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

 |  By Philip Betbeze  
   May 02, 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.

A Misunderstanding of the Documents
"At that time he delivered the appropriate treatment and saved her life," Mirarchi says. "I was following this paper they presented. If it wasn't for him reaming my butt, this never would have had the impact that it has with me. The lesson is, you can easily end up killing patients who have ultimately treatable conditions."

The reason lies with the misunderstanding, at the clinical level, of advance directive documents. Regardless of what patients put on these forms, they probably want to be treated for any condition for which recovery is possible, yet it's not clear to doctors and nurses what they want, and they often interpret the documents differently.

"This thing of misunderstanding of documents is hugely important," says Mirarchi, who adds that his father died of sepsis because his caregivers interpreted his advance directive—a do not resuscitate order—to mean that he was not to be treated for bedsores that developed from his incapacitation.

"My father ended up dying because of it," Mirarchi says. "They left him in a bed to the point at which he developed bedsores that became septic," which ultimately, became his cause of death.

Mirarchi subsequently discovered that there is very little research into how advance directives are interpreted, not only by the physicians and nurses treating patients, but by their own designated surrogate decision-maker, often the spouse.

"These documents have good intended purposes [but] there can be bad unintended consequences from them," he says. "In medicine, a large percentage of practicing physicians look at a document like that and define it as a DNR order."

These orders are routinely misunderstood in medicine, he says, and his research backs up that assertion. To patients, an advance directive might contain assumptions about comfort and end-of-life care (as it did with me).

Documents Lack Federal Standardization
But if you present critically ill somewhere and you can't speak for yourself, the presumed assumption, given the presence of an advance directive, may mean that clinicians will withdraw treatment from you—even if you have a treatable condition. It all depends on the person interpreting the document, says Mirarchi.

"I'm in the minority on this," he concedes, "but from my experience in clinical practice and studying it, there is a nationwide patient safety concern with the documents. They lack federal standardization."

A lot of positive change could come if physicians and nurses knew that when presented with such a document, a pause is in order. Mirarchi, with legal help, developed a checklist poster that he says at least helps clinicians make better decisions based on what's in the document, as well as some advice on interpretation.

"I see people all the time who can't speak for themselves that have very treatable conditions and potential[ly] functional outcomes," he says. "To not treat them would be a medical error."

As for himself, Mirarchi has not and has no plans to complete a living will or advance directive. He does however, have a named surrogate, who is his wife.

"I met with my attorney and as part of my estate planning, he had my living will created. When he presented it to me he kind of laughed and said, 'I'm not sure you're going to sign it,'" says Mirarchi. "He was right. I didn't. Until more safeguards are in the process, I wouldn't complete one."

An Advocate for Safeguards
That doesn't mean he thinks advance directives or living wills are necessarily bad ideas, or that they don't have huge potential to save on expensive, end-of-life care for patients who have no reasonable hope of recovery. And he knows that such documents can't be made perfect. But given his experience and research, he believes there are too many potential drawbacks for him personally.

"Every form is going to have a problem and I don't care anymore what people tell me about new processes," he says. "Every one of these forms has someone interpreting it. Their understanding will carry forward and impact care and treatment."

All of that said, and given his hesitancy to do a living will or advance directive of his own, Mirarchi still wants to be able to advocate for their proliferation.

"But first I need to advocate for safeguards," he says. "They do have a lot of benefits, and I'm not discouraging anyone from doing one, because there's no question they do save money and resources. Those patients who are not gaining any benefit from treatment are very expensive. But first I need to advocate for safeguards."

So what am I and others like me to do? We want to do the right thing, we want not to be a burden to our families or the healthcare system, but we also don't want to die from a treatable condition because our advance directive has been misinterpreted.

Although my form is one that I downloaded, and Mirarchi correctly asked if I had any assistance of guidance filling it out (I hadn't), I still feel it outlines my wishes appropriately. I've made clear to my wife that if there's any chance of recovery, I want her to authorize treatment.

I trust her.

I could go home and tear up my advance directive, but at some level, I have to hope that's enough.

Philip Betbeze is the senior leadership editor at HealthLeaders.

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