On the NBC Nightly News last night (Sunday) I heard a story that disturbed me. The basic facts seem to be:
1 – An 87 year-old resident in an independent living facility called Glenwood Gardens in Bakersfield, California was having trouble breathing.
2 - A staff member, who is a nurse, followed company policy by calling 911.
3 – The 911 dispatcher informed the staff member / nurse that there was not enough time to wait for emergency responders. The resident needed immediate CPR. The dispatcher repeatedly beseeched the staff member to either administer CPR or turn the telephone over to someone who was willing to administer CPR. The dispatcher said she would instruct that person on how to administer CPR and there would be no liability to the staff member or the independent living facility. The staff member refused, citing company policy.
4 – The emergency responders arrived, took the resident to the hospital, where she was declared dead on arrival.
5 – A spokesman for the independent living facility verified the staff member followed company policy and that all residents and their families were informed about this policy before they moved in.
6 – Family members of the resident stated they were comfortable with the level of care she received from the facility.
Below are a couple of links with this story
In the NBC report they played portions of the dispatch tape and the staff member is obviously controlled. Despite anything the dispatcher says, she keeps refusing to do more than call 911 citing company policy. My first reaction was what kind of monster is this woman. She is a nurse, she should have done CPR. In those moments the case seemed black and white.
Then I started thinking. What would this woman say to herself as she headed home? “It was a good day today, I followed company policy.” Although that sounds snarky, it was not intended to be. One assumption I made was that this woman, who identified herself as a nurse to the dispatcher, must have wanted to help people at some time in her life. Nursing is not known as a highly-paid or easy profession, so most people who become nurses do it because they want to be part of a helping profession.
What, I wondered, would change her to a person who would put following this company policy over saving a life? Is she a single parent who desperately needs this job? Does she see this job as the difference between the life and death of her family? Has she become an uncaring automon who finds it easier to do as she is told rather than provide compassionate care? How will she process this and what toll will it take on her? If someone died because of my inaction I would be devastated. It would destroy all my believes about myself as a human being.
And what about the company and its policy? Does the policy mean staff cannot provide compression to a bleeding wound, ice to a twisted ankle, or an aspirin for a headache? Why would any company instruct their staff not to provide common first aid? Liability if the patient dies? Liability if the patient accuses them of providing unwanted care in extending life by artificial means? Convenience for their staff? Lack of appropriate medical facilities? One story cited above mentions that this policy is only applicable to their independent living facility, not to their assisted care facilities. Clearly, in my mind, the policy itself has as much to condemn it as the actions of the staff member.
This reminded me of a book I read a while ago entitled The Reader by Bernhard Schlink (Link to synopses at Amazon) http://www.amazon.com/...
I have not seen the movie that was made from the book. I found the book thought provoking is some ways, and deeply disturbing in others.
Basically the book was set in the time soon after WWII in Germany. There are two main characters, a teenage boy who, in the story, grows to be a young man and a woman who is currently a minor civil servant, however we later find out, she was a guard in a concentration camp during WWII. The book begins with an encounter between the teenager and the woman that turns into a love affair. They lose track of each other and time passes.
He later encounters her during a war crimes trial. (Spoiler Alert) During the war, she and her fellow guards were given the task of escorting women and children prisoners from one concentration camp to another. Of course, their main duty is to make sure no one escapes. The train breaks down, so the guards commandeer a public building in the town, move all the prisoners into the building and lock it. During the night a fire starts in the building. The consensus of the guards is that their main purpose is to ensure no prisoners escape, therefore they cannot unlock the doors as there are not enough guards to ensure no one escapes. The townspeople protest, but the prisoners all perish.
At the trial the woman seems to not understand why she is being condemned. After all, she did her job. Her attitude is that the fact that the prisoners perished was unfortunate, but not her responsibility. I have read other information about the trials of prison guards at Nuremburg. Many of them were shocked that they were being held accountable for their actions when “all they were doing was their job; they were just following the orders of their superiors.”
