Interpreting a Living Will in the ER Setting
Maybe it’s just me, but does it seem to you that there are a lot of articles of late about advance directives and end of life issues? Here’s a recent one published by Kaiser Health News. That ‘Living Will’ You Signed? At The ER, It Could Be Open To Interpretation.
opens with an ER nurse saying DNR because the patient had a living will, but reading the document showed the language to be just the opposite, “‘[d]o everything possible,’ it read, with a check approving cardiopulmonary resuscitation.” The point is to illustrate the mistake that the existence of a living will automatically means no resuscitation. “Unfortunately, misunderstandings involving documents meant to guide end-of-life decision-making are “surprisingly common,” said [the] medical director of advance-care planning and end-of-life education for Huntsville Hospital Health System in Alabama.”
There’s a new report from Pennsylvania, Empowering Patients and Agents to Help Prevent Errors with Living Wills, DNRs, and POLSTs
In 2016, acute healthcare facilities in the Commonwealth reported through the Pennsylvania Patient Safety Reporting System (PA-PSRS) nearly 100 events involving the code status or treatment level of patients. Twenty-nine patients were resuscitated against their wishes. Two patients were not treated when their wishes indicated they should have been. The remaining cases represent near misses that could have affected the patient, but were resolved before harm occurred.
The Pennsylvania Patient Safety Authority is unable to verify whether the do not resuscitate (DNR) orders or physician orders for life-sustaining treatment (POLST) were appropriate, correctly created, or verified prior to these patient safety events occurring in real time.
The Kaiser Health News article details communication missteps and offers that
The problem, Hoffman explained, is that doctors and nurses receive little, if any, training in understanding and interpreting living wills, DNR orders and Physician Orders for Life-Sustaining Treatment (POLST) forms, either on the job or in medical or nursing school.
Communication breakdowns and a pressure-cooker environment in emergency departments, where life-or-death decisions often have to be made within minutes, also contribute to misunderstandings, other experts said.
One expert interviewed for the article suggests these missteps are more common explaining his use of hypotheticals where “he has asked medical providers how they would respond to hypothetical situations involving patients with critical and terminal illnesses.” He goes on to explain
He described a 46-year-old woman brought to the ER with a heart attack and suddenly goes into cardiac arrest. Although she’s otherwise healthy, she has a living will refusing all potentially lifesaving medical interventions. What would you do, he asked more than 700 physicians in an internet survey?
Only 43 percent of those doctors said they would intervene to save her life — a troubling figure…Since this patient didn’t have a terminal condition, her living will didn’t apply to the situation at hand and every physician should have been willing to offer aggressive treatment, he explained.
The article offers some suggestions from one expert to avoid these situations: “[m]ake sure you have ongoing discussions about your end-of-life preferences with your physician, surrogate decision-maker, if you have one, and family, especially when your health status changes… Without these conversations, documents can be difficult to interpret.”