursement for such, along with the active encouragement of end of life counseling by PCPs, turned into "death panels" and "killing grandma" by many who adamantly opposed healthcare reform for no other reason than the people who proposed it did not agree with their political ideologies.

This is one point where I will not place much of the blame on EMS or other professions in similar situations, because I do not believe it is their responsibility, or even within their realm (given current education standards) to give out this kind of advice or consultation, especially given the fact that we all know the only thing that changes a good patient history is a second opinion. How often do we actually get the full picture of what is going on before we make it to the hospital, let alone decide whether or not we will begin resuscitation measures absent signs of obvious death or advanced directives.

I think the line is set at a decent place now. Using common sense and discretion (no resuscitation for obvious death), and short of that, appreciating and honoring any wishes set forth in a living will/advanced directive, or the reasonable wishes of someone with durable power of attorney.

The requirement for education and end of life planning needs to be met at the primary care level, not the EMS level. Further, it should be done years BEFORE the patient arrests, not moments AFTER.

 

[Veneficus]

The time for end of life counseling, especially in demographics which include the patient in this situation, is not when they arrest. It is at their yearly, is semi-yearly appointment with a PCP.

The requirement for education and end of life planning needs to be met at the primary care level, not the EMS level. Further, it should be done years BEFORE the patient arrests, not moments AFTER.

I often hear people talk about what should be done in primary care. But I am not sure everyone understands the reality of what is done in primary care.

No matter who is performing this role, MD, NP, PA, etc, only 2 things are ever done.

1. they doll out epidemiology based medications for common complaints often based soley off the chief complaint, and occasionally off of adjunctive findings.

Absolutely the most minimum of effort is made to spend more than 8-10 minutes on each patient while providing "acceptable treatment." Many current PCPs I have met all over the world can often tell you what they will do for a specific complaint or finding without ever seeing a patient. No matter what the patient says, it will not change that.

It is if:then "medicine."

2. The other thing these providers do is immediately refer to a specialist.

So you either get a guidline or a referal. I am of the opinion they are just useless middlemen.

On top of that, many people cannot afford a primary care visit unless they are sick or need to refil meds. They don't preemptively stop by their doctor just to chat.

In order to even stay in business, these providers need to see patients by volume.

So when and who exactly is supposed to have this conversation?

Moreover, how do they pay a lawyer and all the legal requirements for an advanced directive?

Hospitals are required to discuss end of life care, but it usually is just presented as a checklist the patient doesn't understand anyway. That is why we see weird *** directives like intubation but no compressions, and all the other seemingly illogical combinations.

To steal a phrase, the reality on the ground is that EMS providers are the ones who have to deal with this regularly.

Many times advanced directives are just wishes conveyed to trusted friends or family. Who may or may not be on scene, who may or may not be in a state of mind to effectively convey them.

Even if they do, you have EMS providers blindly following protocol and procedure or playing telephone.

"Hi doc, yea, we're doing CPR and the patient's daughter's niece's, sister says that the patient once said while doing dishes after Christmas dinner that if she ever needed life support she didn't want it. What do you think we should do?"

How would you answer that if somebody called you on the phone and asked that?

So since we know that most people don't have a regular primary care provider, the way we have implemented required end of life discussion doesn't work, primary care providers do not spend time and effort on their patients, and we are faced with these decisions, in a financially burdened system that is unsustainable, what should we be doing since what should happen is never going to?

I think what it really comes down to is if EMS providers want to be professionals, they are going to have to step up to the plate, make the tough calls, and accept responsibility for doing so.

If they want to be paid a livable wage they are going to need to start doing what is valuable to people, not what they want no matter what.

If they don't have the education to make such a decision, maybe it is time for them to invest in it without being "required?"

Isn't the purpose of education to ready people and give them the skills for their chosen job market?

No offense, but claiming this topic is always somebody else's responsibilty proves the point EMS providers at all levels are just trained techs. Demonstrating minimal value and lack of responsibility.

Children in a fantasyland playing make-believe with their toys that they are heroes here to save the day.

They want professional respect and money for this?

Really?

 

[WTEngel]

You know I rarely try to turf responsibility, but this is one case where, until EMS steps up to the plate and effects change to the point they can actually make these decisions with the same authority as a medical director, then the status quo is what we will have.

I think your opinion of primary care is not far from accurate, but perhaps a bit too cynical. I know they have to move patients to get paid, and I know time is money, which is why reimbursement for end of life counseling is such a big deal in my opinion. That should be able to be billed appropriately and fairly given the level of service that it is.

As for patients not having a primary care provider, I know this is a common reality. An alternative would be to have these patients screened and the counseling performed during "admission" (not in the technical sense) to the facility, whether it be SNF, or independent living.

I share similar frustrations with you Vene, I really do. In this specific case, it is not my emotional side that guides me, it is the utter frustration I have with personnel and facilities propagating policies that are incomprehensible.

