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Old 03-06-2013, 09:40 AM   #61
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Originally Posted by growing_older View Post
Interesting that so many seem to agree with the policy of withholding CPR to residents of the less expensive "independent" living section, when it would have been provided as a matter of policy to residents of the more expensive "assisted" living section.
Looking at dad's contract (same company) I see nothing in black and white that says "no CPR by staff". However, it makes it clear that for all health care matters, the resident is responsible. Period. They have an emergency call system and that is clearly described as a system to forward 911 if necessary. They will make accommodations to hold the elevator, clear the way, and get access to the apartment for EMS.

Assisted living is another ballgame. It is licensed as a nursing facility. The rules are totally different.

We're 100% fine with these rules for Independent living.

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I just read that the lady did not have a written care directive but gave her family to understand that she would not want CPR.

If I were in charge at a long term care facility, I would make it a condition of admission that all residents have a written care directive on file. I think many facilities do that.
Reading Dad's contract again. Recall, this is Independent living. Perhaps it is different on the assisted/SNF side.

Here they highly encourage residents to have advance directives and POAs, and if so, provide them confidentially to the staff for access. But they do not have a "rule". Again, I think that is in the spirit of independence.
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Old 03-06-2013, 10:24 AM   #62
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It must be great to be management. You tell a person such as a nurse, that they must do a certain thing in an emergency situation. She does it. When bad publicity surrounds it, its the nurse is headlined as the bad gal, while management's involvement (the real force behind the nurse's decision) is buried in the article.
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Old 03-06-2013, 11:05 AM   #63
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It is unfortunate that the woman's physician did not talk to her about a POLST, she evidently didn't have that or a health care directive.

End-of-life care: an Oregon innovation helps people avoid unwanted interventions | OregonLive.com
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Old 03-06-2013, 12:27 PM   #64
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Hopefully, some good will come out of this. I feel bad for the family being thrust into the spotlight. In any case, senior living companies have learned a lesson too and need to be forthright as to what kind and level of emergency care will be given. Sounds like management has reversed their initial stand on this case. In my Dad's place, it is very grey, yet still it would be understood that EMS was the first responder. It will be interesting to see if we get any correspondence on this issue.

What made this different was that it was in a common area. You'd have to consider this like if you had a heart attack at a restaurant, and a nurse was nearby. What would the nurse's obligation be?

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"It was our beloved mother and grandmother's wish to die naturally and without any kind of life prolonging intervention," the family said. "We understand that the 911 tape of this event has caused concern, but our family knows that mom had full knowledge of the limitations of Glenwood Gardens and is at peace."
The family said it would not sue or try to profit from the death, and called it "a lesson we can all learn from."
"We regret that this private and most personal time has been escalated by the media," the statement said.
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Old 03-06-2013, 12:48 PM   #65
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The more I read about this the more I wonder how the press learned about this. I assume it wasn't the family or the worker that reported it. So it probably came from the 911 operator.

Isn't that a violation of privacy?

To read that CPR in elderly patients almost always results in intubation... Yikes. My mom had a DNR but agreed to intubation for a surgery. Following the surgery she wasn't stable enough, so they left her intubated. She clearly wasn't happy about it but at that point the hospital would not remove it. In an ICU, they tie the patients hands down so they won't mess up the tubes/ports/IVs. The first time they turned their back with her hands not tied down, she extubated herself. (Which had to be awful!) Her first words croaked out were DNR!!!! (She died 12 hours later - but on her own terms.) My brother, who felt all measures *should* be used (anti-DNR?), tried to extubate himself when he was in the ICU, dying. He wanted exceptionally life saving measures, but hated being intubated. I conclude, that being intubated has to be one of the most unpleasant things possible.
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Old 03-06-2013, 01:14 PM   #66
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The more I read about this the more I wonder how the press learned about this. I assume it wasn't the family or the worker that reported it. So it probably came from the 911 operator.

Isn't that a violation of privacy?
My thoughts exactly.

