COMMONWEALTH OF MASSACHUSETTS
BOARD OF REGISTRATION IN NURSING

Nursing Competencies Related to the 
Advisory Ruling on the Initiation and Withholding of Cardiopulmonary Resuscitation in Massachusetts Long-Term Care Facilities with 
24-Hour Skilled Nursing Staff on Duty

The Massachusetts Board of Registration in Nursing (Board), at its meeting on    January 9, 2008, issued a new advisory ruling entitled, 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).  The Board, through this Advisory Ruling, recognizes the presence of signs of irreversible death (e.g. decapitation, decomposition, rigor mortis, dependent lividity) as a second condition, in addition to a patient’s or resident’s valid Do Not Resuscitate (DNR) order, under which the Registered Nurse (RN) or Licensed Practical Nurse (LPN) who practices in a Massachusetts long-term care facility with 24-hour skilled nursing staff on duty may withhold cardiopulmonary resuscitation (CPR).  

The setting-specific Advisory Ruling is based on the American Heart Association (AHA)’s 2005 Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care and incorporates some of the assessment criteria used by the Massachusetts Office of Emergency Medical Services.  It is intended to guide the decision making of the RN and LPN when a patient or resident (“patient”) experiences a cardiac arrest.  

For the purpose of this Advisory Ruling, the RN and LPN should, at a minimum, possess the following competencies: 

I.	Knowledge of related statutes, regulations and standards of nursing practice
A.	Statutes
1.	Massachusetts General Law, Chapter 112, Section 80B: Practice of Nursing Defined 
2.	Massachusetts General Law, Chapter 46, Section 9: …Declaration of Death By Nurse, Nurse Practitioner or Physician’s Assistant
B.	Regulations
1.	244 CMR 3:02: Responsibilities and Functions – Registered Nurse
2.	244 CMR 3.04: Responsibilities and Functions – Practical Nurse
3.	244 CMR 9.03(5): Adherence to Standards of Nursing Practice
4.	244 CMR 9.03(9): Responsibility and Accountability
5.	244 CMR 9.03(11): Performance of Techniques and Procedures
6.	244 CMR 9.03(13): Competency
7.	244 CMR 9.03(44): Documentation
8.	244 CMR 9.03(46): Responsibilities of Nurse in Management Role
9.	105 CMR 150.001: Definition, Long-term Care Facility
10.	105 CMR 170.365: Transport of a Deceased Person
C.	Standards of Nursing Practice
1.	Current American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Care including: 
a.	Basic Life Support for Healthcare Providers
b.	Compression-only CPR 
c.	Automated External Defibrillation (AED)
d.	Criteria for Not Starting CPR  
2.	Advisory Ruling on the Initiation and Withholding of Cardiopulmonary Resuscitation in Massachusetts Long-term Care Facilities with 24-hour Skilled Nursing Staff on Duty issued January 2008 by the Massachusetts Board of Registration in Nursing 
3.	Policy(ies) established by the facility in which the nurse practices relative to resuscitation directives, and the initiation and withholding of CPR

II.	Knowledge of basic anatomy and physiology 

III.	Clinical judgment and decision making skills during and post cardiac arrest
A.	Signs of cardiac arrest
B.	Nursing assessment  (i.e. data collection) 
1.	Responsiveness
2.	Respiration status 
3.	Circulatory status
a.	Palpation of the carotid pulse
b.	Auscultation of the apical pulse
4.	Signs of irreversible death including, but not limited to:
a.	Absence of bilateral pupil response to light
b.	Dependent lividity 
c.	Rigor mortis
5.	Validation of findings of irreversible death including, but not limited to:
a.	Differentiation between dependent lividity and cyanosis
b.	Pulse oximetry: inappropriate use in assessment following cardiac arrest
C.	Decision making related to the initiation and withholding of CPR
D.	Documentation 

IV.	Critical thinking, problem solving, prioritization and delegation skills 
A.	Role of the nurse in obtaining accurate information about the DNR status of all assigned “patients” 
B.	“Patient” autonomy including:
1.	Resuscitation directives and verification of status
2.	“Patient” right to request or refuse CPR
3.	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 
4.	Cultural and religious influences on the “patient’s” decision-making related to resuscitation directives 
5.	“Patient” mechanisms for coping with life transitions
6.	Therapeutic communication with “patient” 
7.	Principles of patient teaching/learning
C.	Ethical issues related to resuscitation directives including the withholding of CPR 
D.	Principles of prioritization including identification of “patient” care priorities in responding to cardiac arrest
E.	Delegation to unlicensed assistive personnel
1.	Assessment of delegation needs based on “patient’s” (or group of “patients”) care needs during and following cardiac arrest
2.	244 CMR 3.05: Delegation and Supervision of Selected Nursing Activities by Licensed Nurses to Unlicensed Personnel
3.	Five “rights” of delegation