The living will: Patients should be informed of the risks.

Living wills are designed to ensure that patients' preferences will be respected at the end of life should they lose capacity to make decisions. However, data on living will use suggest there are barriers to achieving this objective. Moreover, there is evidence that completion of a living will creates a risk of an unwanted outcome: the potential for premature withdrawal of interventions. We suggest a multifaceted approach to improve the ability of living wills to achieve their goals. However, acknowledgment of the current reality should oblige providers offering a living will to their patients to present a balanced view of living wills that includes enumeration of the risk, barriers to achieving the purported benefits, and alternatives to completing a living will, in addition to discussion of the potential benefits. This requires a change in current practice that would encourage shared decision making regarding whether completing a living will or other type of advance directive is desired by the patient and discourage the proliferation of living wills completed without providing these important advantages and disadvantages to the patient.

TRIAD IX: Can a Patient Testimonial Safely Help Ensure Prehospital Appropriate Critical Versus End-of-Life Care?

OBJECTIVE: The present study sought to assess the clarity of Physician Orders for Life-Sustaining Treatment (POLST) or Living Will (LW) documents alone or in combination with a video message/testimonial (VM). METHODS: Emergency medical services (EMS) personnel responded to survey questions about the meaning of stand-alone POLST and LW documents and those used in conjunction with emergent care scenarios. Personnel were randomized to receive documents only or documents with VM. Questions sought a code status for each scenario and a resuscitation decision. Code status responses were analyzed for consensus (95% response rate), resuscitation responses for correct treatment decisions. RESULTS: The survey response rate was 85%. Approximately half of emergency medical technician (EMT) respondents were EMT basic, and half EMT respondents were paramedic, with an average age of 42 years. Less than half had previous POLST/LW training averaging 2 hours. Consensus failed to be reached for stand-alone documents. For clinical scenarios, responses to POLST documents specifying do not resuscitate/comfort measures only or cardiopulmonary resuscitation/full treatment exceeded 80% for code status designation and correct resuscitation decisions. Other POLST resuscitation/treatment combinations showed more disparate responses, and most benefited from VM with changes in responses of 20% or more (P ≤ 0.025). Code status responses to LW-based scenarios evidenced a nonconsensus majority (79%-83%) that was significantly affected with VMs (≥12%, P ≤ 0.004); half evidenced large changes in resuscitation decisions (49%, P < 0.001). CONCLUSIONS: Document clarity, judged by consensus response, was rarely evidenced. video message/testimonial seems to be a helpful aid to both POLST and LWs. Standardized education and training reveal opportunities to improve patient safety to ensure patient wishes.

TRIAD XI: Utilizing simulation to evaluate the living will and POLST ability to achieve goal concordant care when critically ill or at end-of-life-The Realistic Interpretation of Advance Directives.

OBJECTIVE: Utilize simulation to evaluate if living wills (LW) or POLST achieves goal concordant Care (GCC) in a medical crisis. METHODS: Nurses and resident-physicians from a single center were randomized to a clinical scenario with a living will (LW), physician orders for life sustaining treatment (POLST) or no document. Primary outcomes were resuscitation decision and time to decision. Secondary outcome was the effect of education. RESULTS: Total enrollment was 57 and less than 30% received prior training. Types of directives were linked to resuscitation decisions (P = .019). Participants randomized to "No Document" or POLST specifying "CPR" performed resuscitation. If a terminal condition presented with a POLST/ do not resuscitate-comfort measures only (DNR-CMO), 73% resuscitated. The LW or POLST specifying DNR combined with medical support resulted in resuscitations in 29% or more of the scenarios. Documents did not significantly affect median time-to-decision (P = .402) but decisions for "No Document" and POLST/CPR were at least 10 s less than other scenarios. Scenarios involving POLST DNR/Limited Treatment had the highest median time of 43 s. Prior training in LWs and POLST exerted a 10% improvement in decision making (P = .537). CONCLUSION: GCC was not always achieved with a LW or POLST. This conclusion supports prior research identifying problems with the interpretation and discordance with LW's and POLST.

TRIAD XII: Are Patients Aware of and Agree With DNR or POLST Orders in Their Medical Records.

