Monday, March 10, 2014
By Kevin M. Dirksen and Neil S. Wenger
LOS ANGELES — The 911 call last month that led to an emergency dispatcher begging workers at a Bakersfield, Calif., senior living facility to perform CPR on a woman captured the attention of the public. A staff worker told the dispatcher it was against the facility's policy to intervene. The woman, Lorraine Bayless, died.
ABOUT THE AUTHORS
Kevin M. Dirksen is an ethics fellow at the UCLA Health System Ethics Center. Neil S. Wenger is the center's director. They wrote this for the Los Angeles Times.
It is difficult to understand how liability concerns could dissuade anyone from helping a person in distress. However, this stark event should awaken us to another question: Should we be performing CPR on 87-year-olds in a community setting such as a senior home?
It is very likely that performing CPR on Bayless would not have served her well. Studies of CPR performed on individuals 85 years and older who suffer cardiac arrest in a community setting show that few – perhaps 4 in 100 – survive to leave the hospital, and the majority of these "survivors" are moderately to severely neurologically compromised.
For the small number of elderly patients who survive the ambulance ride to the hospital and then make it through the emergency room to be admitted to the intensive care unit, treatment is nearly always burdensome, including being attached to life-sustaining machines. Only rarely does such treatment yield continued life meaningful to the patient.
Because of this, the majority of older people, if properly informed, choose not to receive CPR outside the hospital (or, in most cases, in the hospital either).
But here's the rub: Someone needed to talk with Bayless beforehand about what it would mean to receive resuscitation, and her preference needed to be recorded in an advance directive, or Physician's Orders for Life-Sustaining Treatment.
POLST forms are widely available and legally binding in California. The retirement facility would have kept the form on file to ensure that Bayless received appropriate treatment.
Many would assume that if a treatment worked only a fraction of the time and yielded bad outcomes more often than good ones, it would not be the default approach. Yet CPR is the default approach. When a 911 operator receives a call that a patient is not breathing or doesn't have a pulse, initiation of an attempt at resuscitation is the rule. This sets off a sequence of events leading, almost always, to death in a hospital.
One might ask whether, for groups of patients unlikely to benefit, it might make the most sense to withhold CPR and allow those who want it to "opt in." But such a global decision would require an open discussion at the societal level.
This is not to say that aggressive medical treatments should not be offered or recommended to older patients. Medicine has made remarkable progress and now is able to offer many treatments that substantially enhance the functioning and outcomes of older people.
From joint replacements to heart surgeries, fully informed 80-, 90- and 100-year-olds can benefit greatly from carefully planned procedures that allow them to walk, jump and run. Recent advancements even permit the repair of valves inside the heart without opening the chest, and these can be particularly helpful to older patients who might not be able to tolerate or might not desire a major surgery.
But these procedures, like CPR, need to be used only when and where appropriate.
No human should ever be left without help while others stand by. But the real tragedy is when we mistake medical treatment for care. The care this patient needed was to talk with her physician and her family to ensure that death would happen on her terms, presumably not during the chest compressions of CPR or in an ICU attached to a machine.
If this had been the case, then emergency personnel would not have been called and the 911 operator could have focused on getting aggressive medical treatment to someone who would benefit from it.
– McClatchy-Tribune Information Services