By Dr. Fernando Mirarchi
A 68-year-old male presents with a history of diabetes, hypertension, dyslipidemia, and CAD s/p CABG 10 years ago. Patient is experiencing chest pain. He is clammy. He is in mild distress. Vitals: T: 36C; P:60; RR:22; SaO2: 98%RA. The family gives you his list of medications and living will. Abruptly, the patient becomes unresponsive without palpable pulses. The monitor shows ventricular fibrillation. What next? Read the article, click here to look at the Will and take a two-question quiz.
Advance directives were created with the best of intentions, aiming to protect patient autonomy and honor end of life wishes. Until recently, the risks posed to patient safety by the various incarnations of advance directives were unknown and thus, undisclosed. Often, these well-meaning documents have produced unintended consequences. The TRIAD studies (The Realistic Interpretation of Advance Directives) have disclosed this patient safety risk as reality and on a nationwide scale. The risk is attributable to variable understanding and misinterpretation of advance directives which then translates into over or under resuscitation. At present, this is an unreported safety concern and only by clarifying the terms of advance directives and developing systems to educate providers will we be able to respect our patients’ wishes while still protecting their safety.
The living will was first legalized in California in 1977 and was known as the Natural Death Act.1 It was created by an attorney and utilized to decline life saving measures, essentially intended to provide patients with greater autonomy in end of life decisions. 2 Unfortunately, it also resulted in increasing risks to patient safety. Further fueling this patient safety risk was the development of The Patient Self Determination Act 1990. 3 This mandate, which was never evaluated for safety, requires patients to be provided information regarding their right to execute an advance directive at institutions receiving Medicare/Medicaid funding. With 90 million living wills in existence in the United States, 4 incorrect interpretation can lead to deleterious impacts on the care and safety of patients who summon 911 or experience a medical emergency in a healthcare setting. Clarification of terms, education of providers and implementation of safeguards are needed to protect the safety and autonomy of patients. In the TRIAD III nationwide study, high percentages of participants reported receiving training related to advance directives. However, those indicating receiving education produced no benefit. As health care providers, we need to work together on a national level to improve this education process. To further facilitate understanding, the following terms need to be defined and standardized:
Terminal Illness defined by law
Reversible & Treatable Condition
An “Effective” Living Will
An “Enacted” Living Will
For purposes of clarification, the mere presence of a living will does not mean it should be followed. It simply indicates that this document is “effective,” or that it is valid and legal.5 It should not be followed at this point to guide the care and treatment of the patient.
An “enacted” or “activated” living will is one that has been activated by the triggers in the document, most commonly a terminal or end stage medical condition or a persistent vegetative state. 5 This “enacted” living will now necessitates adherence to its instructions regarding the care of the patient. A terminal or end stage medical condition has a legal definition which essentially states that a patient would be expected to die of their disease process despite sound medical treatment. Therefore, the mere presence of a living will “does not” dictate the care of a critically ill patient who presents with a reversible and treatable condition such as CHF or COPD; rather it applies when that same patient is permanently unconscious and has exhausted all treatment options. A do not resuscitate order (DNR) refers to an actual physicians order that directs health care providers not to intervene with CPR if the patient is found pulseless or apneic.6,7
Otherwise it should have no implication on the care and treatment that the patient is to receive.6,7
Despite the legal and societal definition of DNR, research reveals in the TRIAD studies that medical providers understand DNR to be synonymous with an order to provide comfort and end of life care.8,9,10 A relatively new document called the Physicians Orders for Life-Sustaining Treatment (POLST) is different as it is an order set to be followed that addresses the treatment options of a patient should they present in cardiac arrest as well as the patient’s preferences for care in a non-arrest situation.11
POLST is a national paradigm and its philosophy is being rapidly embraced on both a national and state level. Unfortunately, it is now being nicknamed the Pink DNR form. This nickname needs to be quickly clarified and resolved as patients can be designated as a Full Code or a DNR through the use of this form. This again is a situation where good intentions can have unexpected consequences. SafeGuards are created to promote patient safety. I would like to introduce the SafeGuard known as the Rescuscitation Pause (RP). The RP is a process similar to the surgical pause (time out is the correct term) which is already widely utilized to correctly identify patients and eliminate wrong site surgery. Resuscitation takes on many forms and is not limited to the cardiac arrest situation. Resuscitation takes place when a patient presents critically ill and requires active interventions for conditions such as respiratory distress, sepsis or GI bleeding, etc. Resuscitation takes place with conditions that require immediate evaluation and intervention such as trauma, cardiac and stroke system activations to define care and facilitate treatment. A Pause is a moment to quickly assess and reassess the situation to assure you are defining the appropriate care and treatment. Through the use of a secure, HIPPA protected and interactive educational platform, QuantiaMD, (www.quantiaMD.com) we have been able to educate over 24,000 medical providers and empower them with the RP as a patient safety tool. We have been able to confirm that the medical community nationwide supports the TRIAD concerns that there is a real and present risk to patient safety; they found the education and tool to be useful and have empowered it into their clinical practice.
Advance directives in their various forms have never been evaluated with regard to patient safety though they directly affect well over 90 million patients. This is a medical error and resolution of the issue will require increased awareness and education among medical providers of all disciplines. The Resuscitation Pause holds significant promise as a way to protect patient safety and autonomy. The importance of this issue cannot be overstated as understanding advance directives not only allows us to appropriately provide or withhold life-saving care, but also ensures that we safely honor our patient’s wishes in the process.
How to Interpret a Living Will <http://secure.quantiamd.com/player/yabhqcxpi?u=yxjzuqjvk>
What Do DNR Orders Really Mean? <http://secure.quantiamd.com/player/yafruujyt?u=yxjzuqjvk>
POLST: Physician Orders for Life-Sustaining Treatment <http://secure.quantiamd.com/player/ywebdxfnf?u=yxjzuqjvk>
Understanding Your Living Will; What you need to know before a medical emergency www.addicusbooks.com
Towers B. The Impact of the California Natural Death Act. J Med Ethics. 1978;4:96-8.
Kutner Luis. The Living Will: a proposal. Indiana Law Journal. 1969;44(1):539-554
Patient Self Determination Act http://nhdd.org/facts/
Source: U.S. Census Bureau, 2044 Population Estimates, Census 2000, 1990 Census (http://www.census.gov)
Mirarchi FL. Understanding Your Living Will. Addicus Books 2006
Do Not Resuscitate (DNR) Protocols within the Department of Veterans Affairs. Section 30.02
Code of Medical Ethics Opinion 2.22 Do-Not-Resuscitate Orders. http://www.ama-assn.org/ama/pub/physician-resources/medical-ethics/code-medical-ethics/opinion222.shtml
Mirarchi FL, Hite LA, Cooney TE. TRIAD I – The Realistic Interpretation of Advanced Directives. J Patient Saf. 2008;4:235-40.
Mirarchi FL, Kalantzis S, Hunter D. TRIAD II: Do Living Wills Have an Impact on Pre-hospital Life Saving Care? J Emerg Med.2009;36:105-15
Mirarchi FL, Costello E, Puller J, Kottkamp N. TRIAD III: Nationwide Assessment of living Wills and DNR orders. J Emerg Med. 2012 May;42(5):511-20.
Physicians Orders for Life-Sustaining Treatment (POLST) http://www.polst.org/