A facility where it is policy to sit with the patient and await EMS arrival, despite being pulseless and apneic! How about a facility where it is policy to doscuss the patient and family wishes before this situation ever arises, at which point staff can be held accountable for sitting with their thumb up their rear while a person dies, unless of course they stated previously that they would prefer for the staff to sit with their thumb up their rear while they die, in which case, I am fine with it.

 

[Veneficus]

A facility where it is policy to sit with the patient and await EMS arrival, despite being pulseless and apneic! How about a facility where it is policy to discuss the patient and family wishes before this situation ever arises, at which point staff can be held accountable for sitting with their thumb up their rear while a person dies, unless of course they stated previously that they would prefer for the staff to sit with their thumb up their rear while they die, in which case, I am fine with it.

That is probably the most reasonable idea I have heard in this witch hunt.

 

[reaper]

This was a senior living facility, not a snf or assisted living. It stated that they are not licensed to provide medical care, so the employee is probably not a "nurse" at all. It also stated that every resident signed papers stating they knew that Medical care would not be provided and staff would call 911. So residents and family had full knowledge of this ahead of time.

Yes, EMS has to lose the " Save everyone" mentality. As Vene said, Drs cannot be there to make all decisions and is not right to ask them to make those over a phone. You are the ones on scene and need to rise up and make those decisions "if" resuscitation should even be started or efforts that have started need to be stopped on scene.

We need to step up and take that responsibility of making those decisions. Stop hiding behind the scene. If your system does not allow you to do this, push for change or get out. You have that choice to work where you feel right with how things work.

 

[ExpatMedic0]

UPDATE ON THE STORY: http://www.ems1.com/ems-management/articles/1414223-No-CPR-nurse-spawns-outrage-criminal-investigation/


This statement was also issued:

"The consensus is if they are a nurse and if they are at work as a nurse, then they should be offering the appropriate medical care," said Russ Heimerich, spokesman for the California Board of Registered Nursing, the agency that licenses health care providers.

 

[Veneficus]

part of a PM I thought was worth sharing.

It has just been in the last couple of weeks I have really written this system off. In a "eureka moment", I discovered primary care is just like general surgery. It has become basic training more than an actual specialty. (keep in mind, this coming from a gen surg person)

Once you complete this training, it is then possible to sub specialize in a niche market. In gen surg, it is either remote/rural/austere medicine or other generally underserved populations that will not be served by a GI surgery subspecialty like hepato/biliary.

Though it is my route, even trauma surg is unsustainable as a subspecialty. Which is why modern trauma surgeons are also intensivists and make up "surgical intensive medicine" or "critical care surgery" whatever term you like better.

Primary care is suffering the same fate. It is basically a specialty that doesn't functionally exist anymore. As you described in your father-in-law, a handful really do love it and can make a go of it, but even the most dedicated newcomers (and I have seen a few of them too) don't stand a chance.

The very philosophy is different. PC used to be touted and function as the one stop shop. My family doctor growing up was. I remembering him refering my whole family to a specialist 1 time in our entire multigenerational history with him before he retired at 86. His knowledge was amazing.

But now the philosophy of PC is to either be a quick fix with minimal diagnostics or a refer (Doesn't that sound like an emergency department?) Only the ED has resources like 24 hour lab and a host of radiology and other diagnostics. It is also open when people are not at work and because of law just about everywhere, forced to take people who can't pay.

If the ED gets the pt admitted (aka in patient referal) then an internist/hospitalist/specialist cares for that pt. Not the EM or the patient's PCP (if they have one) That PCP may first be told of the admission and outcome by the pt.

Because of this lack of resources and hyperspecialized modern medical practice, it is not negligent for PCPs to refer, it is actually in the patient's best interest! A PCP referral is really a win for the pt and a credit to the selflessness of the provider. But it doesn't do much for professional satisfaction or payment for service.

I think it is time to admit primary care is beyond "fixing" and relegate it to history. Especially to preserve the dignity and demonstrated ability of the prior generations when there were no specialists to send people to.

 

[hogwiley]

Not one media source I've seen has clarified what license level this "nurse" possessed. I'm guessing she was a at best an LPN and possibly a nurse aide of some sort who isnt required to know CPR and is forbidden by the facility from performing it.

The facility makes it clear to all residents that this is their policy regarding CPR, and they are required to sign paperwork agreeing to this. This woman signed this paperwork, the staff followed the policy, and that is that.

This policy is almost a defacto DNR when you think about it, and is probably how its regarded by the residents and their families, which is possibly why they never bothered with a DNR.

Fortunately the patient's daughter has rejected the media hysteria and public witch hunt and said she has no problem with the care her mother recieved. Probably because she's an RN herself and knows better.

