Advance Directives May Be Hazardous to Your Health

Robert Glatter, MD; Ferdinando L. Mirarchi, DO


December 08, 2014

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Robert Glatter, MD: Good afternoon. My name is Dr Robert Glatter. I am an attending physician in the Department of Emergency Medicine at the Lenox Hill Hospital in New York City, and a member of the Medscape Emergency Medicine Editorial Board.

I am speaking today with Dr Ferdinando Mirarchi. Dr Mirarchi is medical director at the Department of Emergency Medicine at University of Pittsburgh Medical Center Hamot, in Erie, Pennsylvania. He is also the principal investigator of The Realistic Interpretation of Advance Directives (TRIAD) studies.[1,2,3,4]

Advance directives often accompany patients who present to the emergency department (ED) for emergent care, but despite evidence suggesting that misunderstanding could lead to inappropriate care, few studies have actually examined provider understanding of these documents and their effect on patient care.

Dr Mirarchi has agreed to join us today to discuss his findings and the implications for patient care. Welcome, Dr Mirarchi.

Figure 1.

Living Wills, DNR, and POLST Orders

Ferdinando L. Mirarchi, DO: Thank you, Dr Glatter. I am happy to be here.

Dr Glatter: Let's talk about this important research. What are the key findings of the TRIAD studies?

Figure 2.

Problems with Advance Care Planning Directives

Dr Mirarchi: One of the issues is that for patients, living wills, do-not-resuscitate (DNR) orders, and even POLST (physician orders for life-sustaining treatment) documents represent life-or-death scenarios. But what is actually happening in medical practice is not what people were agreeing to in these types of documents.

For example, when patients consent to living wills and POLST documents, their perception is that these documents will not come into play until nothing else can be done for them—when every therapeutic tool has been exhausted. In reality, these directives have affected all phases of care and treatment, especially initially.

That observation was behind the development of our TRIAD studies. TRIAD was based on three findings: (1) these forms often lack individualization for the patient; (2) they lack informed consent on the part of the patient or dependent; and (3) they are misinterpreted as "do not resuscitate" or "do not treat"-type orders. That is what TRIAD revealed. We found that overwhelmingly, there is a lot of confusion across the nation as far as what to do with these documents when they come into play in the clinical scenario of the critically ill patient.

Dr Glatter: This is a very important point, because many providers have this common experience: When a patient comes to the ED without proper documentation, we do not know how aggressive we should be. Your findings speak to the idea that we should have something like a checklist of important documents, and one of these documents should include such a form or an order to make the patient's wishes clear.

Dr Mirarchi: I agree, and I think a checklist should definitely be required in this situation. Ideally, it should include some degree of a quality measure, too.

Right now, there are so many documents. There is a living will. There is a "five wishes" document. There is a "right to live" living will, a "right to die" living will, a "natural dying" living will. The whole process itself lacks procedural safeguards, however.

We need a checklist similar to the procedural pauses in surgery that Atul Gawande recommended in The Checklist Manifesto.[5] This is why we are advocating for an awareness of the resuscitation checklist or the advance directive patient safety checklist, because no one is really watching this process. It is unregulated, and as such it is both under- and unreported.

What is an acceptable rate of error for a life-or-death decision? The Institute of Medicine is trying to make us aware of medical errors that should not happen. But we have no real benchmarks for this. At this time, I believe the patient needs a checklist, such as an advance directive patient safety checklist, or a pause for a conversation to individualize care and design the care plan at the bedside.

Our research shows that overwhelmingly, there are a high number of inaccurate DNR orders, such that every one of them requires confirmation for appropriateness. Moreover, the high percentage of these misinterpretations of DNR orders are actually a misinterpretation of a living will document.

Dr Glatter: Can you describe the elements of the checklist?

Figure 3.


Dr Mirarchi: Sure. The resuscitation checklist or advance directive patient safety checklist takes what we do in emergency medicine and resuscitation—where we follow an ABC (airway, breathing, circulation) mnemonic—and applies this to emergency care. We combine this with what Atul Gawande made very popular in surgery: the pause and the procedural pauses.

The checklist follows an ABCDE mnemonic:

Ask the patient or surrogate to be clear about the intentions of the patient's advance directive, which could be the living will, DNR, or POLST document.

Be clear. We want to be clear about whether the directive applies if the patient has a terminal condition despite sound medical treatment or if the patient is in a persistent vegetative state vs just being critically ill.

Communicate clearly if we believe the condition is reversible and treatable, and if it has a poor or good prognostic outcome.

Design the plan of care and discuss the next steps. For example, say "We can treat your mom for 48-72 hours and see whether there is benefit, or we can talk about deescalating care."

