Reports show that healthcare providers, patients and their families may not understand the different meanings and consequences of living wills and DNR (do not resuscitate) orders
HARRISBURG, Pa., Jan. 12 /PRNewswire-USNewswire/ -- More than 200 events reported to the Pennsylvania Patient Safety Authority in part show that healthcare providers, patients and their family members may not understand the different meanings and consequences of living wills and DNR (do not resuscitate) orders which may pose patient safety risks according to analysis provided in the 2008 December Pennsylvania Patient Safety Advisory.
Potential patient safety risks related to the misinterpretation of living wills and DNR orders may inadvertently result in the delivery of unwanted care or the withdrawing or withholding of otherwise appropriate care that should have been given to the patient.
According to the Authority data: 93 reports regarding living wills or DNR orders indicated that a DNR order may have been misinterpreted as a directive to withdraw or withhold care, suggesting the healthcare providers may not have understood the narrow scope of a DNR order.
"Our data shows that more education must be given to healthcare providers, patients and their families to ensure everyone involved understands that a living will does not become effective automatically -- certain conditions must be met according to Pennsylvania law first," Dr. John Clarke, clinical director of the Pennsylvania Patient Safety Authority said. "Also, in regard to DNR orders, healthcare providers and patients need to know that these particular orders only apply to a patient's wishes not to be resuscitated if they have a heart attack or stop breathing. A DNR order does not mean 'do not treat.'"
Clarke explains that a living will is a document signed by an individual that is intended to convey that person's preferences regarding end-of-life healthcare decisions when he or she cannot express them personally to a physician or other healthcare provider. A living will is considered a type of advance directive. An advance directive refers to a number of different documents executed by an individual intended to convey that individual's preferences about healthcare. However, a DNR is a medical order issued by a physician or other healthcare practitioner authorized to issue medical orders that directs clinicians not to provide cardiopulmonary resuscitation (CPR) in case of a heart attack or the patient stops breathing.
According to Authority data: 37 of the reports related to advance directives have involved a patient receiving potentially unwanted interventions.
"From the data we analyzed there appears to be patients who received unwanted care and were brought back to life and others who did not receive the appropriate care to save their lives," Clarke said. "The issue is very complicated and protocols vary from facility to facility in regard to DNR orders, while what constitutes a living will becoming effective is determined by Pennsylvania statute."
Clarke added that patients and their families must know that due to the varying degrees of DNR orders in facilities, a DNR order in one facility does not automatically carry over to another facility if that patient is transferred. Also, DNR orders are only effective per hospital visit. DNR orders do not remain effective after the patient leaves the hospital.
According to the Authority data: 71 of the reports show some form of communication breakdown related to advance directives. Of the issues reported, the majority of reports involve the lack of understanding of the meaning of the documents by families, lack of communication of the presence of a DNR order between healthcare providers, misidentification of patients and the failure to identify patients with DNR orders.
"The definitions of a living will and other advance directives must be clearly understood for a patient's wishes to be accurately conveyed," Clarke said. Further, a DNR order is much different than a living will. They are not interchangeable.
"Each has its own meaning and circumstance in order to be carried out by the healthcare provider," Clarke added. "The issues surrounding both are not being understood clearly by patients, family members or healthcare providers according to the data we received."
Clarke cited recent studies that show the issue is not just in Pennsylvania. In a survey to determine the level of understanding of a living will among doctors, patients and their families the results show 71% of patients, 42% of family members and 27% of physicians did not understand when a living will becomes effective. Another study showed that patients with living wills poorly understood the meaning of "life-sustaining therapies" and the implications of other advance directives. Of 755 patients admitted to a community teaching hospital during the study period, 264 study participants were surveyed regarding their understanding of CPR. Of these, 82 (31%) had living wills. Most (76%) created their living will with a lawyer or family member; only seven percent involved a physician. After the patients were provided an explanation of the meaning of CPR, 37% of patients with living wills indicated they actually did not want CPR. Their living wills did not accurately reflect their treatment preferences.
The Authority suggests key elements needed for healthcare providers to implement to a successful advance directive program and that may be applied to the process of obtaining a DNR order. The Authority also offers tips for consumers to ensure they are educating themselves and their families about their exact preferences for end-of-life care.
For more information on living wills, DNR orders and Pennsylvania law go to "Understanding Living Wills and DNR Orders" of the 2008 December Pennsylvania Patient Safety Advisory at http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2008/Dec5(4)/Pages/111.aspx.
The Authority's quarterly 2008 December Advisory contains other articles developed from data submitted through real events that have occurred in Pennsylvania's healthcare facilities. The articles also provide advice and prevention strategies for facilities to implement within their own institutions. Highlights include:
For a copy of the 2008 December Patient Safety Advisory or more information on the Pennsylvania Patient Safety Authority, visit the Authority's website at http://www.patientsafetyauthority.org.
|SOURCE Pennsylvania Patient Safety Authority|
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