The end-of-life decision

I’m sure that everyone has heard the tape of the 911 call or read the transcript.  An unidentified nurse at an independent living facility refused to do CRP on a resident who had collapsed.  The resident. 87 year old, Lorraine Bayless, collapsed in a dining room.  The New York Times published the transcript of part of the call

“She’s going to die if we don’t get this started. Do you understand?” the 911 dispatcher asked.

“I understand,” the nurse said. “But I cannot have our other citizens who don’t know CPR do it.”

“Is there anyone that’s willing to help this lady and not let her die?” the exasperated dispatcher said a bit later.

“Um, not at this time,” the nurse replied.

For me the most shocking part of this story is not that no CPR was performed, but that the nurse in question evidently thought she was following company policy.  The Boston Globe story elaborates

During the dramatic 7-minute, 16-second call, dispatcher Tracey Halvorson urged the nurse, who has not been identified, to start CPR. The nurse declined, citing company policy.

‘‘I understand if your boss is telling you, you can’t do it,’’ the dispatcher said. ‘‘But . . . as a human being . . .  you know, is there anybody that’s willing to help this lady and not let her die?’’

‘‘Not at this time,’’ the nurse answered.

Halvorson assured the nurse that Glenwood couldn’t be sued if anything went wrong in attempts to resuscitate the resident, saying the local emergency medical system ‘‘takes the liability for this call.’’

Later in the call, Halvorson asked, ‘‘Is there a gardener? Any staff, anyone who doesn’t work for you? Anywhere? Can we flag someone down in the street and get them to help this lady? Can we flag a stranger down? I bet a stranger would help her.’’

Now comes the firestorm and many, many questions.  Did Ms. Bayless have a DNR on file and did staff know about it?  Even if the independent living facility was “just housing”, don’t people just have an ordinary responsibility to each other to help and not just let someone die?  What was the policy really?  And were there other residents there who saw all this happening?

Like many people of my age, I am very familiar with this type of facility since my mother lived in one for many years.  Yes, she owned her own unit for most of those years and had a kitchen but she also was required to pay for one meal a day in a common dining room.  This is a common practice to help prevent isolation.  The facility also provided recreational activities including exercise classes, trips, a bus to go shopping and a nurse on site.  My mother had a DNR, but I’m not sure who knew about it until she moved into the assisted living section of the facility.  There all the staff knew.  Somehow I cannot begin to imagine that one of the staff in the dining room would not have started CPR if someone collapsed and started breathing.  My mother once choked and a wait staff member did the Heimlich on her.  And I saw other medical emergencies in which staff intervened even while waiting for the EMT’s to arrive.

So what went wrong here?  The NYT article points out the CPR can hurt frail elders more than it can help them.

In one study conducted in King County, Wash., where a surveillance system tracks every out-of-hospital cardiac arrest, University of Washington researchers found that only 9.4 percent of octogenarians and 4.4 percent of nonagenarians survived after CPR, compared with 19.4 percent of younger patients.

In another study of 2,600 out-of-hospital cardiac arrests over four and a half years in Oakland County, Mich., only 3.3 percent of patients over age 80 who received CPR survived to discharge from the hospital.

Even when older people survive CPR, the consequences can be deleterious: broken ribs and fractured sternums, punctures of the lungs or liver, vomit in the lungs and significant pain. Those who argue for CPR in the elderly say these complications, while serious, are preferable to death. Others say quality of life can be, and often is, terribly degraded.

Ms. Bayless’ family has expressed peace of mind with the decision saying that their mother wanted to go quickly, without intervention and given the potential consequences, I can understand their point of view.  But given that fact, why was there no DNR order on file?

Meanwhile everyone is investigating the need for clearer policies, the need for possible legislation and even the possibility of a criminal case.  According to the Globe

…the case has alarmed police, lawmakers, and advocates for the elderly. The Assisted Living Federation of America, the nation’s largest trade group for such centers, said Tuesday that even if facilities have policies saying employees don’t perform CPR, they should cooperate if asked by 911 dispatchers.

‘‘It was a complete tragedy,’’ said Maribeth Bersani, senior vice president of the trade group. “Our members are now looking at their policies to make sure they are clear.’’

Bakersfield police were trying to determine whether a crime was committed when the nurse refused to assist the 911 dispatcher.

And lawmakers are pledging an investigation.

‘‘This is a wakeup call,’’ said Assemblywoman Mariko Yamada, chair of the California Assembly Aging and Long-term Care Committee. ‘‘I’m sorry it took a tragedy like this to bring it to our attention.’’

For me the bottom line is this from the New York Times

There is another lesson here as well, much broader in scope, about what people owe each other in emergencies of this kind. Whether or not we have medical training, “all of us have a duty to respond to people in life-threatening situations,” said Dale Jamieson, director of the Center for Bioethics at New York University. “This is a general ethical commitment we have to each other as part of living in society.”

The main gate of Glenwood Gardens, a retirement community in Bakersfield, Calif., where an elderly woman died after a nurse refused to perform CPR

The main gate of Glenwood Gardens, a retirement community in Bakersfield, Calif., where an elderly woman died after a nurse refused to perform CPR

What develops from this incident will impact all of us boomers as we age.  And for younger people, this might be your parent.