Nurse refuses to give CPR, discuss...

[Zanegray]

Not sure I care... but I could be swayed

http://latimesblogs.latimes.com/lan...give-cpr-to-elderly-woman-who-later-died.html

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[EM2HPM]

I worked in an "Independent Living" facility facility and they had the same rule. I do not know the law but their justification was that they did not provide training and because we were working under the licensing of the facility we were not covered under the good Samaritan law. Any complications could put the facility at risk. I was never put in that situation but did have an emergency that I was not allowed to tend to until EMS arrived.

 

[Druggernaut]

I worked in an "Independent Living" facility facility and they had the same rule. I do not know the law but their justification was that they did not provide training and because we were working under the licensing of the facility we were not covered under the good Samaritan law. Any complications could put the facility at risk. I was never put in that situation but did have an emergency that I was not allowed to tend to until EMS arrived.

I understand why she acted as she did, but it's a pretty sad that our society is so litigious. If they're not breathing and their heart isn't beating, they're dead. What complications do you really have to worry about? Pushing them into ultra-death?

 

[EM2HPM]

Yea I never understood it I just accepted it. My assumption was in the case of someone preforming CPR when they shouldn't have (Nursing assistant's are not the brightest always). I just know CPR and the Hemlich (sp?) were not allowed, and anything out of our normal job had to be cleared with an on-call nurse.

 

[Yorick]

She wasn't a DNR but I wonder if residents are made aware of this policy and accept it when they check into the facility? If so, then I see no problem.

 

[Arcan57]

I was mostly struck by what a ridiculous venture CPR becomes in the very old. Although I'm sure the reason is stupid but I think it would be heroic to not go through the farce of out of hospital resuscitation.

 

[It'sElectric]

I was mostly struck by what a ridiculous venture CPR becomes in the very old. Although I'm sure the reason is stupid but I think it would be heroic to not go through the farce of out of hospital resuscitation.

My exact thoughts. This is little more than sensational media appealing to an uneducated population - by no fault of their own really.

 

[docB]

I think it's good that these stories get publicity. The main problem is that the media will present this as "horrible nurse, horrible facility, patient could have been saved if only." This needs to be presented as:

If you want the right to sue everyone and their dog for anything this is what you get.

Trained and insured nursing staff is expensive. If you want it you have to pay for it even though you really believe at your core that all health care should be free.

CPR is a last ditch, hail Mary. Once you reach that point you have already lost the game.

 

[Birdstrike]

Arrests that are primarily respiratory, often are salvageable. We'll never know if this patient simply was hypoxic, with an initially normal rythm, and may have been saved with simple 02 and bagging as a bridge to EMS arrival. Instead, they let the patient die first, out of a fear of lawsuits, perhaps? Keep cases like this in your memory, and hyperlinks to stories like this on your hard drive for the next time an attorney tries to convince you or anyone else that the unleashing of their blitzkrieg of lawsuits upon American physicians and hospitals "helps people," "protects the innocent," or "preserves and defends the constitution."

Cause of Death: Defensive Medicine

 

[FutureInternist]

She wasn't a DNR but I wonder if residents are made aware of this policy and accept it when they check into the facility? If so, then I see no problem.

That still won't stop the damn lawyers

 

[southerndoc]

Arrests that are primarily respiratory, often are salvageable. We'll never know if this patient simply was hypoxic, with an initially normal rythm, and may have been saved with simple 02 and bagging as a bridge to EMS arrival. Instead, they let the patient die first, out of a fear of lawsuits, perhaps? Keep cases like this in your memory, and hyperlinks to stories like this on your hard drive for the next time an attorney tries to convince you or anyone else that the unleashing of their blitzkrieg of lawsuits upon American physicians and hospitals "helps people," "protects the innocent," or "preserves and defends the constitution."

Cause of Death: Defensive Medicine

This is an independent living facility not a skilled nursing facility. To possess BVM's would violate state law in most states.

She could've done mouth-to-mouth, but honestly, the way I've heard descriptions of her "breathing" I'm leaning toward her having agonal respirations similar to what someone has when they first go into VFib.

We all know how horrible the survival rate for out-of-hospital cardiac arrests is.

 

[Birdstrike]

This is an independent living facility not a skilled nursing facility. To possess BVM's would violate state law in most states.

She could've done mouth-to-mouth, but honestly, the way I've heard descriptions of her "breathing" I'm leaning toward her having agonal respirations similar to what someone has when they first go into VFib.

We all know how horrible the survival rate for out-of-hospital cardiac arrests is.

"collapsed in the home's dining room"

She collapsed in the dining room, per this report. Are you certain that this was not a choking event, and that a quick Heimlich maneuver could not have saved this person, if not for the policy of liability avoidance?

 

[wjs010]

I know some of you docs call it media sensationalism, but, regardless of what really happened or what was definitively wrong with the lady, the only reason the nurse didn't do anything was because her boss was scared of the lawyers...which is sad.

 

[The Undecider]

I'm not gonna get too much into the politics/legalities of this one other than if this lady really went into the light just like that (not a choking or respiratory-induced cardiac arrest as was posited earlier), it wouldn't be so bad to go chewing on a mouthful of meatloaf would it? I agree with whoever it was up there that brought up the CPR being a hail mary thing. She was 87. Sounds like she went awesomely, at least to me. Reading the comments on these news stories are heartbreaking (nurse killed her). Even the way the news presents it - "old lady dies AFTER nurse refuses CPR.........."

ETA 2 stories -

1. Was part of an unsaveable code not too long ago where family wanted us to shock asystole, saying "you can save her, use the paddles..." - thought of this reading the articles' comments section. Maybe it isn't so bad these stories make the news.

