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

Philip Betbeze, for HealthLeaders Media, May 2, 2014

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.

I recently wrote about the idea of making advance directives a condition of obtaining Medicare benefits. Such a move, one major healthcare CEO told me, would be a great way to help reduce the cost of care for patients at the end of life, where so much expensive treatment with dubious results takes place.

It's a good idea… in theory. In current practice, there are some problems, says Ferdinando Mirarchi, DO, who is chairman of the department of emergency medicine at UPMC-Hamot in Erie, PA.

My recent conversation with Mirarchi added some much-needed nuance to the debate about how wise it is, both for patients and physicians, to have these documents in play without greater safeguards and training of clinicians to better interpret what the patient really wants from his or her care when incapacitated.

Mirarchi believes that the standardization and interpretation of advance directives pose grave threats to patient care and to physicians, and he speaks from experience.

"I almost killed a patient," he says, matter-of-factly.

The first physician on the scene when a patient presented at the ED unconscious, he "was at the point of not treating her because there was a living will and a DNR."

A cardiologist who noticed the dithering at the patient's bedside, screamed "What are you doing?!" at Mirarchi, and roughly shoved him out of the way.

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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.