Explain and arrange for palliative care and hospice if that is the next step, because that is a huge void in medicine here today.

Dr Glatter: I agree. The idea of a time-out or pause, just as we do in a procedure, is crucial because these steps are integral to patient care and ultimately patient safety.

What is the difference between a living will and a DNR order? Many people are confused about that.

Dr Mirarchi: This is very important to clarify. Right now, the three most common types of documents we see or hear about are the living will, the DNR order, and the POLST document.

The living will is a legal document. It is supposed to be used when a person cannot speak for him- or herself and has a terminal condition or is in a persistent vegetative state.

The documents themselves are only effective when they are created. You are not supposed to follow them in every situation. Rather, they are supposed to be a conversational piece at a specific point in time. They are not "enacted" or "triggered," but rather should be discussed. They conversation is supposed to begin when patients are unable to speak for themselves, and when they have a terminal condition or persistent vegetative state.

Figure 4.

DNR is mistaken as Do Not Treat

The TRIAD research shows that providers equate a living will with a DNR order. A DNR order is a medical order, but it has a legal definition in state statutes. It comes into play only if the person has no pulse or is not breathing. But the TRIAD study reveals that there is an assumption that a DNR order equates with end-of-life care. That is a misinterpretation of that term, and it has been around for over 20 years.

Now we have the POLST order set, or the POLST medical order set—the nomenclature varies according to state—but the idea is spreading across the country quite quickly.

Figure 5.

Anatomy of POLST

Dr Glatter: That is very important to know. One question is whether any education is necessary, beginning in medical or nursing schools, etc., so that healthcare providers understand these concepts throughout their training. Should we begin the education sooner?

Dr Mirarchi: Absolutely. In fact, TRIAD III[3] looked at this in residents in training and found that, in general, residents are not prepared to deal with these documents or orders and require education. In addition, the TRIAD IV study[4] showed that medical schools are not preparing their students to be able to deal with these documents and orders in critical care scenarios as they enter internship and residency.

Dr Glatter: Going forward, do you believe licensing boards will be using this as a key measure to be accomplished in order to gain or continue licensure?

Dr Mirarchi: That would be a great accomplishment as both a continuing medical education (CME) and a licensure requirement. The TRIAD III study revealed that even though physicians improve as they age in practice, they tend to have similar misunderstandings that living wills equate with DNR orders and that DNR orders equate with end-of-life care.

If you look at the Patient Self-Determination Act, one of its criticisms was a lack of funding for education. These are processes that, until now, have never been researched in terms of patient safety. If you deploy a process without the appropriate education, it can only cause confusion and introduce risk and harm to a patient.

Dr Glatter: Right. In the future, is this something that the Joint Commission on Accreditation of Healthcare Organizations will address as part of its accreditation, so the public knows the facility is safe in that capacity?

Dr Mirarchi: I hope so, because right now this is an unregulated process. The issue of whether or not someone is creating DNR orders correctly or understanding living wills and POLST documents is an unchecked process. With this recent push to get people to address this issue and to control end-of-life spending, which the Institute of Medicine just reported at $170 billion annually, systems are laser-focused on this.

Figure 6.

Which Combination Equates with the Pre-Hospital DNR order?

There are no checks and balances in the system when that DNR order is created, yet it is put into an electronic medical record, posted on a banner bar, and appears right up front in your face, so to speak, so that you are aware of it. But we have no checks in the system to make sure that the healthcare providers understand those documents or orders before getting involved in the patient care.

Ideally, a regulatory body should also become laser-focused on this.

Dr Glatter: Do you see such a regulation being formulated in the near future—for example, in the next decade?

Dr Mirarchi: I hope it happens much sooner than a decade. I have been in conversations with the Joint Commission about this, and they are creating educational modules. But creating standards such as this and persuading regulatory bodies that this is a concern is a very laborious process. Before the TRIAD studies, essentially no one had any idea that living wills represent a patient safety concern, and now we are also representing that potentially, the POLST document may be a concern as well.

Dr Glatter: Do you see any similar initiatives in Europe or in other parts of the world at this point?

Dr Mirarchi: In Europe and in England especially, they are coming to find many errors with respect to DNR orders and their understanding, and the essential placement of DNR orders in charts of patients without their knowledge. That has been recognized here in the United States, as well.

For now, I hope physicians will never write a DNR order or create a DNR document without the appropriate consents of the patient or the patient's proxy.

Dr Glatter: Thank you very much for your insight, Dr Mirarchi, and thanks again for joining us.

Dr Mirarchi: Thank you, Dr Glatter, and thank you, Medscape.


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