Physician: 'I Almost Killed a Patient' Because of an Advance Directive

While advance medical directives can be a benefit to patients, families, and healthcare costs, misinterpretation of these documents by clinicians is common, says a prominent emergency medicine physician, and can lead to irreversible medical errors.

10 comments on "Physician: 'I Almost Killed a Patient' Because of an Advance Directive"
mike (5/19/2014 at 1:53 PM)

I think the advanced directive is a great idea but the forms need to be concise and the pateints should be registered in a place where any MD or RN can look up the entire nature of the "directive". If I have an AD will I carry it if I am traveling? Probably not, but if I have terminal cancer and I suddenly embolize do I want them to intubate me and put me on life support while they attempt to tPA the clot? As a clinician in cardiovascular surgery I saw many that were armed with an AD but the kids wanted the MD to do "anything possible" a real violation of the directive. If health care workers could have access to a national DB this may not happen as often as it does.
Mary Hannon RN (5/6/2014 at 9:37 PM)

I think everyone should have Advanced Directives, as well if they have an irreversible condition a DNR in place. That being said, I have always believed and said just because a patient is a DNR does not mean they are a do not treat. If a patient has Advanced Directives I place, one would hope they have spoken to the designated health care proxy named. While that certainly in reality is not always the case, means we need too scrutinize their wishes more carefully and pose the appropriate questions to that Health Care Proxy. Especially if this time it happens to be a reversible condition. In terms of a DNR status, as I said it does not mean don not treat. So, we also need to understand that simply says, no CPR. It does not say no treatment.
Robert Bramel (5/6/2014 at 2:58 PM)

As an elderly non-medical individual I am quite amazed at the apparent confusion by many in the medical community about the intent of advanced directives. The concept seems clear enough; maintenance of life is not enough, there must be some reasonable chance for reasonable quality of life at the end of treatment. It is not enough to extend the life of someone who will never leave a bed again or communicate again. Of course there will be difficulties with "reasonable chance" (e.g., 50/50, 1 in ten) and "reasonable quality of life" (e.g., mental function, physical abilities), but those are the real issues that need to be addressed. ER doctors ought to have clear guidelines that inform automatic responses without need for reading and interpreting AD legalese. Rather than complain about advanced directives, the community needs to spend more time coming to grips with these issues. Too many medical doctors I've talked to seem to believe that "do no harm" means attempting to keep vital organs functioning at all costs without regard to whether there is going to be anything meaningful left in the patient. Leaving a patient in a nonfunctioning vegetative state is enormously "harmful". Virtually everyone I've ever talked to about end of life issues, and I've talked to many, agree that no one who thinks about it wants to be kept alive connected to tubes, incommunicado, with no chance of a real life ever again. Why this seems hard for so many medical professionals remains puzzling.
Bett Martinez (5/5/2014 at 8:36 PM)

thank you all. reading a few similar stories convinced me to be very careful, and that's why I have a physician friend as my agent on my POLST; we've discussed these very issues. he went so far as to consult with a gastroenterolist friend who told him he's seen pts bounce back after a feeding tube was [INVALID]ed for 60 days. understandably things can get complicated, and errors made, but I'd rather leave decisions to a professional than my kids, who are smart but amateurs. there will be times when doctors seeing me know little or nothing about me, or my history, and that's where the understanding of a physician who's known me for more than 2 decades is the best preparation i can think of. kids (both adults) are numbers 2 & 3, so in case he's not available there's a back up. to the best of my ability I've made my wishes known to all, including my regular PCP. I've even given presentations and webinars: Living Will, Dying Well, with powerpoints, which is taped to the POLST! Dementia, or as a friend calls it, Demention, is a whole 'nuther issue. it's hard to know if what seems like no quality of life from the outside, is something different for the person experiencing it. Going through this with a friend right now. every day, even as he's experiencing a certain - enclosure is the best term I can think of - not much to his life - he's still grateful to have it. so...any comments on this would be welcome.
JD LaBash, DO (5/5/2014 at 12:31 PM)

