The National Academy of Sciences released its groundbreaking report on end-of-life (EOL) care, confirming EOL care is not only broken but accounts for $170 billion in annual spending. To make an impact, living wills (LWs) and physician orders for life-sustaining treatment (POLST) are here to stay. Additionally, Medicare now reimburses for advance-care planning (ACP) conversations.
Physicians have tried to embrace LWs. More recently, the POLST paradigm has emerged to the national forefront. This growth has led to concerns that states cannot educate fast or well enough to ensure their safe and effective utilization. Both LWs and POLST are good documents. How they are applied by others in clinical situations, such as critical illness, has led to the unintended consequences of both over- and under-resuscitation. We have essentially introduced a new patient safety risk that has no quality oversight. We must recognize these risks and act to improve patient outcomes.
Can we accurately interpret POLST or LWs? Most LWs are created by attorneys years in advance of the onset of medical conditions. Often, POLST are completed by other providers (eg, social workers or registered nurses) and signed by physicians who may or may not have been involved in the conversation. So how do frontline emergency physicians interpret these during a brief interaction? Emergency physicians do not know these patients or families and have no established trust or rapport, yet within seconds they are expected to understand the patient’s wishes to either accept or decline lifesaving interventions based upon a form. “Full Code” appears understood. However, with a do-not-resuscitate (DNR) order, things are less clear. With POLST, there are many combinations of treatment options, which make the water murkier.
The TRIAD studies have questioned whether providers understand what to do with LWs, DNR orders, and POLST. We need to figure out who is better off with a LW versus a POLST. We need to set quality standards and abide by them universally. More important, we need to standardize goals-of-care conversations so they are balanced and accurately predict the patient’s wishes. That information then will need to be conveyed to a totally different and disconnected medical provider in a safe and effective manner that ensures no risk to the patient.
Figure 1: Patient Resuscitation Card
This card directs the provider to a video testimonial outlining the patient’s resuscitation wishes. Providers can scan the card to see a video of the patient communicating his or her care wishes to providers in a clear and direct format rather than relying on complicated paper forms. The video password is 911.
At this time of escalating costs, are we also trampling on patients’ wishes? The pioneering work of Volandes, Wilson, and El-Jawahri has shown that educational videos can help patients make informed decisions about CPR. Could we then utilize patient video testimonials to help providers make informed medical decisions for patients in a safe and effective manner? Recently accepted for publication by the Journal of Patient Safety is the TRIAD VIII study. This was a multicenter evaluation to determine if patient video testimonials can safely help to ensure appropriate critical versus EOL care. We can now say that we can do things better to ensure we get it right for patients. Figure 1 is just an example of how we can bring patients back into the actual decision-making process.
With patient video testimonials, we can now hear from patients when they are critically ill and receive their guidance rather than providers guessing after reviewing a form that may or may not have been completed correctly. Resuscitations are complex, and we need to know what to do in the first seconds to 15 minutes—paper forms do not do this well. We will still need POLST and LWs, but we also need to hear from the patients, and with emerging technologies, we need to be able to do this in a safe and cost-effective manner.
In conclusion, we have a safety problem with documents, and TRIAD VIII presents an opportunity to do better. When appropriate, we have to rethink the concept of “treat first, ask questions later.” We need to embrace both LWs and POLST and be sure we set quality standards for their completion and understanding. We further need to investigate technologies to allow us to hear from patients to accurately guide their care.
Dr. Mirarchi is medical director in the department of emergency medicine at UPMC Hamot and chairman of UPMC Hamot Physician Network in Erie, Pennsylvania.
Dr. Aberger is core faculty, emergency medicine/palliative medicine, for St. Joseph’s Regional Medical Center in Paterson, New Jersey. She is also chair of ACEP’s Palliative Medicine Section.