An Advance Directive May Be Hazardous to Your Health

Ferdinando L. Mirarchi, DO


October 27, 2017

Welcome, everyone. I am Dr Ferdinando Mirarchi, chief medical officer of the Institute on HealthCare Directives and medical director of the Department of Emergency Medicine at the University of Pittsburgh Medical Center - Hamot, in Erie, Pennsylvania. I am also the principal investigator for a series of studies[1,2,3,4,5,6,7,8] called The Realistic Interpretation of Advance Directives (TRIAD).

Today I am going to talk about emergencies and natural disasters, end-of-life documents such as living wills and physician orders for life-sustaining treatment (POLST), and patient-to-clinician videos, which TRIAD VIII found to be beneficial.[7]

Let me start with the living will. A living will is an effective document when you come across it, meaning that it is valid and legal, but you must bring a degree of interpretation to it. You are supposed to use it to guide your care and treatment for any patient, but especially for a patient receiving end-of-life care.

A POLST is different. It is a live medical order and is supposed to be immediately actionable. But it still requires some degree of interpretation because areas of care and medical conditions can be vague. Physicians are supposed to clarify those situations. You also should be careful with POLST documents because errors can occur when creating a POLST. Typically, the physician at the bedside is not the one who created the document, and that physician may have had a different perception of the conversation that occurred when it was created.

Finally, there is the patient-to-clinician video. An example of that is something called My Informed Decision on Video (MIDEO). MIDEO or patient-to-clinician video can be factual and directional, and when done correctly it can be quite helpful in guiding care and treatment in any patient care situation, not only for patients receiving end-of-life care. [Editor's note: Dr Mirarchi is the founder of MIDEO.]

End-of-Life Documents in a Disaster

In a disaster—for example, a hurricane or a mass-shooting scenario—if a patient is not currently in end-of-life care, a living will or POLST document could actually place that individual in harm's way. First responders are trained to move quickly to provide care, and thus, they will move in a direction toward those patients wanting to receive care. If that patient has a document such as a living will or POLST, their perception could be that that individual may not want to receive care and treatment. We have shown through TRIAD VIII and previous TRIAD studies that it is common, when confronted with a critically ill patient, for providers to act too aggressively or not aggressively enough to save a life. A patient-to-clinician video can be beneficial for the patient and the provider because it is factual, it is directional, and it is not an interpretation or a guess.

There is a push right now to have all patients create living wills and POLST documents and place them in their natural disaster toolbox. Rather than placing all patients in harm's way, I believe that we should only recommend these to patients who have terminal illnesses or are at high risk for an end-of-life scenario. Those patients should keep a living will or POLST documents in their toolboxes.

All others in the community should store those documents in a safe place, because they are created primarily as part of an estate plan or just good advance-care planning. Let your appointed agents use those documents to make the decision for you when it is time.

Take-Home Points

For disaster care, we should recommend that our patients create some form of patient-to-clinician video. TRIAD research has shown us that education and training is still very much needed for emergency responders.

Living wills and POLST documents should not be part of a person’s disaster toolkit unless that person is terminally ill or at high risk for end-of-life scenarios. Patient-to-clinician video can be helpful and effective for all patients in the community, and for patients in end-of-life care, particularly during disaster scenarios.

More and more products are becoming available. For example, MIDEO is one I mentioned earlier. My Directives® has an arm of its software that can allow for recording a patient-to-clinician video. Another product is My Own Voice™, which provides an app for recording your wishes on a mobile device.

When in a disaster and presented with end-of-life documents, consider using one of the patient safety checklists previously discussed on Medscape[9,10] to help you get it right for patients in a disaster.

Thank you for listening, and thanks to Medscape for asking me to inform you about these critical issues again.


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