Pennsylvania Patient Safety Advisory Understanding Living Wills and DNR Orders ABSTRACT A do-not-resuscitate (DNR) order is a medical order A living will is a document intended to convey a to withhold cardiopulmonary resuscitation (CPR) in patient’s preferences regarding end-of-life healthcare the event of cardiac or respiratory arrest. Typically, a decisions when the patient cannot express them per- DNR order is entered into a patient’s medical record sonally to a physician or other healthcare provider. A after a discussion between the physician and the living will directs healthcare providers or a patient’s patient and/or a patient’s authorized representative.2 authorized representative about the types of medical A DNR order may be entered into a patient’s medical care the patient wishes to have provided or to forgo record in the absence of a living will. at the end of life, consistent with the patient’s values and autonomy. A do-not-resuscitate (DNR) order is a In addition to preserving a patient’s autonomy, medical order issued by a physician or other practi- one of the underlying purposes of living wills and tioner authorized to issue medical orders that directs DNR orders is to give healthcare providers direction clinicians not to provide cardiopulmonary resuscitation regarding a patient’s preferences for end-of-life care in the event of cardiac or respiratory arrest. A DNR and interventions. However, as reflected in PA-PSRS order, by itself, does not address the withdrawal or reports, there is confusion about how to interpret withholding of any medical care other than resuscita- and implement these documents. From June 2004 tion. Despite the prevalence of living wills and DNR to September 2008, PA-PSRS received more than orders, PA-PSRS reports received between June 2004 200 reports involving living wills and DNR orders. and September 2008 have revealed that healthcare An understanding of the implications of living wills providers, as well as patients and families, may not and DNR orders, as well as the understanding that understand the differences between living wills and these documents are not interchangeable, is impor- DNR orders. Misinterpretation of living wills and DNR tant in providing appropriate and respectful clinical orders may inadvertently result in the provision of care. This article will discuss living wills and DNR unwanted care or the withdrawal or withholding of orders as defined in the Commonwealth of Pennsyl- otherwise appropriate interventions. Accurate inter- vania. Strategies are presented to assist clinical staff, pretation and implementation of these documents, in patients, and families to understand what these docu- addition to effective planning and communication, is ments mean to help ensure that a patient’s wishes are essential to ensure that a patient’s end-of-life prefer- communicated and appropriately carried out. ences for medical care are honored. (Pa Patient Saf Background Advis 2008 Dec;5[4]:111-7.) Living Wills In the Commonwealth of Pennsylvania, patient self- determination is governed by the Living Will Act, which provides a statutory framework for healthcare The term “advance healthcare directive” refers to a decision making.1,3 The Living Will Act establishes number of different documents intended to convey a that only competent adults or emancipated minors patient’s preferences about healthcare.1 Some advance are able to make a living will. Pennsylvania law healthcare directives are intended to appoint a person requires that the document be entered into the to make decisions on the patient’s behalf when the patient’s medical record, but entry into the medical patient is unable to do so; some authorize another record does not make a living will operational. A individual to admit the patient to a nursing home living will becomes operational only when a physi- or other type of healthcare facility under certain cir- cian determines that the patient is incompetent and cumstances; and some give specific instructions about certifies in writing that the patient has an end-stage what kind of and under what circumstances medical medical condition or is permanently unconscious.1 care is to be provided or withheld. A living will is a (See “Glossary of Selected Terms.”) type of advance healthcare directive, specifying the Certification of an end-stage medical condition can life-sustaining treatments a patient wishes to receive pose problems when the patient has an illness involv- or forgo when the patient is no longer capable of mak- ing slow deterioration, such as with Alzheimer’s ing decisions for him- or herself and has an end-stage disease. Determinations of competency can be very medical