# Continue CPR or not?



## rhan101277 (Aug 8, 2014)

85 y/o female, initial call comes out as hemorrhage - rectal bleed.  Upon arrival daughter meets us at the entrance to the nursing home.  Upon entering the pt room she is on the floor w/ staff performing compressions.  Pt looks pale, she is pulseless, anpeic.  I prepare to take over chest compressions, and I ask is she a DNR, staff report she is a full code. I take over chest compressions and the daughter says, 'stop right there, that is enough'.  I ask if she is POA and she says she is.  The full code paperwork was signed just a few days ago by the daughter.

Pt has extensive co morbid factors such as kidney failure, cad among others.  I find out later family refused to send her out for her rectal bleed and she has been having it for two days.

I call med control they report they are unsure if a POA superscedes a full code even though the full code paperwork is signed by poa.  Doctor said i won't give you a DNAR but I'll give you a time of death.  Clinically the patient has was not in rigor, no lividity present.  She had probably been down for 5 minutes upon arrival.

Sometimes the right thing to do isn't always clear cut, I think I did the right thing it is what the family wanted.  It still bothers me though, I got a time of death.


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## Angel (Aug 9, 2014)

i have a question sorry...so the doc called time of death? which is essentially telling you to stop CPR? or what does it mean to say no DNAR but calling TOD?

if the daughter who also had POA wanted you to stop and it seems like the doc agreed then i would have. 
They had to have known what would happen keeping her from going to the hospital when she had a rectal bleed.


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## Akulahawk (Aug 9, 2014)

rhan101277 said:


> 85 y/o female, initial call comes out as hemorrhage - rectal bleed.  Upon arrival daughter meets us at the entrance to the nursing home.  Upon entering the pt room she is on the floor w/ staff performing compressions.  Pt looks pale, she is pulseless, anpeic.  I prepare to take over chest compressions, and I ask is she a DNR, staff report she is a full code. I take over chest compressions and the daughter says, 'stop right there, that is enough'. * I ask if she is POA and she says she is.  The full code paperwork was signed just a few days ago by the daughter.*
> 
> Pt has extensive co morbid factors such as kidney failure, cad among others.  I find out later family refused to send her out for her rectal bleed and she has been having it for two days.
> 
> ...


I would have asked the same question about the POA... and I would have asked for documentation of the POA. Without it, how do I know you have POA? I'm not in the habit of blindly trusting people's word about such things. Same with DNR status. Unless I see the DNR or POLST, I'm going to consider the patient full code until proven otherwise. 

Incidentally, you may have your terms mixed up. You keep stating "full code" in several places where "no code" might also be appropriate, given the context. 

However, IMHO, you did the right thing by contacting Med Control for guidance and ultimately probably did the right thing by the patient and family, given that the family refused transport (and therefore likely treatment too) for a GI Bleed leading up to the point where you found the patient... 

Whether or not it was legal for the family to do that, well, that is up to the courts to decide if anyone challenges the issues through that system.


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## rhan101277 (Aug 9, 2014)

Well he continued to ask me if she was dead or not a few times.  I repeated she is pulseless and apneic.  She did have PEA at 80 but it was a pacemaker rhythm.  She did not have positive signs of death and I think the family just wanted to let her go naturally.


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## Rialaigh (Aug 10, 2014)

There is a pretty good possibility that I wouldn't work this code even if the patient is a full code and no one wants me to stop. Given the likely possibility of her arrest etiology and her co morbid factors in addition to her age, it is very likely I would not begin any measures from my end and contact medical control to cover my butt because of the PEA. If she was in Asystole I prob wouldn't even contact med control. Either way I would be more then happy to not work this patient if the daughter asked me not to.


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## Medic Tim (Aug 10, 2014)

Where I work we would have stopped at the family request regardless of what the paperwork said. We are able to take verbal orders from family members if they seem at all reasonable. With this pt a DNR order would certainly be reasonable.


