Nurse Refused To Initiate CPR, What Is Your Opinion?

Hi, Health, apologies for late reply. No law student nor lawyer, funny you should say that, my father used to think I have a talent for that, he insisted I should become one. I don’t. He introduced me to real lawyers since I was a child, which made me evident the difference between my brain and theirs! I chose a completely different path, not in the medical profession either.

I do not think the lady had Alzheimer because she was living in a low-care setting. The very fact that an employee called 911 suggests there is no MD on duty on the site. It also suggests the facility does not routinely asks patients and family to either sign a DNR or express their wish to be resuscitated: with a DNR, assuming 911 is called (it is absurd as you said already, but it may well be called, just to cover their backs and document everything independently), the recording would have been different, with the nurse stating that the patient has a DNR and the document is in her hands and will be shown to EMT upon their arrival.

I agree with you about sanctioning those who, for no reason at all, withhold help. How would you write such a law? It is not easy to implement in practice. Perhaps you remember the debate a few years ago in California.

Health I am afraid all I know about nursing homes and geriatry, has been learned the hard way. The worst part for me is when someone makes decisions according to “advice” and one can at most suggest they should get a second opinion, and then one has to be silent and watch impotently. Incidentally, advice could be to withhold reasonable treatment or to push unreasonable treatment, it can be either way, unfortunately the variable is the amount the insurers will pay the institution for the treatment, and the overhead compared to actual costs.

There is no question everyone involved is guilty, the govt, the insurance companies, the hospital management, the committees who write down protocols of care. And there is no question the employee is much less guilty than any of those. But I can not agree with your conclusion that the employee is innocent. I know it is hard to give up a secure job. But when one is earning parnassa in a way they feel is not permissible, or in any event, they are not proud of, people have a choice. I found myself in a difficult situation (no human life involved), a perfectly legal, but very questionable to me, mode of operation – I took the confrontational path. I was not fired nor demoted and it did not go to court – obviously when the contract expired, that was it. It was very helpful and strengthening for me to know that, about two years earlier, a young man (a nonjew) had quit over the issue, his girlfriend immediately dumped him (they were about to marry), no one from his birth family was supportive. He had no money, no home, highly qualified with no way of finding another job, he had to make a living with small jobs here and there. It was much harder for him and yet he did not think twice. Time has passed and people willing to compromise have been found, but you know what? Some of them quit. Some others became scapegoats. Of course! Do you think President Obama or the manager of the clinic would support the employee? Do you think they will take responsibility for the protocol, Obama for having legislated in a way that calls for such protocols, the manager for having actually signed it? Of course not! How they react depends on how much it goes virally, how incensed public opinion is or pretends to be, and whether headlines and primetime broadcasts of the recording die down quickly enough for them to remain silent without damage to their public image. If it’s called for, they will go on TV with high screams, they will blame her and her only, and might even call for exemplary punishment.

I think the original article said that this was not an assisted living facility but a retirement home of sorts. This was next door to the assisted living facility owned by the same company and the policy was only not to do cpr in the retirement home.

she recognized CPR would be beneficial to the patient and called EMT.

‘beneficial’ is a judgement. she called EMT because that is procedure.

Even if it is the facility’s policy to call EMT always, she will have to explain why she did not follow the dispatcher’s instructions. There is only one good reason not to: a DNR form in her hands. She did not have one, nor did she showed it to the EMT when they arrived 7min later. I understand they aggressively attempted resuscitation and brought her to a local hospital, only in the hospital the lady was declared dead. Also, now the employee is the villain, won’t be easy for her to defend her good faith and good name.

Yes, I agree that there are situations in which CPR is not wished for (and that’s what DNR is for) and that there are situations in which it is futile and even if no DNR is available (unless the patient had requested “try resuscitation no matter what”) a medical professional is justified in withholding it.

However.

– The patient collapsed and we know the golden window is small, we should get CPR started in 3-5 min if the patient is to benefit.