condition or is permanently unconscious.1 A difficult and present a challenge to the determining patient may revoke a living will at any time, even at physician as well as other healthcare practitioners the end of life. In order to implement the terms of a involved in the patient’s care. Competency is not living will in a clinical setting, a physician must deter- static, and a patient’s decision-making capability mine that the patient is no longer competent and may fluctuate. A patient may become confused certify in writing that the patient is in an end-stage when experiencing a high fever but be lucid when medical condition or is permanently unconscious.1 the fever has resolved. In addition, a patient may be Vol. 5, No. 4—December 2008 REPRINTED ARTICLE - ©2008 Pennsylvania Patient Safety Authority Page 111 Pennsylvania Patient Safety Advisory patients with living wills poorly understood the mean- Glossary of Selected Terms ing of “life-sustaining therapies” and the implications Incompetency is a condition in which an indi- of their advance directives. Of 755 patients admitted vidual—despite receiving appropriate medical to a community teaching hospital during the study information, communication support, and techni- period, 264 study participants were surveyed regard- cal assistance—is documented by a healthcare ing their understanding of CPR. Of these, 82 (31%) provider to be unable to had living wills. Most (76%) created their living will ■ understand the potential material benefits and with a lawyer or family member, and 7% involved a risks involved in and alternatives to a specific physician. After the patients were provided an expla- proposed healthcare decision; nation of the meaning of CPR, 37% of patients with ■ make that healthcare decision on his or her living wills indicated they actually did not want CPR. own behalf; or Their living wills did not accurately reflect their treat- ■ communicate that healthcare decision to ment preferences.6 another person. A DNR order is a medical order issued by a physician End-stage medical condition is an incurable and or other authorized practitioner that directs health- irreversible medical condition in an advanced care providers not to administer CPR in the event of state caused by injury, disease, or physical illness that will, in the opinion of the attending physician cardiac or respiratory arrest. A DNR order may be to a reasonable degree of medical certainty, result written in the absence of a living will or the conditions in death, despite the introduction or continuation that would make a living will operative. A living will of treatment. may contain a provision indicating that a patient does Permanently unconscious is a medical condi- not desire CPR. However, if a patient’s preference to tion that has been diagnosed, in accordance forgo CPR is expressed only in a living will, CPR will with currently accepted medical standards and be withheld only when a physician has determined with reasonable medical certainty, as a total and that the patient is not competent and has certified in irreversible loss of consciousness and capacity for writing that the patient has an end-stage medical con- interaction with the environment. The term includes dition or is permanently unconscious.1 Without such an irreversible vegetative state or irreversible coma. physician determination and certification or without Life-sustaining treatment is a medical proce- a DNR order, the patient’s expressed preference for dure or intervention that, when administered withholding CPR is not sufficient.2 In order for a to a patient or principal who has an end-stage patient’s preferences to be carried out, patients, fami- medical condition or is permanently unconscious, lies, and healthcare providers must understand the will only serve to prolong the process of dying or maintain the person in a state of permanent distinction between the circumstances under which a unconsciousness. living will and a DNR order are applicable. Source: 20 Pa. Cons. Stat. § 5442 (2008). A DNR order is not subject to the preconditions imposed by the Living Will Act. A DNR order becomes operative only in the narrow context of cardiac or respiratory arrest regardless of the precipi- found incompetent to make some healthcare deci- tating clinical event and does not preclude otherwise sions, but competent to make others.4 For example, a appropriate treatments or life-sustaining interven- patient may be competent to consent to a chest x-ray tions.2,7 Misinterpretation of DNR orders was but incompetent to agree to complicated surgery. demonstrated by a survey conducted in an outpatient Incompetence does not mean that the patient made