Yes, full resuscitation at the end of life can be very cruel. I have a pretty clear directive, which outlines the conditions under which I do not want to be resuscitated, the nature of the resuscitation, and even mentions that if I wake up and find that they have resuscitated me against my wishes, I and my heirs will sue the pants off them.
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Old 03-06-2013, 02:03 PM   #67
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I recently completed a CPR certification course. We practiced performing CPR on specially-equipped dummies that light up to show you whether the compressions are done correctly (hard enough). Most of us were pretty surprised at how hard we had to work (using both hands) to get it right. We were told that 80% of adults will suffer from broken ribs if the CPR is performed correctly.
I believe in my state you are held harmless if you administer CPR. As you said, done correctly, would will most likely break some ribs even on a young person never mind a frail 87 year old woman.
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Old 03-06-2013, 03:26 PM   #68
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CPR is almost always unsuccessful when performed on elderly patients.
Thanks, I had no idea. Looks like an interesting domain where there's room for progress.
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Old 03-06-2013, 05:10 PM   #69
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There seems to be a lot of discussion of whether or not the woman had a DNR.

She was in California, but let's suppose she was in Texas, and she had DNR forms filled out, her physician had a copy, her family had copies, and so on. The problem is that, in Texas, a DNR applies only to in-hospital situations. In Texas, a standard DNR does not apply to nursing homes, assisted living facilities, the football stadium, the grocery store, or the individual's home.

If EMTs were summoned to assist her and she was not in hospital (and why would they be summoned if she were), then they are required to perform CPR, etc for 20 minutes unless rigor mortis has set in, or she has a different document, an "Out of Hospital DNR (OOH-DNR)" immediately available for the EMTs to find (which would mean she was at home -- because no one carries their DNR/OOH-DNR with them 24/7).

[side note: This is a heck of a good reason to have "VIAL OF LIFE" documents easy for EMTs to find, and to have the OOH-DNR on the top of the stack of papers].

A local EMT tech told me that if someone who does not want extreme measures has died (or is dying), then don't call the EMTs right away. Have "a final cup of coffee with Aunt Millie" so that RM can start (about 20-30 minutes) and thus the dignity in death and the wishes of Aunt Millie will be preserved.

And here's another twist: in Texas you can complete/sign a DNR without consulting your physician. It's your decision, right? But the OOH-DNR must be signed by the physician (in two places) and then signed by you and two witnesses, with those signatures notarized. Yeah, that's right: you've got to have your physician's permission to refuse extreme measures outside of a hospital. And physicians are very reluctant to sign the form, in case the wrath (or worse) of the family descends on them.

Texas makes it very hard for someone, like my 90-year old father, to die peacefully at home, according to his wishes.
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Old 03-06-2013, 07:19 PM   #70
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I found this article on the case interesting and it addresses a lot of the issues discussed in this thread:

Amid CPR Controversy, Many Unanswered Questions - NYTimes.com

To me, if she didn't have a DNR that was applicable then CPR should have been administered, end of story. Whether this is assisted living or not assisted living is irrelevant to me. Someone in this thread asked what if a nurse was a bystander in a restaurant (I think) and I think that a nurse or physician in that situation should administer CPR. I'm not saying it should be legally required, but I think that morally it should be done.

As to the deceased woman's child being satisfied with her mother not getting CPR, I guess my view on that is ....who gives a rat's posterior about anyone's opinion on that rather than the mothers. If it was me and I was the 87 year old and I wanted CPR in that situation then it is irrelevant to me if my daughter would be OK with me not getting it. What matters is the deceased person's wishes. And, since she didn't have a DNR we don't know what she thought. We know (from the article) what her daughter says the mother thought but there is no way to verify it. Lots of people just assume that everyone is elderly would want no CPR in that situation...but that may just be an assumption. That is why DNRs are in writing.

As far as doing CPR on an elderly patient. I would guess it depends. The NY Times article cites to an article on CPR in older patients:

How Successful Is CPR in Older Patients? - NYTimes.com

More on CPR for the Elderly - NYTimes.com

After reading the article, I found that there is a small chance of CPR being successful and there is a chance that the CPR will result in injury. That said, if I was otherwise in stable health (i.e. didn't have a terminal illness or dementia) and I was in my 80s I would want the CPR. And I wouldn't want someone deciding I would rather be dead than have broken ribs or that I would rather die than have a 9.4% chance of the CPR succeeding. (If was terminally ill or had dementia then I would feel differently).

