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CPR: Live or let die?

July 2, 2014
by Alan C. Horowitz, RN, JD
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It’s 6:45 a.m., and you are almost finished with your shift at the nursing home. As you enter a resident’s room, you notice that the resident’s skin seems ashen and mottled. You quickly realize the resident is not breathing and has no pulse. What do you do?

The hypothetical scenario above plays out in virtually every nursing home with variations on the theme. Life and death hang in the balance. Decisions have to be made within seconds, and a wrong decision regarding cardiopulmonary resuscitation (CPR) may have dire consequences.

Unfortunately, there is no shortage of cases in which a skilled nursing facility (SNF) was held responsible for failing to perform CPR. Many SNFs also have been held responsible for performing CPR when it should not have been performed or for not performing CPR properly.

| Related: Long-Term Living articles related to CPR |

A good review of policy and procedures begins with the applicable regulations and current standards of care.


At the time of admission, residents must be notified of their rights, including the right of self-determination.1 Along with other rights, residents have a right to formulate advance directives.2 Few decisions are as important as the right to choose—or forgo—CPR. When a resident has expressed his or her preference regarding CPR, those preferences must be followed—except in very narrow circumstances, as described below. Further, the regulations require that the services provided “must meet professional standards of quality.”3


The gold standard for CPR is the 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.4 The guidelines explain the proper technique for CPR as well as when CPR may be withheld or withdrawn.

For example, once CPR is initiated, it may only be withdrawn under one of the following circumstances:

  1. The victim has a spontaneous return of circulation and breathing,
  2. The victim has been pronounced dead by an individual with the authority to make that determination,
  3. Another trained rescuer relieves the person performing CPR or
  4. The rescuer is either in imminent danger or too exhausted to continue.

CPR may be withheld if:

  1. The victim has a valid do not resuscitate (DNR) order or
  2. Irreversible death has occurred as evidenced by signs such as rigor mortis or livor mortis.


In an actual case that began in 2006, the Centers for Medicare & Medicaid Services (CMS) determined that CPR-related deficiencies existed at a SNF and imposed a civil money penalty (CMP).5 The SNF appealed and the case was assigned to an administrative law judge (ALJ). The issue was whether the facility staff performed CPR appropriately.



Alan C. Horowitz

Partner at Arnall Golden Gregory

Alan C. Horowitz

Alan C. Horowitz, Esq., is a partner at...