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Patient Safety and Advance Directives – Keystone Elder Law – Mechanicsburg, PA

Last week, Attorney Dave Nesbit’s article focused on the PA Senate’s current consideration of a proposal to create an Advance Directive Registry.  The registry would serve as a tool to improve physician access to a patient’s personal documents related to decisions about medical care.  Improved access to these documents would hopefully translate into improvements in an individual’s ability to direct the course of medical treatment during times when the individual is unable to speak for him/herself.  Advance directive documents include not only living wills and health care powers of attorney, but also certain DNR (Do Not Resuscitate) orders and POLST forms (Physician Orders for Life-Sustaining Treatment).

Toward the end of his article, Attorney Nesbit pointed out that the primary value of these documents is not the documents themselves, but the discussions about personal wishes for medical care that an individual has with those who may be called upon to make decisions during the time of a health care crisis. Illness and medical treatment can create many gray situations in which decisions about care are not always clear-cut, even when an individual has written guidelines in place.  This point was driven home to us in a response we received to last week’s article from Dr. Ferdinando Mirarchi, medical director of the University of Pittsburgh-Hamot’s Emergency Department, who has conducted research and published numerous articles and a book about advance directives.

Dr. Mirarchi’s research projects (The Realistic Interpretation of Advance Directives or TRIAD Series) have demonstrated that health care providers including physicians, paramedics, emergency medical technicians, and nurses have an inconsistent understanding of living wills and POLST forms.   Inconsistency in determining when these documents are appropriate guidelines for care and in the interpretation of their contents can result in medical errors of overtreatment  or undertreatment.  Seniors and critically ill individuals, who are more likely than younger and healthier people to have advance directives, can face this risk in any health care setting.  Emergency situations, however, can pose a more significant threat because individuals are receiving care by professionals who are not familiar with their usual state of health and wishes concerning medical treatment.  In addition, treatment may need to be initiated quickly, depending on the severity of the condition, and patients’ and families’ decision-making skills are impacted by the additional stress of an unexpected or critical situation.

Another consideration for patient safety regarding these documents is how the forms are completed.  If an individual completes fill-in-the blank forms regarding choices about care without professional assistance or with the assistance of someone other than a physician, the question arises as to whether or not the individual has enough accurate information to make informed choices.  This consideration is especially important with POLST forms, since the choices made are actual medical orders that must be followed when the document is presented to healthcare providers.  To be accepted, the POLST form also must be properly signed and dated.  Dr. Mirarchi points out that true informed consent by an individual for treatment to be received or withdrawn may not be present in real time due to the variability of circumstances of a health-related situation, the method by which previous decisions were made, and the lack of standardization of advance directive documents (example:  the POLST form may differ between states).  Although living wills often may be completed in an attorney’s office, the choices for care contained in the document are to be implemented only when an individual is determined by a physician to be permanently unconscious or in the end stage of a terminal medical condition.   If an individual has questions about the type of actions that may be taken with the different treatment options contained in a living will, the individual should consult with his/her primary care physician prior to completing the document with an attorney.   A booklet containing a sample of a Pennsylvania living will and the choices it contains can be found at, under “publications & reports,” then “brochures.”

You may be left wondering if these risks outweigh the benefits of advance directive documents.  Already mentioned is Keystone Elder Law’s opinion that discussion about health care wishes between individuals and the important people in their lives is the primary benefit to drafting these documents.  Since many gray areas exist in health care, treatment decisions are very personal.  As none of us can see into the future to anticipate every possible health care scenario that may occur, discussions about health care wishes should take place with all parties that may be involved in decision-making and should occur whenever a change in condition may impact a previously discussed wish.  When a health care power of attorney document is drafted, allowing a health care agent full power to make all health care related decisions for you (if you are unable to make them yourself) will allow flexibility in making treatment decisions based on specific circumstances, and allow the agent the opportunity to truly provide informed consent.   The choice of an agent (and a couple of back-ups), should be based on a level of trust that the agent will follow your wishes as you have expressed them, to the best of their ability. The completion of other advance directive documents can help serve as guidelines for your agent, should you become incapable of making decisions for yourself.

Karen Kaslow, RN