CPR and Obligation in an Emergency: Overview
Cardiopulmonary resuscitation (CPR) is a critical emergency procedure used to revive individuals experiencing sudden cardiac arrest (SCA), significantly increasing their chances of survival. In the United States, approximately 350,000 people face SCA annually outside of hospitals, yet laypersons typically only initiate CPR in half of these cases. Despite over twelve million people being trained to perform CPR, concerns about personal safety, legal liability, and the potential for causing further harm often deter bystanders from taking action. Good Samaritan laws exist in many states to protect individuals assisting in emergencies, though the extent of these legal protections varies, influencing the willingness of laypeople to intervene. Some states have even enacted laws requiring bystanders to assist during medical emergencies, although this can sometimes lead to complications if a rescuer is concerned about their legal liability. The American Heart Association has sought to increase public confidence in performing CPR by promoting simplified techniques, such as hands-only CPR, which emphasize quick action with minimal training. This ongoing dialogue highlights the complexities surrounding the moral and legal obligations of certified individuals to act in emergencies, as well as the importance of increasing awareness and education on CPR. Ultimately, enhancing lay response to cardiac emergencies remains a crucial focus for health organizations to improve survival rates for victims of sudden cardiac arrest.
CPR and Obligation in an Emergency: Overview
Introduction
According to the American Heart Association in 2024, some 350,000 people in the United States experience sudden cardiac arrest outside of hospital settings each year. In these situations, properly administered cardiopulmonary resuscitation (CPR) can be a lifesaving procedure that doubles or even triples a victim's chances of survival. Unfortunately, if administered improperly, CPR can further injure or even kill the victim. Perhaps because of this, even individuals who are able to perform CPR sometimes hesitate to take action in an emergency—laypeople only initiated CPR in 50 percent of the cases of cardiac arrests that occurred outside of the hospital in 2023. Around 90 percent of those who experience sudden cardiac arrest outside of a hospital die.
Each year, over twelve million people in the United States are trained and certified to perform CPR, according to the American Heart Association. Some of these people are medical professionals, while others are simply concerned citizens. However, this raises an important question: if one is certified to perform CPR, does one have a moral or legal obligation to do so? Should this obligation depend on whether the potential rescuer is a medical professional or layperson?
Understanding the Discussion
Cardiopulmonary resuscitation (CPR): A procedure given to a heart attack or SCA victim, where the rescuer breathes into the victim's mouth to provide oxygen and provides chest compressions to maintain blood circulation until normal heart rhythm can be restored.
Do Not Resuscitate (DNR) order: A legal order stating that certain medical procedures are not to be used to prolong a person's life, usually belonging to individuals of advanced age or with terminal illnesses.
Good Samaritan laws: Laws that protect a rescuer from being sued for wrongdoing if he or she voluntarily assists an injured victim.
Heart attack: A medical emergency where the blood supply to part of the heart muscle is blocked; a heart attack can cause sudden cardiac arrest.
Sudden cardiac arrest (SCA): A medical emergency where a person's heartbeat becomes rapid and chaotic, then suddenly stops beating.
History
Cardiopulmonary resuscitation—commonly referred to as CPR—was established in its modern form in 1960. Shortly after its development, the American Heart Association (AHA) officially endorsed the technique and undertook efforts to teach it to medical personnel. Over time, in order to increase awareness of this potentially lifesaving procedure, the AHA expanded its efforts to include individuals without medical training. This shift proved significant, since CPR is most effective when administered immediately following cardiac arrest. If a bystander could begin CPR while waiting for paramedics to arrive, the victim's chance of survival increased significantly.
Despite efforts on the part of the AHA to educate the general public on proper CPR procedure, many bystanders still refused to perform CPR in emergency situations. Surveys conducted by the San Francisco Department of Public Health in 1996 revealed the primary reason bystanders would not perform CPR was concern for their own personal safety—they feared they could injure themselves, catch a communicable disease, or come under attack if the alleged victim is faking distress. Another significant reason for not intervening was concern about performing the procedure incorrectly and potentially causing more harm to the victim. Finally, people expressed concern about facing a lawsuit if they saved the victim's life but caused them additional injury—such as breaking a victim's rib or ribs while administering chest compressions.