cancer center, which showed that only 34% of the a choice that others would not make, such as when patients correctly understood the meaning of a DNR a competent patient chooses to forgo recommended order; 66% of the patients did not realize that a DNR treatment. order would result in not being resuscitated even if the cause of the cardiac or respiratory arrest was Studies have demonstrated the lack of understand- potentially reversible.8 ing about the meaning of terms found in living wills. A survey examined whether cohorts consisting of Patient Safety Risks Related to Living Wills and patients, their physicians, and family members under- DNR Orders stood the meaning of terms used in living wills. The cohort groups had high concordance (83%) regarding The potential for misunderstanding the meaning understanding of the term “the use of life support to and implications of a living will and DNR orders by keep patients alive.” However, 71% of patients, 42% healthcare providers, patients, and families may lead of family members, and 27% of physicians responded to withholding of desired interventions or administer- that a living will could be used to guide treatment ing unwanted interventions. Communication failures decisions in non-end-of-life clinical situations, reflect- between providers, patients, and facilities may lead to ing a lack of understanding about when a living will the same results. These patient safety risks have been becomes operative.5 Another study demonstrated that reported through PA-PSRS. Page 112 REPRINTED ARTICLE - ©2008 Pennsylvania Patient Safety Authority Vol. 5, No. 4—December 2008 Pennsylvania Patient Safety Advisory Unwanted Treatment In the absence of a DNR order, CPR will be admin- Key Points istered, if medically justified, unless a living will has ■ A living will applies only if the patient is become operative. A patient may undergo unwanted incompetent and has an end-stage medical treatment (i.e., CPR) if he or she does not appreciate condition or is permanently unconscious. the important differences between a living will and a ■ A living will does not apply to questions of day- DNR order when expressing, in a living will, the wish to-day care, placement or treatment options, not to undergo CPR. In addition, the risk of a patient and other non-end-of-life circumstances. receiving unwanted care or not receiving desired and ■ A do-not-resuscitate (DNR) order is a medical appropriate care arises when healthcare providers do order issued by a physician or other authorized not interpret or implement a living will appropriately. practitioner that directs clinicians not to pro- Dobbins has shown that the existence of a living will vide cardiopulmonary resuscitation in the event may not affect healthcare decision making. A retro- of cardiac or respiratory arrest. spective review was conducted of the records of 160 ■ A DNR order, by itself, does not include the elderly patients who died in a community hospital to withdrawal or withholding of any medical care determine the effect of living wills on healthcare deci- other than resuscitation. sions. The findings demonstrated that a living will did not influence healthcare provider decisions about the use of life-sustaining treatment and the initiation of comfort care plans or the decision to treat the patient providers. A case series of patients with a living will in the intensive care unit (ICU). The documents did presenting for treatment and their hospital course influence healthcare providers to write DNR orders illustrated these concerns. In one case, the primary more often.9 care physician (PCP) advised the emergency physician (EP) that a patient presenting with chest pain did not From June 2004 to September 2008, 37 of the need to be admitted because the patient had a living PA-PSRS reports related to living wills or DNR orders will. The PCP interpreted the living will as imparting have involved patients receiving potentially unwanted a DNR status. The EP disagreed with the PCP’s inter- interventions. Examples are as follows: pretation, and the disagreement resulted in a delay in A patient was admitted through the [emergency depart- treatment. In another case, a nurse delayed notifying ment (ED)] after suffering a femoral fracture from a the attending physician of a change in the patient’s fall at home. The patient underwent an open reduction clinical status. The nurse mistakenly interpreted the of the fracture and was transferred to the ICU post- patient’s living will as meaning a code status of DNR. operatively due to numerous preexisting comorbidities. In a third case, the EP and PCP misinterpreted a The patient developed hypotension and tachycardia. A