My regular correspondent, Dodge sent me this story and said:
While the story concerned is American and in the strict sense no ambulance related it would be interesting to see your views on this matter, to my way of looking at it, it is a clear case of abandonment.
Retirement Home Nurse Refuses to Perform CPR on Dying Woman
Paul Martella; KTLA5 Local News, 3 March 2013
BAKERSFIELD, Calif. (KTLA) — A nurse at a retirement facility refused to perform CPR on a woman who had collapsed and later died.
The nurse called 911 around 11:00 a.m. on February 27 from Glenwood Gardens when the 87-year-old woman stopped breathing.
The 911 dispatcher instructed the nurse to perform CPR, but she refused saying that it was against the retirement facility’s policy to perform CPR.
The dispatcher asked the nurse to find someone else who would be willing, but no one came forward.
Paramedics arrived several minutes after the call and took the woman to a hospital, where she was later pronounced dead.
The retirement facility released a statement extending its condolences to the family and said its “practice is to immediately call emergency medical personnel for assistance and to wait with the individual needing attention until such personnel arrives.”
You can read more at: http://www.bakersfieldcalifornian.com/health/x837006530/911-recording-details-dispatchers-struggle-to-get-aid-for-elderly-woman
I’m not sure it is a ‘clear’ case of abandonment, there is too much unstated here such as what was this facility, was it a ‘retirement facility’ a high dependence nursing home or even a palliative care facility. What and why does the centre have a no cpr policy and how is that communicated to the patients and their families. Those involved in primary health care know, better than I, the complexity in making decisions about the delivery of life prolonging treatment at the end of life. Do people want, at 87, or their 87 year old family member, put through the indignity and trauma of resuscitation and when do we say ‘that is the end’. These are question that need to be addressed by aged care facilities primarily with the person if they remain mentally competent, and then with family members. One does wonder though, if there is a well thought out, justified and rationale no cpr policy why they would call 911 (or triple zero in Australia) rather than call the staff doctor to examine the patient and ring the family to let them know of their loved one’s death.
It would seem from the story that the centre’s policies were not clearly expressed and the hidden message is that it was some policy designed to protect the centre (from what we don’t know) rather than the best interests of the people there, but just because that’s the way the press reports it doesn’t make it so.
For the sake of the argument though, I would think if the centre simply adopted the policy out of some fear of its own position then its actions would not be ‘in good faith’ by anyone’s definition. Resuscitation can be withheld if it is futile or has been refused by the patient but withholding what is otherwise uncomplicated treatment from a person that needs it would strike me as unprofessional conduct by both the nurse and their employer. If you are a registered health practitioner then your employer’s directives can’t override your professional obligations and duties and your duty to the patient must be paramount, but is there a duty to resuscitate an 87 year old in all cases, or in this case? I would want to know a lot more, from a more authoritative source, before one could make any comment on the actual position.
Reading the case did remind me however of another one I read about that struck me as a more ‘clear’ case of abandonment or unprofessional conduct. See http://www.ems1.com/ems-news/1409702-dallas-man-claims-paralysis-was-result-of-ambulance-crews-negligence/
Dallas man claims paralysis was result of ambulance crew’s negligence
Dallas News, 22 February 2013
DALLAS — A Dallas man is suing the city, saying a Dallas Fire-Rescue ambulance crew was negligent for refusing to take him to the hospital three times in a day after he called them because he could not feel his legs. Walter Beattie was transported to the hospital too late, he claims in a lawsuit filed this week in a Dallas County court, and his permanent paralysis was a direct result of the crew’s negligence.
The plaintiff’s attorney and city officials did not immediately respond to requests for comment. Beattie could not be reached.
In early February 2011, Beattie was discharged from Baylor Regional Medical Center in Plano after being hospitalized for nearly two months with a “critical cardiac condition,” according to court documents.Later that month, Beattie woke up, feeling numbness in his legs. He was unable to walk and called 911 to request an ambulance transport him to the hospital, about two miles from his home. A Dallas Fire-Rescue crew arrived but refused to take Beattie to the hospital. “The crew stated that because Beattie’s ‘vital signs’ were ‘stable’ they would not transport him,” according to the lawsuit.
