Your Living Trust and the ER: When It May Not Be Enough
You’ve created a Living Trust, an Advanced Healthcare Directive and signed a Do Not Resuscitate Order (DNR). You’ve done everything right, but is this enough? In one alarming example, a nurse was under the misguided belief that Living Trusts automatically include DNRs. She instructed the doctor not to resuscitate the elderly patient who been rushed to the emergency room with a urinary tract infection, but was otherwise in good health.
Fortunately, the doctor looked at the medical record that said “Do everything possible,” with a checkmark approving cardiopulmonary resuscitation. The patient was treated, recovered quickly and released within a few days.
Mistakes surrounding documents that guide end-of-life decisions are common
Unfortunately, misunderstandings involving documents meant to guide end-of-life decision-making are “surprisingly common,” said Dr. Monica Williams-Murphy, medical director of advance-care planning and end-of-life education for Alabama’s Huntsville Hospital Health System.
Yet, amid the push to encourage older adults to document their end-of-life preferences, health systems and state regulators don’t systematically track mixups of this kind, and they receive little attention. As a result, information about the potential for patient harm is scarce.
Pennsylvania finds nearly 100 incidents of code status violations in 2016
A new report from Pennsylvania, which has the nation’s most robust system for monitoring patient safety events, treats mixups involving end-of-life documents as medical errors.
In 2016, Pennsylvania health care facilities reported nearly 100 events relating to patients’ “code status”. This includes issues related to whether or not they wish to be resuscitated, if their hearts stop beating, if they stop breathing, etc.
In 29 cases, patients were resuscitated against their wishes. In two cases, patients weren’t resuscitated, despite making it clear they wanted this to happen.
The rest of the cases were “near misses” — problems caught before they had a chance to cause permanent harm. An example of a near miss and its fatal effect on a patient
Asked to describe a near miss, Regina Hoffman, executive director of the Pennsylvania Patient Safety Authority, provides an example. “Let’s say I’m a patient who’s come to the hospital for elective surgery and I have a DNR order in my medical chart. After surgery, I develop a serious infection and a resident finds myDNR order. He assumes this means I’ve declined all kinds of treatment. This could be a fatal decision unless a colleague or someone intervenes.”
Medical staff are not trained to interpret legal forms and their relation to treatment
Doctors and nurses receive little, if any, training in understanding and interpreting Living Trusts, DNR orders and Physician Orders for Life-Sustaining Treatment (POLST) forms, either on the job or in medical or nursing schools.
Communication breakdowns and the pressure-cooker environment in emergency departments, where life-or-death decisions often have to be made within minutes, also contribute to misunderstandings.
Some basics about end-of-life documents:
Living Trusts. A Living Trust is a legal document that details how you will distribute your estate among your heirs. By creating a Living Trust, your family will avoid having to go through Probate. As part of California Document Preparers’ Living Trust package, we include a Power of Attorney and an Advance Healthcare Directive.
Do Not Resuscitate Orders (DNR). Do-not-resuscitate orders are binding medical orders, signed by a physician. A DNR order applies specifically to cardiopulmonary resuscitation (CPR) and directs medical personnel not to administer chest compressions, usually accompanied by mouth-to-mouth resuscitation if someone stops breathing or their heart stops beating.
Physician Orders for Life-Sustaining Treatment (POLST) Orders. A POLST form is a set of medical orders for a seriously ill or frail patient who could die within a year. It is signed by a physician, physician assistant or nurse practitioner.
What can we do about the misinterpretation of end-of-life documents?
We need to become advocates for ourselves and our families. This is especially important for those who are caring for aging family members. Make sure you have ongoing discussions about end-of-life preferences with medical teams, agents for Advance Healthcare Directive and other family members who may be involved in their care. It’s critical that everyone knows your wishes, especially when—not if—health status changes. Without these conversations, documents can be difficult to interpret.
Something to keep in mind: Doctors and EMTs are trained to save lives—it goes against their training to let someone die. It’s up to all of us to make sure we’re following the wishes of those we love.