To address the concern of potential legal liability, most states passed so-called Good Samaritan laws, which are designed to protect volunteer rescuers from legal liability if they provide reasonable assistance to a victim experiencing a medical emergency. However, the protections these laws provide vary significantly by jurisdiction. In some states, such as New Hampshire and New York, these laws protect any bystander who undertakes reasonable efforts to assist a victim, even if he or she is not a professional rescuer. Nevertheless, in other states, such as Arizona and Massachusetts, these laws protect only medical personnel—if a layperson who is CPR-certified undertakes a rescue, he or she could be legally liable for any further harm caused to the victim. As a result, many people who are not medical personnel still hesitate to intervene in an emergency, particularly if they are unsure of their skills or inexperienced with performing CPR.
Ultimately, the survival rate for victims of sudden cardiac arrest outside of a hospital is very low. In attempt to increase the likelihood of survival, the Centers for Disease Control and Prevention (CDC) established the Cardiac Arrest Registry to Enhance Survival (CARES) program in 2005. This program was aimed at helping emergency medical personnel respond more quickly and effectively to cardiac emergencies. However, since paramedics are rarely on the scene at the moment a cardiac event happens, a victim's best hope for surviving sudden cardiac arrest is a properly trained bystander who can immediately begin to perform CPR while waiting for help to arrive. Fear of legal liability continues to deter laypeople from performing this potentially lifesaving procedure in many cases.
In March 2013, a nurse in a Bakersfield, California, assisted living facility called 911 to report that an eighty-seven-year-old resident with a known heart condition was not breathing. However, despite urging from the operator, the nurse refused to perform CPR on the elderly resident, citing the home's policy against intervening in emergency situations. Emergency personnel eventually arrived, but the resident was pronounced dead at the hospital.
In July 2013, a similar incident occurred at an Olive Garden restaurant in Ann Arbor, Michigan. When a customer dining at the restaurant collapsed, a server started to perform CPR. However, after a brief time, a restaurant manager told her to stop, and she did. The paramedics arrived a short time later but were unable to revive the customer, who had already died.
These incidents drew increased attention to the debate about whether CPR-certified individuals should be required to perform the procedure if the need arises. There are several issues complicating the discussion. First, different individuals have varying comfort levels performing CPR, both physically and emotionally, and may not be prepared to do so safely and effectively in certain situations. Second, even if a CPR-certified individual is prepared to assist a victim, the circumstances of his or her employment could complicate taking action.
Many states, such as Michigan, only provide immunity from legal liability to medical professionals. Had the server accidentally injured the victim while performing CPR, the Olive Garden could have faced legal liability for her injuries—even if the server saved the victim's life. Additionally, the restaurant could have faced a worker's compensation claim if the server were injured while performing CPR on the job. These varying circumstances make it difficult to uniformly legislate an individual's obligation, or lack thereof, to perform CPR when the need arises.
CPR and Obligation in an Emergency Today
In most states, there is no legal obligation to assist a victim, unless a particular relationship (such as doctor-patient) exists before the emergency or unless the potential rescuer caused the injury in the first place. However, by the 2020s, Minnesota, Rhode Island, and Vermont had laws requiring all bystanders to assist someone they see experiencing a medical emergency, although the required "assistance" could be as simple as calling 911. Failure to do so could result in a civil penalty, such as a hundred-dollar fine. In turn, these states exempted all bystanders from legal liability for reasonable rescue attempts. Even though most states have some version of Good Samaritan laws, this does not guarantee that individuals who know how to administer CPR will do so when the need arises.
As the debate continued into the 2020s, health experts and organizations such as the AHA continued efforts to educate and certify as many people as possible in performing CPR in the hopes that it would create more opportunity for potential bystander rescues. Starting in 2020, the AHA provided updated guidelines that, among other changes, emphasized compression-only CPR, also known as hands-only CPR, for untrained lay responders. Unlike conventional CPR used by those with CPR training and medical professionals, hands-only CPR can be used on adults and teens and has two steps: (1) call 9-1-1 or have someone else call 9-1-1, and (2) push hard and fast in the center of the chest. The AHA promoted the simplified technique as part of a public awareness campaign to get more lay bystanders to have the confidence to administer CPR and to do so sooner, as a way to increase the out-of-hospital cardiac arrest survival rate.