living will, believing it to be operative. This resulted hospitalist was summoned to the bedside, and medica- in less aggressive treatment of a myocardial infarc- tions were administered. The patient then developed tion.10 The case series author stated that “just because ventricular tachycardia. The patient did have DNR a living will exists, its existence does not cause it to order but an attempt was made to resuscitate the become activated. Also, it must be re-iterated that a patient. The resuscitation attempt was unsuccessful. DNR does not equal ‘do not treat.’”10 A patient was admitted through the ED with A recent study has shown that a misunderstanding increased lung congestion and vomiting blood. Resus- of the meaning of a living will may unnecessarily put citation status was not addressed on admission. The patients at risk when patients present for emergency patient was diagnosed with acute respiratory distress care. A survey administered to physicians, nurses, and due to pneumonia. No chest x-ray had been ordered. first responders at a 350-bed acute care and level II The patient was being assisted with breakfast and sud- trauma center presented a fictitious living will and denly became unresponsive and stopped breathing. A prompted respondents to assign a code status (DNR resuscitation team was called. The patient had living or full code) and define the level of care associated will in the chart indicating no resuscitation. The hos- with the DNR code status. Seventy-nine percent of pitalist spoke with the attending physician, who stated respondents assigned a DNR code status, and 70% the patient’s wishes were . . . DNR; however, the order construed DNR to mean “comfort care/end-of-life was never given. The resuscitation was stopped, and care.”11 Other studies support that DNR orders may the patient expired. be applied to broader treatment decisions and that A patient with numerous comorbidities had a DNR interventions such as hospitalization, blood transfu- order in the chart; when the patient’s vital signs sion, central line placement, and intubation may be changed, the patient was resuscitated despite the withheld based on the existence of a DNR order, even DNR order. when a patient has not requested that these treat- Misperceptions of the Meaning of Living Will ments be withheld.12,13,14 and DNR From June 2004 to September 2008, 93 of PA-PSRS Researchers have raised concerns that DNR orders reports regarding living wills or DNR orders indicated and living wills may be misunderstood by healthcare that a DNR order may have been misinterpreted as Vol. 5, No. 4—December 2008 REPRINTED ARTICLE - ©2008 Pennsylvania Patient Safety Authority Page 113 Pennsylvania Patient Safety Advisory a directive to withdraw or withhold care, suggesting The physician ordered a DNR status; subsequently, staff may not have understood the narrow scope of a the physician noted a DNR sticker was not placed on DNR order. It is important to note that the reports patient’s chart. No report was given to the nurse from do not convey the clinical context of the decision the previous shift regarding code status, and no DNR to withdraw or withhold care, which may have been armband was placed on the patient. based on other factors unrelated to the DNR order. Patient was admitted from another facility as level 2 Examples include the following: DNR. Family member states family discussed level A patient was transferred from the ICU to the of intensity with doctor and requested change to telemetry unit. No monitors were available. . . . Staff level 1 (DNR). Per family, doctor agreed that it was phoned the doctor to see if they could discontinue the appropriate and told them that he would take care of monitor on [another] patient who was DNR to use it. The patient coded with family present. The family on this patient. requested a code. The staff initiated resuscitation but then noted level 2 status and code stopped. A A patient was intubated and restrained due to the nurse spoke to the family, who stated the code status patient pulling on lines. . . . The patient was unable had been changed. The code team was recalled and to be weaned from ventilator. Family and physician resumed resuscitation. The patient was resuscitated discussion revealed code status had been changed successfully. from full code to DNR. Restraints were removed, and the patient was extubated and expired. A patient was wearing a purple wristband (DNR) indicating code status. The band was removed, and an A patient presented to the ED in cardiac arrest. appropriate band for “do not use extremity” applied. After admission, the patient developed a fever. Blood cultures were positive for