When living wills become health hazards

Can the existence of an advance directive put you or your patient in jeopardy?

Living wills are becoming more and more common, often promoted to the public as a way to ensure the patient's right to accept or refuse medical care. A recent Harris Poll shows that 34 percent of adults report having a living will. But do living wills compromise a patient's care and safety? As an emergency physician, I've found three recurring issues with living wills that I consider safety issues.

First, most are drafted by an attorney or organization without input from the patient's physician, according to a state-specific template, and without recognition of a patient's particular medical condition. Consequently, there are no instructions in regard to reversible and treatable conditions.

Second, some patients sign these documents without the information they need. A recent USA Today article describes living will parties where people drink wine, eat snacks, and sign a legal document. Only occasionally are there attorneys and medical personnel who specialize in end-of-life issues in attendance to help guests understand the documents. The article quoted an individual who supports living will parties who stated, "I'd rather have a bad plan than no plan at all." Well, a bad plan in business will cost you money, but a bad plan with a living will could compromise your life.

When a living will is misunderstood

Mr. A is a 75-year-old male with cardiac disease who had a CABG in 2002. He maintains a very active retirement and enjoys traveling. He came into the emergency department with chest pain. During his visit he was asked if he had a living will. He provided a copy for the chart. After his evaluation, the ED physician determined that he was suffering a non-Q wave myocardial infarction.

At 4 a.m. the patient complained of increased pain and diaphoresis and summoned his nurse with the call bell. A cardiologist who just happened to be in the area saw the patient's heart rhythm on the monitor and quickly recognized the patient was in ventricular fibrillation. He ran into the patient's room to attempt to defibrillate him and was stopped by the nurse who informed him that the patient's code is a DNR. He tried again to defibrillate the patient and was stopped a second time by the nursing supervisor, who explained that the patient "has a living will and is a DNR." The patient was finally pronounced dead.

Living wills become activated when a patient is in a defined condition, most commonly terminally ill or persistently vegetative. What is terminal? In most states, a terminal condition is one in which the patient is expected to die shortly despite sound medical treatment.

Medical personnel have to actually read the document to make sure the instructions are followed only when the patient is in a terminal condition or vegetative state. Following the list of "do nots" can prevent the patient from receiving appropriate care if the patient has a reversible and treatable condition. In a crisis situation, it's not uncommon for a medical professional to look at the document, see that the patient has declined various measures, and withhold care.

How to avoid misinterpretations