By Jack Cumming

One of the most controversial issues for senior living staff is whether CPR-trained staff and off-the-wall defibrillators should be everywhere and, if so, should they be used. The kind of incident that gives rise to this decision is often called a “code.” Obviously, it’s not uncommon for old people to “code” at dinner with young wait staff standing nearby.

Logically, most residents tend to want to be resuscitated if there’s any chance that they might have a normal life afterwards. Providers, though, fear liability, and with good reason. Those who know are aware that fragile bones weakened by osteoporosis can easily cave under the compressions of CPR, causing harm or even fatality.

Provider Policy

An incident involving an 87-year-old resident at a Brookdale community in Bakersfield, CA, brought this challenge to national attention. As a 911 operator pleaded for someone to start CPR, community policy prevented on-site staff from doing so. Listening to the pleading and response at the previous link can be heartbreaking, but we live in a litigious society, and intervening can be costly.

While you might think that the United States has the highest rate of litigation in the world, that’s not true. The U.S. comes in fifth in cases per 1,000 of population. The leaders are: 1. Germany: 123.2/1,000 2. Sweden: 111.2/1,000 3. Israel: 96.8/1,000 4. Austria: 95.9/1,000 5. U.S.: 74.5/1,000. That may be unexpected. Still, a popular impression is that fear of the liability exposure connected with serving a frail, often gullible population can put a chill on many provider actions that might otherwise be positive.

Physician Perspective

That brings us back to the question of whether to intervene in a Code Blue or not. I was eavesdropping recently on an online conversation among physicians. Here’s how it went. In response to questioning about what to do with a Code Blue from a doctor early in a medical career, a more experienced physician wrote:

“The only two things with proven mortality benefit in cardiac arrest are 1. high quality CPR (which includes minimizing time off the chest) and 2. early defib for ventricular arrhythmias. Everything else is secondary to those two things, and the way you run a code should reflect that. I count down from 10 as soon as compressions pause (10 seconds is a lot shorter than people think when they’re trying to do things like get IV access or establish an airway).

“Don’t mess around with stuff and extend out that pause. Can’t get an IV that fast? Can’t get an ETT [Endotracheal Tube] in between pulse checks? Either get someone who can do it with compressions ongoing or go IO/SGA [Intraosseous Access/Supraglottic Airway], respectively.

“Control the chaos, kick people out of the room if you need to, and then once you’ve established a good rhythm/flow with the group in the room, run down the list of H’s and T’s [Cardiac mnemonic]. The actual medicine of your standard floor code isn’t hard. It’s keeping all the insanity around you to a minimum.”

A second doctor confirmed the wisdom of the first physician:

“Anesthesiologist here and agree with this advice. As someone who takes a lot of calls and responds to probably 7-10 codes a week. This includes airway like you said. I’ll never have people hold chest compressions for me to intubate. As long as we’re able to ventilate, chest compressions take priority.”

Good Samaritan Rescuers

Obviously, it helps to have experience before attempting resuscitation, though the ethical question of whether to intervene or stand by watching someone perish remains. It’s best to have someone there who does 7-10 codes a week, which is hard to imagine, bringing the level of experience desired. In an emergency, though, you have to go with what’s at hand.

Using an Automated External Defibrillator (AED) is much less hazardous than CPR compressions, though there is a low risk of electric shock to the rescuer. Still, since time is of the essence, CPR is needed to keep oxygenated blood flowing to the brain and vital organs while the AED is analyzing the rhythm or charging.

That brings us to the defense that “good Samaritan laws” protect people who make well-intentioned attempts to help another person who is in distress. Unfortunately, good Samaritan laws vary among the states. Some protect laypersons while others focus on licensed professionals.

Before establishing a policy for such emergencies, providers need to understand the legal context. Significantly, some states not only protect “good Samaritans” but go further to impose a “duty to rescue” on any bystanders. Click here for more authoritative information.

As a disclaimer, I am not an attorney, much less a physician, and am merely drawing attention to an issue that providers and others may wish to explore with a licensed attorney. Ethics would suggest that providers ensure that prospective residents understand the facility’s policy before they commit to living there. Being able to document that understanding would seem like the best defense. Perhaps it shouldn’t be left to marketing.