Which brings me back to the incident in California. Do I think the two situations are completely analogous? No, the residents at Glenwood Gardens are not prisoners; they can come and go, have visitors, and live there because they have chosen to live there. The staff members are not prison guards; they do not have the power of life and death over the residents.
However, I find one commonality of both situations chilling. The staff member at Glenwood Gardens was just doing her job. Unlike the dispatcher, she seemed to give no thought to the consequences of her actions. Listening to the portions of the dispatch call televised by NBC News, it seemed she had the attitude that she was doing her job, she was following company policy. The fact that the woman may die (and later did die) was unfortunate, but not her responsibility.
Update: 11:00 am AST
Several comments have made the point that you never initiate heart massage if there is a pulse. (note: from my days of teaching CPR I was taught that perfect CPR is only 70% as effective as the heart beating at all, which is why if you feel a pulse at the neck, even if you can't feel it at the wrist you DO NOT initiate heart massage.) They also made the point that when a patient is breathing you don't initiate CPR, also true.
Following is a link to the whole 911 call as well as a link to the incident report by the Fire Department.
The link to a copy of the incident report by the Bakersfield Fire Department.
The report states, in part (last paragraph)
E15 was dispatched to a medical aid for a patient in apparent cardiac arrest. While enroute, E15 was contacted by ECC via radio and advised the facility was refusing to intiate CPR. E15 arrived on scene simultaneously with Hall Ambulance. E15 personnel proceeded to the dining room and found a female patient to be pulseless, non breathing and lying supine on the floor. ...There is also a recording of the 911 call. In it you can here the dispatcher ascertain that the patient was not breathing adequately, then asking anyone to initiate CPR. Note: When I learned CPR , the term could also mean just breathing for the patient if there is a pulse.
Update 2 – 3/5/2013 10:30 am AST
I came home after doing errands yesterday to find I was in the Community Spotlight. I’m still new to this site so I’m not sure who or how the mechanisms work to put diaries on the Community Spotlight; so to whoever or whatever, thank you – I’m honored.
I’d also like to thank everyone who commented as well as sunka who wrote a companion diary. I’m fascinated by sunka’s concept of a DNR that also refuses to pay any financial costs not explicitly authorized. After reading many of the comments I realized that 1) this is an extremely timely topic that enables important discussion, and 2) there were some of my thoughts I needed to clarify. Instead of responding to individual comments, I thought this approach would be more coherent.
Before I clarify my thoughts, I want to apologize. Several people were offended by my comparison of the staff member’s actions with a novel based in Nazi Germany. I would like to clarify those remarks in context (below), but I want to assure everyone that I do not think the staff member / nurse is a secret skinhead with a swastika tattooed on her bum. Nor do I think she is guilty of murder, manslaughter, negligence, or any other crime. I apologize for any pain I caused with my lack of clarity.
As I said, there were several very important topics introduced in the comments. While important, these topics aren’t germane to the points I wish to make so I wish to separate them out now.
DNR – As I stated in a comment I made, a while back my mother and I went through the process of filling out the paperwork for a living will and filing it with the local hospital. I absolutely believe in patients’ having the final say in how they will be cared for and what measures will be taken, or not taken, to prolong life. As I listened to the original 911 call (link in update 1) a DNR was never mentioned. Whether it was not known at the time, I do not know; but the reason for refusing to perform CPR was clearly stated as being against company policy. At one point in the tape there is a background conversation and the staff member comes back to the dispatcher and states that her boss has just confirmed that it is against company policy to perform CPR. Staff members are to call 911 and wait with the resident.
Hospice – I have never been directly involved with Hospice, although several relatives and relatives of friends have used Hospice services in several different states. It is amazing to me that I have never heard one bad word about hospice; not even a tiny horror story. I have the utmost respect for Hospice workers, I recognize the wisdom and comfort they bring in the final days of life to both the patient and the patient’s family. I know that should it become necessary for me or my family, I would welcome the help and support they bring to the end of life.
