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Issues Raised by Media Coverage of a Nurse Declining to Do CPR

March 19, 2013

By Doug Olsen, PhD, RN, associate professor, Michigan State University College of Nursing, and AJN contributing editor. Olsen regularly addresses topics related to nursing ethics.

via Wikimedia Commons

via Wikimedia Commons

Several issues are worth addressing in the wake of recent news and opinion pieces about a nurse (her exact professional credentials remain unclear) at a senior living facility in California who told a 911 operator that she would not do CPR on an 87-year-old woman because it was against institutional policy:

  • ethics in journalism
  • advanced directives—individual and institutional policy
  • the poor state of public health care understanding

Let me note up front that some facts in this case remain elusive. According to various news stories, the woman’s family has said the nurse’s inaction was in accordance with their understanding of their mother’s wishes. However, their mother apparently did not have a do-not-resuscitate (DNR) order on file. Many news reports have been speculative, and my conclusions about the case could change if more details are made available. Therefore, this post analyzes the nature of the discussion of this case and notes some general precepts pertinent to the situation as generally described.

Ethics in journalism: At least some of this case’s notoriety stems from inappropriate hyping of this incident by journalists who made little effort to educate themselves about the issues. The focus of many stories has, unsurprisingly, been on a life that might have been saved if the nurse had overridden institutional policy and refused to stand by and just watch someone die. Articles like that of Ana Veciana-Suarez in the Miami Herald take advantage of the report—which described a 911 operator trying to convince a caregiver to perform CPR—to whip up indignation at the nurse’s refusal to “perform a crucial act of simple humanity.”

Yet it’s quite possible that this case had the best possible outcome. According to her family, a woman’s end-of-life wishes were followed and she was allowed to die with some dignity in her chosen place of residence, a place she apparently enjoyed, without useless mutilation of her body by CPR because of policy demands that poorly reflect reality and the basics of patient-centered care.

In addition, something many stories failed to note is that it’s by no means clear that CPR would have saved this woman’s life. Many nurses are familiar with the concept of “slow code” (DePalma, 1999)—that is, CPR given, because of policy demands, to a patient for whom the technique is clinically futile. The chance of a woman that age surviving out-of-hospital CPR is slim. The chance of her surviving with an intact quality of life is even lower (Zwingmann et al., 2012), and a quick conversation with any ICU nurse might have given journalists a clearer sense of this clinical context.

Advance directives and individual and institutional policy: Instead of focusing on depicting an apparent moral travesty committed by a nurse, journalists might have framed this story as a vivid illustration of an institutional policy poorly designed to support a nurse or other caregiver in doing what’s right. Most institutional policy—and the widespread understanding of legal obligations—says that a provider should perform CPR unless there is a medical order that the patient is DNR. Therefore, a good deal of CPR is done because clinicians lack clear direction regarding what the patient wants or fear lawsuits if they don’t do CPR. This often leads to futile, even cruel attempts at CPR. Further, when there is no direction from the patient, families are left struggling with the guilt of limiting treatment on their loved ones without knowing what that person really wanted.

Therefore, the real work that needs doing is to make sure that patients, especially those in a setting like the one described in the case, make their wishes known in advance. While the institution has stated in various reports that all residents are made aware before taking up residence that there is no medical provider always available on staff, the institution should do more to make its policy on doing or not doing CPR clear to patients, staff, and the public. It would be even better served, though, by requesting that patients make their wishes known in advance to staff and family and that this be documented.

Public understanding: One compelling message for many nurses in this case is the stunningly poor understanding of CPR by the public and the news media. This ignorance is demonstrated in many of the reports themselves, but especially in the comments made by readers in response to stories.

This misunderstanding of CPR and its efficacy may be related to popular fictional depictions of CPR in which most patients fully recover. If patients are going to make meaningful choices about CPR through advance directives, they need to understand and appreciate the consequences of those decisions, and that means getting accurate information. Such information should be conveyed in a conversation between a patient and the clinician assisting in the preparation of the advance directive.

