Blog | Tuesday, December 13, 2011

QD: News Every Day--Doctors struggle to interpret advance directives

Struggling with the meaning of life is one thing. Struggling with the meaning of end-of-life directives shouldn't be.

Physicians misidentify living wills as do-not-resuscitate (DNR) designations and DNR orders as end-of-life care directives, concluded a study. Adding code status designations to a standard advanced directive can ensure that patients receive or does not receive the care they want.

The study, "TRIAD III: Nationwide Assessment of Living Wills and Do Not Resuscitate Orders," appeared in the Dec. 5 issue of The Journal of Emergency Medicine.

Researchers conducted an Internet survey of general surgery, and family, internal, and emergency medicine residencies. Program directors were asked to forward survey solicitations to residents and attending faculty. The survey posed a fictitious living will with and without additional clarification in the form of code status. An emergent patient care scenario was then presented that included medical history and signs/symptoms. Respondents were asked to assign a code status and choose appropriate intervention.

Seven hundred sixty-eight faculty and residents at accredited training centers in 34 states responded over 18 months. At baseline, 22% denoted "full code" as the code status for a typical living will, and 36% correctly equated "full care" with a code status DNR. Adding clinical context improved correct responses by 21%, and specifying code status further improved correct interpretation by 28% to 34%. Treatment decisions were either improved 12% to 17% by adding code status such as "Full Code" or "Hospice Care," but were worsened 22% by adding the code status "DNR."

The authors wrote, "It is clear from the data that misunderstanding pervades medical specialties and is not resolved by the current instructional curricula involved advanced directives training and end-of-life decision-making."