The Commonwealth of Massachusetts

Executive Office of Health and Human Services
Department of Public Health
Division of Health Professions Licensure
Board of Registration in Nursing
239 Causeway Street, Suite 200, 2nd Floor, Boston, MA 02114
617-973-0900
617-973-0895 TTY

DEVAL L. PATRICK
GOVERNOR
TIMOTHY P. MURRAY
LIEUTENANT GOVERNOR
JUDYANN BIGBY, MD
SECRETARY
JOHN AUERBACH
COMMISSIONER
RULA HARB
EXECUTIVE DIRECTOR	
Title: Advisory Ruling on the Initiation and Withholding of Cardiopulmonary Resuscitation in Massachusetts Long-term Care Facilities with 24-hour Skilled Nursing Staff on Duty

Advisory Ruling Number: 0801

Authority: The Massachusetts Board of Registration in Nursing (Board) issues this Advisory Ruling on nursing practice pursuant to Massachusetts General Laws (G.L.), chapter 30A, section 8, and chapter 112, section 80B.

Date Issued:  January 9, 2008

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 initiating or withholding 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(11): Performance of Techniques and Procedures; 244 CMR 9.03(12): Competency; 244 CMR 9.03(44): Documentation; and 244 CMR 9.03(46): Role of Nurse in Management Role.  

Advisory:  
Standard 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).  

In its current position, the Board is now specifically recognizing that the signs of irreversible death are a second condition, in addition to a valid DNR order, in which the nurse may withhold CPR.  In the absence of a DNR order and in the absence of signs of irreversible death, the nurse is required to initiate CPR when a patient or resident has a cardiac arrest.  

The nurse is expected to acquire and maintain competence in the performance of nursing techniques and procedures  related to the initiation or withholding of CPR.  Examples of these nursing techniques and procedures include the performance of CPR and the use of automatic external defibrillation (AED) as well as the assessment of signs of irreversible death.  The nurse can obtain these 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, or both. 

Nursing Assessment 
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 by the nurse to support the withholding of CPR.

The nurse is responsible and accountable for his or her nursing judgments, actions and competency with regard to the initiation or withholding 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 the initiation or withholding of CPR, such 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 initiate or withhold 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 the initiation and withholding of CPR include:

•	Provide opportunities for licensed nursing staff to acquire and maintain competencies  related to facility policies and standards of care for the initiation and withholding 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 the initiation or withholding 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 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.