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Mirarchi F, Pope TM. Widespread Misinterpretation of Advance Directives and Portable Orders for Life-Sustaining Treatments Threatens Patient Safety and Causes Undertreatment and Overtreatment. J Patient Saf 2023; 19:289-292. [PMID: 37318847 PMCID: PMC10373840 DOI: 10.1097/pts.0000000000001137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Affiliation(s)
- Ferdinando Mirarchi
- From the Department of Emergency Medicine, UPMC Hamot, and UPMC Northern Tier, Erie, Pennsylvania
- MIDEO Advance Care Planning Service Line, US Acute Care Solutions Research Group, Canton, Ohio
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Driggers KE, Dishman SE, Chung KK, Olsen CH, Ryan AB, McLawhorn MM, Johnson LS. Perceptions of care following initiation of do-not-resuscitate orders. J Crit Care 2022; 69:154008. [DOI: 10.1016/j.jcrc.2022.154008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 01/29/2022] [Accepted: 02/07/2022] [Indexed: 11/16/2022]
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Mirarchi F, Cammarata C, Cooney TE, Juhasz K, Terman SA. TRIAD IX: Can a Patient Testimonial Safely Help Ensure Prehospital Appropriate Critical Versus End-of-Life Care? J Patient Saf 2021; 17:458-466. [PMID: 28622155 DOI: 10.1097/pts.0000000000000387] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
| | | | - Timothy E Cooney
- From the Department of Emergency Medicine, UPMC Hamot, Erie, Pennsylvania
| | - Kristin Juhasz
- From the Department of Emergency Medicine, UPMC Hamot, Erie, Pennsylvania
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Kurin M, Mirarchi F. The living will: Patients should be informed of the risks. J Healthc Risk Manag 2021; 41:31-39. [PMID: 33496056 DOI: 10.1002/jhrm.21459] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Revised: 12/13/2020] [Accepted: 01/04/2021] [Indexed: 11/08/2022]
Abstract
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.
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Affiliation(s)
- Michael Kurin
- Digestive Health Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Ferdinando Mirarchi
- Department of Emergency Medicine, University of Pittsburgh Medical Center Hamot, Erie, Pennsylvania, USA
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Mirarchi F, Juhasz K, Cooney T, Desiderio D. 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. J Healthc Risk Manag 2020; 41:22-30. [PMID: 33301646 DOI: 10.1002/jhrm.21453] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
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.
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Affiliation(s)
| | - Kristin Juhasz
- Department of Emergency Medicine, UPMC Hamot, Erie, Pennsylvania
| | - Timothy Cooney
- Department of Emergency Medicine, UPMC Hamot, Erie, Pennsylvania
| | - Daniel Desiderio
- Department of Emergency Medicine, UPMC Hamot, Erie, Pennsylvania
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Craig DP, Ray R, Harvey D, Shircore M. Factors Which Influence Hospital Doctors' Advance Care Plan Adherence. J Pain Symptom Manage 2020; 59:1109-1126. [PMID: 31846704 DOI: 10.1016/j.jpainsymman.2019.12.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Revised: 11/27/2019] [Accepted: 12/02/2019] [Indexed: 10/25/2022]
Abstract
CONTEXT Advances in medicine have seen changes in mortality in Western countries. Simultaneously, countries such as Australia, Canada, U.S., New Zealand, U.K., and Germany have encouraged consumer-directed care and advance care plan (ACP) completion, giving patients a voice despite incapacity. Adhering to ACPs relies on the decision-making of treating doctors, making hospital doctors key partners, and their perspectives on ACP adherence critical. OBJECTIVES The aim of this review was to explore and map existing research on factors associated with hospital doctors adhering to adult patients' ACPs. METHODS A scoping review of English language publications within CINAHL, Emcare, Medline, PsycInfo, and Scopus was conducted, following PRISMA Extension for Scoping Reviews (PRISMA-ScR) guidelines. ACPs were defined as adult patient-generated, written health care directions or values statements. Studies of any design, which reported original research associated with hospital doctors adhering to ACPs, were included. RESULTS Twenty-seven publications were included in the final analysis. Results suggested ACPs were thought potentially useful; however, adherence has been associated with doctors' attributes (e.g., specialty, seniority), attitudes toward ACP (e.g., applicability), and legal knowledge. CONCLUSION Current literature suggests doctors hold largely positive attitudes toward ACPs that provide useful patient information that enables doctors to make appropriate treatment decisions. Doctors often perceive limitations to ACP applicability due to legal requirements or ambiguity of patient outcome goals.
