CPR In a Nursing Home: One Policy Does Not Fit All Residents

The federal government has warned nursing homes that in developing and implementing a facility-wide policy for administering cardiopulmonary resuscitation (CPR) on residents, the nursing home cannot implement a blanket policy that applies to every resident.

Such a policy is not acceptable, the Centers for Medicare & Medicaid Services (CMS) says, in its October 18, 2013, letter to state survey agency directors.

CPR involves "the use of chest compressions and artificial ventilation to maintain circulatory flow and oxygenation during cardiac arrest," says Medscape. "Although survival rates and neurologic outcomes are poor for patients with cardiac arrest, early appropriate resuscitation—involving early defibrillation—and appropriate implementation of post–cardiac arrest care lead to improved survival and neurologic outcomes."

Studies have shown that the percentage of nursing home residents who sustain cardiac arrest will benefit from CPR is small.
Some nursing homes have implemented a facility-wide no-CPR policy. Federal regulations provide, however, that a resident of a skilled nursing facility or nursing facility has the “right to a dignified existence” and “self-determination” including the right “to formulate an advance directive.”

A resident's right to refuse or consent to CPR falls squarely within the ambit of these rules.

Prior to the arrival of emergency medical services, nursing homes must provide basic life support, including initiation of CPR, to a resident who experiences cardiac arrest (cessation of respirations and/or pulse) in accordance with that resident’s advance directives or in the absence of advance directives or a Do Not Resuscitate (DNR) order.

Moreover, facility policy cannot limit staff to only calling 911 when cardiac arrest occurs. Prior to the arrival of EMS, nursing homes must provide basic life support, including initiation of CPR, to a resident who experiences cardiac arrest in accordance with that resident’s advance directives or in the absence of advance directives or a DNR order.

AMDA and "Dementia in the Long Term Care Setting"
Long term care facilities care for a variety of individuals, including younger patients with chronic diseases and disabilities, short-stay patients needing postacute care, and very old and frail individuals suffering from multiple comorbidities. Medical directors oversee the health care needs of this diverse resident mix.

The most recent Clinical Practice Guidelines published by the American Medical Directors Association emphasize that when a workup or treatment is suggested, it is crucial to consider if such a step is appropriate for a specific individual. Treatment may not be indicated if the patient has a terminal or end-stage condition, if it would not change the management course, if the burden of the workup is greater than the potential benefit, or if the patient or his or her legally authorized representative would refuse treatment.

"Dementia in the Long Term Care Setting," Clinical Practice Guidelines, American Medical Directors Association, (2012).
 

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