When CPR for the Elderly Becomes Morally Gray

BY Jason Kane  March 8, 2013 at 8:25 PM EDT

The call itself took seven minutes, 16 seconds to unfold and not much longer than that to spark outrage throughout the nation.

The scene is now familiar to many: Lorraine Bayless, 87, was barely breathing at Glenwood Gardens independent living facility in Bakersfield, Calif. A nurse looked on, refusing a 911 dispatcher’s pleas to perform CPR because doing so would have violated company policy to wait for emergency responders, she said.

A week later, as the recording continues to echo from television and computer monitors around the world, some are pointing out that nothing about the 911 call is as black-and-white as it first appeared — including the institution’s policy, the nature of the facility or even whether immediate CPR was the best course of action in the first place.

Emergency

It was Feb. 26 and the frustration in 911 operator Tracey Halvorson’s voice bordered on panic.

“I understand if your boss is telling you you can’t do it,” she said. “But … as a human being … you know … is there anybody that’s willing to help this lady and not let her die?”

“Not at this time,” the nurse said.

“Is there a gardener? Any staff, anyone who doesn’t work for you? Anywhere?” the dispatcher asked later in the call. “Can we flag someone down in the street and get them to help this lady? Can we flag a stranger down? I bet a stranger would help her.”

No one did, and Bayless was pronounced dead at the hospital.

The event triggered a police investigation — which later concluded that “no criminal statutes had been violated — and calls nationwide for regulation to prevent similar deaths in the future.

“This is a wake-up call,” said Assemblywoman Mariko Yamada, chair of the California Assembly Aging and Long-term Care Committee. “I’m sorry it took a tragedy like this to bring it to our attention.”

Officials with the Tennessee-based company that owns Glendale Gardens initially stood behind the nurse and said she was simply following standard procedure by dialing 911 and waiting for first responders to arrive. Then, on Tuesday, they released a statement declaring that the nurse had been confused and was on voluntary leave pending an investigation.

“The incident resulted from a complete misunderstanding of our practice with regards to emergency medical care for our residents,” the Tennessee-based company said.

But according to the Assisted Living Federation of America, a trade association that manages senior living communities throughout the U.S., the basic protocol the nurse followed was nothing short of routine.

This was an independent living facility as opposed to personal care homes or assisted living facilities. Before even signing a lease, residents fill out paperwork acknowledging that they understand that meals, activities and housekeeping will be provided. Medical care will not.

“What that means is there’s not going to be staff in the building trained in administering CPR,” said Maribeth Bersani, senior vice president of public policy for the group.

Having a trained nurse in the building was extremely unusual, she said, and the woman wasn’t even acting as a nurse — she was ‘resident services coordinator,’ meaning she arranged the social activities and additional care upon request.

Therefore, “emergency protocol would be to call 911 and wait for medical personnel to administer CPR,” Bersani said. “But no company has any policy that prohibits her from doing what the 911 operator was asking her to do.”

“Immoral and Unethical”

And that’s the part Susan Geffen, an elder law attorney and gerontologist based in Redondo Beach, Calif., doesn’t understand.

“I think it’s immoral and unethical — and in this particular case, since this woman is a trained nurse — it’s unconscionable,” she said.

If something had gone wrong, the federal Cardiac Arrest Survival Act and California’s Good Samaritan Law — which protect individuals assisting a victim during a medical emergency — would have shielded the nurse from civil damages.

But whether or not she could have been terminated is another question, Geffen said, especially if the CPR had cracked a rib that in turn punctured a lung, led to death and opened the company to a lawsuit.

“So in cases like this, I think it’s a combination of fear of litigation, an overzealousness to please authority and fear of losing your job,” she said.

The way Geffen sees it, the entire industry needs more regulation so that policies are in place for someone at all elder-care facilities to assist more swiftly before medical personnel arrive.

“The good thing that comes out of all of this is that maybe we’ll have better regulations and various facilities that house older adults won’t be operated like the Wild Wild West,” she said.

Resuscitation

It now appears that Bayless had a stroke, not cardiac arrest. CPR may not have even helped her.

But when an adult collapses, the vast majority of the time — 75 to 80 percent, in fact — cardiac troubles are to blame, said Dr. Michael Sayre, an emergency physician at the University of Washington.

“There’s no way to know which is which at the time, so we have to jump in and try our best,” he said “And the earlier you start, the bigger the effects.”

The takeaway, even if Bayless was in that 25 percent minority, is that “people need to be prepared,” Sayre said. “And if you do see an adult collapse, you need to call 911 and start chest compression immediately.”

But others say that’s another gray point.

Richard Grimes, president and CEO of the Assisted Living Federation of America, points out that the population living in these facilities tend to be frail. After all, this was not a situation where a 50-year-old man collapsed in a restaurant and immediate CPR is automatically the best option.

“If you perform CPR on an 87-year-old woman who had osteoporosis, in order to do it right you would have to crush her rib cage like a bag of potato chips and that’s torture,” said Richard Grimes. “In most cases like this, it’s probably best for people to wait for professionals with the equipment they need and can use.”

Bayless knew the risks of living in an independent living facility, the family said in a statement. She wanted to “die naturally and without any kind of life-prolonging intervention.”

“We understand that the 911 tape of this event has caused concern,” they wrote, “but our family knows that mom had full knowledge of the limitations of Glenwood Gardens and is at peace.”

So in the end, Bayless died the way she wanted: without intervention. But even if she discussed her preferences with family, friends or doctors, there appears to have been no documentation.

Bayless could have made her wishes official with a do-not-resuscitate order — a document signed by a doctor making clear that she wanted forgo life-saving efforts. Or she could have asked for a Physician Orders for Life-Sustaining Treatment (POLST), which states what kind of medical treatment patients would like to receive.

“But because it wasn’t documented, it created a lot of confusion and emotional distress for the health care providers who responded,” said Judy Citko, executive director of the Coalition for Compassionate Care in Sacramento.

To that end, the family said it will not try to profit from the death with a lawsuit. They described the situation as “a lesson we can all learn from.”