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## DrParasite (Aug 10, 2014)

She's 85, in a SNF, bleeding internally somewhere... did you think the rectal hemorrhage caused her to code?  If so, he's really sick... or did she have some other bad stuff going on that causes the whole mess (and she was PEA, so not even in a shockable rhythm), including all her co-morbidity factors??  So even if you brought her back, what type of quality of life was she going to have?

Good choice on calling the doc..... Family claims to be POA and she's a full code... If we didn't find her in Vtach or Vfib (or any other quickly and easily fixable problem), I'd call the doc for a pronouncement time.


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## samiam (Aug 10, 2014)

A verbal request at anytime can supersede a written order, that is the basic principle of patient autonomy which has to be respected with surrogates as well. As long as the person was the POA and frankly her being the daughter in general I would be fine stopping care. There is also the medical futility aspect of the situation. Not exactly sure what specific local protocols are but in general health care providers have the right to stop medical care that would be futile (less then 1% chance of survival/making it out of the hospital).  Generally the order of who gets to say what would be 
1.  Legal guardian with health care decision-making authority

2.  Individual given durable power of attorney for health care decisions

3.  Spouse

4.  Adult children of patient (all in agreement)

5.  Parents of patient

6.  Adult siblings of patient (all in agreement)


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## JRR (Aug 10, 2014)

I would say no dont continue.


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## Anonymous (Aug 10, 2014)

Legality and protocols aside (as I can't comment on them)  I would not have continued. You did the right thing. 

Think you would have more to worry about if you continued against the daughter's wishes.


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## OnceAnEMT (Aug 10, 2014)

If I don't have the DNR or POLST, its a full code until verified family says otherwise. So, I agree.

I've never seen this so it begs a question... what did the PEA with the pacemaker look like? What type of pacemaker?


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## rhan101277 (Aug 11, 2014)

it was a dual chamber pacemaker, it looked a little different than a pacemaker would since no polarization/depolarization or voltage changes were taking place across the myocardium.  Thanks for all the comments, it makes me feel better.  I have stopped a code before but this was different.  It had me thinking I just let this person die but it truth she was probably already dead just not long enough for definitive signs to develop.  She looked pale I bet her H&H was really low.


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## Handsome Robb (Aug 11, 2014)

I'd have done exactly what you did.

I'd probably ask for confirmation of POA but the SNF should have that but even without it talking with a doc and explaining the situation and that family doesn't want efforts continued is the best course of action here.

Good call on your part.


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## Akulahawk (Aug 11, 2014)

Unfortunately for some, including me, there are protocols that limit the options available without contacting medical control. I would be required to verify that the person that claims to have POA actually does have it before I can accept her instruction to stop efforts. If she cannot provide such proof, then I'm bound to either go full-tilt boogie and try to resuscitate the patient or call med control for an order to stop resuscitation. I'm not disagreeing with the idea that it's probably in the patient's best interest to not resuscitate and to let her go. I just have to find a way to do it that won't put my license in jeopardy.


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## Nightmare (Oct 17, 2014)

I am a basic so if a family member claims POA I need to see paperwork, however if a doctor ever told me he won't give us permission to call it but will give us a TOD then we have an issue. The doc should have said either yay or nay on working the code, if he says yay then I would tell the daughter I need proof of POA and as soon as she shows me that we will cease efforts. I would then "try my very best" to bring this patient back. Simple CYA, this person will have a terrible life if you do bring her back (which from the sounds of it wasn't going to happen).


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## Carlos Danger (Nov 1, 2014)

85 year old with multiple comorbidities in presumed hemorrhagic arrest? I likely wouldn't have even worked it. This person is clearly dead. 

If I did work it, and a close family member told me to stop, I'd stop.


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## medicaltransient (Nov 3, 2014)

You did the right thing. I would stop on the notification of time of death. The doctor could have been a little more clear.


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