- Email: [email protected]
Nursing home resuscitation policies and practices for residents without DNR orders
Instructions to CE enrollees:
The closed-book, multip e-cho ce examnat on :that follows th s art cle s designed to test your Understanding Of the educat onal objectives listed below. The answer form is on page 321. On completion of this article, the reader should be able to: i
1. Identify skilled nursing facilities and their use of do-not-resuscitate orders 2. Discuss policies related to resuscitation Of facility residents 3. Discuss results of this study regarding use of do-n0t-resuscitate Orders
Nursing Home Resuscitation Policies and Practices for Residents without D N R Orders Muriel B. Ryden, PhD, RN, FAAN, Karen Brand, MS, MA, RN, CS, Eileen Weber, BS, RN, Heeyoung Lee Oh, PhD, RN, C. Gross, PhD
A b s t r a c t : The purpose of this study was to explore the policies and practices of nursing homes with
respect to the resuscitation of residents who do not have a do-not-resuscitate (DNR) order. Responses from a survey of 36 facilities revealed that most residents had DNR orders and most facilities were capable of providing basic cardiopulmonary resuscitation (CPR). Less than 30% had performed CPR in the past 6 months, and 22.8% had no written CPR policies. More facilities required CPR in witnessed arrests of non-DNR residents (79.3%) than in unwitnessed arrests (24%). Methods for identifying CPR status need improvement to enable accurate identification and prompt resuscitation of residents who want CPR. (Geriatr Nurs 1998;19:315-20)
Geriatric Nursing Volume 19, Number 6
315
eath is not unexpected in nursing homes, a setting in which the m e a n age of residents is usually 80 or older. However, nurses often face troubling decisions as to whether or not to initiate CPR if a resident's heart and breathing stop. Although C P R originally was developed for otherwise healthy people who experience cardiac arrest, 1 it has become the default procedure in acute care settings unless a written D N R order is in the medical record. Long-term care (LTC) facilities are markedly different, however, often lacking the personnel and technology to p r o v i d e a d v a n c e d cardiac life support. Nevertheless, this same resuscitation practice has been carried over despite the low probability of success. 2-4 For residents who have a D N R order, the decision is c l e a r - - d o n o t resuscitate. However, the situation is m o r e troublesome for residents without a C P R or D N R order. A lack of clarity as to what the resident or family wants and concern about the appropriateness of C P R have led some health care providers to use "slow codes" and partial or inadequate attempts at resuscitation, as well as informal oral D N R orders to allow death and avoid discussion with the resident and family. Supplanting such surreptitious practices with clearly written institutional policies to guide action and promote clear communication with residents and families has been widely advocated.5, 6 Studies of the resuscitation policies and practices in nursing homes include an examination of the prevalence and content of D N R policies in nursing homes in Minnesota, 7 Oregon, 8 North Carolina, 9 Illinois, l° Canada, u and Connecticut. 12 However, little attention has been paid to resuscitation practices for residents who do not have a D N R order. This article is a report of the findings from a segment of a larger study about resuscitation decisions for nursing h o m e residents without a D N R order in which issues were explored from the perspective of competent residents, their designated decision makers, health care providers, and facilities. ~3 The purpose of this phase of the project was to determine the policies and practices of nursing homes regarding resuscitation of residents who did not have a D N R o r d e r .
D
METHOD
The sample of 50 nursing homes in the larger study was a stratified r a n d o m sample, representative of the state profile of proprietary versus nonprofit, sevencounty metropolitan area versus outstate, and large (more than 100 beds) versus small facilities. Facilities were recruited by letters that were sent to administrators and directors of nursing (DONs) informing them of the study and requesting participation. Nonrespondents received a follow-up letter and a telephone call. To reach a sample size of 50 nursing homes, 62 facilities
316
were contacted. To obtain information about resuscitation policies and practices, surveys were mailed to each DON. SAMPLE
Although 50 nursing homes participated in the larger study, the data for this article were taken from only 36 surveys, a response rate of 72%. Follow-up communication in an attempt to increase the response rate revealed that turnover in several facilities' administrative positions interfered with completing the survey. Metropolitan proprietary nursing homes were more likely to be nonresponders than outstate facilities or metro nonprofit homes; in other respects, nonrespontiers and responders were not significantly different. Characteristics of the sample are shown in Table 1. Facilities ranged in numbers of beds from 49 to 559 with a median of 89 beds and mean of 120 beds (SD = 106). iNSTRUMENT
A 25-item survey titled "Facility Policies and Practices Regarding Cardiopulrnonary Resuscitation" was developed to obtain information about current CPR policies and practices in LTC facilities. The survey was based on a literature review and was revised after consultation with a project advisory committee composed of nationally known ethicists, gerontologists, and representatives from the two nursing h o m e trade associations in the state. RESULTS
