Living Wills & DNR: Is Patient Safety Compromised?

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

It is essential that physicians and nurses understand the meaning of a DNR code status and discuss it with their patients. The importance of discussing a chosen code status was clearly demonstrated in the study conducted by Ganzini in 1994 of elderly and depressed patients. It was found that the effects of depression influence the patient's preferences for life-sustaining treatments. Twenty-six percent of severely depressed patients desired more treatment to be used when their depression was treated and they felt better.9 This clearly demonstrates that patient preferences can change after discussion of their DNR code status.

As with the DNR, the living will's effectiveness has been questioned by the medical industry. Standard living wills address the treatments of cardiopulmonary resuscitation, mechanical ventilation, defibrillation, antibiotics, dialysis, and feeding tubes. Patients are able to clarify their wishes further by using the "Medical Living Will with Code Status," which addresses the following treatments:

Cardiopulmonary Resuscitation (CPR)

Advanced Cardiac Life Support Protocols

Endotracheal Intubation

Long Term Mechanical Intubation

Defibrillation

Invasive Procedures

Invasive Emergency Procedures

Invasive Comfort Procedures

Intravenous Fluids

Intravenous Antibiotics

Organ Donation

Long Term Parenteral Nutrition

Feeding Tube

Thrombolytic Medications and Angioplasty

Blood and Blood Products

Hemodialysis and Peritoneal Dialysis

Implanted Pacemaker and Defibrillator

Yet numerous studies have suggested that physicians often ignore their patient's living wills, and institute unwanted care. This raises the question: Was a particular living will enacted and subsequently neglected, or was it simply ignored from the start? Some in the medical industry believe that the use of the living will has become impractical.

The presence of a patient's living will is commonly assumed by many medical personnel to mean that the patient has a DNR code status. This risk of misinterpretation is real and is supported by a recently published case series, "Does a Living Will Equal a DNR? Is Patient Safety Compromised?" (JEM, Vol. 33, No. 3, pp. 299-305, released October, 2007). To determine what physicians, nurses, and pre-hospital personnel actually understand about living wills versus a DNR code status, "The Realistic Interpretation of Advance Directives" (TRIAD) studies were implemented. The results of these studies, which are pending publication, reveal significant concerns for patient safety and further support the recently published case series.

Another document that attempts to communicate a patient's wishes regarding end-of-life treatment options is the Physician Orders for LifeSustaining Treatment (POLST) document. This document is based on the patient's wishes after a physician's discussion with the patient or the patient's surrogate. The POLST is meant to complement an advance directive and should be used in combination with any advance directives the patient may already have provided.