OBJECTIVE: The aim of the study was to determine (1) whether do-not-resuscitate (DNR) orders created upon hospital admission or Physician Orders for Life-Sustaining Treatment (POLST) are consistent patient preferences for treatment and (2) patient/health care agent (HCA) awareness and agreement of these orders. METHODS: We identified patients with DNR and/or POLST orders after hospital admission from September 1, 2017, to September 30, 2018, documented demographics, relevant medical information, evaluated frailty, and interviewed the patient and when indicated the HCA. RESULTS: Of 114 eligible cases, 101 met inclusion criteria. Patients on average were 76 years old, 55% were female, and most white (85%). Physicians (85%) commonly created the orders. A living will was present in the record for 22% of cases and a POLST in 8%. The median frailty score of "4" (interquartile range = 2.5) suggested patients who require minimal assistance. Thirty percent of patients requested cardiopulmonary resuscitation and 63% wanted a trial attempt of aggressive treatment if in improvement is deemed likely. In 25% of the cases, patients/HCAs were unaware of the DNR order, 50% were unsure of their prognosis, and another 40% felt their condition was not terminal. Overall, 44% of the time, the existing DNR, and POLST were discordant with patient wishes and 38% were rescinded. Of the 6% not rescinded, further clarifications were required. Discordant orders were associated with younger, slightly less-frail patients. CONCLUSIONS: Do-not-resuscitate and POLST orders can often be inaccurate, undisclosed, and discordant with patient wishes for medical care. Patient safety and quality initiatives should be adopted to prevent medical errors.

TRIAD VIII: Nationwide Multicenter Evaluation to Determine Whether Patient Video Testimonials Can Safely Help Ensure Appropriate Critical Versus End-of-Life Care.

OBJECTIVE: End-of-life interventions should be predicated on consensus understanding of patient wishes. Written documents are not always understood; adding a video testimonial/message (VM) might improve clarity. Goals of this study were to (1) determine baseline rates of consensus in assigning code status and resuscitation decisions in critically ill scenarios and (2) determine whether adding a VM increases consensus. METHODS: We randomly assigned 2 web-based survey links to 1366 faculty and resident physicians at institutions with graduate medical education programs in emergency medicine, family practice, and internal medicine. Each survey asked for code status interpretation of stand-alone Physician Orders for Life-Sustaining Treatment (POLST) and living will (LW) documents in 9 scenarios. Respondents assigned code status and resuscitation decisions to each scenario. For 1 of 2 surveys, a VM was included to help clarify patient wishes. RESULTS: Response rate was 54%, and most were male emergency physicians who lacked formal advanced planning document interpretation training. Consensus was not achievable for stand-alone POLST or LW documents (68%-78% noted "DNR"). Two of 9 scenarios attained consensus for code status (97%-98% responses) and treatment decisions (96%-99%). Adding a VM significantly changed code status responses by 9% to 62% (P ≤ 0.026) in 7 of 9 scenarios with 4 achieving consensus. Resuscitation responses changed by 7% to 57% (P ≤ 0.005) with 4 of 9 achieving consensus with VMs. CONCLUSIONS: For most scenarios, consensus was not attained for code status and resuscitation decisions with stand-alone LW and POLST documents. Adding VMs produced significant impacts toward achieving interpretive consensus.

TRIAD IV: Nationwide Survey of Medical Students' Understanding of Living Wills and DNR Orders.

INTRODUCTION: Living wills are a form of advance directives that help to protect patient autonomy. They are frequently encountered in the conduct of medicine. Because of their impact on care, it is important to understand the adequacy of current medical school training in the preparation of physicians to interpret these directives. METHODS: Between April and August 2011 of third and fourth year medical students participated in an internet survey involving the interpretation of living wills. The survey presented a standard living will as a "stand-alone," a standard living will with the addition an emergent clinical scenario and then variations of the standard living will that included a code status designation ("DNR," "Full Code," or "Comfort Care"). For each version/ scenario, respondents were asked to assign a code status and choose interventions based on the cases presented. RESULTS: Four hundred twenty-five students from medical schools throughout the country responded. The majority indicated they had received some form of advance directive training and understood the concept of code status and the term "DNR." Based on a stand-alone document, 15% of respondents correctly denoted "full code" as the appropriate code status; adding a clinical scenario yielded negligible improvement. When a code designation was added to the living will, correct code status responses ranged from 68% to 93%, whereas correct treatment decisions ranged from 18% to 78%. Previous training in advance directives had no impact on these results. CONCLUSION: Our data indicate that the majority of students failed to understand the key elements of a living will; adding a code status designations improved correct responses with the exception of the term DNR. Misunderstanding of advance directives is a nationwide problem and jeopardizes patient safety. Medical School ethics curricula need to be improved to ensure competency with respect to understanding advance directives.