2. Long ago an old lady finished her lunch tray I gave her, started on her chocolate chip cookie but ran out of milk. Put half the cookie down, called me in, asked for more milk. Walked up the hall to the galley to get milk, was walking back and she bradyed down to asystole, just like that (monitors the length of the hallway, ~20 second walk). Wasn't really that sick or suffering, literally no complaints, no drama. Just died - DNR I might add. I was a little pissed she didn't get her milk to finish that cookie, but all in all...pretty good way to go if it has to be.

 

[OCDEMS]

This post brings up a good subject: out-of-Hospital arrest. I've noticed many of the physicians here consider it a futile effort, which I understand. In my five years as a paramedic I've only had two such arrest "walk out" of the hospital neurologically intact. One was witnessed infront of me with immediate defibrillation, so I imagine many people wouldn't really call this "out-of-hospital." Both of these patients were higher in age. I believe both were mid-60's, early 70's.

Where I work the system is investing heavy sums into improving EMS response to cardiac arrest. LUCAS CPR machines on nearly every paramedic unit, multiple paramedic units to the scene, first responder care, pit-crew CPR, hypothermia, and most recently emphasis on aggressive management of arrest in the patient's home, before transport. We hear about the systems with 40% survival rates and when we look at the date we see they're measuring V-Fib/V-Tach arrests.

So my question is: Is cardiac arrest a survivable event or are we relegated to calling our treatment of this disease a "Hail Mary Pass," as one poster responded? I know some people consider it death and sit on the side of calling it an inevitable part of life. Do any of you believe it is something that, with time, energy, and new technologies, could be overcome?

I should preface this by saying that I understand that all death eventually involves cardiac arrest. I think what I'm referencing is the otherwise healthy person, with no previously diagnosed serious pathology or advanced age, who suddenly collapses. If so, what do you consider a realistic age for medicine to routinely resuscitate?

I wanted to get the views of physicians. Clearly I think the belief in EMS and certain circles is that it can be a routinely survivable event with time, effort, and advances in medicine.

 

[DoctwoB]

So my question is: Is cardiac arrest a survivable event or are we relegated to calling our treatment of this disease a "Hail Mary Pass," as one poster responded? I know some people consider it death and sit on the side of calling it an inevitable part of life. Do any of you believe it is something that, with time, energy, and new technologies, could be overcome?

I should preface this by saying that I understand that all death eventually involves cardiac arrest. I think what I'm referencing is the otherwise healthy person, with no previously diagnosed serious pathology or advanced age, who suddenly collapses. If so, what do you consider a realistic age for medicine to routinely resuscitate?

I wanted to get the views of physicians. Clearly I think the belief in EMS and certain circles is that it can be a routinely survivable event with time, effort, and advances in medicine.

Therin lies the rub. Otherwise healthy people without serious pathology or advanced age don't suddenly undergo cardiac arrest. If they did, I bet they'd have much better outcomes then your 85 year old end stage CHFer w/ bad COPD, and it would make much more sense to undertake "so called "heroic measures".

 

[High Roller]

Man...You read some of those comments and it makes you realize that people kinda suck. Humility is a lost value on the internet.

But the ethics seem pretty simple to me. If you run an assisted living center, every patient should be required to have an advance directive on file, and every employee should know where that is, and everyone should do their best to abide by it. If someone is stupid enough to be full code at 87...so be it. Get to crackin' those ribs! So yeah...I do see a breach of ethics so to speak. Definitely wrong to me if this person was full code.

I do think theres a white elephant in the room...full code at 87 years old only leads to badness. And on a personal level I think its plain stupid and a little selfish to be full code at that age living in an assisted living center. The flipside would almost surely have been a 50k ICU bill waiting for someone and a death drawn out over several days when the family realizes its a snowball chance in hell for any meaningful neurologic recovery.

If it were me... I'd take croaking in peace with a mouth full of filet mignon any day of the week.

 

[WilcoWorld]

I do think theres a white elephant in the room...full code at 87 years old only leads to badness. And on a personal level I think its plain stupid and a little selfish to be full code at that age living in an assisted living center. The flipside would almost surely have been a 50k ICU bill waiting for someone and a death drawn out over several days when the family realizes its a snowball chance in hell for any meaningful neurologic recovery.

This is why we need death panels that ration care.

I'm serious.

 

[Xerxes1729]

Its not clear why she arrested. But if she choked to death on a piece of food, it'd be a shame if she died because of some asinine policy of not helping people in need.

 

[Old_Mil]

This post brings up a good subject: out-of-Hospital arrest. I've noticed many of the physicians here consider it a futile effort, which I understand. In my five years as a paramedic I've only had two such arrest "walk out" of the hospital neurologically intact. One was witnessed infront of me with immediate defibrillation, so I imagine many people wouldn't really call this "out-of-hospital." Both of these patients were higher in age. I believe both were mid-60's, early 70's.

Where I work the system is investing heavy sums into improving EMS response to cardiac arrest. LUCAS CPR machines on nearly every paramedic unit, multiple paramedic units to the scene, first responder care, pit-crew CPR, hypothermia, and most recently emphasis on aggressive management of arrest in the patient's home, before transport. We hear about the systems with 40% survival rates and when we look at the date we see they're measuring V-Fib/V-Tach arrests.

So my question is: Is cardiac arrest a survivable event or are we relegated to calling our treatment of this disease a "Hail Mary Pass," as one poster responded? I know some people consider it death and sit on the side of calling it an inevitable part of life. Do any of you believe it is something that, with time, energy, and new technologies, could be overcome?