CPR capability. Most facilities (88.9%) required CPR certification for all licensed nurses, and 86.1% provided CPR training for staff. (State law requires that licensed facilities have a nurse with CPR certification on duty at all times.) No facilities required CPR certification for all nursing assistants; however, 36.1% expected that nursing assistants who were CPR-certified would
N = 36
%
Size < 100 b e d s
21
583
> 100 beds
15
41,7
8 28
22:2 77.8
i Governance : Nonprofit Proprietary
12
66.7 33;3
} Corporate
12
33,3
5
13 8
,: Location
Metropolitan Outstate
2 Joint Commission Accreditation
G e r i a t r i c N u r s i n g Volume 19, N u m b e r 6
perform CPR. Most facilities had resources for basic CPR available: 92% had masks with one-way valves, 100% had oxygen, and 86.1% had bedboards. C P R policies. In a departure from the acute care norm, four (11%) facilities reported having a policy that all residents are considered D N R unless they specify otherwise. Eight (22%) facilities reported they had no written policy or guideline that deals with resuscitation. Facilities without written policies did not differ significantly from those with policies in respect to size, location, governance, or corporate status. Of the 12 facilities that were members of a corporate group of agencies, seven reported that decisions about resuscitation policies were made at the facility level; at two facilities, policies were developed at the corporate level, and at three facilities, both levels were involved in policy development. CPR practices. C P R had not been p e r f o r m e d within the past 6 months in 72% of facilities; however, nine homes had p e r f o r m e d CPR from one to three times, and one facility reported eight resuscitation attempts. Most facilities (73.5%) reported that their practice is to give C P R in the event of a witnessed arrest for a resident without a D N R order, 5.9% call 9-1-1 without giving CPR, and 17.6% allow the nurse to use clinical judgment in making the decision. More variance occurs in reported facility practice when a resident without a D N R order arrests without a witness: 35.3% do not resuscitate, 32.4% rely on the nurse's judgment, and 29.4% give CPR. Analysis with logistic regression showed that none of the facility characteristics was significantly associated with reported resuscitation practice for either witnessed or unwitnessed arrests in residents without a D N R order. Ethics committees or consultants. Ethics committees were in place in 15 (44%) facilities; two facilities reported having an ethics consultant but not an ethics committee. Facilities with an ethics committee or consultant were not significantly m o r e likely to have a written CPR policy. A significantly larger proportion of noncorporate facilities (62.5%) had ethics committees or consultants than did corporate facilities (18.2%). Identifying residents with respect to resuscitation status. When asked how they differentiate between a resident who has a D N R order and one who does not, respondents listed a plethora of different methods. In five facilities, nurses had to look inside the chart to determine resuscitation status. Many facilities used colored stickers: red, yellow, blue, green, purple, and orange stickers were mentioned. In some facilities a colored sticker meant CPR; in others it meant D N R . The most c o m m o n place for stickers was on the chart cover, spine, or holder. Frequently the resident had an a r m b a n d or bracelet with an identifying colored dot or his or her name in a certain color. Colored stickers also were placed on the r o o m door or nameplate (one facility used a red heart if CPR was to be ad-
Geriatric Nursing Volume 19, Number 6
ministered), although no facility explained how they differentiate among multiple residents in a room. The bed, wheelchair, kardex, and reed cart were listed as other locations for colored stickers. A list of residents who were to be resuscitated was kept at the desk in one facility and on the med door in another. Respondents were asked the total number of residents in their facility and the number with D N R orders. The percentage of residents with D N R orders ranged f r o m 22.09% to 96.63% with a m e a n of 74.54% (SD = 18.92). Six facilities reported D N R orders for m o r e than 90%, 26 reported percentages from 50% to 89%, and four rep o r t e d that fewer than half their residents had a D N R order. =: 7 ...... " Advance directives. A total of 81% of facilities reported that they had provided residents with information about advance directives within the past year, and 86% had provided in-service sessions for staff about advance directives. Social services was responsible for informing residents about their right to make an advance directive in most fa'::',')!~aL :., 2:: :' ; : s cilities (89%). DISCUSSION
-.i. ~::1.. r~
To understand nursing home practice regard . . . . . ing CPR, one must realize that, except for facilities attached to a hospital, {:: ' ~ , nursing homes have neither the personnel nor the technical resources to provide advanced cardiac life support. Most facilities in this study had trained staff and equipment to administer basic CPR until the paramedics arrived. Few facilities had performed CPR within the past 6 months, possibly because most of their residents had D N R orders or because most arrests were not witnessed. Because changing patterns of health care delivery are prompting nursing homes to establish subacute units or provide transition care to increasing numbers of relatively healthy people who might benefit from resuscitation, CPR may be provided more frequently. The proportion of nursing homes in this study that
