'Do not resucitate' orders often misunderstood by professionals
“Don’t resuscitate this patient; he has a living will,” the nurse told the doctor, Monica Williams-Murphy, handing her a document.
Williams-Murphy looked at the sheet bearing the signature of the unconscious 78-year-old man, who had been rushed from a nurs-
ing home to the emergency room. “Do everything pos- sible,” it read, with a check approving cardiopulmonary resuscitation.
The nurse’s mistake was based on a misguided belief that living wills automati- cally include “do not resuscitate” (DNR) orders. Work
ing quickly, Williams-Murphy revived the patient, who had a urinary tract infection and recovered after a few days in the hospital.
Unfortunately, misunder- standings involving documents meant to guide endof-life decision-making are “surprisingly common,” said Williams-Murphy, medical director of advance-care planning and end-of-life educa
tion for Huntsville Hospital Health System in Alabama.
But health systems and state regulators don’t system- atically track such mix-ups, which receive little attention amid the push to encourage older adults to document their end-of-life preferences, experts acknowledge. As a result, information about the potential for patient harm is scarce.
A new report out of Pennsylvania, which has t he nation’s most robust system for monitoring patientsafety events, treats mix-ups involving end-of-life docu- ments as medical errors — a novel approach. It found that in 2016, Pennsylvania health-care facilities reported nearly 100 events relating
to patients’ “code status” — their wish to be resuscitated or not, should their hearts stop beating and they stop breathing. In 29 cases, patients were resuscitated
against their wishes. In two cases, patients weren’t resuscitated despite making it clear they wanted this to happen.
The rest of the cases were “near misses” — problems caught before they had a chance to cause permanent harm.
Most likely, this is an under- count, said Regina Hoffman, executive director of the Pennsylvania Patient Safety Authority, adding that she was unaware of similar data from any other state.
Asked to describe a near miss, Hoffman, co-author of
the report, said: “Perhaps I’m a patient who’s come to the hospital for elective surgery and I have a DNR order in my (medical) chart. After surgery, I develop a serious infection and a resident (physician) finds my DNR order. He assumes this means I’ve declined all kinds of treatment, until a colleague explains that this isn’t the case.”
The problem, Hoffman explained, is that doctors and nurses receive little if any training in understanding and interpreting living wills, DNR orders and Physician Orders for Life-Sustaining Treatment (POLST) forms.
Communication breakdowns and a pressure-cooker environment in emergency departments, where life-ordeath decisions often have to be made within minutes, also contribute to misunder- standings, other experts said.
Research by Ferdinando Mirarchi, medical director of the Department of Emer- gency Medicine at the University of Pittsburgh Medical Center Hamot in Erie, Pennsylvania, suggests that the potential for con- fusion surrounding end-of- life documents is considerable. In various studies, he has asked medical provid- ers how they would respond to hypothetical situations involving patients with critical and terminal illnesses.
In one study, for instance, he described a 46-year-old woman who is brought to the ER with a heart attack
and suddenly goes into cardiac arrest. Although she is otherwise healthy, she has a living will refusing all poten- tially lifesaving medical inter- ventions. “What would you do?” he asked more than 700 physicians in an Inter- net survey.
Only 43 percent of those doctors said they would inter- vene to save her life — a trou- bling figure, Mirarchi said. Because this patient didn’t have a terminal condition, her living will didn’t apply to the situation at hand and every physician should have been willing to offer aggres- sive treatment, he explained.
In another study, Mirarchi described a 70-year-old man with diabetes and cardiac dis-
ease who had a POLST form indicating he didn’t want cardiopulmonary resuscitation but agreeing to a limited set of other medical interventions, including defibrillation (shocking his heart
with an electrical current). Yet 75 percent of 223 emergency physicians surveyed said they would not have pursued defibrillation if the patient had a cardiac arrest.
One problem is that doctors assumed that defibrillation is part of cardiopulmonary resuscitation. That’s a mistake: They’re sepa
rate interventions. Another problem is that doctors are often unsure what patients really want when one part of a POLST form says “do nothing” (declining CPR) and another part says “do something” (permitting other interventions).
Mirarchi’s work involves hypotheticals, not real-life situations. But it highlights
significant practical confusion about end-of-life documents, said Scott Halpern, director of the Palliative and Advanced Illness Research Center at the University of Pennsylvania’s Perelman School of Medicine.
Attention to these problems is important but shouldn’t be overblown, cau
tioned Arthur Derse, director of the Center for Bioethics and Medical Humanities at the Medical College of Wis
consin. “Are there errors of misunderstanding or miscommunication? Yes. But you’re more likely to have your wishes followed with one of these documents than without one,” he said.
Make sure you have ongoing discussions about your end-of-life preferences with your physician, your surrogate decision-maker if you have one, and your family, especially when your health status changes, Derse advised.