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

Philip Betbeze, for HealthLeaders Media, May 2, 2014

"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.

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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.