317
reported having written resuscitation policies (87.8 %) is markedly higher than the 16% reported in the study of Minnesota nursing homes in 1985 by Miles and Ryden, 7 the 20% reported in Illinois in 1991,10 the 41% rep o r t e d in O r e g o n by Levinson et al. in 1987, 8 and the 37% reported in Canada by Choudhry et Facilities have al. in 1994.11 This study's results are comparable to the 83% reported in 1991 by Brunetti et al. 9
a responsibility tO
ensure
that
the CPR or DNR
status on the rnedica| record accurately
reflects the preference
of
informedj competent
nursing home residents,
in North Carolina and the 87.2% reported in 1995 by Walker et al. 12 in Connecticut. D a t a for this study were collected in 1993 after the passage of the Patient Self-Determination Act (PSDA), which went into effect in late 1991. This legislation m a y have stimulated policy d e v e l o p m e n t in nursing homes. H o w ever, a possibility does exist that facilities without policies may selectively have chosen not to respond to our questionnaire; therefore the proportion with written policies may be inflated somewhat. In any event,
it is disappointing to find that even the presence of ethics committees or a consultant did not guarantee written policies, an essential characteristic of a facility that respects residents' autonomy. Nurses, who bear a major responsibility for implementing C P R policies, should have an active role in developing such policies, according to the position statement of the American Nurses Association on nursing care and D N R decisions. 14 Blanket policies, mandating either the provision or withholding of CPR to all residents, were discouraged in the position paper on C P R published by the Minnesota Association of Nursing H o m e Medical Directors ( M A N H D ) . 15 The increased reliance on the use of clinical judgment to determine whether C P R should be given to residents without a D N R o r d e r when an arrest is unwitnessed is congruent with recommendations in the M A N H D Position p a p e r on CPR, 15 which suggests guidelines need to be developed that allow nurses to de-
318
termine that a resident has died in the nursing home. The wide variations in CPR practice reported in this study point to the need for individuals and families who are considering nursing h o m e admission to request written information about what will be done in the event a person's heart and breathing stops and what process they should use to document their preferences that will result in t h e appropriate formal order in the medical record. The multitude of ways used to differentiate between residents who have D N R orders and those who do not and the inadequacy of many of these methods clearly point to the need for clear, unequivocal, and rapid determination of a resident's preference regarding resuscitation. The effectiveness of CPR depends on rapid response, which allows no time to leaf through a medical record to determine resident wishes. The high staff turnover rate in nursing homes and the use of personnel from external labor pools intensify the need to have mechanisms in place that facilitate immediate identification of a resident's CPR status in the event of an arrest. Such mechanisms both protect against unwanted resuscitation for people with D N R orders and ensure appropriate action for those without them. Facilities have a responsibility to ensure that the C P R or D N R status on the medical record accurately reflects the preference of informed, competent nursing h o m e residents. The documented resuscitation status for cognitively impaired residents should reflect prior decisions made by the individual through an advance directive or by the family in consultation with the physician. The study finding that responsibility for informing residents about their right to make an advance directive was delegated to social workers in most facilities is similar to that reported by Walker et al. 12 Despite legislation mandating action, a minority of facilities reported that they did not inform residents of their right to make an advance directive. Although most facilities said they provide residents with information about advance directives, this claim was not consistent with the report of many residents who were interviewed as part of another phase of the study. In the nine facilities that reported giving information about advance directives, 88% of the residents who were interviewed stated they had not been informed. Although these were competent residents, some may have been too stressed at the time of admission to have retained the information they had been given. Other residents admitted to the nursing h o m e before PSDA implementation may never have received inf o r m a t i o n a b o u t their right to have an advance directive. In the two facilities that said they did not inform residents, 12 in 13 residents confirmed they had not received any information about advance directives. Clearly the optimal time to discuss preferences
Geriatric Nursing Volume 19, Number 6