– The patient is not alone, and the person who sees this (who, incidentally, is not a complete layperson) determines 911 should be called

– 911 operator dispatches a vehicle and EMTs and instructs the caller to perform CPR

– The caller refuses to do so; she admits being trained in CPR and realizing the patient might die, but says it’s against policies; the operator remarks that she would not be liable in following EMS directives; the caller refuses and also refuses to ask another employee or non employee (the operator even suggests asking another senior, I think) to get the phone and perform CPR as instructed; in the meantime the lady is in the throes of death, I imagine on the floor where she collapsed, and if she still is conscious, she can hear this telephone call

– After, if I recall correctly, 7 minutes (that’s about as quick as it gets, but still an eternity) EMS ambulance arrives

– The employee does not tell the EMS personnel to hold off and that the patient has a DNR, handing the paperwork out to them and remarking they would be criminally liable if they attempt resuscitation (thus, it can be inferred such a DNR did not exist)

– EMS start torturing hopelessly the old lady (after seven minutes!) breaking ribs and whatever else they deem necessary, then they decide she is “stable” enough for hospital transfer (it must have taken pretty invasive measures to stabilize her enough)

– The EMS discharge the old lady to the care of a local hospital, where, shortly after admission, she is pronounced dead.

I would not want to be in front of court (secular court) and have to explain my position. Even a jury which is sympathetic towards the attitude “when my time comes, I wish to go gently” will not help: what is the justification for the medically desperate steps of attempting resuscitation, with extremely bleak chances, after 7min? Also, there are plenty of people who are disgustingly hypocrites and won’t pass up the chance to appear as “defenders of the weak”. The employee is the weakest link and I expect she will regret her actions. Again while I think what she did was utterly despicable, I protest painting such people as monsters. If anything, she was naive. A rasha would have faked starting CPR when noticing the dispatcher was getting all worked up. An ordinary person would have started CPR and when called in the office, would have told the manager to listen to the recording and imagine it with a different ending – going viral – 99.99% of EMT dispatcher are “understanding”, I handled this incident as well as I could – the manager would have agreed. Someone outside the ordinary might have looked for another job outside of geriatry. I do not consider her remotely a tzadeket, but she is no monster and no murderer, she is someone who found herself in a difficult situation, handled it badly, got the spotlights and might get burned well beyond her responsibility.

got it daniella so to sum up the main problem you have with the nurse is not handing the phone to somebody else, I guess that makes sense.

The patient may not have had a formal DNR that is irrelevant if my point #2 above is correct. Her job as I understand it is to call 911 and NOT to do cpr. Though It is hard to justify her refusal to hand off the phone.

2scents -“she refused to hand over the phone or ask if anyone else is willing to do CPR. This is taking the companies policy to far.”

Who said that there was anyone else around?

You sure make a lot of assumptions to find fault with this nurse.

“The fact that the EMS crew did try to resuscitate proves that there was no DNR or else they would not do anything.”

No, it doesn’t prove one way or another. It just proves No DNR was handed to them, but perhaps there is one.

In the CBS article it states that there was no DNR, but it was the policy of the retirement home that in case of emergency staff should call 911 and wait with the resident until EMS arrives.

Health true, she does not have a legal requirement (an obligation in criminal law) to listen to instructions from EMT services in California, but if it goes to a hearing, she might lose her licence if she is a RN or receive other sanctions. A medical professional and even a medical student is supposed to get involved whenever no better-qualified professional is on the scene. And she can not argue she felt that resuscitation was not the gold standard of care for that particular patient, she never said so in the call. Also, EMT judged CPR to be gold standard care for the patient, even though a number of minutes had elapsed, and I doubt there was a medical doctor on the EMT crew, so, I would think they strictly followed protocols, EBM and whatnot.

Torah? I am sorry, this is not the basis of the law of the land – we wish! In countries with different legal systems from anglosaxon common law, even assisting a wounded animal may be compulsory. Yes, I think it’s a bestiality. But still, it’s good to be aware of the laws and don’t get in trouble unnecessarily.

