CPR LAWS

amoLucia · Mar 22, 2018

klone - You're right. Mea culpa.

akulahawkRN, ADN, RN, EMT-P · Mar 22, 2018

Does anyone know what the law or statue is for this scenario:
provider wants to stop CPR, no DNR on file, family wants CPR to continue and refuses to sign DNR. What should the nurse do? Please help with this! I have been googling all over the place for help with this answer!

This is very simple, actually. CPR is continued until a rescuer is too fatigued to continue or medical authority determines that further efforts are futile and stops CPR. There is no need for a DNR. If the family has a problem with the decision of the physician, they can complain to the medical board. The nurse's job then shifts to providing care for the family, if that's possible. If the family starts threatening the team, they get to be escorted out and they can come back another time, after they've cooled down.

In that scenario, I stop because the medical provider has ordered that resuscitation stop and stopping efforts is appropriate.

Someone that's coded 5 times, has no brain activity between codes, and codes yet again is a good indicator that the body is trying to die and it will eventually cease responding to resus efforts. Brain death is not at issue. If the heart's not working, it isn't working and it's time to stop.

RNNPICU, BSN, RN · Mar 22, 2018

CPR is an intervention... If the physician deems that all interventions have been tried, no amount of CPR can bring someone back

allnurses Guide · Mar 22, 2018

In the scenario the patient has coded 5 times. EEG was performed and no brain activity. The provider is wanting CPR to stop but the family says keep going.
I keep seeing conflicting results that there has to be 2 providers to state that the patient is brain dead, but what if the family keeps saying do it. Do you do it and get in trouble by your job or do you stop and get sued by the family for stopping?

Odd scenario - Is this a long term setting? ER? Acute Med-surge? At some point The facility Ethics department would get involved. Have you read the case of Jahi McNath who has been brain dead for a least a couple of years now. Hospital had to petition the court to allow removal if life support. Then mom moved her to another Hospital.

Hospital Social services needs to get involved to help the family see there is no prospect of meaningful recovery.

Hppy

KelRN215, BSN, RN · Mar 22, 2018

Well if the physician calls it, even if you continued compressions there's an impending limit. I mean if the pt is in asystole, compressions will keep circulation going for a bit, but even with a Lucas it can't go on forever... hours at best, but not days or weeks. At some point that pt will need defibrillation & drugs, or successful treatment of underlying cause or a pacemaker -- inappropriate for a deceased person.
It's true that confirmatory brain death testing is done by two MDs, independent of each other... I'm assuming the child is on a ventilator though? If one is brain dead, the heart will continue as long as it's receiving O2 because of its intrinsic electrical ability -- unlike other vital functions which require brain stem function.
However if the child is pulseless, it's not a question of brain death or not. If ROSC is not achieved, that is CARDIAC death and not dependent on the results of brain death testing.
It's horrible in any case...I can't even imagine. As parents you want nothing more than to protect your child. Once I actually ran into the path of an oncoming car after my toddler wandered into the street (little guy is FAST!!). I can honestly say in that moment my ONE thought was "save my baby!!" I'm sure they want to save theirs... but here all they can do is plead with the staff to keep going.
But the child is already gone.

I missed where in the OP's scenario it stated this was a child? This could be 98 year old Grandma for all we know whose children just don't want to believe it's her time. Either way, if the patient is dead and further attempts at resuscitation have been determined to be futile, family agreement with a DNR is not needed to stop CPR.

LovingLife123 · Mar 23, 2018

First, there is no law. Second cardiac death and brain death are two different things but are both death. Third an eeg does not determine brain death. Each facility is different and has their own policy on how to declare brain death, but at least at mine an eeg doesn't even enter the equation. But if brain death is declared, the person is dead.

Cardiac death occurs when the physician calls it, not when the family calls it. We are the professionals and experts, not the family. While family is always involved in plan of care, they can't determine when death occurs. The patient does that, by dying. We can't compress someone indefinitely.

