For clarification, the living will’s presence does not mean it should be followed. It simply indicates that this document is “effective” (ie, it’s valid and legal).

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ACEP Now: Vol 33 – No 05 – May 2014

Until recently, the risks posed to patient safety by the various incarnations of advance directives were unknown and thus undisclosed, producing unintended consequences. The TRIAD (The Realistic Interpretation of Advance Directives) series of studies has disclosed this patient safety risk as reality on a nationwide scale. The risk is attributable to variable understanding and misinterpretation of advance directives, which then translates into over- or under-resuscitation.

So what limits advance directives? With 90 million of them in existence in the United States, these limitations can lead to deleterious effects on patient care and safety.¹ These are a few of the more commonly cited limitations:

1. Their use has been mandated but not funded.
2. There is no standardization or clarification of terms.
3. There is variable understanding among providers.
4. They are often not available at the time of need.
5. Informed discussion takes place in the primary care physician’s office.

Standardization is a powerful safety tool. In TRIAD III, high percentages of participants reported receiving training about advance directives, but they received no benefit. The most compelling reason is lack of standardization. To facilitate understanding, the following terms need to be defined and standardized:

• Terminal illness defined by law
• Reversible and treatable condition
• An “effective” living will
• An “enacted” living will
• Do not resuscitate (DNR) order
• Physician Orders for Life-Sustaining Treatment (POLST) document

For clarification, the living will’s presence does not mean it should be followed. It simply indicates that this document is “effective” (ie, it’s valid and legal).2 An “enacted” or “activated” living will is one that has been activated by the triggers in the document, a terminal or end-stage medical condition, or a persistent vegetative state.² This enacted living will now requires adherence to its instructions. Legally defined, a terminal or end-stage medical condition is when patients are expected to die of their disease process despite medical treatment. Therefore, the living will does not dictate the care of critically ill patients who present with a reversible and treatable condition such as congestive heart failure or chronic obstructive pulmonary disease; rather, it applies when those same patients are permanently unconscious and have exhausted all treatment options.