Hello, rosalima-ga!
I am assuming you are referring to situations in pre-hospital
settings where there is no “Do Not Resuscitate” directive in place.
Therefore, I have tried to formulate some ideas for you by researching
a few different avenues.
Let me start by stating that I could find no definitive policies that
give nurses the automatic ability to decide whether or not to initiate
CPR just because the patient appears dead in “their eyes.” However, I
understand your premise that an experienced nurse has experienced
enough death to feel quite sure when a patient has been dead for a
length of time.
As you already know, most protocols use dependent lividity as one of
the major determinants in defining death and thus ruling out the need
for artificial life support. However, it appears that there are some
other determinants that can supersede that requirement. I have
uncovered some articles, which may be helpful to you, and some
parameters used by different EMS services to define instances when
initiating CPR is considered unnecessary.
An important article that may hold the key to parameters used in other
states
*************************************************************
I have run across a review of an article in the Journal of the
American Geriatric Society, titled “Attempting resuscitation in
nursing homes: policy considerations. Finucane, TE, & Harper, GM
(1999). J Am Geriatric Soc, 47(10), 1261-1264 at
http://www.aafp.org/afp/20000415/tips/11.html which seems to go right
to the heart of your question.
An excerpt of the review follows:
“It is known that attempted cardiopulmonary resuscitation (ACPR) is
infrequently performed in the long-term care setting and is rarely
successful (successful being defined as admission to the hospital
alive). Survival (defined as discharge from the hospital) is also
rare. Survival with improved or intact status (neurologic or
functional) is uncommon but does occur. Because ACPR is not
necessarily a painless, free or dignified procedure, other questions
remain to be answered. What is the benefit or harm to the patient of
performing ACPR when it is unsuccessful? What about when ACPR is
successful, but the patient expires within a few days as a hospital
inpatient? The authors point out that these questions cannot be
studied, only decided. The patients in question are usually extremely
vulnerable because of functional or cognitive limitations, and a
myriad of regulations protect them. However, few protective measures
are in place to protect these patients against overtreatment. That is,
as the system now stands, a usual presumption is that not performing
ACPR is neglectful. However, it would be helpful to address what harm
is done in performing ACPR. A case can be made that allocation of
resources in favor of performing ACPR benefits few of these nursing
home residents, and that these resources could benefit many more
patients if allocated in different ways. Simply having the ability to
perform ACPR may appear to many to be a logical reason to perform it,
and this concept may elevate ACPR to being thought of as a "right."
The mere availability of a treatment is a poor reason to use it.
***All nursing homes are not required to offer ACPR. The authors
point out that many nursing homes in the United States, as well as in
other parts of the world, do not offer ACPR.***
“If ACPR is an option, it may be reasonable to offer it only to a
select group of patients. However, this step would likely be seen as
paternalism on the one hand and neglect or abuse on the other.
**Some nursing homes have elected to offer ACPR only to those with a
witnessed arrest, which lowers the survival rate from 3 in 100 to 3 in
1,000.**
(I am unable to access the article over the internet. If you can
access the article and find out which states do not require ACPR, or
“elect to offer it only to those which a witnesses arrest,” you should
have some good ammunition with which to plead your case!)
Refer to another profile of the above paper at
http://www.lastacts.org/files/misc/resuscitation.html )
Some parameters used in the field to determine initiation of CPR might
be “adjusted in wording” to apply to prehospital settings to support
your view
****************************************************************************
San Mateo County:
*Special Circumstances using “lack of CPR observed for at least 10
minutes:
2. A Receiving Hospital Physician may choose to:
2.1 Pronounce the patient dead via radio or telephone communication in
certain situations such as:
2.1.1 The paramedic's determination that a public safety officer has
observed apparent death for at least 10 minutes during which time CPR
could not be initiated and asystole can be verified on EKG.
2.1.2 The physician determines that the patient is dead by other
criteria.
Read “Guidelines for Determining Death in the Field.” San Mateo County
Health Services Agency. (5/2000) at
http://www.smhealth.org/ems/protocols/sel-guide.html
San Luis Obispo County:
San Luis Obispo County Protocol concerning Pre-Hospital Policy and
CPR for EMS personnel and first responders allows for no initiation of
CPR under certain conditions of “Obvious Death”:
*One of these conditions is that there has been…
“No CPR for more than 20 minutes (the source of history must be
reliable)”
(Now, exactly how that is interpreted is not described. In other
words, could that apply to finding a patient lying in bed in a nursing
home who has had no CPR initiated and appears to be dead?)
“When the patient is determined to be "obviously dead",
resuscitation measures shall not be initiated.”
“EMS personnel shall describe the incident and patient’s
condition on the prehospital care report clearly stating the reasons
that life support measures were not initiated.”
Read “Pre-Hospital Policy – Subject: Prehospital Determination of
Death (3/1/1997) at http://www.fix.net/~sloemsa/policy/116.html
1.) Adult patients whose sudden arrest is likely to be medical.
2.) An unwitnessed arrest with delayed CPR (>6 minutes) or delayed
defibrillation (>8 minutes).
Read “Discontinuing Resuscitation,” by Linda E. Wood, BSN, CFRN.
AirFax (4/2002) at http://aircare.org/pdfs/43.pdf
“1. Patients who display advanced signs of death, IE., rigor mortis,
**body cold to touch in an otherwise warm environment,***
dependent morbid lividity, beginning decompositions, may be presumed
dead.”
Read “Presumption of Death in the Field.” Coastal Bend Regional
Advisory Council http://www.cbrac.org/presumption_of_death_in_the_fiel.htm
Wisconsin Parameters may hold promise
*********************************
The Wisconsin Medical Society Policy Compendium 2002-2003
PRP-993
CPR Practice Parameters: The Wisconsin Medical Society reiterates its
support for the CPR Practice Parameters, including allowing
across-the-board no CPR policies in nursing homes. (BOD,1097)
http://www.wisconsinmedicalsociety.org/health_policy/COMP/prp.cfm
I could not find the attachment describing the actual parameters for
facility guidelines.
Also refer to a memo titled “Practice Parameters Regarding the
Inititiation and Implementation of Cardiopulmonary Resucitation (CPR)
in Wisconsin Long-Term Care Facilities at
http://www.dhfs.state.wi.us/rl_DSL/Publications/pdfmemos/92003.pdf
(I was unable to find any further information regarding the actual
wording of the policy online, but it might by worth your while to
investigate if you have access to medical policies by state.)
For Further Consideration
***********************
The futility of providing treatments to patients who will not benefit
has been examined for many years. Some of the arguments presented in
the following articles are applicable to your question.
From “Futitlity and Its Uses,” by Bradley E. Wilson, Ph.D. Community
Ethics at http://www.pitt.edu/~cep/31wils.html
“There are two main uses to which futility judgments are commonly
put. First, a physician might rely on a judgment of futility to
justify not offering a particular treatment as an option to a patient
or their surrogate. For example, for an elderly patient suffering from
multi-organ failure, CPR might be deemed to be futile, and thus would
not be presented as an option to the patient's decision-maker.
Secondly, a physician might override the expressed wishes of a patient
or their surrogate for treatment, on the grounds that the desired
treatment is futile. Here, CPR might be withheld in situations where
it was determined to be futile, even if the patient and/or their
surrogate had indicated that they want it to be provided. In either
case, the judgment of futility provides the basis for making a
decision about whether or not to offer or provide a form of treatment
to the patient.”
“Once the goal of treatment has been identified, there are two
plausible ways of understanding what it means for treatment to be
futile. First, treatment might be judged futile if there is a very low
probability of achieving the goal of treatment under the
circumstances. The very low success rate of CPR in elderly patients
with serious underlying illnesses has been used to support the claim
that such treatment among those groups is futile and need not be
offered. The second way of understanding futility is in terms of no
possibility of achieving the goal of treatment, rather than a low
probability. This notion is sometimes referred to as "physiologic
futility". It applies in far fewer circumstances than the preceding
notion, since it is a rare situation in medicine where there is no
uncertainty about the outcome. Nevertheless, there are situations in
which this notion of futility would apply, such as the use of CPR
where a cardiac rupture makes restoring cardiac function impossible.
From “Setting Limits and Long-Term Care of the Elderly,” by Neil
Nusbaum, JD, MD.Tulane University School of Medicine at New Orleans VA
Medical Center at http://www.sma.org/smj/97feb23.htm
“In discussing CPR it is important to remember that most nursing
home patients will not survive it; the chance of survival depends on
the clinical circumstances in which CPR occurs. A study of
cardiopulmonary arrests over a 4-year period in Milwaukee nursing
homes22 showed that if the arrest was witnessed and if the initial
cardiac rhythm was ventricular fibrillation, just over one fourth
(27%) of those patients survived. Outside these particular
circumstances, however, the survival rate was less than one tenth of
that rate (2.3%).
* In many of the cases of unwitnessed cardiac arrest, of course, it is
likely that the patients were dead (but not pronounced as such) for
some time before the CPR effort was initiated.”*
Recommended Reading
“Withholding CPR in the Prehospital Setting.” Prehospital and
Disaster Medicine (Vol.5, No.1)
(I was unable to access this paper online)
I can certainly understand why your research into other practice
parameters was coming up empty. This was a hard question to research
in terms of definitive answers. However, your most promising lead is
the first article I mentioned, “Attempting resuscitation in nursing
homes: policy considerations.” Hopefully, you can access it through
one of your work databases. That article, combined with the EMS
protocols described above…..especially the parameter of “body cold to
touch in an otherwise warm environment,” might help you to formulate
some workable ideas to write a revised policy stance and help to
effect a change.
If I can find any further definitive parameters which will help, I
will add them in a clarification. I also invite any fellow researchers
to comment if they know of some state specifics policies that allow
nurses to make judgements concerning initiating CPR in prehospital
settings.
umiat-ga
Google Search Strategy
should CPR be initiated if patient obviously dead?
CPR protocols in long-term care facilities
Cardiopulmonary resuscitation policies in long-term care facilities
deciding whether to perform CPR in nursing homes |
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