vital signsHow far are we from “Do Not Resuscitate” becoming everyone’s default medical order? News from California raises that question, among others.

According to KCAL/CBS Los Angeles, an 87-year-old woman from Bakersfield, California died at a hospital last week after being transported from her assisted-living facility, where a nurse declined to perform CPR on her. A recording of the 911 call from the facility describes a tense exchange between the 911 operator and the nurse on scene as the nurse explains that the facility has a no-CPR policy.

Dispatcher: “Are we just going to wait and let this lady die?”

Nurse: “Well, that’s why we’re calling 911.”

Did the woman who died have her own DNR or no-CPR order? At no point in the news story are her wishes reported. The facility’s policy prevailed. Did the residents have to sign a DNR in order to be admitted?

Each human life has value and dignity. Each human life comes to an earthly end. Between those two facts lie a murky maze of medical ethics and political decisions as well as personal beliefs. According to the Patients Rights Council, most states now have advance directive laws under which an individual can set out her or his wishes for end-of-life treatment as well as name a person to have durable power of attorney for health care.  In my own state of New Hampshire, I was present years ago when the debates leading to the passage of advance directive laws featured sharp disagreements between people who saw great danger and people who saw the matter simply as a way to preserve patient autonomy.

Last week’s death in California, coming about as a result of a facility’s policy, makes “patient autonomy” sound like a naive hope.  If a facility has a no-CPR rule, does it apply to all residents, the 65-year-olds as well as the 87-year-olds? Why did the nurse in California call 911? Is a no-CPR order medically appropriate for all residents, or was the policy put in place for other-than-medical reasons?

A final question, indelicate but inescapable: when life-and-death treatment decisions are entrusted to a “facility” as a matter of policy, with no room for case-by-case evaluation of a patient’s wishes, is there a link between non-treatment and cost containment? I attribute no nefarious intentions to the operators of the assisted-living home in Bakersfield. If this is an industry standard, though, let’s at least get it out in the open.

According to a family member reached for comment by KCAL, the woman had been at the facility for three years, receiving “good care,” and CPR would likely not have made a difference to the outcome. The now-deceased resident (may she rest in peace) may very well have made her end-of-life wishes known to her family. Those wishes, however, are nowhere to be discerned within last week’s 911 recording.

A medical ethicist quoted by KCAL called the situation “disgusting” after hearing the 911 tape. I suspect, though, that after brief press coverage and a quiet investigation by the appropriate licensing authority, the facility’s policy will stay in place, away from the glare of publicity. It will become even harder than before to see where personal autonomy ends and institutional “policy” begins. Harder still will it be to discern if respect for life is a factor at all.

Photo credit: Ramberg Media Images via Flickr (CC-by-SA 3.0)

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