In this Journal of Patient Safety article, Ferdinando Mirarchi and I explain the value of video advance diretives. Here is the abstract for "Widespread Misinterpretation of Advance Directives and Portable Orders for Life-Sustaining Treatments Threatens Patient Safety and Causes Undertreatment and Overtreatment."
Advance directives (ADs) and Portable Orders for Life-Sustaining Treatment (POLST) are powerful communication tools that help preserve an incapacitated patient’s wishes regarding life-sustaining treatment. They also help prevent conflicts, reduce moral distress, and control health care costs. Portable Orders for Life-Sustaining Treatments can even predict the location8 and possibly timing of death. However, despite all these benefits, ADs and POLSTs too frequently result in medical errors.
These medical errors manifest as both undertreatment and overtreatment. With undertreatment, a patient suffers harm or dies. For example, clinicians do not perform advance cardiac life support on a patient that should have been a full code patient. The patient fails to receive potentially beneficial life-sustaining treatment that they wanted.
In contrast, with overtreatment, a patient is harmed by receiving unwanted medical treatment. They are often forced to live against their predetermined wish to die naturally, often in the very circumstances that they wanted to avoid. For example, clinicians administer cardiopulmonary resuscitation on a patient with a do-not-resuscitate (DNR) order, or they aggressively treat a patient with orders for comfort measures only (CMO). Today, a growing number of malpractice lawsuits are settled or adjudicated in favor of families when patients receive treatment discordant with their AD or POLST.
In this article, we first describe the issue of discordance. Because clinicians frequently misinterpret POLSTs and ADs, patients regularly get treatment discordant with the orders and instructions in those documents. This discordance often results in wrongful prolongation of life or death. After describing this problem, we turn to solutions. Fortunately, we may already have better tools to mitigate discordance and improve patient safety. We specifically highlight the promise of video testimonials.
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