The thing is that you can't know what someone would want just by knowing that the person is in his or her 80s. And, in the absence of a DNR I think you have to assume that the person would want the chance of CPR succeeding.
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Old 03-06-2013, 08:03 PM   #71
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"Vial of Life" is what they should keep in the freezer. This is the standard place the EMTs are told to look. Thanks for mentioning the name.

Doesn't do any good if you drop in the dining hall, though.

I asked the question about the nurse witnessing this. Her refusal seems strange to me, yet I also understand somewhat having hung out in one of these places for a few weeks. I'm conflicted.

Finally, I want to say there is a difference between early and late 80's, in general. My observation has been that typically there is huge decline in this decade, and your DNR wishes are likely to change in this time. Of course, I speak generally. I met a few early 90's folks at Dad's place that were very vigorous and would probably not want a DNR.

Questions, questions and conflicts. These are not easy questions. We or our family will all face them some day, if we make it that far.
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Old 03-07-2013, 07:06 AM   #72
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To me, if she didn't have a DNR that was applicable then CPR should have been administered, end of story. Whether this is assisted living or not assisted living is irrelevant to me. Someone in this thread asked what if a nurse was a bystander in a restaurant (I think) and I think that a nurse or physician in that situation should administer CPR. I'm not saying it should be legally required, but I think that morally it should be done...

if I was otherwise in stable health (i.e. didn't have a terminal illness or dementia) and I was in my 80s I would want the CPR. And I wouldn't want someone deciding I would rather be dead than have broken ribs or that I would rather die than have a 9.4% chance of the CPR succeeding. (If was terminally ill or had dementia then I would feel differently).

The thing is that you can't know what someone would want just by knowing that the person is in his or her 80s. And, in the absence of a DNR I think you have to assume that the person would want the chance of CPR succeeding.
Just goes to show why public policy should be very clear and people should make their wishes very clear. I would say the exact opposite of each of these points. If I saw a clearly very old (mid 80s+) person collapse on the street and stop breathing I would feel my moral obligation was to let that person die peacefully rather than jump in and do everything I could to insure they get to remain on tubes for a few extra months. Same for nurses and doctors who would more likely succeed in precipitating that unfortunate situation.

If I was in my mid 80s I would not want someone administering CPR. I wouldn't want someone deciding I would rather have the CPR succeeding and likely leaving me disabled, in a hospital bed, maybe even intubated for weeks instead of peacefully dying.

Texas' policy (described in a post above) sounds like the most intrusive, arrogant "do it our way or be damned" policy I can imagine.
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Old 03-07-2013, 08:39 AM   #73
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CPR: Less Effective Than You Might Think - Medical Myths - Harvard Commentaries | Aetna InteliHealth

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For example, when a person has stopped breathing because of low body temperature (such as someone rescued after falling through ice into a cold lake) or another readily reversible condition, the success rate is higher. On the other hand, when an elderly person has stopped breathing because of heart problems or pneumonia, especially when other medical problems are present, CPR has a very low success rate.
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Old 03-08-2013, 08:12 AM   #74
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Heck, shouldn't DNR be the default policy in nursing homes? Heck, shouldn't DNR be the default policy in nursing homes?
I assure you, it is not. And even if you have one, it doesn't mean they'll honor it. Not in my state anyway, and especially not if the patient is private pay. They want to keep those hanging on for as long as they can. I had to threaten to sue to get my mother put on hospice. She was 92, suffered from a stroke that left her paralyzied from the waist down, and she had Alzheimer's and chronic heart failure. They insisted on submitting her to physical rehab every six months. I'm still pretty bitter about the whole thing. Good comfort care is one thing, but trying to "rehab" someone with all those issues was ridiculous. Someone please just shoot me when I get there.
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Old 03-13-2013, 04:45 PM   #75
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As a person who was "almost dead" and was considered in a state of "walking death" by my Internist of over 20 years (the quotes are what he said to my wife), I am wary of people's simplistic view of whether all people who are 87 should be left to die when they need CPR. I had terminal, end stage kidney failure and was fast approaching heart failure and had congestive heart failure. I felt absolutely horrible and felt like I was being poisoned. BTW, I know what it feels like to have Arsenic poisoning so I am not just making that up. I would not have wanted to be denied CPR just because I was a basket case. I very much wanted to live. I was pretty much cured of the kidney failure and heart failure and congestive heart failure overnight. I got a kidney and pancreas transplant in April, 1996. It literally saved my life. Before the transplant my BP was 250/125 and a day after it was almost back to normal. When the organs became available, I was second on the list but got the organs because the person who was first had the flu. The sickest person gets moved up the list the fastest. I was really, really sick. I was only on the list for four months. The usual wait is 4 years.