methicillin-resistant Staphy- A DNR order was entered for a patient. The unit lococcus aureus. The patient expired after the secretary prepared a DNR band and gave it to the family made the patient a DNR and did a terminal nurse’s aide to apply to the patient. The nurse’s wean [from the ventilator]. aide then passed it on to a second nurses’ aide, who applied the band to the wrong patient. Shortly after admission, the patient went into respira- tory arrest. The patient was intubated, and restraints Patient had a blue armband indicating DNR order. were applied to prevent the patient from removing No DNR order was found on the patient’s chart. the endotracheal tube. The patient then requested [The discrepancy was] discussed with the patient, and DNR status, restraints and endotracheal tube were the patient wanted full code status. The blue arm- removed, and the patient expired. band was removed. A patient was on a Levophed® drip. When the Risk Reduction Strategies drip began running out, no Levophed was available As the above PA-PSRS reports indicate, living wills to mix another dose. The patient was a DNR, and and DNR orders may be misunderstood by healthcare Levophed was discontinued. providers, families, and patients. Communication Miscommunication breakdowns, including the lack of appropriate docu- PA-PSRS reports show that there is a potential for a mentation and patient misidentification, also present breakdown in communication between healthcare patient safety risks. Several strategies may be used to providers and between healthcare providers, patients, reduce this risk. (For additional resources, see “Com- and families. Seventy-one reports submitted through panion Online Information.”) PA-PSRS from June 2004 to September 2008 related Improving Communication to living wills or DNR orders indicated some form of The implementation of a DNR order may preclude a communication breakdown. The majority of reports number of procedures, including chest compressions, involved a lack of understanding of the meaning of cardiac defibrillation, medications, and endotracheal the documents by families, lack of communication intubation.2 A DNR order may apply to any com- of the presence of a DNR order among healthcare bination of these interventions, potentially leading providers, misidentification of patients, and failure to confusion. For example, a patient may want to to identify patients with DNR orders. All these issues be intubated but may not wish to receive any other may lead to a patient’s preferences not being carried treatment. DNR protocols have been developed that out. Examples of these issues reported through integrate these procedures; however, these protocols PA-PSRS include the following: may differ among facilities in terminology, scope, and A patient was admitted through the ED from a content. For example, PA-PSRS reports from different long-term care facility (LTCF). The patient’s [living facilities throughout the state include the following will] was not sent with information from the LTCF. terms: DNR A through D, DNR levels I through V, Shortly after admission, the patient had a respiratory modified DNR II, and DNR/DNI. arrest. A code was called, and the patient was suc- In addition to inconsistent terminology, in Pennsylva- cessfully resuscitated. The family was called to notify nia, a DNR order is not portable after the patient is of code. [The family] advised staff that the patient discharged or transferred to another facility. The Phy- had [a living will] and was a DNR. sician Orders for Life-Sustaining Treatment (POLST) Page 114 REPRINTED ARTICLE - ©2008 Pennsylvania Patient Safety Authority Vol. 5, No. 4—December 2008 Pennsylvania Patient Safety Advisory families regarding end-of-life treatment preferences. Companion Online Information The following have been identified as key elements of a successful advance directive program and may be Caring Connections applied to the process of obtaining a DNR order.2,16 ■ Caring Connections, a program of the National Hospice and Palliative Care Organi- ■ Develop an individualized plan of care through zation, provides a variety of information about a process of interaction with the patient that is advance directives for patients and families. specific to the patient’s values and goals, including Available from Internet: http://www.caringinfo. consideration of the patient’s relationships, cul- org/Home.htm. ture, and medical condition. Pennsylvania Department of Aging ■ Engage individuals who are close to the patient so ■ The department provides a brochure, which that they understand and support the plan. Discuss includes an advance directive statutory form. with the patient and surrogate