Health

Wednesday, Mar 06 2013 06:49 PM

Decision not to perform CPR may sometimes be most humane

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    By Henry A. Barrios / The Californian

    Glenwood Gardens is shown in a March 6 file photo.

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BY STEVEN MAYER AND RACHEL COOK Californian staff writers smayer@bakersfield.com, rcook@bakersfield.com

The death of 87-year-old Lorraine Bayless last week at a senior living center in Bakersfield prompted widespread outrage after a recording of a 911 call showed that a staff member refused to perform CPR on Bayless.

But while some in medicine argue it's best to err on the side of prolonging life, others say aggressive resuscitation efforts often do more harm than good.

Dr. Peter Boling, a professor of geriatric and internal medicine at the Virginia Commonwealth University School of Medicine, said deciding not to perform CPR on a frail, elderly person, especially those with advanced conditions, may be the kindest and most appropriate response possible.

CPR generally does not work well on people with advanced chronic conditions, he said. The person may end up in worse condition and suffer a lot in the process.

"They usually don't come back to a meaningful existence," Boling said.

But CPR can be very effective for a person who is vital and healthy, he added.

Dr. Susan Leonard, an assistant clinical professor of geriatric medicine at UCLA, said some aggressive resuscitative efforts can harm a frail person.

Geriatric patients with a wide range of medical conditions might not be the best candidate for heroic efforts like CPR and intubation that could leave them with broken ribs or a collapsed lung, Leonard said.

The incident, recorded on a 911 audio tape, has attracted comment and attention across the country. That's because the Glenwood Gardens staffer who called 911 and identified herself as a nurse told the dispatcher neither she nor other facility staffers would perform CPR.

The dispatcher implored her, unsuccessfully, to try to resuscitate the woman or find someone else who would.

Jeffrey Toomer, executive director at Glenwood Gardens, originally said in a statement that the staff member correctly followed the company's protocol.

But on Tuesday, Brookdale Senior Living, Glenwood Gardens' parent company, issued a statement saying "this incident resulted from a complete misunderstanding of our practice with regards to emergency medical care for our residents.

"Glenwood Gardens is conducting a full internal investigation," Brookdale said, "which we are fully supporting, and the individual is on voluntary leave during the process."

The company is conducting a companywide review of policies involving emergency medical care, the statement said.

While Bayless later died, her family has made it clear that she wanted to die naturally and did not want aggressive measures taken to prolong her life.

Christopher Meyers, health care ethicist and director of the Kegley Institute of Ethics at Cal State Bakersfield, suggested the staff member at Glenwood, who identified herself as a nurse on the 911 tape, may well have done the right thing under very trying circumstances.

"The chance of a successful resuscitation was probably less than 1 percent," Meyers said. "The chance of causing additional trauma ... close to 100 percent."

But refraining from heroic measures doesn't mean we can't offer comfort and support, Meyers said.

"There are all kinds of other ways to comfort someone in distress," he noted. "Getting down on the floor, talking to her, hugging her, reassuring her, holding her hand. I hope they did that at Glenwood."

'PRETTY AGGRESSIVE'

Dan Lynch, the Emergency Medical Services director for Fresno, Kings, Tulare and Madera counties, said those who work on the streets, those who respond to frantic calls for help, don't always have the luxury of determining the details of a patient's medical background.

"I can tell you we're pretty aggressive with it," Lynch said of decisions to perform CPR. "I commend the dispatcher in Bakersfield for what she did."

If a patient has not been breathing for some time, or there are other signs -- beyond lack of pulse or breathing -- that he or she is lifeless, CPR will not be initiated, Lynch said.

"People are living longer and stronger," he said. "We will give anybody the benefit of the doubt."

Kern County Fire Engineer Corey Wilford agreed.

If a family member informs the first reponder that the patient has an advanced illness or another extenuating circumstance exists, a paramedic or emergency responder may then adjust protocol. But in most situations, they err on the side of action.

"You always have to fight for the survival of the patient," Wilford said.

TALK IT OUT

These differences in philosophy and approach are exactly why these issues must be discussed at dinner tables and in doctors' offices across America, Meyers said.

It's important to talk about what a patient wants while he or she is still comfortable and able to make those decisions, not to wait until a crisis unfolds, he said. And they should put their wishes in writing.

In the absence of such paperwork, loved ones and physicians may be left to make medical decisions without good information about what a patient and his or her family wants.

Making these decisions in advance is the ethical thing to do, Meyers said.

"We in fact have a moral obligation," he said, "to relieve others from having to make those decisions for us."

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