Understanding What People Intend: Is It Possible From Written Advance Directives?

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.