Regina M. Hoffman, MBA, BSN, RN, CPPS
Executive Director
Pennsylvania Patient Safety Authority

Ferdinando L. Mirarchi, D.O., FAAEM, FACEP*
Medical Director
Department of Emergency Medicine, UPMC Hamot
Chief Medical & Scientific Officer of the Institute on HealthCare Directives
Founder of MIDEO™ (My Informed Decision on VidEO)

Corresponding Author

Regina M. Hoffman

* Dr. Mirarchi is an owner of Video Directives, LLC. Ms. Hoffman and the Editor have no financial relationship with products or services discussed in this editorial.

From the Executive Director's Desk

An unconscious patient shows up with the words "DO NOT RESUSCITATE" tattooed across his chest and goes into cardiac arrest.¹ What do you do?

Does a little attorney sitting on your shoulder say you must resuscitate this patient because a tattoo across the chest has no legal standing? Does your own internal ethical compass tell you not to? Surely, someone who has gone to such lengths to communicate this message must mean it, right?

This real-life story engaged a doctor and myself (a nurse) on social media late one evening as the national debate around this actual event ensued. We have each written a section of this commentary.

We represent an entire healthcare community that is faced with making these critical decisions when time is of the essence. We are also forced to live with those decisions when we find out later that we had incorrect information. It is no more comforting to know a person's last moments were spent receiving medical interventions that they did not want than knowing a person was not resuscitated who wished to live.

In 2016, acute healthcare facilities in the Commonwealth reported through the Pennsylvania Patient Safety Reporting System (PA-PSRS) nearly 100 events involving the code status or treatment level of patients. Twenty-nine patients were resuscitated against their wishes. Two patients were not treated when their wishes indicated they should have been. The remaining cases represent near misses that could have affected the patient, but were resolved before harm occurred.

The Pennsylvania Patient Safety Authority is unable to verify whether the do not resuscitate (DNR) orders or physician orders for life-sustaining treatment (POLST) were appropriate, correctly created, or verified prior to these patient safety events occurring in real time.

Examples include the following:*

Failed to initiate cardiopulmonary resuscitation (CPR) or call a code. Advance directive stated patient wanted CPR.

CPR was initiated as per electronic record stated "CPR assess needed," so it needed to be treated as full code until otherwise ordered. RN showed code team the POLST copy and during the code, one of the ED MDs called family who stated to stop interventions at that time. Patient had already had compressions done and an attempt at starting a central line until patient and family wishes were clarified.

Patient in ventricular fivrillation (V-fib). RN entered the patient room to find the patient unresponsive and without a pulse. A DNR bracelet was not visualized on the patient so a code was initiated along with CPR. DNR order was found and the code and CPR was immediately stopped.

_________
* Details of PA-PRSR event narratives in this article have been deidentified to preserve confidentiality.

A Physician's Perspective

This is yet another example of major communication failures within the larger healthcare system—failures about which patients are aware. Given the expanse of knowledge and technological capacity available to us as medical professionals, a patient should never feel the need to result to such extremes as permanently marking their body to prevent an error in over-treatment from occurring. This unfortunate situation reveals the reality of a nationwide patient safety concern related to medical errors that involve living wills and DNR and POLST orders.

Interpretation complications have caused medical errors of both over-treatment and under-treatment. Over-treatment against the patient's wishes costs the system an enormous sum of money² and uses precious healthcare resources. Under-treatment results in patients not receiving aggressive treatment, resulting in injury or even premature death.

Systems must vigilantly look for these errors; if you do not look for them, you will not see them occurring. To be advocates for patient safety, we must empower patients and agents at points of entry into healthcare settings, where errors often start.

The first process error is creation of an inaccurate code status related to provider misunderstanding of patient wishes and documents. From a body of research called TRIAD (The Realistic Interpretation of Advance Directives), we know that living wills are misinterpreted nationally as DNR orders at an alarming occurrence rate of 80%. This same research reveals that DNR orders are also misinterpreted as end-of-life care orders or do not treat orders.^3,4

In the next process, two common questions are asked of patients or agents on behalf of patients after they enter a healthcare setting:

1. "Do you have a living will?"
2. "How do you want to be treated in the event of cardiac arrest?"

