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    014 护士有义务行CPR吗?
    日期:2015-09-20 23:14:25    来源:奥医教育

    一名护士打911报告居住在一家老年机构的病人虚脱了,她根据机构的规定,已经拒绝进行CPR。那么,她这样做是不是错了呢?
     

    Is a Nurse Obligated to Perform CPR?
    Carolyn Buppert, NP, JD

    Question
    A nurse called 911 to report that a resident of a senior living facility had collapsed. She declined to begin CPR, citing the facility's policy. Was she in the wrong?
     
    "Sorry, I Can't Give CPR"
    In February, a nurse made national news for refusing to perform cardiopulmonary resuscitation (CPR) on an 87-year-old woman who collapsed in the dining room of the retirement community where she lived.
    News stories featured audio of a fire department dispatcher in Bakersfield, California, pleading with a staff member -- who described herself as a nurse -- at a senior living facility.[1] The nurse had called 911. The nurse said that the woman wasn't breathing, and the dispatcher told her to start CPR. The staff member refused, saying that the facility had a policy directing staff to call 911 and stay with the individual but not perform CPR. When the dispatcher pleaded with the nurse to ask a bystander to perform CPR, she responded, "I understand. I am a nurse but I can't have our other senior citizens, who don't know CPR, do it. We are in a dining room."[2] The dispatcher argued with the nurse for 7 minutes. No CPR was given and the woman died.
    Later reports said the "nurse" wasn't practicing as a nurse but as an administrator. The family of the deceased woman said that their relative didn't want intervention, and they were not planning to complain about the facility's handling of the matter. The facility did not have a do-not-resuscitate (DNR) order on the woman.
    What is the responsibility of the facility? What is the responsibility of a nurse working at such a facility? What is the responsibility of a nurse who is not working as a nurse but as an administrator? For nurses, this case raises the following question: If a facility's policy is contrary to general medical practice, general ethical principles, and/or the legal requirements of a nurse, should a nurse follow the policy or do what he or she thinks is appropriate?
    Facility Responsibilities
    First, let's consider the facility's responsibility. "Independent living" can mean different things to different people, but typically in such facilities, residents have their own apartments, are served meals in a dining room, and are offered social-gathering opportunities. Independent living facilities are not required to offer registered nurse services, but some do so as an added benefit for residents. In a written statement, the executive director of the facility described the facility's policy for emergencies. "In the event of a health emergency at this independent living community, our practice is to immediately call emergency medical personnel for assistance and to wait with the individual needing attention until such personnel arrive. That is the protocol we followed."[3]
    Some people have argued that this facility's policy is ethical, because residents were informed of the policy when they moved in and because "independent living" means that no healthcare is provided. And, given that some individuals do not want intervention if they stop breathing, performing CPR would be against their wishes. The legal responsibility of the facility depends on the agreement between the individual resident and the facility. If the facility clearly states, "We offer neither healthcare nor emergency care. If you have an emergency, we will call 911 and have someone wait with you until emergency personnel arrive," then the facility is not responsible for performing CPR. However, if the facility also says in their advertisements or verbally to residents, "We have trained staff (or an administrator who also is a nurse)," then the facility is implying that it offers nursing help in an emergency. If a resident relies on that statement in making the choice to live there, the facility has taken on the responsibility to provide nursing care.
    A Nurse's Duty in a Healthcare Setting
    If the nurse is working as a nurse, he or she has a duty to perform CPR when an individual at the workplace is not breathing and/or has no pulse. A search of the California Board of Nursing Website produced several cases involving nurses who lost their licenses for failing to start CPR on a patient who had no pulse and/or respirations. In one case, the nurse worked at a hospital and came upon a patient who appeared to her to be dead. There was no DNR order. The nurse called a physician but didn't initiate CPR. The Board believed the nurse's allegation that she thought the patient was dead; however, because of other allegations, the Board revoked the nurse's license and then stayed the revocation and put her on probation.
