Patient Videos Clarify End-of-Life Documents

Marcia Frellick

February 22, 2017

Adding a patient-made video to information in end-of-life forms helps correctly physicians interpret patients' directives, according to a study published online February 17 in the Journal of Patient Safety.

Ferdinando L. Mirarchi, DO, medical director of the University of Pittsburgh Medical Center Hamot's emergency department in Erie, Pennsylvania, and colleagues developed a survey that included nine scenarios involving critically ill patients who had a Physician Orders for Life-Sustaining Treatment (POLST) document or a living will.

The survey asked physicians to interpret code status and make resuscitation decisions for each scenario based on the documents alone or with a patient video. The authors published their results

The researchers sent the web-based survey links to 1366 physicians at 13 teaching hospitals in several states that had graduate medical education programs in emergency medicine, family practice, or internal medicine. The response rate was 54% (741 participants.) Most had no training in interpreting POLST or living wills.

The researchers randomly assigned half of the participants to receive a scripted video, in addition to the documents, in which patients talked about their treatment choices. The other half received only the written documents to guide their treatment decisions.

The authors measured the effect of the video on whether physicians could reach a consensus (defined as 95% agreement) regarding what the patient wanted given the scenario.

Those in the documents-only group reached consensus on code status (97% - 98% responses) and treatment decisions (96% - 99%) in only two of the nine scenarios. Treatment decisions included full aggressive treatment, including cardiopulmonary resuscitation; treatment with a brief attempt at cardiopulmonary resuscitation; or allowing a natural death.

In contrast, those in the video group reached consensus in four of the nine scenarios regarding code status; adding the video also significantly changed code choices by 9% to 62% (P ≤ .026) in seven of the scenarios.

Similarly, respondents in the video group also reached consensus on four of the nine scenarios on resuscitation. Having the video changed resuscitation choices by 7% to 57% (P ≤ .005), the authors write.

Errors Common With Documents

The survey results are important as both the POLST (a newer document now used in 26 states) and living wills are often misinterpreted, the authors say.

"Previous research has demonstrated that healthcare providers conflate do-not-resuscitate (DNR) code status with 'do not treat' when patients present in nonarrest situations," they write.

Both documents have shown benefits in increasing patient autonomy, preventing unwanted resuscitations, and reducing in-hospital deaths and healthcare costs, the authors note.

However, errors in interpreting the documents can lead to harms including overusing medical resources, taking a life inappropriately, or preventing a wish to die naturally.

Lack of Physician Training

The survey pointed to a lack of physician training on interpreting either of the documents. Only 41% of survey responses said they had such training. Those who were trained had median training times of 1 to 2 hours.

"Ultimately, regulatory oversight might be required to ensure and set standards for educating health care providers on [living will] and POLST interpretation," the authors write.

The authors acknowledge that one limitation of the study is that they did not control for how states define DNR. In some states, DNR is for patients who are both pulseless and apneic, and in others, it is for those who are pulseless or apneic.

The authors have disclosed no relevant financial relationships.

J Patient Saf. Published online February 17, 2017. Full text

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