LEGAL AND ETHICAL ISSUES
Florida Lawsuit Draws Attention to Issues of CPR in Elderly Patients
Published online May 30, 2013.
A Florida woman is suing the hospital where her 91-year-old mother was given cardiopulmonary resuscitation (CPR) despite a Do Not Resuscitate (DNR) order. According to a press release, Sharon Hallada of Lakeland, FL, is suing Lakeland Regional Medical Center for violating the wishes of her mother, Marjorie Mangiaruca, who received CPR and other invasive life-prolonging measures after going into cardiac arrest at the nursing home where she resided. According to the complaint document, on September 29, 2011, Ms. Mangiaruca arrived at the emergency department (ED) of Lakeland Regional Medical Center for chief concerns of weakness and increased confusion. She had a diagnosis of Alzheimer’s disease for 10 years. After evaluation, the ED physician admitted her to the hospital for treatment of a urinary tract infection. During the patient’s stay in the hospital, Ms. Hallada, who had durable power of attorney for her mother, spoke to the attending physician about her mother’s end-of-life wish to refuse any life-prolonging medical treatment in the event of an emergency. The physician signed the DNR order and wrote DNR on the patient’s chart.
Ms. Mangiaruca was discharged from the hospital to the nursing home on October 6, 2011. According to the complaint document, the hospital staff failed to transfer a copy of the DNR order to the nursing home staff, and the hospital did not take any other action to make the patient’s DNR status known to the nursing home staff, such as giving her a designated wristband. On October 10, Ms. Mangiaruca was experiencing respiratory distress and taken to the ED. When Ms. Mangiaruca appeared to be unresponsive to the emergency medical technicians (EMTs) who arrived on the scene, they rushed her to the hospital and attempted CPR in the ambulance; when CPR failed to revive the patient, the EMTs performed a tracheostomy and injected the patient with medication for restarting the heart. They also injected her with muscle-paralyzing agents so that she could not resist the intervention. Upon admission to the ED, the hospital staff replaced the tracheostomy with an endotracheal tube, inserted a nasogastric tube, and connected her to an artificial respiratory machine. The ED physician determined that the patient had experienced a myocardial infarction. The patient was then transferred to an intensive care unit and subsequently a palliative care unit. Several days later, Ms. Hallada decided to disconnect her mother from the ventilator, allowing her to die.
The civil suit, which was filed in the circuit court of the 10th judicial circuit in Polk County, FL, seeks financial damages from the hospital and nursing home staff for negligence, emotional distress, breach of fiduciary duty, elder abuse, violation of rights, and injunctive relief to ensure that staff training in will prevent future violations of patient rights. The complaint document can be accessed here.
This news story is just one of many that highlights the ethical dilemmas faced by healthcare providers and families regarding the role of CPR in elderly patients. Michael Gordon, MD, director of medical ethics and medical program director of palliative care at Baycrest Geriatric Health Care System, has written extensively on these ethical issues. In response to this case, he said:
“It is unfortunate when loving and devoted family members feel that the healthcare system has failed to provide the level of care associated with compassion that they expect and took all apparently necessary steps to achieve. Whatever transpires with the legal deliberations, the important message for all substitute decision-makers (often called proxies) is to make sure that they verify with all healthcare facilities and responsible healthcare professionals what advance directives exist and that they are documented on the necessary health record. One clinical problem is that a DNR order may be interpreted as not covering a serious respiratory or cardiac condition that does not result in immediate cardiac arrest and therefore there may be an intrinsic professional reflex to begin salvage treatment, which is short of CPR. Therefore not only should advance directives be documented and communicated, but they must include the wide range of interventions that are to be withheld so that even in the absence of the proxy being immediately available for consent they will not be undertaken which as is demonstrated in this case leads to a cascade of unwanted interventions that took their toll on the patient and her family.”
For more information about end-of-life wishes and advance directives, look for these other articles from Dr. Gordon in Annals of Long-Term Care: