Off the Charts

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

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.

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