I should preface this by saying that I understand that all death eventually involves cardiac arrest. I think what I'm referencing is the otherwise healthy person, with no previously diagnosed serious pathology or advanced age, who suddenly collapses. If so, what do you consider a realistic age for medicine to routinely resuscitate?

I wanted to get the views of physicians. Clearly I think the belief in EMS and certain circles is that it can be a routinely survivable event with time, effort, and advances in medicine.

A shockable rhythm with immediate defibrillation has decent outcomes. PEA, not so much.

 

[Old_Mil]

I know some of you docs call it media sensationalism, but, regardless of what really happened or what was definitively wrong with the lady, the only reason the nurse didn't do anything was because her boss was scared of the lawyers...which is sad.

A great deal of what we do in medicine is because we are scared of lawyers.

 

[engineeredout]

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

Last week, shortly after Bayless' death, the family said they were satisfied with the care she received, according to KGET.

"I never said I was fine with that," daughter Pamela Bayless told CNN Monday before hanging up the phone. "That was completely taken out of context, and I have no further comment."

Sounds like a family member said how they felt after it happened, then they hear from a (probably multiple) JD who informs them how much money they can sue for. Now it amounts to "I didn't say it. Okay I did say it but its not what I meant, and now someone is telling me not to speak anymore".

 

[galaxyx]

I don't understand that refusal to give CPR under instruction from the 911 dispatcher. Once the dispatcher says perform CPR, wouldn't the nurse be acting under the authority of the 911 call, not the policy of the facility? If the facilities stated policy is to call 911, wouldn't refusing the advice of 911 be counterproductive to the call 911 policy?

 

[la gringa]

my dear grandmother recently died in her assisted living facility at age 93, but no one had even BROUGHT UP a DNR til i mentioned it to my aunt a few years ago. being a sensible woman (and my grandma's HCPOA), she had one for my grandma. she was one of VERY FEW who had one there.

grandma didn't wake up one morning, and that was that. my aunt says the staff there state this rarely happens... usually their patients die in the hospital. who over the age of 75, 80, whatever, pick a #, wants to die in the hospital??? i, and the rest of my extended family, am relieved that my sweet, loving grandma didn't suffer in death. no better way to go at that age.

i agree w/ the above posters that out of hospital true ARRESTS in the elderly are nearly 100% futile... based on my way too extensive experience "coding" elder arrests.

i think that the "intro to Medicare" visits that all get under the ACA should include video of real CPR, ICU care, suctioning of an ETT, what it's like to have a PEG, statistics on out of hospital arrest survival, and testimonies from families whose loved ones died peacefully b/c of a DNR. all most people know is what happens on TV, and there have been studies out on the real vs TV % survival....

it would be wrong to TELL someone they have to be DNR, but i think we have a LONG ways to go as far as educating the public about what it means to be FULL CODE.... and therefore most people are NOT making an informed decision b/c they don't know what "do everything" really means.

 

[e30ftw]

I stopped reading at: "..87 year old.."

 

[K31]

my dear grandmother recently died in her assisted living facility at age 93, but no one had even BROUGHT UP a DNR til i mentioned it to my aunt a few years ago. being a sensible woman (and my grandma's HCPOA), she had one for my grandma. she was one of VERY FEW who had one there.

grandma didn't wake up one morning, and that was that. my aunt says the staff there state this rarely happens... usually their patients die in the hospital. who over the age of 75, 80, whatever, pick a #, wants to die in the hospital??? i, and the rest of my extended family, am relieved that my sweet, loving grandma didn't suffer in death. no better way to go at that age.

i agree w/ the above posters that out of hospital true ARRESTS in the elderly are nearly 100% futile... based on my way too extensive experience "coding" elder arrests.

i think that the "intro to Medicare" visits that all get under the ACA should include video of real CPR, ICU care, suctioning of an ETT, what it's like to have a PEG, statistics on out of hospital arrest survival, and testimonies from families whose loved ones died peacefully b/c of a DNR. all most people know is what happens on TV, and there have been studies out on the real vs TV % survival....

it would be wrong to TELL someone they have to be DNR, but i think we have a LONG ways to go as far as educating the public about what it means to be FULL CODE.... and therefore most people are NOT making an informed decision b/c they don't know what "do everything" really means.

I just went through the same thing with my grandmother, who died at 86. A few years ago my mother, her MPOA, made her DNR a few years ago at my urging (I also recently found out her PCP brought the same thing up to my mother right around the same time). Thanks to that, and realistic expectations on my mother's part, my grandmother was able to pass peacefully in her bed with my mother at her side rather than in the hospital.

I've always been an advocate of discussing end-of-life care (although I know what we can do in the ED is limited), and the positive experience my family had with a well-planned death has reinforced this.

 

[Geebeejay]

Yea I never understood it I just accepted it. My assumption was in the case of someone preforming CPR when they shouldn't have (Nursing assistant's are not the brightest always). I just know CPR and the Hemlich (sp?) were not allowed, and anything out of our normal job had to be cleared with an on-call nurse.

Whoa now, I understand CPR, but Heimlich? That seems a bit over the top....especially since many laypeople know how to give at least a half-decent heimlich....That's like forbidding the nurses from holding pressure when a resident gets a lac from stumbling into a bush....or forbidding nurses from giving a patient his own epi-pen when he gets stung by a bee.

 

[EM2HPM]

Whoa now, I understand CPR, but Heimlich? That seems a bit over the top....especially since many laypeople know how to give at least a half-decent heimlich....That's like forbidding the nurses from holding pressure when a resident gets a lac from stumbling into a bush....or forbidding nurses from giving a patient his own epi-pen when he gets stung by a bee.