The first question has been propagated as a Condition of Medicare Participation, which began with the passage of the Patient Self Determination Act of 1990.⁵ The second question is meant with good intentions but is often presented in such a way that it produces a dichotomous answer of "Yes" or "No." The reality is that the answer can often be "it depends." Healthcare systems are not created to allow the "it depends" option. Nevertheless, the answer to the cardiac arrest question should be that it depends. It depends on the condition from which the patient is suffering and whether that condition might benefit from cardiopulmonary resuscitation (CPR) and advanced cardiac life support (ACLS). Note, too, that CPR differs from ACLS; the latter often includes CPR.

The third process in this critically ill versus end-of-life spectrum is the use of the POLST and its rapid deployment nationally. Across the country, systems have changed their code-status order generation to mirror what is documented on the state-approved POLST form. This has resulted in many providers trying to interpret living will documents and create code status designations. The POLST is not the same as a living will and can also be misinterpreted, resulting in both over-treatment and under-treatment medical errors.^4,6,7

Recently, my practice of medicine has evolved to combine evidence-based practices with patient safety initiatives, culminating in the creation of "patient-to-clinician videos." I consider this a best practice of advance care planning. I use this approach and technology to medically evaluate patients for acute end-of-life risk, risk related to interpretation errors, and risk of POLST outside of its specified indications.

The evidence-based research from the TRIAD VIII study confirms this is a best practice to prevent medical errors related to misinterpretation of documents.⁴ TRIAD VIII also confirms we can prevent the medical errors related to under-use of resuscitation (causing harm and potentially death) as well as over-use (causing harm, not allowing natural death, and wasting expensive medical resources).⁴ My medical practice further educates and trains my patients to carry documentation of their advance-directive videos with them and present this information at points of entry into the healthcare system to prevent the first error of inaccurate code-status order creation. Several companies offer video-documentation products, with varying degrees of scripting and other guidance.

If we empower patients and agents with processes to ensure their informed consent, these same patients and agents can be empowered with the answers to address these crucial initial questions. These answers at healthcare points of entry can prevent the first medical error of incorrect code-status order generation and produce enormous patient safety benefits that will be advantageous to patients and providers as well as the healthcare facilities and financial payment systems.

Additional Resources

These commentaries touch on two related aspects of advance directives and medical decision-making. One part of this process involves providing information and support to help patients articulate informed decisions about their own end-of-life care. The other part of this process is communicating the patient's current desires to healthcare providers in a comprehensive, infallible manner.

Factors that interfere with the ability of patients to communicate their medical care wishes are complex, particularly if care decisions must be made emergently or if patients have chronic or temporary cognitive impairments. These situations are frustrating for patients and their families and challenging for providers. They have been difficult to resolve because they involve nuanced medico-legal, ethical, and logistical considerations. To explore these factors in greater depth, the following resources may be useful:

• Discussion of the ethical dilemmas posed by the tattooed patient mentioned above is available online¹: http://dx.doi.org/10.1056/NEJMc1713344
• Discussion of additional factors that influence the effectiveness of do not resuscitate (DNR) decisions is available online⁸: http://dx.doi.org/10.1007/s11606-011-1632-x
• Principles approved by the American College of Emergency Physicians are available online⁹: https://www.acep.org/Clinical---Practice-Management/Ethical-Issues-of-Resuscitation/
• In response to a question about whether the "Pennsylvania Orders for Life-Sustaining Treatment" (POLST) form must be used, regulatory clarifications published by the Commonwealth of Pennsylvania Department of Human Services state that "Out of hospital DNRs and any document accepted by the home's local EMS [emergency medical services] responders would also be acceptable"¹⁰: http://www.dhs.pa.gov/cs/groups/webcontent/documents/document/c_261131.pdf
• A discussion of legal considerations and list of registries, including those that offer video recording, is available from the American Bar Association Commission on Law and Aging's Bifocal journal.¹¹
• A discussion of living wills and DNR orders published in the Pennsylvania Patient Safety Advisory in 2008 is online¹²: http://patientsafety.pa.gov/ADVISORIES/Pages/200812_111.aspx.

