Living Wills & DNR: Is Patient Safety Compromised?

Human Life Review, Fall 2007 by Mirarchi, Ferdinando L, Conti, Lucia

Do you have a Living Will? Do you know what it says? Could it be a danger to you? These are all important questions as the use of living wills and Do Not Resuscitate (DNR) orders are on the rise. Contrary to the theory that the more something is used the safer it becomes, these advance directives have been accused of compromising patient safety.

Living wills have received national attention as a health-care tool patients can use to communicate their personal wishes regarding treatment, but they have never been evaluated with respect to patient safety. The disconnect between patient safety and living wills has begun to present multiple problems, especially as the percentage of the American population over the age of 65 increases.

The geriatric population will have a huge impact on health resources from 2010 to 2030, and as this happens there will be an increase in the use of living wills and DNR orders. It is important, though, to point out that the living will is not just for the elderly or terminally ill: It is often created as part of an estate plan when people are young and healthy. The aging population is not the only factor driving the increase in living-will use. Resources such as the US Living Will Registry and VeriChip are making it easier for people to create a living will without knowing that it could do them harm.

Our investigations of living-will documents have uncovered serious problems with them, including a lack of individualization and informed consent that commonly leads to misinterpretation. The right medical-care course of action is not always clear, and-even though the point of a living will is to clarify what the patient wants-it may not express the patient's true wishes. In fact, the living will often is automatically interpreted as a DNR order.

The lack of individualization in a living will stems from the fact that living wills are built using a template. They are often created as part of an estate plan instead of with a physician. They also contain language or address situations that are unfamiliar to health-care workers, often leaving out many key factors-including classes of treatments that are used to treat critical conditions. The living will is also left on file for years and only used when needed. Often, the patient does not take into consideration that medical treatments change on a continual basis, and that her wishes at the age of 30 may be totally different when she is 60. Living wills and all advance directives need to be continually re-evaluated and updated as conditions in the patient's life and the medical industry change.

Living wills also lack the process of informed consent. Informed consent means that the patient has been communicated to about her medical condition and the treatment needed to solve or stabilize that condition. The patient should understand all the risks and benefits involved with the physician's treatment decision and the effects that the treatment will have.

Similarly, when a patient is admitted into a hospital, the hospital is required by law to provide information about living wills to the patient if she does not already have one. However, this information is usually generic and does not offer all of the information and details needed for the patient to fully understand her end-of-life decisions. In most cases, the patient does not have the time to study the form or the options it offers due to the medical emergency that brought her to the hospital. Therefore, when a patient signs her living will while being admitted into the hospital, she is often signing it without informed consent.

Not only do you have the issue of living wills not fitting the patient's specific needs, or the fact that most people do not understand what they are agreeing to anyway, but there is still another aspect to consider. There is a possibility that the physician can misinterpret the patient's wishes. Living wills often contain terms such as "terminal condition," "incurable illness," and/or "serious injury"-and each of these terms has the potential to be interpreted differently from physician to physician. One physician may understand a term or phrase to mean the patient is requesting aggressive treatment, while another physician may believe the patient is communicating a desire to withdraw treatment. In many situations, as we mentioned before, the living-will document is misinterpreted as simply a DNR order or Do Not Treat order.

In order that the patient communicate her wishes in the clearest possible way, we recommend that she complete the living will with the assistance of a physician. By enlisting the help of a doctor, the patient can be reassured that at least that physician understands her preferences. Getting the help of a physician will also help the patient understand what a "code status" is, and why she should include the code status in her living will.

There are many code-status designations, including: full code, hospice care/comfort care, slow code, no code, chemical code, DNI, and DNR. A code status can often be interpreted differently by various physicians and be incorrectly implemented. Which code status is safe for a patient to use, and which clearly communicates her intentions to physicians?