Right but this was not in a hospital it was in an assisted living facility. And we were not trained as nurses and there was often not a nurse in the building. It was just nurses aides. Either way I probably would have tried it if the situation arose. But for the most part a lot of the other aides I worked with probably didn't know what the Heimlich was used for so I don't really blame the facility for putting the rule in.

 

[jl lin]

I worked in an "Independent Living" facility facility and they had the same rule. I do not know the law but their justification was that they did not provide training and because we were working under the licensing of the facility we were not covered under the good Samaritan law. Any complications could put the facility at risk. I was never put in that situation but did have an emergency that I was not allowed to tend to until EMS arrived.

This is utterly ridiculous. Been an RN for a long time. . .never heard of this.

They need to ensure that their people are trained in CPR HP, period.

I guess I'd take the heat; b/c unless they pulled out an advanced directive that said otherwise, I'd do CPR. Course, when I got tired, I guess not other bozos in the area would help me.

This is a total crock.

 

[jl lin]

Therin lies the rub. Otherwise healthy people without serious pathology or advanced age don't suddenly undergo cardiac arrest. If they did, I bet they'd have much better outcomes then your 85 year old end stage CHFer w/ bad COPD, and it would make much more sense to undertake "so called "heroic measures".

God help us. Not all 80 some year old people (notice the word people) are CHF'ers or COPDers.

Screw the ageism. God knows how frightened the poor person was and no one willing to help.

This attitude so digusts me. I am sorry. I so see where our society is going with this whole anti-age mentality.

I'd like to see something like this go to the SC--and let guys like Scalia weigh in on it.

Each situation is unique, as is each person. You don't write people off b/c of age for God's sake or for "being beyond someone's idea of utility."

I was just at a funeral yesterday and nearly dropped over to find out this distant cousin of mine was 80. She freaking looked and acted and moved like 60 tops.


So to the person that said that they stopped reading at 87; well, I can't really repeat here what I am thinking, but I'd sure like to do so.

 

[jl lin]

This is why we need death panels that ration care.

I'm serious.

Remember the words as they come back to haunt.

 

[jl lin]

Man...You read some of those comments and it makes you realize that people kinda suck. Humility is a lost value on the internet.

But the ethics seem pretty simple to me. If you run an assisted living center, every patient should be required to have an advance directive on file, and every employee should know where that is, and everyone should do their best to abide by it. If someone is stupid enough to be full code at 87...so be it. Get to crackin' those ribs! So yeah...I do see a breach of ethics so to speak. Definitely wrong to me if this person was full code.

I do think theres a white elephant in the room...full code at 87 years old only leads to badness. And on a personal level I think its plain stupid and a little selfish to be full code at that age living in an assisted living center. The flipside would almost surely have been a 50k ICU bill waiting for someone and a death drawn out over several days when the family realizes its a snowball chance in hell for any meaningful neurologic recovery.

If it were me... I'd take croaking in peace with a mouth full of filet mignon any day of the week.

I was with you but for what's in bold.

How wrong. It depends upon the person, and since when does being elderly mean you don't have a right to self-determination either way?

Wow. Age does not necessarily = end of life, no care, etc. Look at the freaking person as an individual--as you want to be viewed as an individual. Don't make a judgment value on it. We don't know the person that didn't receive any help. Even bystanders on the street will give help. I know. My own mother fell from sudden cardiac arrest. Part of the reason she survived is due to bystander help.

No one said anything about this person in the report being end of life stage IV whatever. No one should just assume this.

Regardless without an AD, it comes down to core human ethics being trumped by dollars. If the mentality is applied to one group of people (generalized to elderly), it can easily be applied to others.

There's a time for CPR, and there's a time for no CPR. W/o an AD or any serious knowledge about the person, regardless of age, you go with CPR until you reach the ethical saturation point.

 

[WilcoWorld]

Remember the words as they come back to haunt.

Glad I got your attention.

So, you think it is in a person's best interests to get tubed, lined and to get CPR (all without sedation, since they're BP is too low to tolerate any) when they get septic from their 4th multi drug resistant UTI for the year? Or is it the large decubitus ulcer that's making them septic? It's hard to say, because this 25 year old person has been unable to communicate or move since his devastating traumatic brain injury 3 years ago.

I'm not ageist. I simply believe that performing painful interventions in futile cases is cruel.

 

[jl lin]

Glad I got your attention.

So, you think it is in a person's best interests to get tubed, lined and to get CPR (all without sedation, since they're BP is too low to tolerate any) when they get septic from their 4th multi drug resistant UTI for the year? Or is it the large decubitus ulcer that's making them septic? It's hard to say, because this 25 year old person has been unable to communicate or move since his devastating traumatic brain injury 3 years ago.

I'm not ageist. I simply believe that performing painful interventions in futile cases is cruel.

Sir after working a very good number of years in critical care, I have repeatedly seen what you have described and in general agree, but you miss my point--and it is NOT a trivial one.

How can one be unbiased or scientific or ethical if they look and react at a situation without all the facts? How can any of us presume to know what is or may be in the best interest of the individual patient, without knowing something of their details--regardless of silly generalizations about age?

You may one day live to be 87. You may be a generally healthy 87 y. o., if your have good genetics and have taken care of yourself. You may then have an entirely different view, and you may not want whatever time in your life you have left brushed off as non-essential or unimportant simply b/c of a number (age) or b/c of some ridiculous rule that comes from fear of liability.

I am beginning to think that more ethics courses should be required for admission to med school; although people can take courses and not really learn a damn thing. Just like life experiences. It amazes me how people generalize, but they don't learn how to look at not only the big pieces in life but all the little pieces as well. They don't learn to appreciates the many angles of life and even the many nuances of great significance.

