Title: Withholding Initiation of Cardiopulmonary Resuscitation in Long-term Care Facilities
Advisory Ruling Number: 0801
Authority: The Massachusetts Board of Registration in Nursing issues this Advisory Ruling on Nursing Practice pursuant to Massachusetts General Laws (MGL) Chapter 30A, section 8 and MGL c. 112, s 80B.
Date Issued: January 9, 2008
Date Revised: March 13, 2013
Scope of Practice: Registered Nurses and Licensed Practical Nurses
Purpose: To guide the decision-making of the Registered Nurse and the Licensed Practical Nurse (“the nurse”) in withholding initiation of cardiopulmonary resuscitation (CPR) when a patient or resident in a long-term care facility with 24-hour skilled nursing staff on duty has experienced a cardiac arrest.
The nurse’s practice must be in compliance with G.L. c. 112, s. 80B; 244 CMR 3.02: Responsibilities and Functions - Registered Nurse; 244 CMR 3.04: Responsibilities and Functions – Practical Nurse; 244 CMR 9.03(5): Adherence to Standards of Nursing; 244 CMR 9.03(9): Responsibility and Accountability; 244 CMR 9.03(10): Acts within Scope of Practice; 244 CMR 9.03(11): Performance of Techniques and Procedures; 244 CMR 9.03(12): Competency; 244 CMR 9.03(14): Asepsis and Infection Control; 244 CMR 9.03(44): Documentation; and 244 CMR 9.03(46): Role of Nurse in Management Role.
Standing of Nursing Practice
The nurse licensed by the Massachusetts Board of Registration in Nursing (Board) is expected to engage in the practice of nursing in accordance with accepted standards of practice. It is the Board’s current position that these standards, in the context of practice in a Massachusetts long-term care facility with 24-hour skilled nursing staff on duty, require the initiation of CPR when a patient or resident has experienced a cardiac arrest except when the patient or resident has:
- A current, valid Do Not Resuscitate (DNR) order; OR
- Signs of irreversible death (e.g. decapitation, decomposition, rigor mortis, dependent lividity); OR
- Situations where attempts to perform CPR would place the rescuer at risk of serious injury or mortal peril.
The Board specifically recognizes that the signs of irreversible death are a condition in which the nurse may withhold initiation of CPR. In the absence of a DNR order or in the absence of signs of irreversible death or in situations where attempts to perform CPR would not place the rescuer at risk of serious injury or mortal peril, the nurse is required to initiate CPR when a patient or resident has a cardiac arrest.
Nursing Competency Related to Advisory Ruling (AR)
For the purpose of this Advisory Ruling, the licensed nurse should, at a minimum, attain and maintain the following competencies through the nurse’s successful completion of entry-level nursing education programs or continuing education experiences developed in accordance with Board regulations at 244 CMR 5.00: Continuing Education:
- Basic anatomy and physiology;
- Related statutes and regulations that pertain to this AR including those related to RN pronouncement and the definition of LTC;
- Related standards of nursing practice;
- Current American Heart Association (AHA) Guidelines for Cardiopulmonary Resuscitation and Emergency Care including:
- Basic Life Support for Healthcare Providers,
- Current science and treatment recommendations from the AHA,
- Automated External Defibrillation (AED) science and treatment recommendations from the AHA, and
- AHA criteria for Not Starting CPR;
- Policy(ies) established by the facility in which the nurse practices relative to resuscitation directives, and withholding initiation of CPR;
- Signs of cardiac arrest; and
- Documentation practices consistent with adherence to accepted standards of nursing practice in withholding initiating of CPR
- Clinical judgment and decision making skills related to withholding initiation of CPR during and post cardiac arrest; and
- Problem solving, prioritization and delegation skills.
Demonstrate competency to assess (i.e., data collection):
- Respiration status;
- Circulatory status;
- Palpation of the carotid pulse;
- Auscultation of the apical pulse; and
- Signs of irreversible death including, but not limited to:
- Absence of bilateral pupil response to light,
- Dependent lividity, and
- Rigor mortis.
Possess ability to validate findings of irreversible death including, but not limited to:
- Differentiation between dependent lividity and cyanosis; and
- Inappropriate use of Pulse oximetry in assessment following cardiac arrest.
- Role in obtaining accurate information about the DNR status of all assigned "patients";
- "Patient" autonomy including:
- Resuscitation directives and verification of status,
- "Patient" right to request or refuse CPR, and
- Informed consent based on the "patient's" receipt and understanding of accurate information about his or her condition, prognosis, proposed interventions, and the risks and benefits of alternatives such as CPR in the event of an unwitnessed cardiac arrest;
- Principles of patient teaching/learning including:
- Cultural and religious influences on the "patient's" decision-making related to resuscitation directives ,
- "Patient" mechanisms for coping with life transitions, and
- Therapeutic communication with "patient";
- Ethical issues related to resuscitation directives including the withholding of CPR;
- Principles of prioritization including identification of "patient" care priorities in responding to cardiac arrest; and
- Responsibilities when delegating appropriate activities to unlicensed personnel, pursuant to 244 CMR 3.00, the “five rights of delegation”, and based upon "patient's" (or group of "patients") care needs during and following cardiac arrest.
