A Living Will Misinterpreted as a DNR Order: Confusion Compromises Patient Care

Addressing end-of-life care in the chronically ill: Conversations in the emergency department

Patients present to the emergency department in various stages of chronic illness. Advance directives (ADs) aid emergency physicians in making treatment decisions, but only a minority of Americans have completed an AD, and the percentage of those who have discussed their end-of-life wishes may be even lower. This article addresses the use of common ADs and roadblocks to their use from the perspectives of families, patients, and physicians. Cases to examine new approaches to optimizing end-of-life conversations in patients who are chronically ill, such as the Improving Palliative Care in Emergency Medicine Project, a decision-making framework that opens discussion for patients to gain understanding and determine preferences, and the Brief Negotiated Interview, a 7-minute, scripted, motivational interview that determines willingness for behavior change and initiates care planning, are used.

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.

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.

Burnout and Related Factors of Nurses Caring for DNR Patients in Intensive Care Units, South Korea

This study examined the factors related to burnout, depression, job stress, and job satisfaction in intensive care unit (ICU) nurses caring for do not resuscitate (DNR) patients, as well as analyzed any differences. A cross-sectional descriptive design was employed. Study participants involved a total of 115 nurses caring for DNR patients in ICUs in South Korean hospitals. Measures involved a demographic form, Copenhagen Burnout Inventory (CBI), Center for Epidemiologic Studies Depression Scale, Nursing Job Stress Scale (Korean version), and Nursing Job Satisfaction Scale (Korean version). Data were collected from February to March 2017. The analyses illustrated a higher level of burnout, a slightly lower level of depression, a slightly lower level of nursing job stress, and a very slightly higher level of nursing job satisfaction compared with the median value of the score range for each scale. Burnout had a significant, positive relationship with depression and nursing job stress, and depression had a significant, positive relationship with nursing job stress. This study illuminates preliminary evidence that ICU nurses who are caring for DNR patients have a higher level of burnout compared with the median value of the score range in the CBI (Korean version). Burnout, depression, job stress, and job satisfaction were interrelated in ICU nurses.

Nurses' perceptions of medical procedures and nursing practices for older patients with non-cancer long-term illness and do-not-attempt-resuscitation orders: A vignette study

Aim

To elucidate influence of a do-not-attempt-resuscitation (DNAR) order on nurses' perceptions of the medical procedures and nursing practices for non-cancer older patients.

Design

A vignette-based questionnaire study.

Methods

A questionnaire survey asking nurses their perceptions of clinical practices for the following three vignettes was performed in a community hospital in Japan (N = 120): the control vignettes with an older patient with repeated heart failure who was living alone and the other two with either an absence of relatives or a diagnosis of dementia. We also prepared additions to each vignette describing a DNAR order.

Results

Nurses' perception on cardiopulmonary resuscitation, defibrillation, blood tests and intravenous nutrition showed statistically significant and minimally important declines after the DNAR order compared with before for all three vignettes (p < .001). DNAR orders can influence nurses' perceptions of clinical practices for non-cancer older patients with chronic heart failure.

Review of Ordering Don't Resuscitate in Iranian Dying Patients

Making decision on not to resuscitate is a confusing, conflicting and complex issue and depends on each country's culture and customs. Therefore, each country needs to take action in accordance with its cultural, ethical, religious and legal contexts to develop guidelines in this regard. Since the majority of Iran's people are Muslims, and in Islam, the human life is considered sacred, based on the values of the community, an Iranian Islamic agenda needs to be developed not taking measures about resuscitation of dying patients. It is necessary to develop an Iranian Islamic guidelines package in order to don't resuscitate in dying patients.

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.

Decisions by Default: Incomplete and Contradictory MOLST in Emergency Care

OBJECTIVES

What patients intend when they make health care choices and whether they understand the meaning of orders for life-sustaining treatment forms is not well understood. The purpose of this study was to analyze the directives from a sample of emergency department (ED) patients' MOLST forms.

PROCEDURES

MOLST forms that accompanied 100 patients who were transported to an ED were collected and their contents analyzed. Data categories included age, gender, if the patient completed the form for themselves, medical orders for life-sustaining treatment including intubation, ventilation, artificial nutrition, artificial fluids or other treatment, and wishes for future hospitalization or transfer. Frequencies of variables were calculated and the associations between them were determined using chi-square. An a priori list of combinations of medical orders that were contradictory was developed. Contradictions with Orders for CPR (cardiopulmonary resuscitation) included the choice of one or more of the following: Comfort care; Limited intervention; Do Not Intubate; No rehospitalization; No IV (intravenous) fluids; and No antibiotics. Contradictions with DNR orders included the choice of one or more of the following: Intubation; No limitation on interventions. Contradictions with orders for Comfort Care were as follows: Send to the hospital; Trial period of IV fluids; Antibiotics. The frequencies of coexisting but contradictory medical orders were calculated using crosstabs. Free text responses to the "other instructions" section were submitted to content analysis.

RESULTS

Sixty-nine percent of forms reviewed had at least one section left blank. Inconsistencies were found in patient wishes among a subset (14%) of patients, wherein their desire for "comfort measures only" seemed contradicted by a desire to be sent to the hospital, receive IV fluids, and/or receive antibiotics.

CONCLUSIONS

Patients and proxies may believe that making choices and documenting some, but not all, of their wishes on the MOLST form is sufficient for directing their end-of-life care. The result of making some, but not all, choices may result in patients receiving undesired, extraordinary, or invasive care.

What is the true definition of a "Do-Not-Resuscitate" order? A Japanese perspective

Background

Japan has no official guidelines for do-not-resuscitate (DNR) orders. Therefore, we investigated the effect of DNR orders on physician decision making in relation to performing noncardiopulmonary resuscitation (CPR) and CPR procedures.

Methods

A case-scenario-based questionnaire that included a case of advanced cancer, a case of advanced dementia, and a case of nonadvanced heart failure was administered to physicians. The questions determined whether physicians would perform different non-CPR procedures and CPR procedures in the presence or absence of DNR orders. The number of non-CPR procedures each physician would perform and the number of physicians who would perform each non-CPR and CPR procedure in the absence and presence of DNR ocrders were compared. Physicians from three Japanese municipal acute care hospitals participated.

Results

We analyzed 111 of 161 (69%) questionnaires. Physicians would perform significantly fewer non-CPR procedures in the presence of DNR orders than in the absence of DNR orders for all three case scenarios (median [interquartile range] percentages: Case 1: 72% [45%–90%] vs 100% [90%–100%]; Case 2: 55% [36%–72%] vs 91% [63%–100%]; Case 3: 78% [55%–88%] vs 100% [88%–100%]). Fewer physicians would perform non-CPR and CPR procedures in the presence of DNR orders than in the absence of DNR orders. However, considerable numbers of physicians would perform electric shock treatment for ventricular fibrillation in the presence of DNR orders (Case 1: 26%; Case 2: 16%; Case 3: 20%).

Conclusion

DNR orders affect physician decision making about performing non-CPR procedures. Although some physicians would perform CPR for ventricular fibrillation in the presence of DNR orders, others would not. Therefore, a consensus definition for DNR orders should be developed in Japan, otherwise DNR orders may cause harm.

Preventing Safety Hazards Associated With Do-Not-Resuscitate Orders

Do-not-resuscitate orders can promote patients' dignity near the end of life, but they also can carry safety hazards associated with miscommunication and inappropriate withdrawal of certain kinds of care. Oncology nurses have a responsibility to identify these potential hazards and to intervene as necessary.
.