The Ethics Behind A No-CPR Policy
March 6, 2013 1:02 p.m.
Tony Chicotel, staff attorney for California Advocates for Nursing Home Reform
Neil Farber, M.D., practices general internal medicine at UC San Diego, he studies end of life care and medical ethics
Related Story: The Ethics Behind A No-CPR Policy
CAVANAUGH: The recorded 911 call was powerful. An emergency services operator in Bakersfield pleads with a worker at the Glenwood Gardens senior living facility to perform CPR on a woman collapsed on the floor. The woman who identified herself as a nurse said it was against facility policy to administer CPR. Lorraine Bayless died at the hospital. This has brought the senior care industry into the spotlight. It's an industry that a spokesman for the California nurses' association calls "the wild west of healthcare." Joining me to discuss what people need to know about these care facilities are my guests. Doctor Neil Farber who practices general internal medicine at San Diego with an interest in medical care and end of life ethics.
FARBER: Thank you.
CAVANAUGH: Tony Chicotel staff attorney for the California nursing home reform.
CAVANAUGH: We contacted assisted living facilities in San Diego, they were not able to provide any representative for this interview. Let me start with you if I may, Mr. Farber. The parent company of Glenn wood says the worker who called 911 was not a nurse, and she misunderstood company policy not to administer CPR. Would there of be a legitimate medical reason to withhold CPR?
FARBER: Well, there is a legitimate reason if the patient wishes to withhold CPR. And patients have the right to do that. Some people who are at the end of their lives decide that CPR might not be advisable for them, and that's something that's acceptable.
CAVANAUGH: Without knowing whether or not a particular person may have wanted that at the end of their life, would there be any other extenuating circumstances that might make it not wise for someone to perform CPR?
FARBER: Well, it's an interesting question. One is looking at the issue of does CPR constitute medical care or does it constitute sort of the typical thing any individual can do? We know that basically medical care needs to be done by someone who is licensed to be able to do so and who is trained to do so. But CPR is something that the lay people in this country can perform. And so there is no reason for someone who knows how to give CPR to not do so unless the person requests that it not be done.
CAVANAUGH: Does a facility open itself open to liability by performing CPR?
CHICOTEL: It's possible. But I don't think likely, and I don't think it was likely enough to actually justify a policy that would forbid providing CPR to someone who hasn't declared that they tonight it. If whatever care was provided incompetently and make the situation worse there, is potential liability there. But I just don't see it being likely enough to justify intervening in a a case like this.
CAVANAUGH: Glenwood gardens says they were very clear that there were no medical staff at the facility. But that doesn't necessarily mean patients who faint won't be revived. Is that the kind of connection that you would make as well? Even though nobody could provide medical care, you would still -- they would still try to revive you if you fell on the floor?
CHICOTEL: I'm not seeing the distinction there. It seems to me that their protocol as it's been relayed before, I understand there's now maybe a different interpretation. But the way I understood it before is that if somebody is found unconscious or in need of emergency medical assistance, their protocol was to call 911 and to wait and to not intervene at least in the independent living section of this facility.
CAVANAUGH: Do other California facilities have no CPR policies that you know of?
CHICOTEL: There are facilities. It's hard to say how many or how prevalent the policy is. But I am aware of facilities even at a higher level of care, called the assisted living level of care, where there are policies to call 911 or to call a private ambulance service instead of providing direct intervention.
CAVANAUGH: The news today is that the family of Mrs. Bayless says that she did not want her life prolonged artificially. But isn't that different than being given CPR?
FARBER: Well, there are many different aspects to prolonging someone's life in terms of medical means. CPR is one component of it. There can be others, such as feeding tubes, respirator, etc. CPR is one of them. But that has to be specifically clarified by the individual.
CAVANAUGH: Now, Tony, Glenwood gardens is an independent senior living facility. And you've already made conference to the fact that there are different levels of care in different facilities. What other kinds of senior living facilities are out there?
>> We like to talk about the long-term care continuum, going from one end where somebody is totally independent, can meet all of their needs without assistance, and then moving along the continuum you have maybe some in-home care, something like the Glenwood gardens situation where you have a congregate living scenario. There might be some basic activities, fun things for the residents, but really no direct interventions with getting by for their day to day needs. Then there's assisted living, which is a level of care where people do need sometimes lots of assistance with basic things like cooking meals, laundry, getting dressed, bathing, those kinds of things. And then sort of the highest level at least in long-term care is the skilled nursing facility setting, nursing homes where you have a nurse on home 24 hours a day, people with very sometimes intense medical need, usually rehabilitating from a surgery or a major incident like a stroke.
CAVANAUGH: And there are some facilities that have all of these services under one banner; isn't that right?
CHICOTEL: Right. And Glenwood gardens is one of those facilities. And they've actually applied for official recognition of that status with the State of California. My understanding is that it's not been approved. These all in one campuses are called continuing care retirement communities. And that's what makes the Glenwood garden situation a little more dramatic in my opinion because there is a health level component to the campus. So when I think people go there, there's an expectation of basic healthcare competence that might not be an expectation at a pure independent living facility without any additional levels of care.
CAVANAUGH: Even on these campuses though, are there different staffs for each of the different levels of care provided?
CHICOTEL: Yes, typically the staff are segregated by the level of care. So I wouldn't expect a lot of healthcare training in the independent -- among the independent living staff members. But there were people on the campus who could have provided -- who were probably well trained in CPR and could have provided it to this resident.