how much leeway See “Advance Directives for Health Care, the surrogate has in decision making. Living Wills and Powers of Attorney in Pennsyl- ■ Document the plan, including identification of vania.” Available from Internet: http://www. the designated surrogate in the event the patient aging.state.pa.us/aging/lib/aging/ Advance_Directives_brochure1.pdf. is deemed no longer competent or able to commu- nicate, in the form of an actionable directive that Pennsylvania Medical Society addresses wishes for treatment with specific medi- ■ The Pennsylvania Medical Society provides an cal orders reflecting the patient’s current treatment online summary of the Living Will Act. Avail- preferences. able from Internet: http://www.pamedsoc. ■ Plan for a proactive but appropriately staged and org/mainmenucategories/Government/ timed discussion about healthcare decisions. The LawsAffectingPhysicians/AdvanceDirectives/ Act169facts.aspx. discussion must be revisited when the patient’s prognosis becomes known or changes. Healthy The Hospital & Healthsystem Association of adults can benefit from advance care planning to Pennsylvania (HAP) prepare for sudden, severe illness or injury. For ■ HAP provides an informational brochure on individuals with advanced chronic disease and advance directives. See “Decide for Yourself: A frailty, include a discussion regarding changing Guide to Advance Healthcare Directives.” treatment goals as the patient’s prognosis changes. Available from Internet: http://www.haponline. Plans should be updated over time and available org/downloads/decideen.pdf. when needed. Hamot Medical Center ■ Ensure that patients, families, and/or surrogates ■ Ferdinando L. Mirarchi, DO, medical director, understand the terminology contained in a living emergency medicine, Hamot Medical Center, will and/or DNR order, as appropriate. presented an informational lecture on living Healthcare providers can improve their own under- wills and DNR orders at the University at Buf- standing and their communication with each other falo on September 10, 2008. See “To Live or about a patient’s wishes as expressed in a living will, Let Die! Living Wills and DNR Orders.” Available from Internet: http://www.hamot. the DNR order, or both, by implementing the follow- org/livingwillvideo/. ing strategies: ■ Establish ongoing education about living wills and DNR orders for residents, attending physicians, and nursing staff.2 form has been recommended in other states as one mechanism for issuing a single medical order that ■ Ensure that residents, attending physicians, reflects a patient’s end-of-life preferences expressed and nursing staff understand when a living will through a living will and is transferrable across care becomes operative.10,16 settings to help ensure the patient’s wishes are hon- ■ Ensure that residents, attending physicians, and ored throughout the healthcare system.2,15,16 (The nursing staff understand that the existence of POLST form has not been adopted in Pennsylvania, a living will does not imply that a patient has a however, and current healthcare regulations preclude DNR order.10 physicians from issuing medical orders that transfer ■ Ensure that residents, attending physicians, and from one facility to another in most cases. The Penn- nursing staff recognize that a DNR order applies sylvania Department of Health currently has a task only to cardiopulmonary arrest and has no effect force reviewing the advisability of adopting a POLST- on any other treatment decision. In other words, a like medical order statewide.) DNR order does not mean “do not treat.”10 Healthcare providers can use a number of strate- ■ Encourage physicians to obtain skills training in gies to facilitate communication with patients and communication about end-of-life decision making.2 Vol. 5, No. 4—December 2008 REPRINTED ARTICLE - ©2008 Pennsylvania Patient Safety Authority Page 115 Pennsylvania Patient Safety Advisory ■ Establish policies that require a discussion and 2008 Sep 3]. Available from Internet: http://aspe.hhs. documentation of any exception to a DNR order gov/daltcp/reports/2007/advdirlr.pdf. during the perioperative period, such as suspen- 5. Upadya A, Muralidharan V, Thorevska N, et al. sion of a DNR order during surgery.2 Patient, physician, and family member understand- ■ Ensure that the existence of a living will is estab- ing of living wills. Am J Respir Crit Care Med 2002 Dec lished on admission and documented in the 1;166(11):1430-5. patient’s medical record.2 6. Thorevska N, Tilluckdharry L, Tickoo S, et al. Patients’ understanding of advance directives and cardiopulmo- ■ If the facility uses color-coded wristbands to com- nary resuscitation. J