Medicine can should never be all about generalizations--and even standards of practice should not be based on mere generalizations. Once the individual is thrown out of the equation, at least in terms of clinical practice, it's about robotic functioning and working the assembly line. Once human life is devalued simply b/c of something such as a number, medicine has lost any decency or honor.


But don't misunderstand me one bit. I am not for coding someone into multiple hours of ugliness. Been there--seen and done it too many times. I am usually one of the ones that say, OK, this is getting to be too much now--even with kids, where in general, right, wrong, or indifferent, in codes people usually go well above and beyond time limits of 40 minutes. I have participated in codes where kids are clearly without hope, only to be digusted by someone that decides to call in the ECMO team and the pupils are 8+ and fixed, there is extreme coagulopathy and a kids is bleeding--oozing and oozing from every orifice, bubbling up through the ETT, bleeding from every IV site and cut-down site, and the art line can't stay in because of the continual flow of dark blood--and the art blood is a pH of 6.7--not to mention the growing smell of old, pooling, poorly oxygentated blood that is so bad, it has now reached a concentration of stench that is indescribable. Moreover, it's utterly ugly and horrible to watch, much less be a part of--and your soul is screaming for people to stop torturing the kid; but people want to push on beyond what is clearly reasonable. So, I'm not for being unreasonable in totally hopeless situations--that's not what I am talking about.

We don't know this person's details in the article. And honestly, just to write them off b/c of age and fear of liability is unethical and just a total disgrace.

Rant done.

 

[oceanillusion42]

Sir after working a very good number of years in critical care, I have repeatedly seen what you have described and in general agree, but you miss my point--and it is NOT a trivial one.

How can one be unbiased or scientific or ethical if they look and react at a situation without all the facts? How can any of us presume to know what is or may be in the best interest of the individual patient, without knowing something of their details--regardless of silly generalizations about age?

You may one day live to be 87. You may be a generally healthy 87 y. o., if your have good genetics and have taken care of yourself. You may then have an entirely different view, and you may not want whatever time in your life you have left brushed off as non-essential or unimportant simply b/c of a number (age) or b/c of some ridiculous rule that comes from fear of liability.

I am beginning to think that more ethics courses should be required for admission to med school; although people can take courses and not really learn a damn thing. Just like life experiences. It amazes me how people generalize, but they don't learn how to look at not only the big pieces in life but all the little pieces as well. They don't learn to appreciates the many angles of life and even the many nuances of great significance.

Medicine can should never be all about generalizations--and even standards of practice should not be based on mere generalizations. Once the individual is thrown out of the equation, at least in terms of clinical practice, it's about robotic functioning and working the assembly line. Once human life is devalued simply b/c of something such as a number, medicine has lost any decency or honor.


But don't misunderstand me one bit. I am not for coding someone into multiple hours of ugliness. Been there--seen and done it too many times. I am usually one of the ones that say, OK, this is getting to be too much now--even with kids, where in general, right, wrong, or indifferent, in codes people usually go well above and beyond time limits of 40 minutes. I have participated in codes where kids are clearly without hope, only to be digusted by someone that decides to call in the ECMO team and the pupils are 8+ and fixed, there is extreme coagulopathy and a kids is bleeding--oozing and oozing from every orifice, bubbling up through the ETT, bleeding from every IV site and cut-down site, and the art line can't stay in because of the continual flow of dark blood--and the art blood is a pH of 6.7--not to mention the growing smell of old, pooling, poorly oxygentated blood that is so bad, it has now reached a concentration of stench that is indescribable. Moreover, it's utterly ugly and horrible to watch, much less be a part of--and your soul is screaming for people to stop torturing the kid; but people want to push on beyond what is clearly reasonable. So, I'm not for being unreasonable in totally hopeless situations--that's not what I am talking about.

We don't know this person's details in the article. And honestly, just to write them off b/c of age and fear of liability is unethical and just a total disgrace.

Rant done.

Visiting from the med student section, wanted to see what the discussion was like over here...

Thank you, you said what I couldnt adequately put into words.

Also, as a side note, this was an independent living facility to my knowledge, not assisted. Regardless, I know the odds are infinitesimal that you make it thru any such ordeal at the age of 87, but nonetheless I agree with your reasoning above.

Not trying to spark debate cause there really isn't a right answer, just commenting here... I have broken enough ribs doing compressions on the elderly to know that its not what I'd want or what I'd want for my family, but it isn't about my beliefs and I feel that it would be a disservice to make a decision for another based on my own, swayed, thought process.

(Yes, I'm also a hippocrit in that I agree with hypothetically "delaying" a prehospital EKG on a suicide jump from over 15 stories up that landed face first on the sidewalk with enough facial trauma that pupils can't be checked (PEA, really gonna code that?), but I feel that this is a different circumstance.)

 

[Residentcool]

I think it's good that these stories get publicity. The main problem is that the media will present this as "horrible nurse, horrible facility, patient could have been saved if only." This needs to be presented as:

If you want the right to sue everyone and their dog for anything this is what you get.

Trained and insured nursing staff is expensive. If you want it you have to pay for it even though you really believe at your core that all health care should be free.

CPR is a last ditch, hail Mary. Once you reach that point you have already lost the game.

Absolutely. We live in a ******ed society where it's ok to sue everyone for everything all the time, and when people actually follow protocol in order not to be sued, then they are presented as evil and wrong. I even heard on this one talk show where some lame hosts were talking saying oh can you imagine what an awful person would do that that she wouldn't give CPR to a patient in need, bla bla and she goes on to say oh if it were me i'd risk losing my job to save someone's life. They have no clue, and most people are never put in the position we as healthcare providers are put every day. Also I think the concern is the fracturing of ribs for the most part, and that that can lead to punctured lungs, and other complications. I think that's the rationale for them not allowing staff to do CPR, which is not unreasonable.