a b o u t r e s u s c i t a t i o n a n d o t h e r t r e a t m e n t s is b e f o r e t h e stressful event of admission to a nursing home. H o w e v e r , f o r h e a l t h c a r e p r o v i d e r s to b e a b l e to r e s p e c t t h e a u t o n o m y o f elders, L T C f a c i l i t i e s a r e o b l i g a t e d to i n s t i t u t e c o n s i s t e n t p r a c t i c e s to d e t e r m i n e w h e t h e r all t h e i r r e s i d e n t s h a v e m a d e a d v a n c e d i r e c t i v e s a n d inf o r m t h e m o r t h e i r f a m i l i e s o f t h e i r r i g h t to d o so. T h i s s t u d y was l i m i t e d to s e l f - r e p o r t by facilities. Actual policies were not examined nor were practices observed; therefore neither the quality of the policies nor the congruence between policy and practice could be d e t e r m i n e d . C o n f u s i o n a b o u t w h a t c o n s t i t u t e s a facility p o l i c y was r e v e a l e d in a s t u d y by E n d e r l i n a n d W i l h i t e , 10 w h o f o u n d t h a t o n l y six in 10 p o l i c i e s s u b m i t t e d f o r r e v i e w w e r e a c t u a l l y in p o l i c y s t a t e m e n t f o r m a t : t h r e e w e r e p e r m i s s i o n or c o n s e n t f o r m s f o r D N R o r d e r s a n d o n e was a l e t t e r to t h e f a m i l y a b o u t D N R o r d e r s . T h e f i n d i n g s s u g g e s t t h e n e e d f o r f a c i l i t i e s to r i g o r o u s l y self-assess their resuscitation policies and practices. CONCLUSION I n s u m m a r y , b e t t e r m a n a g e m e n t o f s i t u a t i o n s involving a decision for or against CPR necessitates: • Clear policies regarding the process and documentation of decision-making about resuscitation to ensure an authentic, informed choice by residents or families/guardians • Provision for ensuring the congruence between residents' preferences and the medical orders r e l a t i n g to r e s u s c i t a t i o n • A mechanism for accurate and rapid identificat i o n o f r e s i d e n t s f o r w h o m a r e s u s c i t a t i o n att e m p t is t h e p r e f e r r e d t r e a t m e n t • P o l i c i e s t h a t d e l i n e a t e a p p r o p r i a t e a c t i o n in t h e e v e n t o f e i t h e r an u n w i t n e s s e d o r a w i t n e s s e d c a r d i a c a r r e s t in p e o p l e w h o d o n o t h a v e a D N R order • Staff members who are knowledgeable about the e t h i c a l a n d l e g a l issues i n v o l v e d in r e s u s c i t a t i o n a n d t h e u s e o f a d v a n c e d i r e c t i v e s to e n a b l e residents' preferences to be honored • S t a f f m e m b e r s w h o a r e c o m p e t e n t to p r o v i d e basic CPR until paramedics arrive • C l e a r l y w r i t t e n i n f o r m a t i o n a v a i l a b l e f o r resid e n t s a n d f a m i l i e s o u t l i n i n g w h a t t h e y c a n expect regarding resuscitation
Geriatric Nursing Volume 19, Number 6
REFERENCES 1. Kouwenhoven WB, Jude JR, Knickerbocker GG. Closed-chest cardiac massage. JAMA 1960;265:1874-6. 2. Applebaum GE, King JE, Finucane TE. The outcome of CPR initiated in nursing homes. J Am Geriatr Soc 1990;38:197-200. 3. Awoke S, Mouton, CR Parrott M. Outcomes of skilled CPR in a long-term care facility:futile therapy? J Am Geriatr Soc 1992;40:593-5. 4. Murphy DJ, Murray AM, Robinson BE, Campion EW. Outcomes of cardiopulmonary resuscitation in the elderly.Ann Intern Med 1989;111:199205. 5. Crimmins TJ. Cardiopulmonary resuscitation in nursing homes: continuing concerns. Minn Med 1992;75:33-4. 6. American Medical Association. Standards and guidelines for cardiopulmonary resuscitation and emergency cardiac care. Chicago: The Association; 1986. 7. Miles SH, Ryden MB. Limited treatment policies in long-term care facilities. J Am Geriatr Soc 1985;33:707-11, 8. Levinson W, Shepard MA, Dunn PM, Parker R. Cardiopulmonary resuscitation in long-term care facilities: a survey of do-not-resuscitate orders in nursing homes. J Am Geriatr Soc 1987;35:1059-62. 9. Brunetti LL, Weiss MJ, Studenski SA, Clipp ED. Cardiopulmonary resuscitation policies and practices.Arch Intern Med 1990;150:121-6. 10. Enderlin A, Wilhite M. Establishing incidence and administrative protocols for do not resuscitate orders. J Gerontologic Nuts 1991;17(3):10-6. 11. Choudhry NK, Ma J, Rasooly I, Singer PA. Long-term care facility policies on life-sustaining treatments and advance directives in Canada. J Am Geriatr Soc 1994;42:1150-3. 12. Walker L, Wetle T, Blechner B. Do-not-resuscitate orders in nursing homes: institutional policies and practices.J Ethics Law Aging 1995;1:97-106. 13. Ryden MB. Resuscitation decisionsin residents with no DNR orders. Report to funders American Heart Association and National Center for Nursing Research; 1994. 14. American Nurses Association. Position statement on nursing care and donot-resuscitate decisions.Washington (DC): The Association: 1992. 15. Minnesota Association of Nursing Home Medical Directors. Position paper: cardiopulmonary resuscitation in Minnesota nursing homes. Minn Med 1992;75:35-7.
This article is dedicated to our friend and colleague Karen Brand, MS, MA, RN, CS, who died before this work was published. MURIEL B. RYDEN, PhD, RN, FAAN, is a professor at the University of Minnesota School of Nursing in Minneapolis. EILEEN WEBER, BS, RN, is a doctoral student, and C. GROSS, PhD, is an associate professor at the university. HEEYOUNG LEE OH, PhD, RN, is a lecturer at Yonsei University in Seoul, Korea. This study from the Nursing Research Center for Long-Term Care of Elders at the University of Minnesota School of Nursing was carried out with grant support from the American Heart Association, #92014170, and from the National center for Nursing Research, #1 R03NR02849-01A1. Copyright @ 1998 by Mosby, Inc. 0197-4572/98/$5.00 + 0
34/1/84064
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.
.
.
.
.
.
.
.
