March 14, 2013 | Posted By Wayne Shelton, PhD

A story last week from Bakersfield, California received an enormous amount of attention and seemed to capture the public’s imagination. The story was in both the print and electronic media as though a great injustice has been unearthed.  People were outraged that no action was taken to provide cardiopulmonary resuscitation (CPR) on an 87 year-old woman who had arrested in an independent living facility where she was a resident. The story was the rage on Facebook and other social media—people weighing in with their concerns, which again was mostly outrage and disbelief that something like this could have happened. Now that we are a week or so out from when this event happened, I thought it might be worth thinking about what happened in this story and see what lessons we can learn.

The story begins when Lorraine Bayless, the 87 year-old resident of Glendale Gardens, a Bakersfield independent living facility, collapsed and someone, presumably an employee, called 911. Apparently the employee called to report this emergency and was expecting the paramedics to respond quickly. The dispatch operator, realizing the importance of a quick response, admonished the caller to begin CPR herself, before the paramedics arrived. The caller, who identified herself as a nurse, told the dispatcher that she was not permitted by the facility to provide CPR for patients. Glendale Gardens is an independent living facility that says by law they are "not licensed to provide medical care to any of its residents." So in the cool light of calm reflection, did something wrong take place?

Some have argued that if the caller to 911 was in fact a nurse then she had a professional obligation to perform CPR.  A position statement from the American Nurses Association (ANA) that comes from the American Academy of Ambulatory Care Nursing – 2012 states that “RNs are fully accountable in all ambulatory care settings for all nursing services and associated patient outcomes provided under their direction.” So if the caller were in fact an RN we can assume she should have provided appropriate care for this patient. In fact it was not clear if the caller was an RN—all we know was actually employed at the facility as a resident services director, the company said Tuesday. Regardless, we can ask, what was the appropriate care? The reactions from the case in the media seemed to suggest that CPR was clearly the appropriate response.

But Glendale Gardens provide independent residential living for elderly people and expressly say that they are not a health care facility and do not provide medical care. But what if one of the residents suddenly is found choking on a piece of food, would they not perform the Heimlich maneuver to save the patient’s life? It would seem that to provide no medical emergency care at all for their residents would be wrong. The Heimlich maneuver would require touching the resident and performing a procedure and it would likely be effective to remove the food that is choking the resident. My sense is that this is precisely how most people reacting to this story were viewing CPR. If only the person who was calling had performed CPR Lorraine would have responded and returned to her baseline. The data on CPR paint a very different picture. 

Although the success rate of CPR on TV provide an impression to the public that CPR most always leads to a successful outcome, the opposite is most often true, especially outside of the hospital. And the chances of success with a very elderly patient are even lower. If Lorraine was having a full cardiac arrest when 911 was called, the chances of her being revived and returning to her baseline would be negligible, almost zero. Granted the chances of someone beginning CPR immediately after she collapsed might have had a better chance of a positive outcome. But there is also the chance that she would have been intubated and taken to the ICU to die. We just don’t have the facts of what precisely happened when Lorraine collapsed. Was it a mild event or a full cardiac arrest? At any rate, it is likely that CPR was not the easy antidote to the problem that was portrayed in the media.

Finally my sense is that the real point of this story is the necessity of elderly people, for that matter everyone, to have advance directives about how they want to be cared for when such events occur. It is unthinkable that a facility like Glendale Gardens would not have a protocol for how to manage such situations. From the comments of Lorraine’s family she would not have wanted CPR and intubation. But those wishes should have been made explicit and those caring for her should have been better prepared to take the action consistent with those wishes.

The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our website.

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