How end-of-life documents create dilemmas in the ER: 6 insights

Clinician's misunderstanding of end-of-life documents can have significant ramifications for patients, yet most U.S. health systems and state regulators don't track these mix-ups when they surface, according to a column written by Kaiser Health News and published in The Washington Post Aug. 5.

Here are five things to know:

1. Pennsylvania has the U.S.'s largest system for monitoring patient safety events, which labels mix-ups pertaining to end-of-life documents as medical errors. In 2016, Pennsylvania healthcare facilities reported nearly 100 events relating to patients' resuscitation wishes. There were 29 cases of patients being resuscitated against their wishes and two cases of patients not being resuscitated when they should have been. These figures are likely an undercount, Regina Hoffman, executive director of Harrisburg-based Pennsylvania Patient Safety Authority, told Kaiser Health News.

2. These mix-ups are "surprisingly common," Monica Williams-Murphy, MD, critical care specialist at Huntsville (Ala.) Hospital Health System, told Kaiser Health News. Yet, these events are barely communicated to health systems and state regulators. As a result, information on how this miscommunication potentially harms patients is limited.

3. Physicians and nurses receive little training to understand and/or interpret living wills, DNR orders or Physician Orders for Life-Sustaining Treatment, according to Ms. Hoffman.

"Perhaps I'm a patient who's come to the hospital for elective surgery, and I have a DNR order in my chart. After surgery, I develop a serious infection and a resident [physician] finds my DNR order. He assumes this means I've declined all kinds of treatment, until a colleague explains that this isn't the case," Ms. Hoffman told Kaiser Health News.

4. Communication breakdowns in high-pressure environments emergency departments also foster misunderstandings. Ferdinando Mirarchi, DO, medical director of the department of emergency medicine at Erie, Pa.-based University of Pittsburgh (Pa.) Medical Center Hamot, has conducted several studies polling physicians on how they would react to various hypothetical situations involving end-of-life care decisions for patients in the ED.

5. In one study, only 43 percent of physician respondents said they would intervene to save the life of a 46-year-old woman who went into cardiac arrest after a heart attack, citing her living will refusing life-saving medical interventions. However, since the woman did not have a terminal condition, the living will would not apply to this situation and "every physician should have been willing to offer aggressive treatment," according to the report. Physicians are unsure what patients want when one part of their POLST form indicates to do nothing and another part says to do something, according to the report. In another study, Dr. Mirarchi described a situation involving a 70-year-old diabetic man with cardiac disease who had a POLST form, indicating he did not want cardiopulmonary resuscitation, but agreed to a limited number of other medical interventions, including defibrillation. Seventy-five percent of 223 emergency physicians responded they would have not used defibrillation, assuming defibrillation is included within cardiopulmonary resuscitation, even though they are separate interventions.

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