Can you imagine a lawyer saying, so nurse X performed CPR and she negligently fractured this poor patient's ribs, which lead to her death from a lung puncture or something like that. Let's not forget that as you mentioned once the patient needs CPR, half the battle is lost, and that the patient was like 90 already I think.

But in our litigious society, you get what you pay for.

 

[Residentcool]

That still won't stop the damn lawyers

Those lawyers are their own worst enemies right now. Their greed is consuming them all-there are about 45,000 lawyers being pumped out per year, and about 15,000 real lawyer jobs. You do the math and figure out how many of them can have actual lawyer jobs. The problem is so bad that grads are suing their own law schools for misrepresentation of the potential to find jobs and make good money. It's kind of entertaining.

 

[WilcoWorld]

Sir after working a very good number of years in critical care, I have repeatedly seen what you have described and in general agree, but you miss my point--and it is NOT a trivial one.

How can one be unbiased or scientific or ethical if they look and react at a situation without all the facts? How can any of us presume to know what is or may be in the best interest of the individual patient, without knowing something of their details--regardless of silly generalizations about age?

I think you've misunderstood my point. I have never advocated for making the DNR decision based on age alone or with incomplete information. I have advocated for the much maligned "death panels" because I think that they (if properly structured) have the best chance of making an unbiased, scientific and ethical choice on who will benefit from further care.

If death panels were set up in a way that I would endorse (decisions based on likelihood of a meaningful recovery, not age/contribution to society/religious beliefs/wealth), I would be completely comfortable allowing them to determine my code status (now and at the age of 87).

 

[WilcoWorld]

I am beginning to think that more ethics courses should be required for admission to med school; although people can take courses and not really learn a damn thing. Just like life experiences. It amazes me how people generalize, but they don't learn how to look at not only the big pieces in life but all the little pieces as well. They don't learn to appreciates the many angles of life and even the many nuances of great significance.

I think that if you go back and read my posts carefully (look at the little pieces as well) you'll see that I have never once advocated for generalization. What I advocate for is a thoughtful group of people trained in both medicine and ethics to review each case individually before coming to a conclusion (aka, a death panel).

 

[WilcoWorld]

Sorry, the above comes across as antagonizing. What I mean to say is this- In my initial post, I was responding to a comment that an 87 yo in assisted living should be a DNR. My response? This is why we need death panels. Not because everybody over 85 should be DNR, but because some should and some shouldn't. A group of people trained in medicine, ethics, and probably some other stuff I haven't thought of, are in a much better position to make a compassionate and informed decision than a grieving family or a malpractice-fearing MD.

 

[Hypomanics]

Therin lies the rub. Otherwise healthy people without serious pathology or advanced age don't suddenly undergo cardiac arrest. If they did, I bet they'd have much better outcomes then your 85 year old end stage CHFer w/ bad COPD, and it would make much more sense to undertake "so called "heroic measures".

Am I the only one that's noticed that people who are sicker seem to survive cardiac arrest...better? I'm talking about the drug addicts with a PMH of HTN, DM, HLD, COPD, CHF, Hep C, HIV, Syphilis lost to follow-up & just restarted penicillin injections for the 3rd time in clinic, who've been in ICU multiple times for DKA or hypoglycemia or ETOH withdrawal or whatever. Finally arrest with ROSC and neuro function preserved! Granted, the ones I've seen have had pretty fried brains prior to arrest due to all of their various habits, so returning to baseline isn't saying much.

And then the middle aged guy with h/o HTN only arrests, returns after 10 mins, and neuro function is just done son.

It's like the first patient has been spending their whole life training for this event by overdosing on heroin over and over with an SBP of 1 million and fingerstick of 400 and leaving AMA from the ICU as soon as they are coherent enough to demand their 180mg of methadone.

 

[jl lin]

Sorry, the above comes across as antagonizing. What I mean to say is this- In my initial post, I was responding to a comment that an 87 yo in assisted living should be a DNR. My response? This is why we need death panels. Not because everybody over 85 should be DNR, but because some should and some shouldn't. A group of people trained in medicine, ethics, and probably some other stuff I haven't thought of, are in a much better position to make a compassionate and informed decision than a grieving family or a malpractice-fearing MD.

Personally, I believe the only standard that can and should be held up in our particular society (see founding documents and US Constitution) is one that allows for self-determination, or the closest thing to that, which would be of course an AD or a close family member. Without those, then it must go to an ethics committee.

About anything even close to a death panel, which will become inevitable with the OC, I am against it--b/c it will bypass self-determination and/or those closest to the individual straight out the gate. And it is only one of a number of reasons I am against OC/ACA--which does NOT = being against healthcare reform. The devil will always be in the details and how they will be applied. . .but that's another topic for another thread.

I have recovered 80 year olds post-open heart surgery that have faired exceptionally well as compared to some 30 and 40 year olds with comorbidities that overwhelmed them. I am fully against giving chronological age the almighty dismissive power that many seem to want to give it. Regardless of EBP, each patient is a person--an individual. BTW, you can break a kid's ribs in CPR as well. When a person can't breath or circulate blood, the benefits of giving CPR outweigh the risks, except when there is an AD or something close to that--like a family member that can attest to the fact that his/her father has end stage cardiac disease or some such thing, and he does not want life-support measures. It may seem financially expensive to look first to the individual and self-determination, but the greater risks to society are omnious without keeping that as a priority. History teaches this more than any EB research could.