In the event of an unwitnessed patient or resident cardiac arrest, the nurse is expected to immediately conduct a sequential assessment of the patient or resident and to initiate CPR without delay unless there is a valid DNR order or all of the following clinical signs are present:
- No response when the patient or resident is tapped on the shoulder and asked, “Are you all right?”; and
- No respirations as determined by opening the airway using the head tilt-chin lift maneuver (or jaw thrust if a cervical spine injury is suspected) and observing for the rise and fall of the chest wall while listening and feeling for breath for at least 30 seconds (the use of pulse oximetry is not appropriate for this assessment); and
- No pulse as determined by palpation of the carotid or auscultation of the apical pulse for at least 30 seconds; and
- Dilated bilateral pupils (if assessable) that are unresponsive to bright light; and
- Dependent lividity. If rigor mortis is present, as determined by the presence of hardening of the muscles or rigidity of the jaw, shoulders, elbows or knees, then a finding of dependent lividity is not required.
The assessment set forth above must be conducted and documented by the licensed nurse to support withholding initiation of CPR.
The nurse is responsible and accountable for his or her nursing judgments, actions and competency with regard to withholding initiation of CPR in accordance with the accepted standard of practice. In addition, the nurse must make complete, accurate and legible entries in all appropriate patient or resident records required by federal and state laws and regulations, and accepted standards of practice. To demonstrate that the nurse has adhered to the accepted standard of nursing practice in withholding initiation of CPR, documentation entries must include:
- Patient or resident DNR status (or absence of);
- Findings from the nurse’s sequential assessment of the patient or resident including responsiveness; respiratory status; cardiac status; pupillary responsiveness; and the presence of dependent lividity and/or rigor mortis that substantiates the nurse’s determination of irreversible death;
- Judgments and interventions made by the nurse based on his or her sequential assessment of the patient or resident including, the decision to withhold initiation of CPR;
- Collaboration and communication with other health care providers to ensure quality and continuity of care including dates and times of notifications of primary care providers;
- Collaboration and communication with the patient or resident’s family or significant others including dates and times of notification.
Nursing Management in the Long-term Care Setting
The nurse employed in a nursing management role in the long-term care setting with 24-hour skilled nursing staff on duty is expected to adhere to accepted standards of practice for that role including the development and implementation of the necessary measures to promote and manage the delivery of safe nursing care in accordance with accepted standards of nursing practice. Examples of such measures related to withholding initiation of CPR include:
- Provide opportunities for licensed nursing staff to acquire and maintain competencies related to facility policies and standards of care for withholding initiation of CPR, the assessment of the signs of irreversible death, resuscitation directives, the performance of CPR and the use of AED which will be completed, at a minimum, through new employee orientation, novice nurse transition and mandatory annual continuing education programs;
- Standardize hand-off communications using a standardized format that includes the patient’s current resuscitation status;
- Incorporate unit-level nursing staff in the systematic evaluation of clinical policies and procedures related to the assessment of the signs of irreversible death, resuscitation directives, CPR and AED;
- Ensure patient identification mechanisms are easily accessible to all direct-care nursing staff at all times and for all patients;
- Ensure that information about each patient’s resuscitation directive is readily accessible to all direct-care nursing staff; and
- Adopt strategies to regularly audit nursing practice to verify nursing competency and ongoing compliance with standards of care related to withholding initiation of CPR, assessment of the signs of irreversible death, resuscitation directives and the performance of CPR and the use of AED.
Pronouncement of Death
The nurse’s decision to withhold initiation of CPR based on an assessment that is conducted in accordance with the above Nursing Assessment section is separate and distinct from the pronouncement of death for the purpose of allowing removal of the decedent’s body. Pronouncement of death for the purpose of allowing removal of the decedent’s body is governed by Massachusetts General Law, Chapter 46, Section 9.
Application of Advisory Ruling
This advisory is only applicable to the nurse who practices in a Massachusetts long-term care setting (with or without a sub-acute skilled care component) with 24-hour skilled nursing staff on duty. While some of the underlying principles may be the same, it is not intended for application, in whole or in part, to the practice of nursing in any other setting at this time.
2010 American Heart Association (AHA) Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care
2012 Massachusetts Emergency Medical Services Pre-Hospital Treatment Protocols