TRIAD VI: how well do emergency physicians understand Physicians Orders for Life Sustaining Treatment (POLST) forms?

BACKGROUND: Physician Orders for Life-Sustaining Treatment (POLST) documents are active medical orders to be followed with intention to bridge treatment across health care systems. We hypothesized that these forms can be confusing and jeopardize patient safety. OBJECTIVES: The aim of this study was to determine whether POLST documents are confusing in the emergency department setting and how confusion impacts the provision or withholding of lifesaving interventions. METHODS: Members of the Pennsylvania chapter of the American College of Emergency Physicians were surveyed between September and October 2013. Respondents were to determine code status and treatment decisions in scenarios of critically ill patients with POLST documents who emergently arrest. Combinations of resuscitations (do not resuscitate [DNR], cardiopulmonary resuscitation) and levels of treatment (full, limited, comfort measures) were represented. Responses were summarized as percentages and analyzed by subgroup using the Fisher exact test. P = 0.05 was considered significant. We defined confusion in response as absence of consensus (supermajority of 95%). RESULTS: Our response rate was 26% (223/855). For scenarios specifying DNR and either full or limited treatment, most chose DNR (59%-84%) and 25% to 75% chose resuscitation. When the POLST specified DNR with comfort measures, 90% selected DNR and withheld resuscitation. When cardiopulmonary resuscitation/full treatment was presented, 95% selected "full code" and resuscitation. Physician age and experience significantly affected response rates; prior POLST education had no impact. In most scenarios depicted, responses reflected confusion over its interpretation. CONCLUSIONS: Significant confusion exists among members of the Pennsylvania chapter of the American College of Emergency Physicians regarding the use of POLST in critically ill patients. This confusion poses risk to patient safety. Additional training and/or safeguards are needed to allow patient choice as well as protect their safety.

TRIAD VII: do prehospital providers understand Physician Orders for Life-Sustaining Treatment documents?

BACKGROUND: Physician Orders for Life-Sustaining Treatment (POLST) documents are medical orders intended to honor patient choice in the hospital and prehospital settings. We hypothesized that prehospital personnel will find these forms confusing. OBJECTIVES: The aim of this study was to determine whether POLST documents accord consensus in determining code status and treatment decisions among emergency medical services providers on the basis of an Internet survey. Consensus in this context reflects content clarity. METHODS: A statewide survey of Pennsylvania emergency medical technicians and paramedics was conducted from October 2013 to January 2014. Respondents supplied code status and treatment decisions for scenarios involving critically ill patients who present with POLST documents and then develop cardiac arrest. The gamut of combinations of resuscitations (do not resuscitate [DNR], cardiopulmonary resuscitation) and treatment (full, limited, comfort measures) was represented. Subgroup analysis was done using the Fisher exact test with a Bonferroni-corrected P = 0.017 as significant. We defined consensus as a supermajority of 95%. RESULTS: Response to the survey was 18.4% (1069/5800). For scenarios specifying DNR and full or limited treatment, most chose DNR (59%-84%) and 25% to 75% chose resuscitation. With DNR and comfort measures specified, approximately 85% selected DNR and withheld resuscitation. When cardiopulmonary resuscitation/full treatment was presented, 95% selected "full code" and resuscitation. Respondent age significantly affected response rates (P ≤ 0.004); prior POLST education had no impact. For most scenarios, responses failed to attain consensus, suggesting confusion in interpretation of the form. CONCLUSIONS: In the Pennsylvania prehospital setting, POLST documents can be confusing, presenting a risk to patient safety. Additional research, standardized education, training, and/or safeguards are required to facilitate patient choice and protect safety.

TRIAD III: nationwide assessment of living wills and do not resuscitate orders.