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Affiliation(s)
- Denise Patricia Craig
- College of Medicine and Dentistry, James Cook University, Cairns, Queensland, Australia.
| | - Robin Ray
- College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
| | - Desley Harvey
- College of Healthcare Sciences, James Cook University, Cairns, Queensland, Australia
| | - Mandy Shircore
- College of Business, Law and Governance, James Cook University, Cairns, Queensland, Australia
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Mirarchi FL, Juhasz K, Cooney TE, Puller J, Kordes T, Weissert L, Lewis ML, Intrieri B, Cook N. TRIAD XII: Are Patients Aware of and Agree With DNR or POLST Orders in Their Medical Records. J Patient Saf 2019; 15:230-237. [PMID: 31449196 PMCID: PMC6728055 DOI: 10.1097/pts.0000000000000631] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
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.
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TRIAD IV: Nationwide Survey of Medical Students' Understanding of Living Wills and DNR Orders. J Patient Saf 2017; 12:190-196. [PMID: 24583955 DOI: 10.1097/pts.0000000000000083] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
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.
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White BP, Willmott L, Williams G, Cartwright C, Parker M. The role of law in decisions to withhold and withdraw life-sustaining treatment from adults who lack capacity: a cross-sectional study. JOURNAL OF MEDICAL ETHICS 2017; 43:327-333. [PMID: 27531924 DOI: 10.1136/medethics-2016-103543] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/16/2016] [Revised: 06/20/2016] [Accepted: 07/15/2016] [Indexed: 06/06/2023]
Abstract
OBJECTIVES To determine the role played by law in medical specialists' decision-making about withholding and withdrawing life-sustaining treatment from adults who lack capacity, and the extent to which legal knowledge affects whether law is followed. DESIGN Cross-sectional postal survey of medical specialists. SETTING The two largest Australian states by population. PARTICIPANTS 649 medical specialists from seven specialties most likely to be involved in end-of-life decision-making in the acute setting. MAIN OUTCOME MEASURES Compliance with law and the impact of legal knowledge on compliance. RESULTS 649 medical specialists (of 2104 potential participants) completed the survey (response rate 31%). Responses to a hypothetical scenario found a potential low rate of legal compliance, 32% (95% CI 28% to 36%). Knowledge of the law and legal compliance were associated: within compliers, 86% (95% CI 83% to 91%) had specific knowledge of the relevant aspect of the law, compared with 60% (95% CI 55% to 65%) within non-compliers. However, the reasons medical specialists gave for making decisions did not vary according to legal knowledge. CONCLUSIONS Medical specialists prioritise patient-related clinical factors over law when confronted with a scenario where legal compliance is inconsistent with what they believe is clinically indicated. Although legally knowledgeable specialists were more likely to comply with the law, compliance in the scenario was not motivated by an intention to follow law. Ethical considerations (which are different from, but often align with, law) are suggested as a more important influence in clinical decision-making. More education and training of doctors is needed to demonstrate the role, relevance and utility of law in end-of-life care.
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Affiliation(s)
- Benjamin P White
- Australian Centre for Health Law Research, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Lindy Willmott
- Australian Centre for Health Law Research, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Gail Williams
- School of Population Health, University of Queensland, Brisbane, Queensland, Australia
| | - Colleen Cartwright
- ASLaRC, Southern Cross University, Tweed Heads, New South Wales, Australia
| | - Malcolm Parker
- University of Queensland, Brisbane, Queensland, Australia
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TRIAD VI: how well do emergency physicians understand Physicians Orders for Life Sustaining Treatment (POLST) forms? J Patient Saf 2015; 11:1-8. [PMID: 25692502 DOI: 10.1097/pts.0000000000000165] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
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.
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TRIAD III: Nationwide Assessment of Living Wills and Do Not Resuscitate Orders. J Emerg Med 2012; 42:511-20. [DOI: 10.1016/j.jemermed.2011.07.015] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2011] [Accepted: 07/13/2011] [Indexed: 11/20/2022]
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Katsetos AD, Mirarchi FL. A Living Will Misinterpreted as a DNR Order: Confusion Compromises Patient Care. J Emerg Med 2011; 40:629-32. [DOI: 10.1016/j.jemermed.2008.11.014] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2008] [Revised: 09/17/2008] [Accepted: 11/08/2008] [Indexed: 10/21/2022]
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TRIAD II: Do Living Wills Have an Impact on Pre-Hospital Lifesaving Care? J Emerg Med 2009; 36:105-15. [DOI: 10.1016/j.jemermed.2008.10.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2007] [Revised: 09/23/2008] [Accepted: 10/10/2008] [Indexed: 11/21/2022]
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