When advance directives can be dangerous

ED director has created a checklist to avoid deadly misinterpretations

In a Health Leaders Media interview with Philip Betbeze, UPMC-Hamot ED chair Ferdinando Mirarchi highlights the importance of advance directives, but warns that a lack of standardization in the documents can leave patients in danger of misinterpretation.

The ABCDEs of advance care planning

Mirarchi's near-death misinterpretation

In fact, Mirarchi's misinterpretation of an advance directive nearly cost one of his patients her life when he was on-call as a young doctor. When he encountered an unconscious patient in the ED, he says he "was at the point of not treating her because there was a living will and a" do not resuscitate (DNR) order.

"I was following this paper they presented," Mirarchi says, adding that fortunately a cardiologist pushed him out of the way and began treating the patient.

"The lesson is, you can easily end up killing patients who have ultimately treatable conditions," Mirarchi says, adding that the documents "have good intended purposes [but] there can be bad unintended consequences from them." Mirarchi says "a large percentage of practicing physicians look at a document like that and define it as a DNR order."

Moreover, when patients cannot speak for themselves, clinicians may forgo treatment—even for a treatable condition—when an advance directive and DNR order is present. He added the documents "lack federal standardization."

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Guarding against dangerous situations

With legal guidance, Mirarchi developed a checklist poster to help his fellow clinicians make informed decisions based on the contents of an advance directive, as well as guidelines on interpreting the documents.

Mirarchi personally does not have an advance directive, but he has named his wife as his medical surrogate.

Mirarchi says, "They do have a lot of benefits, and I'm not discouraging anyone from doing one, because there's no question they do save money and resources. Those patients who are not gaining any benefit from treatment are very expensive" (Betbeze, Health Leaders Media, 5/2).

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