I am still pretty much a basket case of problems but I am not terminally ill anymore. If I get really sick because I am old and have no hope of getting better then I will get a DNR.

Deciding whether a person should have a DNR by default is crazy. Ignoring an old person having a CPR moment on the sidewalk because they are old is foolish. Resuscitate them and let them get a DNR for next time. If you let them die and they wanted to live then you've made an irreversible mistake.

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Old 03-13-2013, 05:01 PM   #76
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And I wouldn't want someone deciding I would rather be dead than have broken ribs or that I would rather die than have a 9.4% chance of the CPR succeeding. (
I've had broken ribs 3 times in my life, never with pneumothorax. It is painful for a while, but from my standpoint no especially big deal. I would never let fear of broken ribs make me prefer being dead.

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Old 03-13-2013, 05:17 PM   #77
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As a person who was "almost dead" and was considered in a state of "walking death" by my Internist of over 20 years (the quotes are what he said to my wife), I am wary of people's simplistic view of whether all people who are 87 should be left to die when they need CPR.
But were you 87 when you came back from the dead? I didn't see anyone suggesting that the average Joe should be treated as a DNR if he or she collapses on the street. But once people get into their mid to late 80s it is questionable that the default should be to take every possible action to prolong life.
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Old 03-13-2013, 05:29 PM   #78
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Old 03-13-2013, 06:08 PM   #79
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IMO, With both the 911 dispatcher and facility nurse doing their jobs. If either of them did things differently, they could lose their jobs. .
Had the employee NOT followed the institution protocol, she not only could possibly have been fired, but she may have been "black-balled" from the profession - having a reputation of NOT following prodecures. That would be a huge risk for any potential employer.

My own 2 cents - It looks like the protocol was followed as specified in the literature given to new residents. The 911 operator did what SHE thought to be morally right. The care home did what her employer required her to (not) do.

I think Mid-pack nailed it - each did "the right thing" and it turned out the way it turned out. The only "lesson" that I think society should glean from this incident is that PERHAPS there needs to be a stronger identification of the rules up front. Also, it is not unreasonable to assume that this particular institution will have a similar situation on a somewhat recurring basis. With that in mind, perhaps there could be better training of 911 operators to let them know that when this institution calls, CPR is not an option. Dispatch rescue and pray.
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Old 03-14-2013, 02:55 PM   #80
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As a person who was "almost dead" and was considered in a state of "walking death" by my Internist of over 20 years (the quotes are what he said to my wife), I am wary of people's simplistic view of whether all people who are 87 should be left to die when they need CPR. I had terminal, end stage kidney failure and was fast approaching heart failure and had congestive heart failure. I felt absolutely horrible and felt like I was being poisoned. BTW, I know what it feels like to have Arsenic poisoning so I am not just making that up. I would not have wanted to be denied CPR just because I was a basket case. I very much wanted to live. I was pretty much cured of the kidney failure and heart failure and congestive heart failure overnight. I got a kidney and pancreas transplant in April, 1996. It literally saved my life. Before the transplant my BP was 250/125 and a day after it was almost back to normal. When the organs became available, I was second on the list but got the organs because the person who was first had the flu. The sickest person gets moved up the list the fastest. I was really, really sick. I was only on the list for four months. The usual wait is 4 years.

I am still pretty much a basket case of problems but I am not terminally ill anymore. If I get really sick because I am old and have no hope of getting better then I will get a DNR.

Deciding whether a person should have a DNR by default is crazy. Ignoring an old person having a CPR moment on the sidewalk because they are old is foolish. Resuscitate them and let them get a DNR for next time. If you let them die and they wanted to live then you've made an irreversible mistake.

Mike D.
Mike,

I enjoyed reading your post. Glad that you bounced back from being on death's door. You are living proof that decision for a DNR or not isn't always cut and dry.

In your situation when you were gravely ill, did you and your wife explicitly state to your doctors/hospital that you do not have a DNR order and asked them to comply with the request?

Easysurfer
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