A New CMS Rule Opens Up Old Wounds in CPR Case

Allison Musante, ELS, is the associate editor of Annals of Long-Term Care and Clinical Geriatrics.

As I was digging through e-mails this morning, I came across an article that reminded me of a story that attracted national attention earlier this year, and I’m curious to know what your thoughts are on it.

On October 18, the Centers for Medicare & Medicaid Services (CMS)issued a memorandum stating that nursing homes are not permitted to implement facility-wide policies that would prevent cardiopulmonary resuscitation (CPR) for residents who experience a cardiac arrest. The memo states that prior to the arrival of emergency medical services, nursing home staff, which must include CPR-certified staff at all times, are required to provide basic life support, including initiation of CPR, in accordance with the individual’s advance directive. The same care must also be provided to residents if they do not have an advance directive or a Do-Not-Resuscitate Order on file. The memo went out to state survey agency directors to enforce this policy in compliance with federal regulations that protect residents’ rights to formulate an advance directive. According to the memo, surveyors will ascertain that facility policies related to emergency response require staff to initiate CPR as appropriate and that records do not show situations in which CPR was not initiated by staff even though the resident requested CPR or did not have an advance directive on file.

According to the CMS memo, some nursing homes have apparently implemented facility-wide “no CPR” policies. One facility, in particular, made national headlines earlier this year. According to news sources, a nurse at Glenwood Gardens independent living facility in California refused to give CPR to 87-year-old resident Lorraine Bayless after she collapsed in the dining hall. The nurse called 911, but reportedly told the dispatcher, who urged her repeatedly to give CPR until the emergency responders arrived, that it was against facility policy for staff to intervene. The resident died shortly thereafter at a hospital. Although no criminal charges could be filed against the facility or the nurse, the nurse’s actions were perceived by many as neglectful or apathetic, setting off a national discussion about regulations that could help prevent deaths like Lorraine’s in the future.

It was later reported that residents of the independent living facility were informed when signing their lease with Glenwood Gardens that CPR-certified staff and medical care would not be provided. Only meals, housekeeping, and activities were provided to residents of this facility. Lorraine’s family reported that Lorraine understood these risks and wished to die peacefully, without life-sustaining interventions; however, her wishes were not documented in an advance directive or in any other record filed with the facility.

Further, it was later reported that Lorraine died of a stroke—not cardiac arrest—so it is unclear whether CPR would have saved her life. The nurse was later described by the Glenwood managers as a “resident services coordinator,” who was primarily responsible for arranging social activities and additional care upon request—she was not CPR-certified. Also, there is a lack of evidence supporting positive outcomes associated with CPR in the elderly, particularly in the frail elderly, and in some cases, CPR can cause more harm than good. For example, we published an article in Annals of Long-Term Care examining the ethics of CPR. The author describes the use of CPR in some cases as a “brutal assault on a dying person,” which is often at-odds with the family members’ desire to prolong life at any cost. Although this article is a few years old, it’s clear that these ethical issues are far from resolved.

In light of this recent CMS memo, what do you think the best course of action would have been in Lorraine’s case? How should the nurse who witnessed her collapse have handled the situation? Please share your thoughts with us below.