Legal / Ethics

Ethics case study: ‘Just watch them die…’

According to the Associated Press, a Brookdale Senior Residence facility* worker who identified herself as a nurse, refused to administer cardiopulmonary resuscitation (CPR) to Lorraine Bayless, an 87-year-old woman who collapsed in the facility’s dining hall because “It was against company policy.” Although the nurse called 911, and the dispatcher urged her to start CPR or to find someone who was willing to do so, the nurse refused. The press reports that there was no Do Not Resuscitate (DNR) directive in place. Shortly after this report, Brookdale Senior Living issued a statement saying the employee’s failure to heed to a 911 dispatcher’s directions was a mistaken interpretation of the policy. Fortunately for this company, Bayless family members said she did not want life-prolonging treatment.

Believe it or not, this case study is not about whether or not an 87-year-old person should receive CPR: it is, after all is said and done, a matter of personal choice for the patient. A 2012 study showed that only about 2% of adults who collapse on the street and receive CPR recover fully. Another from 2009 showed that anywhere from 4% to 16% of patients who received bystander CPR were eventually discharged from the hospital. And only about 18% of seniors who receive CPR at the hospital survive to be discharged, according to a study from Ehlenbach and colleagues. So, enough on this subject.

The points at issue are:

1. Did the nurse have a duty of care to this person — even if she had only passed her by on the street?
2. Does company policy trump ethical or legal obligations?
3. Does age or place of residence (a senior living facility) exclude one from the rights accorded to other citizens?
4. Does this “policy of noninterference” (other than to call 911) in a medical emergency extend to other kinds of emergencies? The woman collapsed in the dining hall, so it is not inconceivable that she could have slipped with her knife and cut an artery. Would the nurse simply watch her exsanguinate while 911 is on its way? If she slipped and fell and hit her head, would she be ignored until the emergency squad arrived?

As Carolyn Rosenblatt, a nurse attorney writing in Forbes commented, “I was not surprised to learn that there was ‘company policy’ about a nurse in an independent seniors’ residence not giving nursing care…However, the horrible image of a nurse standing by refusing to permit anyone else there to get emergency instructions from the 911 dispatcher is most disturbing, no matter what kind of a home this was.”

In response to the points at issue:


Points 1 and 2: In the face of a company policy that refuses intervention in an emergency situation, the nurse still has a duty of care to a resident even though this facility does not provide skilled nursing care. Although the patient was living in an assisted living facility and not a nursing home, the American Nurses Association Code of Ethics for Nurses is clear: “The nurse’s primary commitment is to the patient, whether an individual, family, group or population.” This is clear, but just in case there is a possibility of misinterpreting it, the statement means that a facility’s policies do not supersede a nurse’s obligation to a patient, resident, or, for that matter, a passerby.

Point 3: Let’s put this another way: Is there such a thing as equal rights for the elderly? If one joins a senior living facility, is one’s right to life abrogated by its policies? I think not. One of the most important characteristics about policies is that they should be clear. Apparently Brookdale’s policy to call 911 in an emergency is clear; however, Brookdale’s policies on the emergency care of its residents until 911 gets there apparently is not clear. Why would the company have its employees call 911 if they are not to follow the instructions given to them by the 911 dispatcher?

Point 4: Certainly the elderly woman in question has a right to refuse treatment – and can do so by executing an advance directive. The fact that she did not do so is both salient and unsurprising. Most of us do not — and all of us should do so. A person or someone who holds his or her healthcare power of attorney may refuse treatment for that person. A nurse, administrator, institution, or company may not — through their policies or any other means. Can you imagine an organization with a policy that forbids employees from helping to save the life of its clients (or of other employees) in an emergency?

A duty to care

To put the matter succinctly, the nurse, if she was a nurse as she told the 911 operator (we know it was a she because copies of the 911 call were shared with the public), had a duty of care to this resident regardless of policies or her own uncertainties. This is a professional and ethical obligation. I am not a lawyer so I cannot say that she had a legal obligation to so. However, Good Samaritan laws offer legal protection to people who give reasonable assistance to those who are injured, ill, in peril, or otherwise incapacitated, especially to doctors and nurses. Good Samaritan laws provide a defense against torts arising from the attempted rescue.

I don’t think such laws don’t constitute a legal duty to rescue. But just as certainly, we don’t expect to see nurses on the phone with a 911 dispatcher refusing to even hand the phone to a passerby so the dispatcher can instruct someone else to administer CPR. And do what? Even though CPR is at best marginally effective in such circumstances, what is the alternative? Just watch them die?

*According to its website (www.brookdale.com) Brookdale is a national company that operates approximately 1,150 communities, with 80,000 associates serving about 100,000 residents every day.

Selected references
Ehlenbach WJ, Barnatao AE, Curtis JR, et al. Epidemiologic study of in-hospital cardiopulmonary resuscitation in the elderly. N Engl J Med. 2009;361:22-31. www.ucdenver.edu/academics/colleges/medicalschool/departments/medicine/intmed/imrp/CURRICULUM/Documents/Ehlenbach%20WJ–In-hosp%20CPR%20epidemiology%202009.pdf

Hagihara A, Hasegawa M, Abe T, et al. Prehospital epinephrine use and survival in patient with out-of-hospital cardiac arrest. JAMA. 2012;307(11). 1161-8. http://www.acc.org/latest-in-cardiology/articles/2014/07/18/17/33/prehospital-epinephrine-use

Rosenblatt C. Nurse refuses to give CPR, senior dies: Ethical problem or legal issue? Forbes. March 8, 2013. www.forbes.com/sites/carolynrosenblatt/2013/03/08/nurse-refuses-to-give-cpr-senior-dies-ethical-problem-or-legal-issue/

Sasson C, Rogers MAM, Dahl J, Kellerman AL. Predictors of survival from out-of-hospital cardiac arrest: A systematic review. Circulation. 2010;3:63-81 (published online November 10, 2009). www.firstaidcorps.org/wp-content/Predictors-of-Survival-From-Out-of-Hospital-Cardiac-Arrest-A-Systematic-Review-Meta-Analysis.pdf

Leah Curtin is Executive Editor, Professional Outreach for American Nurse Today

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