In addition, this case highlights the need to go beyond one-to-one education to achieve a better and more widespread public understanding regarding the limits of health care at the end of life. Unfortunately, much of the most effective and widespread public education regarding health care is driven by market forces rather than need. Thanks to advertising and marketing, the public is far better informed on medical treatment and adverse effects of erectile dysfunction medication than on CPR outcomes or on how to prepare oneself and loved ones for the last stage of life.

Zwingmann, J. et al. (2012).  Survival and neurologic outcome after traumatic out-of-hospital cardiopulmonary arrest in a pediatric and adult population: a systematic review. Critical Care, 16. http://ccforum.com/content/16/4/R117

DePalma, J. et al. (1999). ‘Slow’ Code: Perspectives of a Physician and Critical Care Nurse. Critical Care Nursing Quarterly 22(3), 89-99.

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7 comments

  1. I disagree w/ J. Paradisi RN, who said that no one should die in a residential bed “or on the floor”……we don’t know where the ill woman was. Probably in her bed, I’d assume. WHY would she have moved her? Instituted WHAT “comfort care”??? If the woman was in the process of dying, perhaps even comatose, she needed LESS, not MORE intervention by strangers.

    The facility should have had mandatory DNR’s in the files of patients who wished for them. Otherwise, they should have supported the nurse (if she was a nurse, not an aide) in doing CPR. BUT, if the patient had an understanding, even verbal, that she was a DNR, then that should have been lived up to.

    I don’t understand WHY the “nurse” called 911…..that’s another unanswered question in this confusing case.

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  2. As a lay-person who has cared for several family members at this stage of life (that is, impending death) and observed others still, my feeling is that the most humane and ethically sound action is to let the person die, if that is what they would have wanted, which is how the caregiver and the family evidently understood the person’s wishes. I would be very thankful to the caregivers who have worked with my family members when they were in senior living if they had acted as did this nurse.

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  3. A major part of the lack of public understanding is that a lot of the general public choose not to have “the discussion” about end of life wishes feeling it is “too morbid”. Everyone knows you don’t get out the world alive but subscribe to the Scarlett O’hara school of thought-“I’ll think about that tomorrow”. The general public has little perception of the realities of what happens when we resuscitate someone but their body is devastated from the initial insult. Just once I would like to see a general public medical show that shows “survivors” of resuscitations where we really shouldn’t have given that “last dose of epinephrine”. I recall that a few years back, the Advanced Cardiac Life Support manual included a statement that sometimes the last beat of a patient’s heart should be the last beat. It has been removed from subsequent manuals.

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  4. The US has about 850,000 licensed physicians and about 2.7 million licensed RNs working as nurses (and many with advanced degrees including PhDs) – yet journalists rarely interview nurses. Thank goodness for publications like AJN!

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  5. This is an excellent post regarding the pit falls of trial by media, public perception of emergency care, CPR, and end of life issues.

    As mentioned by the author, the facts of this story remain unknown. Most importantly, is knowing the patient’s POLST (Physician’s Orders for Life Saving Treatment) status. Secondly, if a POLST exists, outpatient facilities must have a mechanism to provide comfort measures for a patient with a signed DNR. It is inhumane and inappropriate to allow a human being to expire on a lobby floor or resident bed (we don’t know) without initiating comfort care. It may mean the patient requires medical transport to a location where this can be accomplished, without initiating the EMS (Emergency Medical Response).

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  6. Just reinforces we nurses could be doing more to educate the public re: end of life decisions. Plus who we are and what we do.

    The “nurse” in this nursing home could have been an aide since the term nurse is applied to others besides registered nurses.

    Yes, our journalists are woefully uneducated and have little incentive to become more knowledgeable. How I wish they would ask a nurse!

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  7. Well put Doug!

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