11 Test I.D. No.: G84064 Contact hours: 1.0 Processing fee: $9 Passing score: 70%
. H o w many facilities in the study required licensed nurses to know CPR? A. 100% B. 92% C. 89% D. 84%
. H o w were patients identified for CPR? A. N a m e tags B. Chart designation C. Methods for identifying individuals were inconsistent. D. List at the front desk
. H o w m a n y facilities in the study required nursing assistants to know CPR? A. 100% B. 89% C. 84% D. None
. Who is responsible for discussing advanced directives with residents? Ao Physician B. Nurse C. Social worker D. Chaplain
. Approximately what percent of the study facilities called 9-1-1 without first giving CPR? A. 6% B. 18% C. 74% D. 92%
. The optimal time to discuss resuscitation and advance directive issues is: A. Before admission to the facility B. Within the first hour of admission C. The first opportunity the social worker has D. In the physician's office
. Which group is most likely to have an ethics committee or consultant? A. Corporate facilities B. N o n c o r p o r a t e facilities C. No distinction was made D. All had committees or consultants
. This study received the most responses from: A. Large, rural, proprietary facilities B. Small, rural, nonprofit facilities C. Large, urban, proprietary facilities D. Small; urban, nonprofit facilities
320
Geriatric Nursing Volume 19, Number 6
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Geriatric Nursing Volume 19, Number 6
321
The closed-book, multip e-cho ce examnat on :that follows th s art cle s designed to test your Understanding Of the educat onal objectives listed below. The answer form is on page 321. On completion of this article, the reader should be able to: i
1. Identify skilled nursing facilities and their use of do-not-resuscitate orders 2. Discuss policies related to resuscitation Of facility residents 3. Discuss results of this study regarding use of do-n0t-resuscitate Orders
Nursing Home Resuscitation Policies and Practices for Residents without D N R Orders Muriel B. Ryden, PhD, RN, FAAN, Karen Brand, MS, MA, RN, CS, Eileen Weber, BS, RN, Heeyoung Lee Oh, PhD, RN, C. Gross, PhD
A b s t r a c t : The purpose of this study was to explore the policies and practices of nursing homes with
respect to the resuscitation of residents who do not have a do-not-resuscitate (DNR) order. Responses from a survey of 36 facilities revealed that most residents had DNR orders and most facilities were capable of providing basic cardiopulmonary resuscitation (CPR). Less than 30% had performed CPR in the past 6 months, and 22.8% had no written CPR policies. More facilities required CPR in witnessed arrests of non-DNR residents (79.3%) than in unwitnessed arrests (24%). Methods for identifying CPR status need improvement to enable accurate identification and prompt resuscitation of residents who want CPR. (Geriatr Nurs 1998;19:315-20)
Geriatric Nursing Volume 19, Number 6
315
eath is not unexpected in nursing homes, a setting in which the m e a n age of residents is usually 80 or older. However, nurses often face troubling decisions as to whether or not to initiate CPR if a resident's heart and breathing stop. Although C P R originally was developed for otherwise healthy people who experience cardiac arrest, 1 it has become the default procedure in acute care settings unless a written D N R order is in the medical record. Long-term care (LTC) facilities are markedly different, however, often lacking the personnel and technology to p r o v i d e a d v a n c e d cardiac life support. Nevertheless, this same resuscitation practice has been carried over despite the low probability of success. 2-4 For residents who have a D N R order, the decision is c l e a r - - d o n o t resuscitate. However, the situation is m o r e troublesome for residents without a C P R or D N R order. A lack of clarity as to what the resident or family wants and concern about the appropriateness of C P R have led some health care providers to use "slow codes" and partial or inadequate attempts at resuscitation, as well as informal oral D N R orders to allow death and avoid discussion with the resident and family. Supplanting such surreptitious practices with clearly written institutional policies to guide action and promote clear communication with residents and families has been widely advocated.5, 6 Studies of the resuscitation policies and practices in nursing homes include an examination of the prevalence and content of D N R policies in nursing homes in Minnesota, 7 Oregon, 8 North Carolina, 9 Illinois, l° Canada, u and Connecticut. 12 However, little attention has been paid to resuscitation practices for residents who do not have a D N R order. This article is a report of the findings from a segment of a larger study about resuscitation decisions for nursing h o m e residents without a D N R order in which issues were explored from the perspective of competent residents, their designated decision makers, health care providers, and facilities. ~3 The purpose of this phase of the project was to determine the policies and practices of nursing homes regarding resuscitation of residents who did not have a D N R o r d e r .
D
METHOD
The sample of 50 nursing homes in the larger study was a stratified r a n d o m sample, representative of the state profile of proprietary versus nonprofit, sevencounty metropolitan area versus outstate, and large (more than 100 beds) versus small facilities. Facilities were recruited by letters that were sent to administrators and directors of nursing (DONs) informing them of the study and requesting participation. Nonrespondents received a follow-up letter and a telephone call. To reach a sample size of 50 nursing homes, 62 facilities
316
were contacted. To obtain information about resuscitation policies and practices, surveys were mailed to each DON. SAMPLE
Although 50 nursing homes participated in the larger study, the data for this article were taken from only 36 surveys, a response rate of 72%. Follow-up communication in an attempt to increase the response rate revealed that turnover in several facilities' administrative positions interfered with completing the survey. Metropolitan proprietary nursing homes were more likely to be nonresponders than outstate facilities or metro nonprofit homes; in other respects, nonrespontiers and responders were not significantly different. Characteristics of the sample are shown in Table 1. Facilities ranged in numbers of beds from 49 to 559 with a median of 89 beds and mean of 120 beds (SD = 106). iNSTRUMENT
