{"id":4575,"date":"2018-06-21T10:36:17","date_gmt":"2018-06-21T14:36:17","guid":{"rendered":"http:\/\/www.silvercentury.org\/?p=4575"},"modified":"2018-06-21T10:39:13","modified_gmt":"2018-06-21T14:39:13","slug":"when-the-time-comes-will-your-living-will-prevail","status":"publish","type":"post","link":"http:\/\/78.142.243.82\/~silvercentury\/2018\/06\/when-the-time-comes-will-your-living-will-prevail\/","title":{"rendered":"When the Time Comes, Will Your Living Will Prevail?"},"content":{"rendered":"


\nIt\u2019s all too easy for medical providers to misinterpret living wills and other end-of-life instructions. In a disturbing report, Judith Graham, a contributing columnist for Kaiser Health News<\/a> (KHN), covers recent studies that have revealed problems. KHN posted her article on June 14, 2018.<\/em><\/p>\n

\u201cDon\u2019t resuscitate this patient; he has a living will,\u201d the nurse told Monica Williams-Murphy, MD, handing her a document.<\/p>\n

Williams-Murphy looked at the sheet bearing the signature of the unconscious, 78-year-old man, who\u2019d been rushed from a nursing home to the emergency room. \u201cDo everything possible,\u201d it read, with a check approving cardiopulmonary resuscitation.<\/p>\n

The nurse\u2019s mistake was based on a misguided belief that living wills automatically include \u201cdo not resuscitate\u201d (DNR) orders. Working quickly, Williams-Murphy revived the patient, who had a urinary tract infection and recovered after a few days in the hospital.<\/p>\n

Unfortunately, misunderstandings involving documents meant to guide end-of-life decision-making are \u201csurprisingly common,\u201d said Williams-Murphy, medical director of advance-care planning and end-of-life education for Huntsville Hospital Health System in Alabama.<\/p>\n

But health systems and state regulators don\u2019t systematically track mix-ups of this kind, and they receive little attention amid the push to encourage older adults to document their end-of-life preferences, experts acknowledge. As a result, information about the potential for patient harm is scarce.<\/p>\n

A new report<\/a> out of Pennsylvania, which has the nation\u2019s most robust system for monitoring patient-safety events, treats mix-ups involving end-of-life documents as medical errors\u2014a novel approach. It found that in 2016, Pennsylvania health care facilities reported nearly 100 events relating to patients\u2019 \u201ccode status\u201d\u2014their wish to be resuscitated or not, should their hearts stop beating and they stop breathing. In 29 cases, patients were resuscitated against their wishes. In two cases, patients weren\u2019t resuscitated despite making it clear they wanted this to happen.<\/p>\n

Medical providers get little or no training in how to respond to living wills, POLST forms and do-not-resuscitate orders.<\/p><\/blockquote>\n

The rest of the cases were \u201cnear misses\u201d\u2014problems caught before they had a chance to cause permanent harm.<\/p>\n

Most likely, this is an undercount, said Regina Hoffman, executive director of the Pennsylvania Patient Safety Authority, adding that she was unaware of similar data from any other state.<\/p>\n

Asked to describe a near miss, Hoffman, co-author of the report, said, \u201cPerhaps I\u2019m a patient who\u2019s come to the hospital for elective surgery and I have a DNR (do not resuscitate) order in my [medical] chart. After surgery, I develop a serious infection and a resident [physician] finds my DNR order. He assumes this means I\u2019ve declined all kinds of treatment, until a colleague explains that this isn\u2019t the case.\u201d<\/p>\n

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.<\/p>\n

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.<\/p>\n

Research by Dr. Ferdinando Mirarchi, medical director of the department of emergency medicine at the University of Pittsburgh Medical Center Hamot in Erie, PA, suggests that the potential for confusion surrounding end-of-life documents is widespread. In various studies, he has asked medical providers how they would respond to hypothetical situations involving patients with critical and terminal illnesses.<\/p>\n

In one study<\/a>, for instance, he described a 46-year-old woman brought to the ER with a heart attack [who] suddenly goes into cardiac arrest. Although she\u2019s 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.<\/p>\n

Only 43 percent of those doctors said they would intervene to save her life\u2014a troubling figure, Mirarchi said. Since this patient didn\u2019t have a terminal condition, her living will didn\u2019t apply to the situation at hand, and every physician should have been willing to offer aggressive treatment, he explained.<\/p>\n

Despite possible misunderstandings, your final wishes are more likely to be followed with these documents than without them.<\/p><\/blockquote>\n

In another study<\/a>, Mirarchi described a 70-year-old man with diabetes and cardiac disease who had a POLST form indicating he didn\u2019t want cardiopulmonary resuscitation but agreeing to a limited set of other medical interventions, including defibrillation (shocking his heart with an electrical current). Yet 75 percent of 223 emergency physicians surveyed said they wouldn\u2019t have pursued defibrillation if the patient had a cardiac arrest.<\/p>\n