Credentials of Staff Member – When the staff member identified herself as a nurse it was in response to the Dispatcher asking if she understood the consequences of not initiating CPR; that’s when the staff member stated she was a nurse who understood the consequences. Several people questioned whether she was credentialed as an RN or LPN or not. I know a person who is an accounting clerk who routinely self-identifies as an accountant, so this is an important point. However, what I believe is more important to this discussion is the staff member acknowledgement that there are consequences to this decision, no matter what her level of credentials.
Level of Care – In all articles I have seen, the facility is identified as an Independent Living facility. My understanding is in such facilities residents are mobile, relatively free of debilitating chronic illness, and don’t require medical intervention or assistance. One commenter spoke of his mother who was placed in an Independent Living facility whose condition deteriorated but was not moved to assisted care or a nursing home due to concerns about how a move would affect her. I recognize there are exceptions, but I am assuming that most residents, including the patient we are discussing, are elderly but in decent health. That may be one reason why the facility did not know about a DNR; it may not have been appropriate because this is not a health care facility.
So after separating those issues that are important but are not contributing to my deep concerns, I realize there are three issues that chill me to the bone.
One – I have worked with companies who encourage staff to learn first aid, CPR, using the defibrillator, etc. They certainly do not require staff to take these classes nor do they penalize those who don’t. It is an opportunity many staff take advantage of. I have worked in other companies who have a standard first aid kit in the kitchen area, period. However, I have never worked for a company that prohibits staff from administering first aid or CPR to other staff members or customers in an emergency.
Think for a moment, if you were the clerk at a department store. A customer falls down grabbing her chest. You know CPR, but due to the company policy all you can do is call 911 and hold her hand. Or, imagine the guy in the cube next to you has what appears to be heart failure. You know CPR but don’t dare use it because it might place your job in jeopardy. I find it appalling that a non-medical facility can, or would, implement and enforce a policy prohibiting their staff from taking emergency action.
Two – Before I could teach CPR for the Red Cross years ago I was required to take a “train the trainers” class. One of the things they emphasized was that each class should end by discussing the legal and ethical issues surrounding performing CPR. So, in the last ½ hour or so of the class I handed out our state’s Good Samaritan law, and we used that as a springboard to discuss issues such as “Is it OK not to perform CPR.” “Once you start, is it OK to stop?” So how did I get from here to Germany?
Years ago when I learned world history, I learned that while the global depression was devastating around the world, it was much worse in Germany. After WWI, the Allies required Germany to provide reparation to the Allies. It left the German economy in worse shape than everyone else’s. Today, we look back at Hitler through the lens of what we know happened. At the time, the German people saw Hitler as a charismatic, principled, and prescient leader. They were sure he knew how to lead them from economic desperation back to their place as a leader among nations. Sure, many knew the Jews were rounded up and shipped out of town to the country; but most Germans at that time did not know about the genocide.
In order to survive many Germans adopted an attitude of heads down, eyes forward, and do what you’re told to ensure a bright tomorrow. I’m seeing the same attitude, to a lesser extent, today. It is exemplified by the staff member at Glenwood Gardens. On Daily Kos we have criticized, justifiably in my opinion, Citizens United, corporate lobbying, the NRA, the banking industry, etc. all as large corporate organizations shaping government and the world to their needs and wants. However, if we as individuals abdicate our responsibility to make ethical decisions and instead toe the company line, are we not putting ourselves into the same position the German people did almost a century ago? This is what chills me, not whether the staff member did, or should, have performed CPR.
Three – There seems to be a barely spoken attitude that the age of the patient changes the value of that person’s life. What if an elementary school aged child fell from a playground apparatus during recess and his heart was knocked into arrhythmia. The playground monitor had the ability to perform CPR but chose not to due to school district policy. Would there be more outrage? Several people have said that at 87, they would not want to be revived. OK, that is your decision for yourself; but can any of us make the decision for someone else based only on their age? I find this implied lack of value for this woman because of her age to be chilling as well.
Thank you for taking the time to read my comments.