“Stella,” Dr. Hamilton barked at me as he filled out admission papers for his ninety-two-year-old mother, “I don’t understand why you’re asking me whether I want CPR for my mother. If she gets sick, I want everything done for her. You should know that.”
As we sat at my desk laboring through the required forms, Dr. Hamilton’s irritation was obvious. During the past twenty years, he had admitted numerous residents to our nursing home. But today he was simply a son dealing with the powerful emotions that surface on the day of admission.
Because CPR (cardiopulmonary resuscitation) is one if the most misunderstood subjects that I discuss with families, I did not look forward to reviewing it with a physician, especially Dr. Hamilton. I could see that he, like many health-care professionals, was failing to grasp the implications of CPR in regard to the elderly.
“If Mom needs oxygen, of course I want her to have it,” he continued, still sounding agitated.
“Has your mother signed a power of attorney for health care form?” I gently inquired.
“Yes, and I’m her designated agent,” he answered. “We want no heroics or aggressive measures,” he quickly added.
“If your mother’s heart stops,” I asked gently, “do you want us to attempt to restart it?”
“Stella, if her heart stopped, it would mean she had died. Why would I want you to restart it?”
“That is why I asked about CPR,” I cautiously continued. “CPR is an emergency method that can only be used if a person’s heart or breathing has stopped. Only then would we begin resuscitation.”
Dr. Hamilton sat looking down at the form in front of him. Then he wrote, “No CPR” in bold letters, underlining it three times.
“I should have let you finish explaining the form to me,” he added quietly. “I wasn’t thinking. No, Stella, I do not want CPR if my mother’s heart stops.”
As I reminded Dr. Hamilton, CPR only comes into play once the heart has stopped and the patient has died. The overall health of the patient is a major factor in determining the appropriateness of the procedure. Another factor is how long the heart has been stopped. For example, if you saw your friend collapse on the golf course and his heart stopped beating, you would naturally begin CPR—he was healthy enough to be on the golf course and resuscitation efforts could begin immediately. However, such situations rarely exist in long-term care. Residents are likely to be infirm or elderly, and they are often discovered in bed, without vital signs. If more than four minutes have elapsed since the patient’s heart stopped beating, brain damage will have occurred.
CPR: What Really Happens
Once CPR is initiated, it takes on a life of its own. If your parent is discovered without a heartbeat, the staff will place her on the floor or slip a cardiac board beneath her because they need a hard surface. Then, one nurse will begin external heart massage, a vigorous and forceful pumping action. At the same time, another nurse will begin mouth-to-mouth breathing. The force of the procedure often causes severe bruising and fractured ribs, which in some cases may puncture the lungs and damage the liver.
As soon as the nurses begin CPR, the staff is required to call 911. Paramedics will transport your mother in an ambulance to the emergency room, where everything possible will be done to resuscitate her. Unless you have previously requested “No CPR,” it becomes the responsibility of the nursing home, the paramedics, and the hospital to keep your mother alive.
The emergency room may try to defibrillate her with electric shock paddles. She will probably be connected to a ventilator to help her breathe. After the emergency room has stabilized her, she will be transferred to intensive care, where she will be hooked up to an IV with multiple medications.
Many who survive these circumstances die within a few hours or days. For elderly or seriously ill patients, actual survival to a hospital discharge is less than 5 percent.
Families frequently ask me: “What if Mom needs oxygen? What if she’s choking? I don’t want her to suffer.” Please bear in mind, if your mother’s heart is beating, she will receive oxygen and any medications needed for comfort, and her doctor will be notified.
CPR DOCUMENTATION
Orders for “No CPR” relate only to CPR, not to other treatments such as those for pain or shortness of breath. Other names for orders restricting resuscitation are “DNR” (do not resuscitate) and “no code” (used in hospitals). In a nursing home, CPR forms must be discussed with families at the time of admission. If the resident or family decides against resuscitation, the family signs a form stating “No CPR.” The doctor then co-signs the form and writes an order on the resident’s chart.
In assisted living also, DNR forms should be discussed during the admission process. An advance directive is not enough for paramedics. After your parent (or family member) and the doctor sign the form, it becomes part of your parent’s file. Should you notice your parent declining in health while in assisted living, it would be helpful to discuss with the administrator putting the DNR form on the wall by your parent’s door, with the words “For Paramedics.” This gives notice and legal authority to staff and paramedics not to perform CPR. In the absence of this form, medical personnel will always proceed with resuscitation.
Laws governing the content of DNR documents vary from state to state. You can obtain official preprinted forms through the state or county medical association, the bar association, or a local Area Agency on Aging.
Health-Care Professionals Have a Responsibility
Admissions personnel are required to ask, “Do you want CPR for your parent?” This question is unintentionally misleading; it prompts a belief that CPR may offer a real benefit. Thus, the family may feel obligated to request CPR. On the other hand, signing a Do Not Resuscitate form can leave a family feeling guilty and neglectful. As one daughter told me, “I feel like I’m saying, ‘Sure, go ahead and let my mother die.’”
CPR is an intense, undignified treatment with a high probability of extended suffering. I believe the admitting facility has a professional responsibility to review and explain the exact implications of CPR. When your parent’s wishes are known, having a DNR in place means that no critical decision awaits you when you may be emotionally unprepared; it means that you have accepted that your parent may die a natural death and that you do not wish to prolong her life artificially, but rather to allow a dignified, end-of-life experience.