Finally, with all due respect, no you do not know that you will be OK with having other fallible humans make decisions about your healthcare and your life and death in the future. It's a totally different matter when it's happening to you or your loved one. Yes, there is a problem with the costs from futile treatments, but this is not the way to approach it, especially in our society. It's more than dangerous. We must maintain respect for each person as an individual--and self-determination--or the closet thing we can possibly get to it.

 

[Doctor Bob]

Personally, I believe the only standard that can and should be held up in our particular society (see founding documents and US Constitution) is one that allows for self-determination, or the closest thing to that, which would be of course an AD or a close family member. Without those, then it must go to an ethics committee.

I would agree with this... if the patient (or their family) was paying for their healthcare out of pocket (or through a private insurance). But when they are not and they are relying on the largess of society to pay for their healthcare, then there should be some dispassionate party which can assess if society is getting its money's worth.

 

[WilcoWorld]

Finally, with all due respect, no you do not know that you will be OK with having other fallible humans make decisions about your healthcare and your life and death in the future. It's a totally different matter when it's happening to you or your loved one. Yes, there is a problem with the costs from futile treatments, but this is not the way to approach it, especially in our society. It's more than dangerous. We must maintain respect for each person as an individual--and self-determination--or the closet thing we can possibly get to it.

You're speaking to someone with an 88 year old grandma who is healthy aside from HTN and arthritis, a 66 year old dad who has survived an out of hospital cardiac arrest and a grandfather who had GBM at 49. Please do not lecture me on how I'll feel when it's happening to my loved ones.

I'm arguing for compassion-driven decisions made by well-informed panels. That is exactly what I want for me and my loved ones.

Also, please stop accusing me of "giving chronological age the almighty dismissive power", I have stated multiple times that I do not support this.

 

[eagles22]

Personally, I believe the only standard that can and should be held up in our particular society (see founding documents and US Constitution) is one that allows for self-determination, or the closest thing to that, which would be of course an AD or a close family member. Without those, then it must go to an ethics committee.

About anything even close to a death panel, which will become inevitable with the OC, I am against it--b/c it will bypass self-determination and/or those closest to the individual straight out the gate. And it is only one of a number of reasons I am against OC/ACA--which does NOT = being against healthcare reform. The devil will always be in the details and how they will be applied. . .but that's another topic for another thread.

I have recovered 80 year olds post-open heart surgery that have faired exceptionally well as compared to some 30 and 40 year olds with comorbidities that overwhelmed them. I am fully against giving chronological age the almighty dismissive power that many seem to want to give it. Regardless of EBP, each patient is a person--an individual. BTW, you can break a kid's ribs in CPR as well. When a person can't breath or circulate blood, the benefits of giving CPR outweigh the risks, except when there is an AD or something close to that--like a family member that can attest to the fact that his/her father has end stage cardiac disease or some such thing, and he does not want life-support measures. It may seem financially expensive to look first to the individual and self-determination, but the greater risks to society are omnious without keeping that as a priority. History teaches this more than any EB research could.

Finally, with all due respect, no you do not know that you will be OK with having other fallible humans make decisions about your healthcare and your life and death in the future. It's a totally different matter when it's happening to you or your loved one. Yes, there is a problem with the costs from futile treatments, but this is not the way to approach it, especially in our society. It's more than dangerous. We must maintain respect for each person as an individual--and self-determination--or the closet thing we can possibly get to it.

I think you gloss over the difficulty in a family making someone DNR. A lot of the time people do want to have their loved one's suffering ended, but can't bring themselves to say "Let mom/dad/grandpa die please." There are religious, social, political and numerous other factors that prevent someone from becoming DNR who should be. Also, It's a huge emotional burden to be THE person who made the call that allowed a family member to die. Thus, we allow people to be kept alive far too long (at astronomical costs) to spare that burden from the survivors. Having a "death" panel can allow these people to live regret free and comforted knowing that their loved one wasn't suffering needlessly since someone else made that call for them.

http://www.ncbi.nlm.nih.gov/pubmed/22047113

 

[jl lin]

You're speaking to someone with an 88 year old grandma who is healthy aside from HTN and arthritis, a 66 year old dad who has survived an out of hospital cardiac arrest and a grandfather who had GBM at 49. Please do not lecture me on how I'll feel when it's happening to my loved ones.

I'm arguing for compassion-driven decisions made by well-informed panels. That is exactly what I want for me and my loved ones.

Also, please stop accusing me of "giving chronological age the almighty dismissive power", I have stated multiple times that I do not support this.

Sir, (I have assumed sir, if maam, I fully apologize.) I never directly accused you, personally, of anything. This is a discussion board. I don't know you and am unable to fairly accuse you of anything.

There is a tendency in healthcare for people to lump people as, well, dumpable and not necessarily to be given the fullest standard of care when looking at age--or giving undue emphasis to age. It's not you per se; it's our society.

When people make general statements like, "I read 87 and then stopped," that suggests a similar, prevalent mentality.

 

[jl lin]

I think you gloss over the difficulty in a family making someone DNR. A lot of the time people do want to have their loved one's suffering ended, but can't bring themselves to say "Let mom/dad/grandpa die please." There are religious, social, political and numerous other factors that prevent someone from becoming DNR who should be. Also, It's a huge emotional burden to be THE person who made the call that allowed a family member to die. Thus, we allow people to be kept alive far too long (at astronomical costs) to spare that burden from the survivors. Having a "death" panel can allow these people to live regret free and comforted knowing that their loved one wasn't suffering needlessly since someone else made that call for them.

http://www.ncbi.nlm.nih.gov/pubmed/22047113

I also know a bit about this clinically as well. The whole death panel discussion, however, is really off topic. It should a separate thread. This was not about any death panel use, and I clearly feel that for a licensed nurse, without anything firm to indicate otherwise, an ethical duty should have superceded a bogus IL facility rule. In fact, such a rule could and should be argued in court. Now, if the nurse had some previous knowledge of health wishes, that MAY be one thing. Even so, however, to drop over in the dining room and receive no assistance from a licensed healthcare professional, who was in attendance, well, in general, is just plain screwy.