Notes

1. Holt GE, Sarmento B, Kett D, Goodman KW. An unconscious patient with a DNR tattoo. N Engl J Med. 2017 Nov 30;377(22):2192-3. Also available: http://dx.doi.org/10.1056/NEJMc1713344. PMID: 29171810
2. Institute of Medicine (IOM). Dying in America: improving quality and honoring individual preferences near the end of life. Washington (DC): The National Academies Press; 2014.
3. Mirarchi FL, Costello E, Puller J, Cooney T, Kottkamp N. TRIAD III: nationwide assessment of living wills and do not resuscitate orders. J Emerg Med. 2012 May;42(5):511-20. Also available: http://dx.doi.org/10.1016/j.jemermed.2011.07.015. PMID: 22100496
4. Mirarchi FL, Cooney TE, Venkat A, Wang D, Pope TM, Fant AL, Terman SA, Klauer KM, Williams-Murphy M, Gisondi MA, Clemency B, Doshi AA, Siegel M, Kraemer MS, Aberger K, Harman S, Ahuja N, Carlson JN, Milliron ML, Hart KK, Gilbertson CD, Wilson JW, Mueller L, Brown L, Gordon BD. TRIAD VIII: nationwide multicenter evaluation to determine whether patient video testimonials can safely help ensure appropriate critical versus end-of-life care. J Patient Saf. 2017 Jun;13(2):51-61. Also available: http://dx.doi.org/10.1097/PTS.0000000000000357. PMID: 28198722
5. Silveira MJ, Kim SY, Langa KM. Advance directives and outcomes of surrogate decision making before death. N Engl J Med. 2010 Apr 1;362(13):1211-8. Also available: http://dx.doi.org/10.1056/NEJMsa0907901. PMID: 20357283
6. Mirarchi FL, Doshi AA, Zerkle SW, Cooney TE. TRIAD VI: how well do emergency physicians understand Physicians Orders for Life Sustaining Treatment (POLST) forms?. J Patient Saf. 2015 Mar;11(1):1-8. Also available: http://dx.doi.org/10.1097/PTS.0000000000000165. PMID: 25692502
7. Mirarchi FL, Cammarata C, Zerkle SW, Cooney TE, Chenault J, Basnak D. TRIAD VII: do prehospital providers understand Physician Orders for Life-Sustaining Treatment documents?. J Patient Saf. 2015 Mar;11(1):9-17. Also available: http://dx.doi.org/10.1097/PTS.0000000000000164. PMID: 25692503
8. Yuen JK, Reid MC, Fetters MD. Hospital do-not-resuscitate orders: why they have failed and how to fix them. J Gen Intern Med. 2011 Jul;26(7):791-7. Also available: http://dx.doi.org/10.1007/s11606-011-1632-x. PMID: 21286839
9. Ethical issues of resuscitation. [internet]. Irving (TX): American College of Emergency Physicians; 2015 Jun [accessed 2018 Feb 19]. [2 p]. Available: https://www.acep.org/Clinical---Practice-Management/Ethical-Issues-of-Resuscitation/.
10. Commonwealth of Pennsylvania Department of Human Services, Bureau of Human Services Licensing. Personal Care Homes (55 Pa.Code Chapter 2600). Q/A - Regulatory Clarifications. Harrisburg (PA): Pennsylvania Department of Human Services; 2017 Apr. 3 p. Also available: http://www.dhs.pa.gov/cs/groups/webcontent/documents/document/c_261131.pdf.
11. Sandza R. Video advance directives: your smartphone records your wishes. Bifocal. 2017 May-Jun;38(5):79-81.
12. Understanding living wills and DNR orders. Pa Patient Saf Advis. 2008 Dec;5(4):111-7. Also available: http://patientsafety.pa.gov/ADVISORIES/Pages/200812_111.aspx.