Who Gets to Decide to Withhold CPR?

I’m not sure what I’d do if a patient collapsed in front of me and the administrator said, “No CPR. It’s our policy.” Since I’ve been a nurse, I’ve heard of slow codes, where the unspoken agreement is that if the person stops breathing the staff will purposely react as slowly as possible to give the person a chance to die, but I’ve never participated in one. The decision to either be resuscitated or be a DNR (do not resuscitate) is a personal one and the slow code takes that decision away from the individual. That goes against my philosophy of nursing.

English: CPR training

English: CPR training (Photo credit: Wikipedia)

Today’s news involves a nurse who did, in fact, stand by and refuse to do CPR when a patient went down. The facts seem simple. A woman collapsed in the dining room of an independent living facility. A nurse called 911 to report the incident. The 911 dispatcher asked the nurse to start CPR. The nurse refused, stating it was against company policy.

The 911 dispatcher didn’t give up. She asked the nurse to find someone who would start CPR, asking “Is there anybody that’s willing to help this lady and not let her die?” Again the nurse said no. The dispatcher continued to plead, as if the provision of CPR was the only surefire way to prevent this woman’s death.

Seven minutes 16 seconds later, emergency personnel arrived. The woman had no pulse and was not breathing. They started CPR.  The 87-year-old woman was declared dead at the hospital.

This has upset a lot of people. Upset some to the point that the police are trying to figure out if they can charge the nurse with a crime. The belief is that CPR would have saved this woman and the absence of CPR caused her death, and that’s not entirely correct.

According to Dr. Robert Shmerling in a post entitled, CPR: Less Effective Than You Might Think

“As opposed to many medical myths, researchers have reliable data concerning the success rates of CPR (without the use of automatic defibrillators) in a variety of settings:

  • 2% to 30% effectiveness when administered outside of the hospital
  • 6% to 15% for hospitalized patients
  • Less than 5% for elderly victims with multiple medical problems”

Another study that looked at out of hospital cardiac arrests found that successful resuscitation decreased with age. 40 and 50 year olds had a 10% chance of a successful resuscitation while patients over 80 only had a 3.3% survival rate.

No magic bullets here. There is no guarantee that CPR would have prevented this woman’s death. If she’d survived, there’s no guarantee of the quality of life she’d enjoy afterwards.

In this case, the independent living facility (not assisted living, not a nursing home, not a rehabilitation unit) maintains the residents are advised that in the event of a medical emergency staff members will call emergency services, but not provide CPR.  Employees are told the same thing.

The dead woman’s daughter said, “I don’t believe if CPR were done it would’ve helped or changed the result. This is not about my mother or me, this is about the policy of the facility, and we understood the policy, and I agree with what was done.”

Which brings me back to the original question. If the woman collapsed in front of me and, as a condition of living in the facility she’d agreed the staff wouldn’t perform CPR, would I have stood by and done nothing? With an underlying belief that the patient gets to make the decisions, I very well might have.

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Zombies Wanted, But Are They Dead or Alive?

One of my favorite lines in the Wizard of Oz goes like this:  “As Coroner I must aver, I thoroughly examined her, and she’s not only merely dead, she’s really most sincerely dead.”  It has a measure of decisiveness and finality. If someone is dead, we’d like assurances that they’re really and truly dead.
In order to determine the relative deadness of a person, there are two different criteria that may be used.  There’s the always popular clinically dead, the medical term for when the heart stops pumping and the lungs stop breathing. Then there’s brain dead, based on neurological criteria, that allows for a beating heart and working lungs (many times artificially maintained by a ventilator or respirator), but a nonfunctioning brain. Brain death determination looks at cessation of cerebral and brainstem functions and demonstration that the changes are irreversible.
Some definitions of death include all three markers, meaning death is defined as the cessation of all vital functions of the body including the heartbeat, brain activity (including the brain stem) and breathing.
And that makes me think of zombies.
Unfortunately, most definitions of zombies include some reference to the supernatural or witchcraft. The Centers for Disease Control Preparedness 101 Zombie Apocalypse home page states: “Although its meaning has changed slightly over the years, it refers to a human corpse mysteriously reanimated to serve the undead.” New theories support the notion that zombies are merely humans infected with a parasite that spreads through saliva. No matter what definition is chosen, a zombie is a human form that has lost the ability to reason and is no longer reliant on a heartbeat or breathing to survive. He or she retains the ability to move, but their movements are slow and awkward (unless one believes in zoombies).  Zombies have brain function, and that is the trait that causes most of us to fear the Zombocalypse.  Luckily their brain function is very limited. Enough for them to stagger around. Enough for them to capture people. Enough to remember that brains are their choice of food. Mobility, lack of brain function, and a hunger for brains is a terrifying combination.
But traditionally zombies are not considered alive or undead.  They are categorized as dead, and though they fit the criteria because of their lack of breathing and circulation, what about their brain function?
Dr. Steven C. Schlozman, an assistant profession of psychiatry at Harvard Medical School, postulates that zombies suffer from Ataxic Neurodegenerative Satiety Deficiency Syndrome or ANSD. He contends that zombie brains have some function, as well as dysfunction, in their cerebellar and basal ganglia. He likens the amount of brain function in zombies to that of a crocodile. Their unpleasant behaviors, including their insatiable appetites, derive from the lack of activity in the parts of the brain that modulate behavior.  But does this make them dead?
Since, at this point in time, medical technology has not created a need for zombie organ donation, devising new definitions of dead are not at the forefront of medical science. If, in the future, a method to safely use zombie organs is developed, I have no doubt that a new definition will arise and it will include the presence of limited brain function in the absence of respiration and circulation. The process will follow the same path to definition and acceptable use that occurred when human organ transplantation became viable. Prior to the need of organs, one definition of death, absence of heart beat and breathing, sufficed. After organ transplantation, a new definition of death, brain death, arose. When the need for zombie organs is great enough, medical science will become interested in ensuring that the answer to the question, are zombies dead or alive,  will become “really most sincerely dead.”
Interested in reading more about zombies? Check out: