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When in Doubt, Try to Save a Life

Posted by Dr. Lachlan Forrow  March 11, 2013 06:00 AM

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What would you do if a frail elderly woman collapsed nearby?  Would you rush to start CPR?  Or if you don't know CPR, would you scream for help from someone who can?

That's not what happened last week when Lorraine Bayless, 87, collapsed at her independent living facility shortly after lunch in the dining room there.  What happened after a staff member of the facility called 911 was horrifying:

Bakersfield fire dispatcher Tracey Halvorson pleaded with the woman on the other end of the line, begging her to start CPR on an elderly woman who was barely breathing.

“It’s a human being,” Halvorson said, speaking quickly. “Is there anybody that’s willing to help this lady and not let her die?”

The woman paused.

“Um, not at this time.”

On a 911 tape released by the Bakersfield Fire Department, the woman on the other end of the line told Halvorson that she was a nurse at Glenwood Gardens, a senior living facility in Bakersfield. But on Tuesday, the nurse refused to give the woman CPR, saying it was against the facility’s policy for staff to do so, according to the tape.

Later news reports included reassuring comments from Lorraine Bayless's family, indicating that she would not have wanted CPR initiated.  They explained that she had chosen to live in a facility without medical staff, and that "it was our beloved mother and grandmother's wish to die naturally and without any kind of life-prolonging intervention."

Nonetheless, criticism of both the nurse and the facility has, quite correctly, been widespread, and the event has triggered calls for reviews of policies in our nation's facilities:

The nation's largest trade group for senior living facilities has called for its members to review policies that employees might interpret as edicts to not cooperate with emergency responders.

"It was a complete tragedy," said Maribeth Bersani, senior vice president of the Assisted Living Federation of America. "Our members are now looking at their policies to make sure they are clear. Whether they have one to initiate (CPR) or not, they should be responsive to what the 911 person tells them to do."

It is almost impossible to believe that CPR would not have been started immediately if the Lorraine Bayless was 27, or even 57.  And while we know that many 87 year old women would share Lorraine Bayless's wish to "die naturally", we also know that some don't.

In the Emergency Department at my medical center, this issue arises almost daily -- should we initiate CPR for a patient whose wishes are unknown?  What if s/he is 87?  97? What if s/he obviously has a terminal illness and will die soon anyway?  

If a patient's wishes are truly unknown, our own practice is unequivocal: even for a patient who will likely die soon anyway we err on the side of life.  This isn't just because as doctors and nurses saving lives is so important to us.  It is also because death is irreversible. If we ever mistakenly allow someone to die when we might have been able to keep them alive, we cannot reverse the error.  Even a frail 97 year old, or a patient with a clear late-stage terminal illness, might want heroic efforts in the hope of seeing a soon-to-be-born baby, or having one final visit from a cherished loved one.

There are two, and only two, limits to this: (1) CPR should not be attempted if there is no realistic possibility that it might succeed; and (2) CPR -- or any other burdensome intervention -- should not be attempted if it would be clearly inhumane, defined as causing suffering or other burdens that are grossly disproportionate to any realistic medical benefits.

Of course, it would be far better if a person's wishes were clear, which is why conversations with loved ones about our wishes are so crucial -- now, not later, because "it's always too early until it's too late."  And why some people wear medical alert bracelets with "DNR" guidance (note that the rules about these vary from state to state).

But when there is any reasonable doubt, we err on the side of life.  And staff in senior living facilities, as well as any of us who is ever a bystander when someone collapses, should do so as well.

This blog is not written or edited by or the Boston Globe.
The author is solely responsible for the content.

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About the author

Lachlan Forrow, MD is Director of Ethics Programs and Director of Palliative Care Programs at Boston's Beth Israel Deaconess Medical Center and Associate Professor of Medicine at Harvard Medical School. More »

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