A 25-item survey titled "Facility Policies and Practices Regarding Cardiopulrnonary Resuscitation" was developed to obtain information about current CPR policies and practices in LTC facilities. The survey was based on a literature review and was revised after consultation with a project advisory committee composed of nationally known ethicists, gerontologists, and representatives from the two nursing h o m e trade associations in the state. RESULTS
CPR capability. Most facilities (88.9%) required CPR certification for all licensed nurses, and 86.1% provided CPR training for staff. (State law requires that licensed facilities have a nurse with CPR certification on duty at all times.) No facilities required CPR certification for all nursing assistants; however, 36.1% expected that nursing assistants who were CPR-certified would
N = 36
%
Size < 100 b e d s
21
583
> 100 beds
15
41,7
8 28
22:2 77.8
i Governance : Nonprofit Proprietary
12
66.7 33;3
} Corporate
12
33,3
5
13 8
,: Location
Metropolitan Outstate
2 Joint Commission Accreditation
G e r i a t r i c N u r s i n g Volume 19, N u m b e r 6
perform CPR. Most facilities had resources for basic CPR available: 92% had masks with one-way valves, 100% had oxygen, and 86.1% had bedboards. C P R policies. In a departure from the acute care norm, four (11%) facilities reported having a policy that all residents are considered D N R unless they specify otherwise. Eight (22%) facilities reported they had no written policy or guideline that deals with resuscitation. Facilities without written policies did not differ significantly from those with policies in respect to size, location, governance, or corporate status. Of the 12 facilities that were members of a corporate group of agencies, seven reported that decisions about resuscitation policies were made at the facility level; at two facilities, policies were developed at the corporate level, and at three facilities, both levels were involved in policy development. CPR practices. C P R had not been p e r f o r m e d within the past 6 months in 72% of facilities; however, nine homes had p e r f o r m e d CPR from one to three times, and one facility reported eight resuscitation attempts. Most facilities (73.5%) reported that their practice is to give C P R in the event of a witnessed arrest for a resident without a D N R order, 5.9% call 9-1-1 without giving CPR, and 17.6% allow the nurse to use clinical judgment in making the decision. More variance occurs in reported facility practice when a resident without a D N R order arrests without a witness: 35.3% do not resuscitate, 32.4% rely on the nurse's judgment, and 29.4% give CPR. Analysis with logistic regression showed that none of the facility characteristics was significantly associated with reported resuscitation practice for either witnessed or unwitnessed arrests in residents without a D N R order. Ethics committees or consultants. Ethics committees were in place in 15 (44%) facilities; two facilities reported having an ethics consultant but not an ethics committee. Facilities with an ethics committee or consultant were not significantly m o r e likely to have a written CPR policy. A significantly larger proportion of noncorporate facilities (62.5%) had ethics committees or consultants than did corporate facilities (18.2%). Identifying residents with respect to resuscitation status. When asked how they differentiate between a resident who has a D N R order and one who does not, respondents listed a plethora of different methods. In five facilities, nurses had to look inside the chart to determine resuscitation status. Many facilities used colored stickers: red, yellow, blue, green, purple, and orange stickers were mentioned. In some facilities a colored sticker meant CPR; in others it meant D N R . The most c o m m o n place for stickers was on the chart cover, spine, or holder. Frequently the resident had an a r m b a n d or bracelet with an identifying colored dot or his or her name in a certain color. Colored stickers also were placed on the r o o m door or nameplate (one facility used a red heart if CPR was to be ad-
Geriatric Nursing Volume 19, Number 6
ministered), although no facility explained how they differentiate among multiple residents in a room. The bed, wheelchair, kardex, and reed cart were listed as other locations for colored stickers. A list of residents who were to be resuscitated was kept at the desk in one facility and on the med door in another. Respondents were asked the total number of residents in their facility and the number with D N R orders. The percentage of residents with D N R orders ranged f r o m 22.09% to 96.63% with a m e a n of 74.54% (SD = 18.92). Six facilities reported D N R orders for m o r e than 90%, 26 reported percentages from 50% to 89%, and four rep o r t e d that fewer than half their residents had a D N R order. =: 7 ...... " Advance directives. A total of 81% of facilities reported that they had provided residents with information about advance directives within the past year, and 86% had provided in-service sessions for staff about advance directives. Social services was responsible for informing residents about their right to make an advance directive in most fa'::',')!~aL :., 2:: :' ; : s cilities (89%). DISCUSSION
-.i. ~::1.. r~
To understand nursing home practice regard . . . . . ing CPR, one must realize that, except for facilities attached to a hospital, {:: ' ~ , nursing homes have neither the personnel nor the technical resources to provide advanced cardiac life support. Most facilities in this study had trained staff and equipment to administer basic CPR until the paramedics arrived. Few facilities had performed CPR within the past 6 months, possibly because most of their residents had D N R orders or because most arrests were not witnessed. Because changing patterns of health care delivery are prompting nursing homes to establish subacute units or provide transition care to increasing numbers of relatively healthy people who might benefit from resuscitation, CPR may be provided more frequently. The proportion of nursing homes in this study that