Horseshoe, BSN, RN · Mar 23, 2018

Odd scenario - Is this a long term setting? ER? Acute Med-surge? At some point The facility Ethics department would get involved. Have you read the case of Jahi McNath who has been brain dead for a least a couple of years now. Hospital had to petition the court to allow removal if life support. Then mom moved her to another Hospital.
Hospital Social services needs to get involved to help the family see there is no prospect of meaningful recovery.
Hppy

Not the same as the issue in the OP, which is when to terminate futile CPR, not when to take a patient with a beating heart off of mechanical ventilation. Jahi was revived in that a pulse and sustainable rhythm was achieved. There was no reason to call an end to CPR because they were able to get a rhythm and get her on a ventilator. The brain death was diagnosed several days later and the saga began at that time. Brain death is not called during a code. If they cannot get a sustainable rhythm back, brain death is a completely moot point-cardiac death has occurred. If cardiac death occurs, ventilation achieves nothing. When it's only the brain that has died, ventilation can keep the heart beating.

Horseshoe, BSN, RN · Mar 23, 2018

Does anyone know what the law or statue is for this scenario:
provider wants to stop CPR, no DNR on file, family wants CPR to continue and refuses to sign DNR. What should the nurse do? Please help with this! I have been googling all over the place for help with this answer!

The patient's family does not/cannot "sign a DNR" during the middle of a code. If a code is initiated, the resuscitation has already been attempted. A family cannot decide how long the code goes on or how long compressions will be done-that is a medical decision. But if a family wants a full code status on the patient, the patient codes, the team attempts resuscitation, and the doctor decides that it's futile after a given time that he determines was sufficient to give the patient a fighting chance, there is nothing the family can do at that point because the provider HAS followed the wishes of doing a full code. If by "the provider wants to stop CPR" you ACTUALLY mean that the provider wants to remove mechanical support that is already in place, that is a completely different issue.

Horseshoe, BSN, RN · Mar 23, 2018

Okay, I've re-read the OP and the follow up post. Personally, I don't think the posts were well written and clear. It sounds as though the patient has coded several times and been resuscitated. The provider apparently wants a DNR put into the record so that the "next time" the patient has an arrest, CPR will not be initiated. With the OP's reference to brain death and two providers testing for that, it's also not clear in the OP's scenario if the provider wants to go even further by declaring the patient brain dead and removing mechanical support altogether.

If the OP could come back and clarify, it would be helpful.

Here.I.Stand, BSN, RN · Mar 23, 2018

I missed where in the OP's scenario it stated this was a child? This could be 98 year old Grandma for all we know whose children just don't want to believe it's her time. Either way, if the patient is dead and further attempts at resuscitation have been determined to be futile, family agreement with a DNR is not needed to stop CPR.

You're right... either I'm conflating or losing my mind. :bag:

JKL33 · Mar 23, 2018

Okay, I've re-read the OP and the follow up post. Personally, I don't think the posts were well written and clear. It sounds as though the patient has coded several times and been resuscitated. The provider apparently wants a DNR put into the record so that the "next time" the patient has an arrest, CPR will not be initiated. With the OP's reference to brain death and two providers testing for that, it's also not clear in the OP's scenario if the provider wants to go even further by declaring the patient brain dead and removing mechanical support altogether.
If the OP could come back and clarify, it would be helpful.

Agree. I think, after several readings, what was originally meant is that the providers don't feel it is appropriate to initiate ACLS next time the patient arrests.

So the whole thing is about the controversies surrounding care that is felt to be futile. There is no perfect answer for the nurse stuck in the middle. It's an ethics and medico-legal issue and those consultants will have to weigh in.

lifelearningrn, BSN, RN · Mar 23, 2018

This sounds like a family wanting someone already declared dead (brain death) to be a full code. CPR can be initiated if breathing, heart stops, but when it's called, it's called. We can't just keep pumping and breathing indefinitely. Are we talking about life support here, or actual CPR?