CAVANAUGH: Let me ask you one more question about this, Tony. The fact that the nurses' association calls all of this, senior living and nursing care, the wild west of healthcare, it seems to suggest there's not much oversight out there. Would you agree?
CHICOTEL: Absolutely. With independent living, there is no oversight. Sometimes there's some federal subsidies and maybe state subsidies that are tied in with the payment of rent. But there's very little structural regulations or substantive regulations on the day-to-day operations. And even at assisted living level of care, there's a whole lot of healthcare going on, and it's -- the facilities aren't licensed or regulated to provide that kind of healthcare. It's one of the things we've been trying to draw attention to over the last ten years or so. People in assisted living were in nursing homing a generation ago. And there needs to be recognition at the regulatory level that this is the reality.
CAVANAUGH: Do patients routinely consult with physicians about what level of care they might need or what the facility should provide for them if they're thinking of entering one of these establishments?
FARBER: Well, certainly the establishment has the obligation, at least in hospitals, the obligation of communicating with patients about that. That was actually enacted into law in the 1990s. And we as physicians have promulgated the idea that patients do need to discuss this, and physicians on a routine basis do so. Unfortunately, only about a quarter of patients actually have advanced directives indicating what kind of care they would want. But it certainly behooves patients to do so. And it can help avoid these kinds of situations.
CAVANAUGH: If a patient were to come to you, doctor Farber and basically say, you know, these are the medical issues that I have to deal with at this time, and this is the type of level of care I want, but I don't want any care beyond such and such intervention. Would you work with a patient like that in order not only to draw up the necessary legal documents but also find a facility that worked with those concerns?
FARBER: Sure. And in fact there's a form that is available in California called the pulset form, POLST. The directives are sort of a guide, it's a legal document by a patient, but it's a guide basically for physicians about what that patient wants. It's the physician who has to put the order into place in a healthcare institution. But the form is actually a written order by the physician which has to be adhered to in any hospital that a patient would go to. Now, some of the nursing homes are beginning to work with those forms as well and are aware of them. I'm not sure about institutions like either independent living situations or any other of the intermediate types of care facilities. But as a physician, I would certainly are work with the patient to ensure that their wishes were made known.
CAVANAUGH: I want to sort of open up this conversation a little bit from this one incident to the larger issue. People seemed really disturbed by that 911 call that was released earlier this week. It seemed to open up a lot of anxieties about end of life care for both their parents and themselves. Tony, is this an issue we really haven't thought through as a society?
CHICOTEL: I think for the most part the answer is yes. Seniors tend to think about it more than the average person. But as doctor Farber mentioned, only 25% of the population roughly has done an advanced directive. And I know that I've been doing long-term care advocacy for 15 years, and this is the first time the issue's come up in my practice. So I think people need to think about this. Healthcare directives are pretty easy to accomplish. It's just a matter of committing about an hour you to reading -- find ache document, reading the document, and filling it out. And particularly with places that are going to cater to seniors with fragile medical conditions, they need to have expressed policies and procedures and let their clients know that this is what to expect if there's ever a time when there's a medical emergency.
CAVANAUGH: Tony, the family of Lorraine bayless says she knew that she was moving into a facility that had no medical staff, the family is fine with the decision made by the worker. They don't intend to pursue any legal action. Does that strike you as perhaps the exception to the rule? Wouldn't you think most -- I don't know, maybe this is an extravagant comment, but wouldn't you think most people who lived in a senior independent living situation expect a certain level of CPR care or medical services if they were to collapse?
CHICOTEL: Yeah, I think so. I think the expectation for most people would be that they would get care and they would want care. It appears that it wasn't the case this time. But the law presumes that people want care, and there has to be some sort of document that says otherwise for emergency medical technicians to not provide the care. I think there would be a lot of 87 year-olds who wouldn't want the care provided. But for most people and certainly people who are younger, the expectation is we're going to get the care and someone is going to help me out if I'm in distress.
CAVANAUGH: Right what. Kind of your reform is your organization looking for in this large issue of nursing home and senior care?
CHICOTEL: Well, it's a new one on us, and we need some time to think it through, but obviously nursing homes are going to provide CPR when residents need it, unless there's a do not resuscitate order in place. We think assisted living is the level of care that might be a good target of potentially a regulation or a new law that clarifies what facilities' policies are. Maybe not to tell facilities that they have to provide the intervention, but training might be in order. Right now there's a requirement for first aid training, but it doesn't include CPR is my understanding. And then also that the facility make their policies expressed to individuals upon admission.
FARBER: Not only for CPR. In fact if you look at the data, most patients who have CPR outside a hospital don't survive it. It's not a -- always a life-saving measure. But there are some who do. But more important than that are the situations where if somebody got care, they in a timely fashion before CPR were necessary, they might more likely survive. For example, as a simple for example, somebody having a heart attack, if they're given an aspirin, there's a 25% reduction in mortality associated with it. So there are simple measures that could be carried out that would improve the survivability as well as the quality of life of individuals in an assisted living facility.
CAVANAUGH: And doctor Farber, would you agree that this incident has focused attention on perhaps an issue that we don't like to think about but need to?
FARBER: Yeah. Certainly no one wants to think about their own mortality or the possibility thereof. But it is something that obviously we all do face, and it's something that if we have some ideas of what we want ahead of time, it can help. Practitioners and others make our wishes fulfilled.
CAVANAUGH: I want to thank you both.
FARBER: You're welcome.
CHICOTEL: You're welcome.