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reported having written resuscitation policies (87.8 %) is markedly higher than the 16% reported in the study of Minnesota nursing homes in 1985 by Miles and Ryden, 7 the 20% reported in Illinois in 1991,10 the 41% rep o r t e d in O r e g o n by Levinson et al. in 1987, 8 and the 37% reported in Canada by Choudhry et Facilities have al. in 1994.11 This study's results are comparable to the 83% reported in 1991 by Brunetti et al. 9
a responsibility tO
ensure
that
the CPR or DNR
status on the rnedica| record accurately
reflects the preference
of
informedj competent
nursing home residents,
in North Carolina and the 87.2% reported in 1995 by Walker et al. 12 in Connecticut. D a t a for this study were collected in 1993 after the passage of the Patient Self-Determination Act (PSDA), which went into effect in late 1991. This legislation m a y have stimulated policy d e v e l o p m e n t in nursing homes. H o w ever, a possibility does exist that facilities without policies may selectively have chosen not to respond to our questionnaire; therefore the proportion with written policies may be inflated somewhat. In any event,
it is disappointing to find that even the presence of ethics committees or a consultant did not guarantee written policies, an essential characteristic of a facility that respects residents' autonomy. Nurses, who bear a major responsibility for implementing C P R policies, should have an active role in developing such policies, according to the position statement of the American Nurses Association on nursing care and D N R decisions. 14 Blanket policies, mandating either the provision or withholding of CPR to all residents, were discouraged in the position paper on C P R published by the Minnesota Association of Nursing H o m e Medical Directors ( M A N H D ) . 15 The increased reliance on the use of clinical judgment to determine whether C P R should be given to residents without a D N R o r d e r when an arrest is unwitnessed is congruent with recommendations in the M A N H D Position p a p e r on CPR, 15 which suggests guidelines need to be developed that allow nurses to de-
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termine that a resident has died in the nursing home. The wide variations in CPR practice reported in this study point to the need for individuals and families who are considering nursing h o m e admission to request written information about what will be done in the event a person's heart and breathing stops and what process they should use to document their preferences that will result in t h e appropriate formal order in the medical record. The multitude of ways used to differentiate between residents who have D N R orders and those who do not and the inadequacy of many of these methods clearly point to the need for clear, unequivocal, and rapid determination of a resident's preference regarding resuscitation. The effectiveness of CPR depends on rapid response, which allows no time to leaf through a medical record to determine resident wishes. The high staff turnover rate in nursing homes and the use of personnel from external labor pools intensify the need to have mechanisms in place that facilitate immediate identification of a resident's CPR status in the event of an arrest. Such mechanisms both protect against unwanted resuscitation for people with D N R orders and ensure appropriate action for those without them. Facilities have a responsibility to ensure that the C P R or D N R status on the medical record accurately reflects the preference of informed, competent nursing h o m e residents. The documented resuscitation status for cognitively impaired residents should reflect prior decisions made by the individual through an advance directive or by the family in consultation with the physician. The study finding that responsibility for informing residents about their right to make an advance directive was delegated to social workers in most facilities is similar to that reported by Walker et al. 12 Despite legislation mandating action, a minority of facilities reported that they did not inform residents of their right to make an advance directive. Although most facilities said they provide residents with information about advance directives, this claim was not consistent with the report of many residents who were interviewed as part of another phase of the study. In the nine facilities that reported giving information about advance directives, 88% of the residents who were interviewed stated they had not been informed. Although these were competent residents, some may have been too stressed at the time of admission to have retained the information they had been given. Other residents admitted to the nursing h o m e before PSDA implementation may never have received inf o r m a t i o n a b o u t their right to have an advance directive. In the two facilities that said they did not inform residents, 12 in 13 residents confirmed they had not received any information about advance directives. Clearly the optimal time to discuss preferences
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a b o u t r e s u s c i t a t i o n a n d o t h e r t r e a t m e n t s is b e f o r e t h e stressful event of admission to a nursing home. H o w e v e r , f o r h e a l t h c a r e p r o v i d e r s to b e a b l e to r e s p e c t t h e a u t o n o m y o f elders, L T C f a c i l i t i e s a r e o b l i g a t e d to i n s t i t u t e c o n s i s t e n t p r a c t i c e s to d e t e r m i n e w h e t h e r all t h e i r r e s i d e n t s h a v e m a d e a d v a n c e d i r e c t i v e s a n d inf o r m t h e m o r t h e i r f a m i l i e s o f t h e i r r i g h t to d o so. T h i s s t u d y was l i m i t e d to s e l f - r e p o r t by facilities. Actual policies were not examined nor were practices observed; therefore neither the quality of the policies nor the congruence between policy and practice could be d e t e r m i n e d . C o n f u s i o n a b o u t w h a t c o n s t i t u t e s a facility p o l i c y was r e v e a l e d in a s t u d y by E n d e r l i n a n d W i l h i t e , 10 w h o f o u n d t h a t