BACKGROUND: Concern exists that living wills are misinterpreted and may result in compromised patient safety. OBJECTIVE: To determine whether adding code status to a living will improves understanding and treatment decisions. METHODS: An Internet survey was conducted of General Surgery, and Family, Internal, and Emergency Medicine residencies between May and December 2009. The survey posed a fictitious living will with and without additional clarification in the form of code status. An emergent patient care scenario was then presented that included medical history and signs/symptoms. Respondents were asked to assign a code status and choose appropriate intervention. Questions were formatted as dichotomous responses. Correct response rate was based on legal statute. Significance of changes in response due to the addition of either clinical context (past medical history/signs/symptoms) or code status was assessed by contingency table analysis. RESULTS: Seven hundred sixty-eight faculty and residents at accredited training centers in 34 states responded. At baseline, 22% denoted "full code" as the code status for a typical living will, and 36% equated "full care" with a code status DNR. Adding clinical context improved correct responses by 21%. Specifying code status further improved correct interpretation by 28% to 34%. Treatment decisions were either improved 12-17% by adding code status ("Full Code," "Hospice Care") or worsened 22% ("DNR"). CONCLUSION: Misunderstanding of advance directives is a nationwide problem. Addition of code status may help to resolve the problem. Further research is required to ensure safety, understanding, and appropriate care to patients.

A living will misinterpreted as a DNR order: confusion compromises patient care.

BACKGROUND: Advance directives are becoming ever more commonplace in the United States. Correct interpretation of living wills and do-not-resuscitate (DNR) orders is essential if patient safety and autonomy are to be preserved. OBJECTIVES: 1) To recount a case in which a living will was misinterpreted as a DNR order; 2) To make known the ramifications of this misinterpretation; 3) To advocate for improved education of health care professionals regarding the interpretation and implementation of advance directives. CASE REPORT: Mr. S. is an 89-year-old nursing home resident who agreed to the terms of a living will. This living will was subsequently misinterpreted as a DNR order by the patient's physician. This misinterpretation set off a cascade of events that led to the completion of an out-of-hospital DNR order and a compromise of patient care. CONCLUSION: This case study underscores the potential for misunderstanding of an advance directive and the consequent effect on patient care. Likely this is the result of a fundamental lack of understanding about the terminology and definitions inherent in an advance directive document.

TRIAD II: do living wills have an impact on pre-hospital lifesaving care?

BACKGROUND: Living wills accompany patients who present for emergent care. To the best of our knowledge, no studies assess pre-hospital provider interpretations of these instructions. OBJECTIVES: Determine how a living will is interpreted and assess how interpretation impacts lifesaving care. DESIGN SETTING: Three-part survey administered at a regional emergency medical system educational symposium to 150 emergency medical technicians (EMTs) and paramedics. Part I assessed understanding of the living will and do-not-resuscitate (DNR) orders. Part II assessed the living will's impact in clinical situations of patients requiring lifesaving interventions. Part III was similar to part II except a code status designation (full code) was incorporated into the living will. RESULTS: There were 127 surveys completed, yielding an 87% response rate. The majority were male (55%) and EMTs (74%). The average age was 44 years and the average duration of employment was 15 years. Ninety percent (95% confidence interval [CI] 84.6-95.4%) of respondents determined that, after review of the living will, the patient's code status was DNR, and 92% (95% CI 86.5-96.6%) defined their understanding of DNR as comfort care/end-of-life care. When the living will was applied to clinical situations, it resulted in a higher proportion of patients being classified as DNR as opposed to full code (Case A 78% [95% CI 71.2-85.6%] vs. 22% [95% CI 14.4-28.8%], respectively; Case B 67% [95% CI 58.4-74.9%] vs. 33% [95% CI 25.1-1.6%], respectively; Case C 63% [95% CI 55.1-71.9%] vs. 37% [95% CI 28.1-44.9%]), respectively. With the scenarios presented, this DNR classification resulted in a lack of or a delay in lifesaving interventions. Incorporating a code status into the living will produced statistically significant increases in the provision of lifesaving care. In Case A, intubation increased from 15% to 56% (p < 0.0001); Case B, defibrillation increased from 40% to 59% (p < 0.0001); and Case C, defibrillation increased from 36% to 65% (p < 0.0001). CONCLUSIONS: Significant confusion and concern for patient safety exists in the pre-hospital setting due to the understanding and implementation of living wills and DNR orders. This confusion can be corrected by implementing clearly defined code status into the living will.

Does a living will equal a DNR? Are living wills compromising patient safety?

Living wills are thought to protect the medical decision-making capacity of patients. Presented are three case scenarios of patients with living wills presenting to health care facilities for treatment, and their hospital courses. Living wills have never been thought to compromise patient care or safety, but their use has not been adequately studied with respect to risks, benefits, or consequences. This case series will define a scenario as well as how that scenario was affected by the presence of a living will. In addition, existing data regarding the care provided to patients with a code status designation of DNR (do not resuscitate) are reviewed.