Crit Care 2005 Mar;20(1):26-34. municate DNR status to clinicians, ensure that policies address who is responsible for applying 7. Berger JT. Ethical challenges of partial do-not-resuscitate and removing DNR color-coded wristbands and (DNR) orders: placing DNR orders in the context of a how DNR wristband information is documented life-threatening conditions care plan. Arch Intern Med 2003 Oct 27;163(19);2270-5. and communicated.17 8. Rohrer JE, Esler WV, Saeed Q, et al. Risk of mistaken Conclusion DNR orders. Support Care Cancer 2006 Aug;14(8):871-3. A living will is an important mechanism for provid- 9. Dobbins EH. End-of-life decisions: influence of ing guidance and direction to healthcare providers advance directives on patient care. J Gerontol Nurs 2007 regarding a patient’s end-of-life preferences. A DNR Oct;33(10):50-6. order is one way a physician or other authorized 10. Mirarchi FL. Does a living will equal a DNR? Are living practitioner can direct clinicians to respect a patient’s wills compromising patient safety? J Emerg Med 2007 wishes about receiving CPR in the event of cardiac Oct;33(3):299-305. or respiratory arrest. However, there is no substitute 11. Mirarchi FL, Hite LA, Cooney TE, et al. TRIAD I-the for collective, informed decision making and clinical realistic interpretation of advanced directives. J Patient judgment, requiring open communication between Saf 2008 Dec;4(4):235-40. patients, families, and physicians. In order to commu- nicate effectively, all parties involved must understand 12. Beach MC, Morrison RS. The effect of do-not-resusci- the meaning and implications of living wills and tate orders on physician decision-making. J Am Geriatr DNR orders. Living wills and DNR orders are Soc 2002 Dec;50(12):2057-61. intended to honor a patient’s end-of-life preferences. 13. Holtzman J, Pheley AM, Lurie N. Changes in orders Through planning, education, and effective commu- limiting care and the use of less aggressive care in a nurs- nication, healthcare providers can assist patients in ing home population. J Am Geriatric Soc 1994 Mar;42(3): realizing their end-of-life treatment goals. 275-9. Notes 14. Sulmasy DP, Sood JR, Ury WA. The quality of care plans for patients with do-not-resuscitate orders. Arch 1. Living Will Act, enacted as part of Act 169 of 2006, 20 Intern Med 2004 Jul 26;164(14):1573-8. Pa. Cons. Stat. § 5441 et seq. (2008). 15. Dunn PM, Tolle SW, Moss AH, et al. The POLST para- 2. ECRI Institute. Do-not-resuscitate orders. Healthc Risk digm: respecting the wishes of patients and families. Ann Control 2008 Mar;2:Ethics 3:1-13. Long-Term Care 2007 Sep;15(9):33-40. 3. Pennsylvania Medical Society. Guide to Act 169 for 16. Hickman SE, Hammes BJ, Moss AH, et al. Hope for the physicians and other health care providers [online]. 2006 future: achieving the original intent of advance direc- [cited 2008 Sep 3]. Available from Internet: http:// tives. Hastings Cent Rep 2005 Nov-Dec; Spec No:S26-30. www.pamedsoc.org/MainMenuCategories/ 17. Pennsylvania Patient Safety Reporting System. Update Government/LawsAffectingPhysicians/ on use of color-coded wristbands. PA PSRS Patient Saf AdvanceDirectives/Act169facts.aspx. Advis [online]. 2006 Aug 9 [cited 2008 Oct 5]. Available 4. Wilkinson A, Wegner N, Shugarman LR. Literature from Internet: http://www.psa.state.pa.us/psa/lib/psa/ review on advance directives [online]. 2007 Jun [cited advisories/v3_s1_sup_advisory_8-9-06.pdf. (See Self-Assessment Questions on next page.) Page 116 REPRINTED ARTICLE - ©2008 Pennsylvania Patient Safety Authority Vol. 5, No. 4—December 2008 ? Pennsylvania Patient Safety Advisory ? Self-Assessment Questions The following questions about this article may be useful for internal education and assessment. You may use the following about the implications of the DNR order, the physician enters a DNR order in the patient’s medical record. On examples or come up with your own. her second postoperative day, the patient’s condition dete- 1. A patient safety risk related to the misinterpretation of a riorates and she suffers a cardiopulmonary arrest. do-not-resuscitate (DNR) order by healthcare providers is Which of the following is an accurate statement about the the withholding or withdrawing of otherwise appropriate appropriateness of CPR for this patient? clinical interventions. a. CPR may be withheld in the presence of the DNR a. True order only if the patient was determined to be b. False incompetent. 