At the hospitals where I did my medical residency it was almost universally assumed that "DNR" meant "allow to die." Nurses resisted, or in one case delayed to the point of futility, life-saving orders I gave for a "DNR" patient with an acute condition. This went as far as resistance to giving antibiotics. There was also the widespread belief that the elderly (e.g. 70) should be "DNR" (by their definition of "do not treat".) From this experience, I would never recommend advance directives to my friends and family.
Earl W. Ferguson, MD, PhD, FACC, FACP, FACPM (5/5/2014 at 11:22 AM)

Good Advanced Directives make the patient's wishes very clear and physicians have a duty to follow those wishes, unless the patient changes their mind and verbally or in writing revokes that Directive. Directives distinguish patient wishes for irreversible, terminal illnesses and transient problems that can be quickly and easily resolved with antibiotics or other treatment. Doing CPR and putting a patient on a ventilator who has made it clear that these interventions were not to be done is assault and puts providers who do not follow the patient's wishes at significant legal risk. An Advanced Directive DOES NOT prevent comfort care and managing bed sores, etc. as one commenter suggested. I discuss end-of-life issues in American Healthcare Reform: Fixing the Real Problems.
Daniel Hanley, MD (5/5/2014 at 10:22 AM)

I agree with the comments made previously. To interpret DNR as non-treatment is shockingly bad medicine, as even medical students know that bed sores need treatment, if for no other reason than patient comfort (allowing this to progress to sepsis is deeply concerning). However, I applaud the ER physician for owning up to his mistake with the unconscious patient. That said, this is a system issue, because if highly educated and intelligent professionals are consistently getting confused, then the overall process and workflow needs another look. Is it a question of language? of intent? of education? of whatever? It's evident that a more streamlined, simpler method is needed, and the proper education needs to be a specific Joint Commission requirement. The information is out there, as a two-second search on Pubmed yields high-quality articles such as this: Bottom line: we can do a better job.
jane (5/5/2014 at 10:07 AM)

The very reason I have an advance decision directive is so that I won't end up being treated when there is "any chance" of recovery to the point of "potential function." Especially in the elderly, what this frequently means is that you are more likely to be bound for the nursing home than to recover to the point where you have a real life again - and you may have been "saved" from a clean quick death, like those cardiologists love to prevent, in order to suffer a much slower and worse death.
Lael Duncan,MD (5/2/2014 at 9:46 PM)

We certainly have a long way to go if an ER physician confuses an UNCONSCIOUS patient with a patient who has NO PULSE and IS NOT BREATHING. Only in the latter instance (patient clinically dead or at death) would you invoke the DNR order. DNR NEVER means do not treat. Patients deserve to get the care and treatments they do want and and they deserve to not get the care they don't want. Advance directs will help ensure this. It is our responsibility as clinicians to assist them and to interpret intentions. This patient obviously did want treatment for reversible conditions and did not want to have chest compressions and ACLS etc. I am glad this patient had a directive. It is unfortunate that the DNR was misinterpreted. Fortunately, this is becoming less common. I recommend all physicians who have not done so receive some formal training in assisting patients and families with Advance Directive choices. Know how to have The Conversation.
Steven E Frank MD MS FACP (5/2/2014 at 4:09 PM)

This article underscores three overarching concerns that frontline clinicians have about advanced directives. Concern #1 is that they are so vaguely worded as to be functionally useless. We know better than to attempt to intervene in truly hopeless situations. That being said what constitutes a hopeless situation is in the eye of the beholder. What does or does not constitute an acceptable goal of therapy is a highly individual, evolving question. No amount of standardization is going to clarify this. Concern number 2 is that DNR does not mean do not treat. It means, to most of us anyway, do not attempt CPR or invasive forms of life support. It certainly does NOT mean don't treat bedsores. Any such interpretation is patently ridiculous. Finally, concern number three is that despite an advanced directive, nearly anyone opposed to it can choose to ignore it. In the scenario described here, a cardiologist decided whatever was going on was treatable and barged right on in. Just because some CAN be treated doesn't necessarily mean it SHOULD be treated. Quite often, despite a patient's expressed wishes, a surrogate cannot bring themselves to 'let go'. The patient ends up getting painted into a corner. The advanced directive becomes unenforceable. Even formal POLST documentation has its attendant weaknesses. A better approach is "The Five Wishes". A one size fits all federally-standardized advanced directive isn't going to work.


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