    In another case, the Board invoked similar discipline when a nurse did not perform CPR on a patient hospitalized in a psychiatric facility. In a third case, a nurse did not initiate CPR because he thought the patient was a "no code," when in fact there was no DNR order. His license was also revoked but he was put on probation. The charges against these nurses were unprofessional conduct, negligence, and incompetence.
    There are several distinctions between these cases and the Bakersfield case. In the California Board of Nursing cases, the patients were in facilities where healthcare was provided. In the Bakersfield case, the woman was in an independent living facility. Furthermore, in the Bakersfield case, the nurse apparently wasn't working as a nurse. It could be argued that if the nonpracticing nurse held herself out as a nurse, then she should be held to the standard of a nurse. During the 911 call, she said that she was a nurse. If she was not going to perform as a nurse, she should have let her license lapse and/or never mentioned to anyone that she was a nurse.
    An Associated Press story quoted a spokesperson from the California Board of Nursing. "If she's not engaged in the practice of nursing, there is no obligation (to help)," agency spokesman Russ Heimerich said. "What complicates this further is the idea that she wouldn't hand the phone over [to a bystander] either. So that's why we want to look into it."[4]
    Nurses in Other Capacities
    It is clear that in a healthcare facility a nurse must initiate CPR and whatever other emergency system the facility has in place when finding a patient with no respirations and/or no pulse. It is also clear that an individual (even a nurse) who encounters a pulseless person on the street has no legal duty to initiate CPR. The individual on the street can follow his or her conscience.
    What is unclear, and worth thinking about, is the responsibility of a nurse who is not working in the capacity of a caregiver in a facility that doesn't provide healthcare services. Is it her responsibility to do her best and attempt CPR? Is it her responsibility to call for help from other staff and/or residents? Is it her responsibility to follow whatever policy the facility has in place? The spokesman from the Board of Nursing indicates that she should have handed the telephone over to someone else. However, putting the responsibility on an untrained bystander senior citizen, when you are a nurse, isn't a great choice.
    What Facilities Should Consider
    Reportedly, independent living facilities are now taking close looks at their policies. They should consider the following:
    1. If a facility decides to have a nurse available, then the facility has to allow the nurse to perform as the Board of Nursing would expect the nurse to perform; that is, initiate CPR when an individual is not breathing or is without a pulse and the individual has not been pronounced dead. If a facility offers a nurse and CPR, then the facility should initiate a discussion with each resident, on arrival and periodically thereafter, about the resident's desire to be or not be resuscitated, and obtain DNR orders for residents who do not want to be resuscitated. A policy to offer CPR and therefore to keep and track DNR orders can be problematic, in that the nurse or other staff member expected to perform CPR must know at all times who has DNR orders and who does not.
    2. If the facility does not provide any nursing services, then clearly inform residents of this fact when they arrive and periodically thereafter. Don't have a nurse as administrator, or, if the facility has a nurse as administrator, don't tell people that the administrator is a nurse.
    The Bakersfield facility's problem was its mixed messages: "Call 911, but don't start CPR." "We have a nurse, but she won't act like a nurse." The facility's policy put the nurse in a terrible position -- violate the policy and be fired, or follow the policy and be reviled by society, possibly sanctioned by the Board of Nursing, and, in the end, probably fired anyway. (The nurse in this case is reportedly on voluntary leave pending investigation.[4])
    A Different Standard
    Nurses need to know that by being a nurse, they are held to a standard different from the average person's, a standard that requires CPR when they are at work and they encounter a patient who needs it. If an employer has a policy that keeps the nurse from living up to the standard of care, the nurse should ask that the policy be brought into line with his or her responsibilities as a nurse. If the facility won't do that, the nurse should refuse to work there or, at minimum, should refuse to let the facility use the nurse's credential in any way.
     
    原文链接:http://www.medscape.com/viewarticle/781098_4
     




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