In regard to halacha, she is a nonjew I think, she did not murder, I don’t think she stole in an enforceable way either, so I think she is not deserving of any punishment.

That I don’t know because it depends on California law. Is it allowed for someone to write such a clause and for parties to sign it? in fact, not merely stating they will not perform CPR (suppose a mobility impaired dry cleaner, of course they will not perform CPR no matter what) but, basically, that they will, or might, hinder efforts. If the clause is not legally allowed, which I strongly suspect (much more so in a setting such as a living facility which has a disproportion between the contractual power of the average resident and the institution’s, so, even much milder agreements are rejected all the time as unconscionable clauses) our contracts and signatures are not worth the piece of paper that got wasted.

First question, from the way the media is reporting the story yes it is allowed and in fact that is precisly what took place as she entred the facility

Regarding your second question: Then (i assume) they would do cpr and if not the nurse wouldve been wron for not helping somebody who never agreed to forgo cpr. My understanding is that when entering the facility the resident /family agreed that the staff would not perform cpr (havent we been through this point?). (Again, though I agree she shouldve found somebody who would do it.)

2scents -“Then she says that at this time there is no one that is willing to help, therefore she will not hand over the phone or let the dispatcher talk to anyone. Interesting how she knew this without even asking anyone”

Why are you implying that she is lying? Maybe all that were around were seniors and staff. She knows the staff won’t do it and perhaps she is well aquainted with the seniors and know they won’t either. You can assume anything negative you want, but it doesn’t mean it’s true.

daniela -“Health true, she does not have a legal requirement (an obligation in criminal law) to listen to instructions from EMT services in California, but if it goes to a hearing, she might lose her licence if she is a RN or receive other sanctions. A medical professional and even a medical student is supposed to get involved whenever no better-qualified professional is on the scene. And she can not argue she felt that resuscitation was not the gold standard of care for that particular patient, she never said so in the call. Also, EMT judged CPR to be gold standard care for the patient, even though a number of minutes had elapsed, and I doubt there was a medical doctor on the EMT crew, so, I would think they strictly followed protocols, EBM and whatnot.”

This whole paragraph goes off on such a tangent -I don’t get your point. This will never go to a hearing and even if it did -her defense is unshakable -she is following her employer’s orders which is in congruence with the facility’s Medical protocols.

I repeat from my posts before -she is NOT under the Medical Authority of EMS.

“Torah? I am sorry, this is not the basis of the law of the land – we wish!”

I was refering to your belief that her actions’ were immoral. They were Not immoral, nor were they illegal.

I am quite puzzled about all your posts here in this topic. Almost every single one of them you post like this is the law and you are the expert. I really haven’t found one of your posts yet that you were correct in Medical law. Perhaps you need to research this topic throughly before you post?

The nurse acted correctly morally and legally given the circumstances.

daniela -“the one and only monster is the nurse, now lawyers and PR have got to get busy, so that no long-term damage to the brandname should occur.”

Here a quote from AP

“Brookdale Senior Living, which owns the facility, initially said its employee acted correctly by waiting until emergency personnel arrived. But late Tuesday, it issued a new statement saying the employee had misinterpreted the company’s guidelines and was on voluntary leave while the case is investigated, the Associated Press reported.””

Perhaps she is the one telling the truth and the company is just doing CYA?

“As I knew all along! The employee “misinterpreted” the written guidelines. And now is on “voluntary” leave (unpaid?)

As for the prospects of her keeping her job, which supposedly was the reason she refused to perform a CPR, we will see.”

Maybe she didn’t at all? If they fire her to be their scapegoat -hopefully she has written documentation that that’s their policy and she can sue them.