At any rate, what you and wilco have brough up is not directly relevant to the OP's topic, and I more than alluded to that in a previous response. (I'm trying to be a good little SDN member.) Let someone start it as a separate thread. 🙂


It is mored than reasonable to help the person that fell in the DR at the IL facility--just like it is when someone drops to the floor when I am dining out in a restaurant. Some people get all bent out of shape about possible litigation. As a critical care nurse of 20 years, I have never been sued. Yes, someone of that is probably luck, but not all of it. I have had cases that had questionable details on decisions, which led to bad outcomes and where they deviated from the standard of practice, and although I refused to deviate from such standards, attempts were made to pass the buck to me. But it never could be, and I believe a good piece of that is b/c I don't compromise certain things, even if it means I may piss someone else off. Now I will bend on many reasonable things, and I certainly know my place. But there are lines I do not cross, and I can honestly say when I go home at night or in the morning, I am able to sleep the sleep of the just. So, no. I will not bypass helping someone out of fear of some legal retalilation. Yes, the threat of litigation hanging precariously over physicians' heads is beyond stressful and in a number of cases have made practice for them just ridiculouos and unnecessarily hard. My values, however, dictate a level of conscience with which I am able to sleep, walk, and live each day. I admit that I a person of faith, and so that possibly may be where I may differ with some with regard to fears of litigation or even fear in general. I trust the guiding hand of the one in whom I believe. Still, there is having the good sense to know to help someone in distress. You don't have to be a person of faith to know to do that. It's just that I don't fear retaliation for doing what I know is the right thing. The right thing is to help someone in distress. Once something has been established that says "nothing more can be done," or something that says an AD is in place, then I can let it go.

Also let's again consider this. If someone falls in a dining room or a restaurant, do we not have an ethical obligation to try and help them? I mean even if they are end stage AML, as my father was when I took him out for one of his last dinners with me--if he is choking on something, does he still not get help from me or from another fellow human being? I mean it's about being reasonable here. His days in the end were precious. A few days or weeks that we take for granted, well, those that know they are on a short lease of time do not take for granted. So if he had been choking on a piece of his fish, should I say, "Oh well, you will be dead in a couple weeks anyway, so what the heck?" Of course not.
If I had not been there is such a situation, I would have been eternally grateful for the person that put aside litigation fears, since he/she would have given me a few more days or weeks with my father.


The author, Huge Prather, makes a great point. There is something worthy of consideration for physicians and healthcare professionals in the following quote:

"To live for results would be to sentence myself to continuous frustration. My only sure reward is in my actions and not from them."

Now that is something that medicine has often struggled with, b/c it is so forced to be results-oriented--and that too makes sense to a large degree, as it should. But there are many points and places where medicine cannot fixate only on being results-oriented. Knowing that you have done your best to respect and value each human life you serve--that's the reward of your actions. Many people suffer and die regardless of what we do; yet we are still doing our best when we value each human enough to work toward giving them the best shot--to value them enough as individuals to be worthy of whatever time they can glean from this life. The issue of quality of life or survival cannot always preceed a critical event that could lead to death or injury. It's unreasonable to think that it could. And what the OP has set forth--this particular situation--demonstrates that clearly to me.


As far as the OP's topic, I think I've said all I need to say on it. When I can't live by ethics and my own conscious, that's when it's time to fight or walk away from a job. That's how I live my life. Principles matter. The best quote I can think of right now to support this is one from James Madison:

"Temporary deviations from fundamental principles are always more or less dangerous. When the first pretext fails, those who become interested in prolonging the evil will rarely be at a loss for other pretexts. The first precedent too familiarizes the people to the irregularity, lessens their veneration for those fundamental principles, & makes them a more easy prey to Ambition and self Interest."

 

[jl lin]

I would agree with this... if the patient (or their family) was paying for their healthcare out of pocket (or through a private insurance). But when they are not and they are relying on the largess of society to pay for their healthcare, then there should be some dispassionate party which can assess if society is getting its money's worth.

This is dangerous. See my quote above from James Madison.

 

[Apollyon]

Am I the only one that's noticed that people who are sicker seem to survive cardiac arrest...better? I'm talking about the drug addicts with a PMH of HTN, DM, HLD, COPD, CHF, Hep C, HIV, Syphilis lost to follow-up & just restarted penicillin injections for the 3rd time in clinic, who've been in ICU multiple times for DKA or hypoglycemia or ETOH withdrawal or whatever. Finally arrest with ROSC and neuro function preserved! Granted, the ones I've seen have had pretty fried brains prior to arrest due to all of their various habits, so returning to baseline isn't saying much.

And then the middle aged guy with h/o HTN only arrests, returns after 10 mins, and neuro function is just done son.

It's like the first patient has been spending their whole life training for this event by overdosing on heroin over and over with an SBP of 1 million and fingerstick of 400 and leaving AMA from the ICU as soon as they are coherent enough to demand their 180mg of methadone.

You've described the "law of inverse value" - the less you do for society, the bigger the insult you can tolerate with no sequel.

 

[e30ftw]

You've described the "law of inverse value" - the less you do for society, the bigger the insult you can tolerate with no sequel.

rule number one man, "gomers don't die."