Avoiding Malpractice: The Importance of Advance Directives

Nevada RNformation, May 2006 by Singh, Tracy L

The Terri Sheivo case may have increased public awareness to the potential problems that can occur in the absence of living wills and other Advance Directives. However, nurses and other health care providers are no strangers to the potential conflicts created by not having one's wishes known by others in advance, especially when it comes to life saving interventions.

While advance directive forms are most commonly seen in hospitals, nurses who work in doctors' offices, home health care, hospice or virtually any other patient care setting should also be aware of the importance of advanced directives and the impact they could have on avoiding malpractice and other types of claims.

Advance Directives involve various complex issues that directly impact health care delivery to patients. For example, in the event of a "code 99" or "Code blue" in a hospital setting, several questions will need to be answered. Is there a living will? Is this person categorized? If so, to what extent are they categorized? (In other words, are there "Do Not Resuscitate" orders for this patient?) Who should be contacted? Should we call the spouse, guardian, next of kin, or significant other? Is there a medical power of attorney who should decide whether to continue? Is this person an organ donor?

If the person does not survive, there are still more questions that will need to be answered. What is this person's religious belief? Would this person want a priest to be called? Were funeral arrangements already made or should we call the first available mortuary to collect the body? Will there be an autopsy? If so, who will authorize or request one? Who should the personal belongings be given to? If and when patients become incapacitated, or are unable to communicate their wishes to others, it is imperative that there be a way to determine what should be done, if anything.

Unfortunately, (his is a topic that most people do not think about until there is an actual emergency or a terminal diagnosis. In some cases, the subject is not approached until it is too late to make any real difference. Health care providers in the acute care setting are faced with these issues on a regular basis. Yet, many times, these same questions go unanswered and nurses may find themselves caught in the middle when family members and loved ones cannot decide what to do.

Patients who do not have their wishes spelled out in advance will often have their treatment plans changed day to day, or even in the same day, while their families, nurses, physicians, insurance companies, and in rare occasions such as Terri Sheivo's case, even the courts will get involved to discuss what should be done, if anything.

When a patient has taken a turn for the worse and advance directives are not in place, it can cause undue stress for everyone involved not just family members. The nurse who is caring for the patient, the physicians who must decide what orders to give, the physical and respiratory therapists who do not know whether to continue seeing the patient or not, and even the lab technician who was supposed to draw blood in the morning. For example, if a patient has been "categorized" and it has been determined that only comfort measures should be provided, and an outstanding blood draw order exists, family members may become upset when the lab technician comes in to stick their loved one with a needle unnecessarily.

The issue of "Categorization" is obviously a very personal and sensitive topic. However, most people may not realize that it is also a financial one. When advance directives are not in place, and there are no individuals to speak for incapacitated patients, other individuals or entities with financial incentives may ultimately make these decisions for them and the bottom line is... categorization saves money!

When patients are in the intensive care unit of a hospital, and are unable to speak for themselves, it is possible that their insurance companies will see to it that they are categorized and down graded to save the carrier money, regardless of whether those patients would want "everything done" to keep them alive. Others may stand to gain by the patient's death financially if they are beneficiaries of a will or a life insurance policy. Or they may simply be relieved of the tremendous financial burden associated with prolonging the life of a loved one when medical insurance coverage is non-existent or inadequate.

On the other hand, there may be patients who wish not to be sustained on life support but, there may be individuals who will see to it that everything is done. This is more common for loved ones as it is often difficult to let someone go, even when they know there is no chance of survival. Some family members may lose benefits such as retirement and social security checks when the patient dies. However, there may be others who may try to intervene as well.

For example, a patient's surgeon may not wish to give up so easily, and may take it personally when someone suggests categorization after just having done everything he or she could to save the patient in surgery. Not to mention, when a patient dies in less than thirty days following surgery, it may negatively affect their survival rates. In fact, some surgeons will not operate on patients who refuse to give consent in advance for certain postsurgical life saving interventions. A common example of this would be a Jehovah's Witness patient who refuses to consent to blood transfusions based on religious beliefs during and/or following invasive procedures.