2. A living will becomes applicable when all of the following b. CPR may be withheld based on the living will since the conditions occur EXCEPT: patient suffered a cardiopulmonary arrest. a. A copy is provided to the attending physician. c. A healthcare provider may not withhold CPR based on b. The patient is determined to be incompetent by the the DNR order without the existence of the living will. attending physician. d. The healthcare provider may withhold CPR based on c. The patient is determined to have an end-stage medical the DNR order without the provisions expressed in the condition or to be permanently unconscious. patient’s living will becoming applicable. d. The determination of all applicable conditions is con- 5. All of the following are strategies that would help reduce firmed with a second opinion. the risk of misinterpretation and/or miscommunication of 3. Living wills may be applicable to questions about day- a living will or DNR order EXCEPT: to-day care, placement or treatment options, or other a. Determine on admission whether a patient has a living healthcare decisions involving patients who lack capacity in will, and ensure that it is appropriately documented in non-end-of-life circumstances. the patient’s medical record. a. True b. Recognize that obtaining skills training in communica- b. False tion about end-of-life decision making is best delegated to the hospital ethics committee. 4. An elderly patient with a medical history of stroke, myo- cardial infarction, and congestive heart failure is admitted c. Ensure that residents, attending physicians, and nurs- after a fall at home. The patient is diagnosed with a hip ing staff recognize that a DNR order applies only to fracture. The patient has a living will indicating she does cardiopulmonary arrest and has no effect on any other not wish to undergo cardiopulmonary resuscitation (CPR), treatment decision. which is placed in her medical record. Before surgery to d. Ensure that patients, families, and/or surrogates under- repair her fractured hip, the patient reminds her physician stand the terminology contained in a living will and/or that she does not wish to undergo CPR. After a discussion DNR order. Vol. 5, No. 4—December 2008 REPRINTED ARTICLE - ©2008 Pennsylvania Patient Safety Authority Page 117 PENNSYLVANIA PATIENT SAFETY ADVISORY This article is reprinted from the Pennsylvania Patient Safety Advisory, Vol. 5, No. 4—December 2008. The Advisory is a publication of the Pennsylvania Patient Safety Authority, produced by ECRI Institute and ISMP under contract to the Authority as part of the Pennsylvania Patient Safety Reporting System (PA-PSRS). Copyright 2008 by the Pennsylvania Patient Safety Authority. This publication may be reprinted and distributed without restriction, provided it is printed or distributed in its entirety and without alteration. Individual articles may be reprinted in their entirety and without alteration provided the source is clearly attributed. This publication is disseminated via e-mail. To subscribe, go to https://www.papsrs.state.pa.us/ Workflow/MailingListAddition.aspx. To see other articles or issues of the Advisory, visit our Web site at http://www.patientsafetyauthority.org. Click on “Advisories” in the left-hand menu bar. THE PENNSYLVANIA PATIENT SAFETY AUTHORITY AND ITS CONTRACTORS The Pennsylvania Patient Safety Authority is an independent state agency created by Act 13 of 2002, the Medical Care Availability and Reduction of Error (“Mcare”) Act. Consistent with Act 13, ECRI Institute, as contractor for the PA-PSRS program, is issuing this publication to advise medical facilities of immediate changes that can be instituted to reduce Serious Events and Incidents. For more information about the PA-PSRS program or the Pennsylvania Patient Safety An Independent Agency of the Commonwealth of Pennsylvania Authority, see the Authority’s Web site at http://www.patientsafetyauthority.org. ECRI Institute, a nonprofit organization, dedicates itself to bringing the discipline of applied scientific research in healthcare to uncover the best approaches to improving patient care. As pioneers in this science for nearly 40 years, ECRI Institute marries experience and independence with the objectivity of evidence-based research. More than 5,000 healthcare organizations worldwide rely on ECRI Institute’s expertise in patient safety improvement, risk and quality management, and healthcare processes, devices, procedures and drug technology. The Institute for Safe Medication Practices (ISMP) is an independent, nonprofit organization dedicated solely to medication error prevention and safe medication use. ISMP provides recommendations for the safe use of medications to the healthcare community including healthcare professionals, government agencies, accrediting organizations, and consumers. ISMP’s efforts are built on a nonpunitive approach and systems-based solutions.