Living Wills, Do Not Resuscitate Orders Not Well
Understood by Emergency Responders
Relief seen in better education and a clearly defined
code status designation within the living will
Feb. 26, 2009 A new study finds that confusion
and concern for patient safety exists in the pre-hospital setting due to
the misunderstanding and wrongful implementation of living wills and DNR
(do not resuscitate) orders. Living wills have the potential to impact
patient care for patients who call 911 in a medical emergency.
The study conducted at the Hamot Medical Center in
Erie, Pennsylvania, shows that there is a lack of education and
understanding in what sets a living will in motion in a pre-hospital
setting. But, they report that education and implementation of code
status designations can clarify this confusion.
The researchers began their quest after deciding
the use of living wills and their impact on patient care had not been
adequately studied. Their study aimed to determine how a living will is
interpreted and assess how interpretation impacted lifesaving care.
When a living will is present with the patient
experiencing a critical illness, it has the potential to limit or delay
lifesaving care. This confusion can be mitigated by implementing clearly
defined code status into the living will.
Three-part survey was administered to 150 emergency
medical technicians (EMTs) and paramedics.
Part I assessed understanding of the living will
and do-not-resuscitate (DNR) orders.
Part II assessed the living will's impact in
clinical situations of patients requiring lifesaving interventions.
Part III was similar to part II except a code
status designation (full code - Full code status means that all possible
measures are taken to revive a person and sustain life) was incorporated into the living will.
There were 127 surveys completed, and 90% of
respondents determined that, after review of the living will, the
patient's code status was DNR, and 92% defined their understanding of
DNR as comfort care/end-of-life care.
When the living will was applied to clinical
situations, it resulted in a higher proportion of patients being
classified as DNR as opposed to full code (Case A 78% vs. 22%); Case B
67% vs. 33%; Case C 63% vs. 37%.
With the scenarios presented, this DNR
classification resulted in a lack of or a delay in lifesaving
interventions. Incorporating a code status into the living will produced
statistically significant increases in the provision of lifesaving care.
In Case A, intubation increased from 15% to 56%;
Case B, defibrillation increased from 40% to 59%; and Case C,
defibrillation increased from 36% to 65%.
Significant confusion and concern for patient
safety exists in the pre-hospital setting due to the understanding and
implementation of living wills and DNR orders. This confusion can be
corrected by implementing clearly defined code status into the living
will, the authors wrote in conclusion.
"The results of the study are important because
they provide clarification as to when a living will is enacted and
promotes patient care and safety. It ensures the provision of lifesaving
care for those who call 911 for a medical emergency," according to lead
researcher Ferdinando L. Mirarchi, DO, FAAEM, FACEP.
The results of this study suggest that the current
structure of the living will leads the majority of pre-hospital health
care providers to incorrectly assume a patient is a DNR.
Living wills should not be considered synonymous
with DNR orders, the researchers say.
DNR is misunderstood to define comfort
care/end-of-life care, a confusion that can compromise lifesaving care.
This confusion and concern for patient safety can be rectified by
incorporating a clearly defined code status designation within the
living will.
Educational efforts and provider protocols must be
reevaluated and implemented to ensure patient safety.
The Journal of Emergency Medicine is an
international, peer-reviewed publication featuring original
contributions of interest to both the academic and practicing emergency
physician. Published eight times per year, the Journal contains research
papers and clinical studies as well as articles focusing on the training
of emergency physicians and on the practice of emergency medicine. It is
the official publication of the American Academy of Emergency Medicine
and its Editor-in-Chief is Stephen R. Hayden, MD. The Journal of
Emergency Medicine is available online at
http://www.jem-journal.com.
Nursing Home Abuse, Medical Malpractice? Contact a lawyer.
click here
Keep up with the latest news for senior citizens, baby
boomers
Feb. 26, 2009 A new study finds that confusion
and concern for patient safety exists in the pre-hospital setting due to
the misunderstanding and wrongful implementation of living wills and DNR
(do not resuscitate) orders. Living wills have the potential to impact
patient care for patients who call 911 in a medical emergency.