Member Article

On October 18, 2013, the Centers for Medicare & Medicaid Services (CMS) published Survey & Certification Letter 14-01-NM, which clarified the obligations of a skilled nursing facility (SNF) or nursing facility (NF) (collectively “nursing homes”) to provide cardiopulmonary resuscitation, or CPR, to its residents. Explaining the source of this obligation, CMS cited both a nursing home’s duty to meet professional standards of quality and to provide the services necessary to permit a resident to attain the highest practicable well-being, as well as a resident’s “right to a dignified existence,” and “self-determination,” including the right to formulate an advance directive.  CMS summarized a nursing home’s obligation to provide CPR as follows:

• Prior to the arrival of emergency medical services (EMS), nursing homes must provide basic life support, including CPR, to a resident who experiences cardiac arrest, in accordance with the resident’s advance directive or in absence of an advance directive or Do Not Resuscitate (DNR) order.
• CPR-certified staff must be available at all times.
• Nursing homes must not establish facility-wide No CPR policies. 
• Nursing homes must implement policies and procedures in accordance with the above.

The foundation for these CMS standards are the American Heart Association’s (AHA’s) guidelines regarding evidence-based decision-making for initiating CPR outside a hospital setting, which includes in a nursing home.  Because brain death begins 4-6 minutes following cardiac arrest if CPR is not administered, AHA recommends CPR be started in the case of cardiac arrest unless: “1) a valid DNR order is in place; 2) obvious signs of clinical death (e.g., rigor mortis, dependent lividity, decapitation, transection, or decomposition) are present; or 3) initiating CPR could cause injury or peril to the rescuer.” 

The S&C Letter acknowledges that CPR is generally ineffective in the elderly nursing home population (research shows post-CPR survival rates between 2-11 percent). However, CMS also notes that the nursing home population is becoming younger, which may impact the effectiveness of CPR for a given resident and that resident’s desire to have CPR performed. Additionally, the nursing home population is becoming more ethnically diverse, which may impact residents’ willingness to discuss and implement No CPR decisions.  Given these two trends, CMS directs nursing homes to undertake individualized assessments of each resident’s preferences regarding CPR and end-of-life care, to implement treatment plans based on those preferences and to implement policies and procedures that foster such considerations and actions and that follow the above guidelines. 

 

Footnotes: In light of these CMS directives, we recommend each facility undertake a review of its policies and procedures regarding end of life care, advance directives, No CPR orders, staff CPR training, and use of CPR in the facility.  Please contact Dykema attorneys Joanne Lax (248-203-0816 or [email protected]) orKathleen Reed (231-348-8134 or [email protected]), or your Dykema relationship attorney, should you have any questions or require assistance regarding this matter.

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