 

[WTEngel]

A defacto DNR is not a DNR. Paperwork stating we call 911 for help =/= DNR. What you are saying is that the people generally have informed consent and are aware that if they need help, 911 is called. I am not employed at this facility, but I can guarantee you that it is not explained to the patient and family in this manner: "if you need any help at all, we call 911 and do nothing more. We do not perform CPR, even if requested to by dispatcher, and we will refuse to hand the phone off to anyone that may do CPR, effectively meaning that if you go into cardiac arrest here, you will die." If it is in fact explained to the patient and family this clearly, then I will eat crow.

I am by no means a "we must save every life" type of paramedic. I am by all means a "everyone deserves to die with dignity" type of person. Lying on the ground, gasping like a fish out of water, while some imbecile hems and haws on the phone about "I'm not comfortable doing that" is not dying with dignity. Having a proper DNR in place before this event occurs and having your wishes observed is dying with dignity, even if the two situations played out the exact same way!

The only thing that has been stated by the facility is that their policy is to call 911 and wait next to a patient if they need help. I fail to see how this excuses a healthcare professional from providing immediately necessary, potentially life saving care, whether they think the outcome will be positive or not. The time for making those decisions has already passed.

Calling 911 and waiting next to a patient with a broken hip is much different than calling 911 and waiting next to a patient who is pulseless and apneic. Doing so because it is policy does not make this any more reasonable.

Defense arguments similar to this were used in Nuremberg, and effectively shown to be invalid. Following orders or hiding behind policy is no defense for a behavior like this. The only defense for this is following the official wishes of an advanced directive or observations concurrent with obvious death, not obvious DYING...which is what was observed here.

The bottom line is that this is not a proper way to manage end of life care. This situation is end of life care in the most sloppy and irresponsible manner. If a patient wants a DNR, they need proper consultation and documentation prior to the event happening, or at the very least they need to express their wishes in clear terms. Using processes like these as a backdoor DNR is disgusting. Using this process of calling 911 and providing no care in order to circumvent the pesky process of doing the right thing and actually educating patients and their families, along with proper consultation, is mind boggling to me. A healthcare worker of any level should know better than this.

 

[Veneficus]

The bottom line is that this is not a proper way to manage end of life care. This situation is end of life care in the most sloppy and irresponsible manner. If a patient wants a DNR, they need proper consultation and documentation prior to the event happening, or at the very least they need to express their wishes in clear terms. Using processes like these as a backdoor DNR is disgusting. Using this process of calling 911 and providing no care in order to circumvent the pesky process of doing the right thing and actually educating patients and their families, along with proper consultation, is mind boggling to me. A healthcare worker of any level should know better than this.

Profit based care. Is it any different from most nursing homes you have been to?

 

[WTEngel]

Profit based care. Is it any different from most nursing homes you have been to?

Fair enough. Still disgusting...

 

[mycrofft]

This company apparently treats their independent living facility like an apartment house; your landlord is not obligated to provide first aid, AED, etc. THat's defensible, especially since residents sign an agreement that those services are not supplied. Legally, even if on the clock, a staffer has no duty to respond if it happens at the residential section versus care sections. Morally and meeting licensure professional standards is another thing.

(What would happen if an "Independet Arms" resident was visiting a friend in "Assisted Living Acres" and keeled over? :unsure:

The question is what a nurse was doing there, if there indeed was one, since the company said that area was below the medical care level. The initial AP news article says the 911 dispatcher THOUGHT she was talking to a nurse, but then goes on to sound as though it was indeed a nurse.

This followup story is full of postured indignation. These indignant politicos are the same ones who vote down aid for elders, etc etc. Their only role here is to be the dorsal fins looking for juicy legs hanging out of the life rafts when everyone goes to cover.

Anyone from that jurisdiction? Is this a recurrent issue at that home?

 

[Bullets]

More information

Seems that this employee was not employed as a Nurse (big N) and was the Resident Services Director. The facility does not provide medical care in any capacity. There is no Good Samaritan law in California so if this employee did CPR and the patient 'lived' as a vegetable on life support, she could be sued for damage.

Seems that a case in 2008 in California involving a passing motorist rendered aid to a woman involved in a car wreck and pulled the woman from the car. The woman involved in the accident ended up paralyzed and sued the passing motorist and won, the state courts stated that "a person has no duty to come to the aid of another. If, however, a person elects to come to someone's aid, he or she has a duty to exercise due care"

So even though they have a GS law on the books, this case nullified it. Stop and render aid at your own risk, you're better of keep walking


http://www.cnn.com/2013/03/04/health/california-cpr-death/index.html?hpt=hp_t2

 

[Aidey]

We have a few facilities in town that are Independent Arms, Assisted Acres, and Sunset Skilled all in one building with 3 separate wings. Each is licensed separate from the others, and staff are not permitted to cross over. So if Ethel in Independent Arms keels over, the RN from Sunset Skilled can't go over and treat her, even if they are technically all in the same building.