o n l y six in 10 p o l i c i e s s u b m i t t e d f o r r e v i e w w e r e a c t u a l l y in p o l i c y s t a t e m e n t f o r m a t : t h r e e w e r e p e r m i s s i o n or c o n s e n t f o r m s f o r D N R o r d e r s a n d o n e was a l e t t e r to t h e f a m i l y a b o u t D N R o r d e r s . T h e f i n d i n g s s u g g e s t t h e n e e d f o r f a c i l i t i e s to r i g o r o u s l y self-assess their resuscitation policies and practices. CONCLUSION I n s u m m a r y , b e t t e r m a n a g e m e n t o f s i t u a t i o n s involving a decision for or against CPR necessitates: • Clear policies regarding the process and documentation of decision-making about resuscitation to ensure an authentic, informed choice by residents or families/guardians • Provision for ensuring the congruence between residents' preferences and the medical orders r e l a t i n g to r e s u s c i t a t i o n • A mechanism for accurate and rapid identificat i o n o f r e s i d e n t s f o r w h o m a r e s u s c i t a t i o n att e m p t is t h e p r e f e r r e d t r e a t m e n t • P o l i c i e s t h a t d e l i n e a t e a p p r o p r i a t e a c t i o n in t h e e v e n t o f e i t h e r an u n w i t n e s s e d o r a w i t n e s s e d c a r d i a c a r r e s t in p e o p l e w h o d o n o t h a v e a D N R order • Staff members who are knowledgeable about the e t h i c a l a n d l e g a l issues i n v o l v e d in r e s u s c i t a t i o n a n d t h e u s e o f a d v a n c e d i r e c t i v e s to e n a b l e residents' preferences to be honored • S t a f f m e m b e r s w h o a r e c o m p e t e n t to p r o v i d e basic CPR until paramedics arrive • C l e a r l y w r i t t e n i n f o r m a t i o n a v a i l a b l e f o r resid e n t s a n d f a m i l i e s o u t l i n i n g w h a t t h e y c a n expect regarding resuscitation
Geriatric Nursing Volume 19, Number 6
REFERENCES 1. Kouwenhoven WB, Jude JR, Knickerbocker GG. Closed-chest cardiac massage. JAMA 1960;265:1874-6. 2. Applebaum GE, King JE, Finucane TE. The outcome of CPR initiated in nursing homes. J Am Geriatr Soc 1990;38:197-200. 3. Awoke S, Mouton, CR Parrott M. Outcomes of skilled CPR in a long-term care facility:futile therapy? J Am Geriatr Soc 1992;40:593-5. 4. Murphy DJ, Murray AM, Robinson BE, Campion EW. Outcomes of cardiopulmonary resuscitation in the elderly.Ann Intern Med 1989;111:199205. 5. Crimmins TJ. Cardiopulmonary resuscitation in nursing homes: continuing concerns. Minn Med 1992;75:33-4. 6. American Medical Association. Standards and guidelines for cardiopulmonary resuscitation and emergency cardiac care. Chicago: The Association; 1986. 7. Miles SH, Ryden MB. Limited treatment policies in long-term care facilities. J Am Geriatr Soc 1985;33:707-11, 8. Levinson W, Shepard MA, Dunn PM, Parker R. Cardiopulmonary resuscitation in long-term care facilities: a survey of do-not-resuscitate orders in nursing homes. J Am Geriatr Soc 1987;35:1059-62. 9. Brunetti LL, Weiss MJ, Studenski SA, Clipp ED. Cardiopulmonary resuscitation policies and practices.Arch Intern Med 1990;150:121-6. 10. Enderlin A, Wilhite M. Establishing incidence and administrative protocols for do not resuscitate orders. J Gerontologic Nuts 1991;17(3):10-6. 11. Choudhry NK, Ma J, Rasooly I, Singer PA. Long-term care facility policies on life-sustaining treatments and advance directives in Canada. J Am Geriatr Soc 1994;42:1150-3. 12. Walker L, Wetle T, Blechner B. Do-not-resuscitate orders in nursing homes: institutional policies and practices.J Ethics Law Aging 1995;1:97-106. 13. Ryden MB. Resuscitation decisionsin residents with no DNR orders. Report to funders American Heart Association and National Center for Nursing Research; 1994. 14. American Nurses Association. Position statement on nursing care and donot-resuscitate decisions.Washington (DC): The Association: 1992. 15. Minnesota Association of Nursing Home Medical Directors. Position paper: cardiopulmonary resuscitation in Minnesota nursing homes. Minn Med 1992;75:35-7.
This article is dedicated to our friend and colleague Karen Brand, MS, MA, RN, CS, who died before this work was published. MURIEL B. RYDEN, PhD, RN, FAAN, is a professor at the University of Minnesota School of Nursing in Minneapolis. EILEEN WEBER, BS, RN, is a doctoral student, and C. GROSS, PhD, is an associate professor at the university. HEEYOUNG LEE OH, PhD, RN, is a lecturer at Yonsei University in Seoul, Korea. This study from the Nursing Research Center for Long-Term Care of Elders at the University of Minnesota School of Nursing was carried out with grant support from the American Heart Association, #92014170, and from the National center for Nursing Research, #1 R03NR02849-01A1. Copyright @ 1998 by Mosby, Inc. 0197-4572/98/$5.00 + 0
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11 Test I.D. No.: G84064 Contact hours: 1.0 Processing fee: $9 Passing score: 70%
. H o w many facilities in the study required licensed nurses to know CPR? A. 100% B. 92% C. 89% D. 84%
. H o w were patients identified for CPR? A. N a m e tags B. Chart designation C. Methods for identifying individuals were inconsistent. D. List at the front desk
. H o w m a n y facilities in the study required nursing assistants to know CPR? A. 100% B. 89% C. 84% D. None
. Who is responsible for discussing advanced directives with residents? Ao Physician B. Nurse C. Social worker D. Chaplain
. Approximately what percent of the study facilities called 9-1-1 without first giving CPR? A. 6% B. 18% C. 74% D. 92%
. The optimal time to discuss resuscitation and advance directive issues is: A. Before admission to the facility B. Within the first hour of admission C. The first opportunity the social worker has D. In the physician's office
. Which group is most likely to have an ethics committee or consultant? A. Corporate facilities B. N o n c o r p o r a t e facilities C. No distinction was made D. All had committees or consultants
. This study received the most responses from: A. Large, rural, proprietary facilities B. Small, rural, nonprofit facilities C. Large, urban, proprietary facilities D. Small; urban, nonprofit facilities
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Geriatric Nursing Volume 19, Number 6
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