One issue here: physicians assumed that defibrillation is part of cardiopulmonary resuscitation. That\u2019s a mistake: they\u2019re separate interventions. Another issue: physicians are often unsure what patients really want when one part of a POLST form says \u201cdo nothing\u201d (declining CPR) and another part says \u201cdo something\u201d (permitting other interventions).<\/p>\n

Mirarchi\u2019s work involves hypotheticals, not real-life situations. But it highlights significant practical confusion about end-of-life documents, said Dr. Scott Halpern, director of the Palliative and Advanced Illness Research Center at the University of Pennsylvania\u2019s Perelman School of Medicine.<\/p>\n

Attention to these problems is important but shouldn\u2019t be overblown, cautioned Dr. Arthur Derse, director of the center for bioethics and medical humanities at the Medical College of Wisconsin. \u201cAre there errors of misunderstanding or miscommunication? Yes. But you\u2019re more likely to have your wishes followed with one of these documents than without one,\u201d he said.<\/p>\n

Make 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, Derse advised. Without these conversations, documents can be difficult to interpret.<\/p>\n

Here are some basics about end-of-life documents:<\/p>\n

Living wills.<\/strong> A living will expresses your preferences for end-of-life care but is not a binding medical order. Instead, medical staff will interpret it based on the situation at hand, with input from your family and your surrogate decision-maker.<\/p>\n

Living wills become activated only when a person is terminally ill and unconscious or in a permanent vegetative state. A terminal illness is one from which a person is not expected to recover, even with treatment\u2014for instance, advanced metastatic cancer.<\/p>\n

Bouts of illness that can be treated\u2014such as an exacerbation of heart failure\u2014are \u201ccritical\u201d not \u201cterminal\u201d illnesses and should not activate a living will. To be activated, one or two physicians have to certify that your living will should go into effect, depending on the state where you live.<\/p>\n

DNRs.<\/strong> Do-not-resuscitate orders are binding medical orders, signed by a physician. A DNR order applies specifically to cardiopulmonary resuscitation (CPR) and directs medical personnel not to administer chest compressions, usually accompanied by mouth-to-mouth resuscitation, if someone stops breathing or their heart stops beating.<\/p>\n

The section of a living will specifying that you don\u2019t want CPR is a statement of a preference, not a DNR order.<\/p>\n

A DNR order applies only to a person who has gone into cardiac arrest. It does not mean that this person has refused other types of medical assistance, such as mechanical ventilation, defibrillation following CPR, intubation (the insertion of a breathing tube down a patient\u2019s throat), medical tests or intravenous antibiotics, among other measures.<\/p>\n

Even so, DNR orders are often wrongly equated with \u201cdo not treat\u201d at all, according to a 2011 review<\/a> in the Journal of General Internal Medicine<\/em>.<\/p>\n

POLST forms.<\/strong> A POLST form is a set of medical orders for a seriously ill or frail patient who could die within a year, signed by a physician, physician assistant or nurse practitioner.<\/p>\n

These forms, which vary by state, are meant to be prepared after a detailed conversation about a patient\u2019s prognosis, goals and values, and the potential benefits and harms of various treatment options.<\/p>\n

Problems have emerged with POLSTs\u2019 increased use. Some nursing homes are asking all patients to sign POLST forms, even those admitted for short-term rehabilitation or whose probable life expectancy exceeds a year, according to a recent article<\/a> authored by Charlie Sabatino, director of the American Bar Association Commission on Law and Aging. Also, medical providers\u2019 conversations with patients can be cursory, not comprehensive, and forms often aren\u2019t updated when a patient\u2019s medical condition changes, as recommended.<\/p>\n

\u201cThe POLST form is still relatively new and there\u2019s education that needs to be done,\u201d said Amy Vandenbroucke, executive director of the National POLST Paradigm<\/a>, an organization that promotes the use of POLST forms across the US. In a policy statement<\/a> issued last year and updated in April 2018, it stated that completion of POLST forms should always be voluntary, made with a patient\u2019s or surrogate decision-maker\u2019s knowledge and consent and offered only to people whose physician would not be surprised if they die within a year.<\/p>\n

KHN\u2019s coverage of these topics is supported by the John A. Hartford Foundation, the Gordon and Betty Moore Foundation and the SCAN Foundation.<\/em><\/p>\n","protected":false},"excerpt":{"rendered":"

It\u2019s all too easy for medical providers to misinterpret living wills and other end-of-life instructions. In a disturbing report, Judith Graham, a contributing columnist for Kaiser Health News (KHN), covers recent studies that have revealed problems. KHN posted her article…<\/span><\/p>\n

Read more When the Time Comes, Will Your Living Will Prevail?<\/span> ›<\/span><\/a><\/div>\n

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