You can read more at: http://www.dallasnews.com/news/community-news/dallas/headlines/20130221-dallas-man-sues-city-claims-paralysis-was-result-of-ambulance-crews-negligence.ece
The gist of the story is that after being discharged from hospital the plaintiff woke unable to feel his legs. He rang 911 but the paramedics refused to transport him as his vital signs stable. They left him sitting on the floor. He rang 911 again, the same crew returned and again refused to transport him and threatened to call the police if he rang again. The paramedics again left, leaving him on the floor but they accidentally left behind their radio. They returned for the radio and again refused to transport the man despite requests to do so from his apartment manager. Finally, on the fourth call, they transported the man to hospital.
The plaintiff says the delay in transporting him to the hospital resulted in his permanent paraplegia. Upon his arrival at the hospital, doctors found that his spinal column had swollen and the emergency surgery to reduce the swelling was too late to prevent permanent damage.
Again we cannot accept that what appears in the media is necessarily correct, but that seems like much clearer case of inappropriate behaviour. The paramedics may have had their doubts about his bona fides but if the patient is left sitting on the kitchen floor complaining that they cannot walk, that would suggest a fairly poor standard of care or compassion. Again we will have to wait and see if we hear from a court what the court determines actually happened and whether there could be any justification for this behavior.
Michael Eburn
5 March 2012.
Australian Emergency Law 
Michael, I think there’s definite issues about the level of care provided (poor), however I think that the claim that “his permanent paralysis is a direct result of their negligence” is an interesting claim for him to make. I wonder what the medical opinion is of that?
When it’s reported in the paper there doesn’t need to be a medical opinion, just a claim! It is an essential issue in a negligence action that the plaintiff can prove actions by the defendant would have made a difference; if the delay in treatment leads to no different outcome then in theory the plaintiff loses. It’s more complicated in the US where cases are heard by a jury who might find for the plaintiff just to punish the defendant. That’s less likely in Australia where cases are heard by a judge alone (but let me say, not impossible – In Kent v Griffiths a case heard in the UK by judge, not a jury, I suspect the judge found it easier to find for the plaintiff over the delay in sending an ambulance when he found there was no reason for the delay, and worse, the paramedics lied on their case sheet times and evidence).
You can read another version of the story and see a US television report that includes audio from the 911 call at http://www.firefighternation.com/article/news-2/california-woman-dies-dispatcher-begs-nurse-perform-cpr.
Hi Dr Eburn,
Thank you for your informative blog, I had only just stumbled upon it and read some of your publications at university which have greatly helped me in my career as a paramedic.
I was shocked initially that this happened in the USA, until I had a case recently where the same thing happened at an Australian nursing home. The staff refused to do CPR when required, as they were “not allowed” by policy. The patient may have had a chance due to the time frame. There was no DNR order in place. Sadly, when we arrived, too much time had elapsed for a successful outcome.
I’m not sure what the legalities are in Australia, but ethically I do not agree with their policy which I consider archaic. Is it law in Australia that a provider (with trained health professionals) has to perform CPR? Would the RN on scene have had a duty of care to start resuscitation (over policy) knowing that the patient may have had a good outcome as it was within the time frame initially to commence CPR?
I believe in the US case and the case I was unfortunately called too – health professionals working in NH’s should have a duty of care to protect their paying customers.
I do not know much about the nursing home’s protocols or if they tell their family that they do not perform resuscitation.
Thanks,
Andrew
No it is not the law that “a provider (with trained health professionals) has to perform CPR”. They can withhold treatment for a number of reasons including a determination that the treatment would be ‘futile’. That is not merely a medical judgement (though it may be; my doctor can refuse to prescribe antibiotics for my viral infection on the basis that it’s futile no matter how much I want it); in the context of CPR deciding whether the treatment is futile should involve discussions with the patient and, if they consent or are incompetent, their family. A blanket policy of no CPR may not be illegal but is less than good practice.
The RN could have a duty to treat contrary to policy if the policy is simply wrong, so an RN or a doctor can’t hide behind policy to engage in conduct that would constitute unsatisfactory professional conduct just because their employer directs them too. If they can’t act ethically they will be in a difficult position no doubt.
It’s really impossible to give any more comment than that without know more about the stated policy and why it was in place and to whom it was meant to apply. A blanket policy that ‘no staff are to do CPR to anyone, ever’ may not be ‘illegal’ but should and could be the subject of investigation by licensing and registration authorities.