According to the AHA in 2024, by 2021 forty states had adapted their curriculum to require or had passed laws mandating CPR training in order for students to be able to graduate high school. Additionally, some states considered alterations to Good Samaritan laws similar to those in Vermont, Minnesota, and Rhode Island to make citizens legally responsible for providing reasonable assistance to those in emergency need. However, critics argued that such laws vary from state to state, had proven difficult to enforce, and could actually put more laypeople at physical risk if they tried to help in perilous circumstances.
The AHA conducted a fall 2023 survey on factors that influenced bystanders' willingness to respond to sudden, out-of-hospital cardiac emergencies. According to the survey results, 35 percent of participants responded that they had the confidence to perform CPR when needed, compared to 30 percent who had the confidence in 2021. The survey also showed that 39 percent of respondents were familiar with conventional CPR, while only 23 percent were familiar with hands-only CPR.
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Bibliography
American Heart Association. "What Is CPR?" CPR & First Aid: Emergency Cardiovascular Care, American Heart Association, 2024, cpr.heart.org/en/resources/what-is-cpr. Accessed 3 Apr. 2024.
"American Heart Month 2024 Brings Renewed Focus on CPR, Urgent Need for Nation of Lifesavers™" American Heart Association: Newsroom, 30 Jan. 2024, newsroom.heart.org/news/american-heart-month-2024-brings-renewed-focus-on-cpr-urgent-need-for-nation-of-lifesaversTM. Accessed 3 Apr. 2024.
American Red Cross. First Aid/CPR/AED Participant’s Manual. Staywell, 2011.
Benjamin, Emelia J., et al. "Heart Disease and Stroke Statistics—2019 Update: A Report from the American Heart Association." Circulation, vol. 139, no. 10, 2019, doi:10.1161/CIR.0000000000000659. Accessed 24 May 2020.
“CARES Cardiac Arrest Registry to Enhance Survival.” Centers for Disease Control, 23 July 2013, www.cdc.gov. Accessed 4 Dec. 2013.
"CPR Training at School Now Required in 38 States." American Heart Association, 23 Aug. 2018, www.heart.org/en/news/2018/08/22/cpr-training-at-school-now-required-in-38-states. Accessed 18 May 2020.
Dainty, Katie N., et al. "Understanding the Importance of the Lay Responder Experience in Out-of-Hospital Cardiac Arrest: A Scientific Statement from the American Heart Association." Circulation, 21 Mar. 2022, doi.org.10.1161/CIR.0000000000001054. Accessed 3 Apr. 2024.
“Lawsuit: Olive Garden Management Stopped CPR on Dying Woman.” CBS Detroit, CBS Radio, 26 July 2013, www.cbsnews.com/detroit/news/lawsuit-oliver-garden-management-stopped-cpr-on-dying-woman/. Accessed 4 Dec. 2013.
Lerner, Barron H. The Good Doctor: A Father, a Son, and the Evolution of Medical Ethics. Beacon, 2014. EBSCOhost, search.ebscohost.com/login.aspx?direct=true&db=nlebk&AN=751568&site=ehost-live. Accessed 9 Nov. 2015.
Nicholson, William C. Emergency Response and Emergency Management Law: Cases and Materials. Thomas, 2012.
Peter, Elizabeth, Shan Mohammed, and Anne Simmonds. “Narratives of Aggressive Care: Knowledge, Time, and Responsibility.” Nursing Ethics, vol. 21, no. 4, 2014, pp. 461–472. EBSCOhost, search.ebscohost.com/login.aspx?direct=true&db=a9h&AN=97191000. Accessed 9 Nov. 2015.
Ryan, Cy. “Court to Decide Casino's Responsibility in Aiding Heart Attack Victim.” Las Vegas Sun, 6 Mar. 2015. EBSCOhost, search.ebscohost.com/login.aspx?direct=true&db=pwh&AN=2W6726631143&site=pov-live. Accessed 9 Nov. 2015.
Timmermans, Stefan. Sudden Death and the Myth of CPR. Temple UP, 1999.
"Why It's Hard to Punish 'Bad Samaritans.'" PEW, 19 Sept. 2017, www.pewtrusts.org/en/research-and-analysis/blogs/stateline/2017/09/19/why-its-hard-to-punish-bad-samaritans. Accessed 18 May 2020.