No, the company covered their behind long ago. You can’t expect Brookdale (I had not noticed it was them, I had the impression it was some small company operating one or two homes) to be this foolish. Their guidelines no doubt stated that in an emergency, employees should call 911 and wait with the resident. Gamanit heard that on CBS (see above) but it is quite obvious, given that Brookdale are no amateurs. These guidelines, when brought to the courtroom or to the case study at the next medical ethical conference, do not mean one should stand by, but rather, administering help as appropriate. We are well aware the employee might have been told by her supervisor – or more likely, lead into believing – that she should do absolutely nothing. This was not official policy and not in writing. Chances are it was not even actually said (recording devices being cheap and easily available). I expect instead that the paragraph “in the event of an emergency” was next to the blurb about the facility being not licensed to offer medical care and liability for employees who do so (including scary remark such as “will lead to immediate termination”). Of course the employee is a scapegoat, but she made her bed and has not yet realized how uncomfortable it’ll be to sleep in it.

In addition, she can hardly blame the facility and their rules, because throughout these long minutes she did not ask her supervisor, much less management, for clarification of guidelines. A supervisor would have instructed the employee to start CPR on this particular patient. Yes, had she involved a supervisor, the employee might have created a few problems for herself (especially if she is incapable of driving home the point that investors and brandname assets must be protected and we can’t allow media to jump on this sort of stories). But nothing in comparison to her situation now.

Now there is a mess, and the employee still thinks she can get away with it, because that’s what always happened in the last X years she worked at this job, and moreover, the family of the deceased are supporting her, and the deceased’s daughter is a nurse. She does not realize the piling up of mistakes upon mistakes, nor the seriousness of her situation; she probably feels relieved that “elder abuse” charges were dismissed (they were blatantly absurd of course), she probably was pleasantly surprised by the non-confrontational and sympathetic attitude of police and prosecutors, and I expect she is not getting much of a legal counsel at this time. And yes, according to a statement from the family, a DNR document now surfaced, after the local fire dept confirmed there was no DNR on file – the silence of Brookdale speaks volumes. There is also a document, signed by the deceased’s personal physician, indicating stroke as the cause of death.

This incident might or might not spark a change in legislation requirements for assisted living communities. It might or might not spark an extension of failure to care, unprofessional conduct etc. It might or might not spark a greater uniformity of regulations nationwide (see e.g. RN disciplinary codes in California vs Tennessee). In any event I expect future guidelines of Brookdale’s facilities to address in more detail the issue of assistance while waiting for EMS (I expect employees to be briefed there is no change in policy, only in wording). Other similar providers are already doing so. As for Brookdale “We are conducting a company-wide review of our policies involving emergency medical care across all of our communities.” Also, Brookdale have put the employee on leave and are now promising a “thorough internal review of this matter”.

In the meantime, from Brookdale’s statement to the media.

“This incident resulted from a complete misunderstanding of our practice with regards to emergency medical care for our residents”.

daniela -“No, the company covered their behind long ago. You can’t expect Brookdale (I had not noticed it was them, I had the impression it was some small company operating one or two homes) to be this foolish. Their guidelines no doubt stated that in an emergency, employees should call 911 and wait with the resident. Gamanit heard that on CBS (see above) but it is quite obvious, given that Brookdale are no amateurs. These guidelines, when brought to the courtroom or to the case study at the next medical ethical conference, do not mean one should stand by, but rather, administering help as appropriate. We are well aware the employee might have been told by her supervisor – or more likely, lead into believing – that she should do absolutely nothing.”

The last part is probably what happened. How much will the parent company distance themselves from this with lies – all depends on the consequences. In this case, the liklihood of the family suing the company or some agency talking about this in some conference is slight to none. So I think the outcome will be she will get her job back. The company is only interested in themselves and right now their biggest concern is the News Media. I think this will die down and the company will keep things the way they are or change their policies so noone can claim they meant do nothing.

2scents -“She had a few other reasons for not doing CPR. none had anything to do with the PT having a DNR.”

And what reason did she give the dispatcher? I didn’t listen to the tape.