Discrepant Advanced Directives and Code Status Orders: A Preventable Medical Error

The United States health system has been criticized for its overuse of aggressive and medically ineffective life-sustaining therapies (LST).¹ Some professional societies have elevated dialog about end-of-life (EOL) care to a quality measure,² expecting that more open discussion will achieve more “goal-concordant care”³ and appropriate use of LST. However, even when Advanced Directives (AD) or Physician Orders for Life-Sustaining Therapy (POLST) have been created, their directions are not always followed in the hospital. This perspective discusses how preventable errors allow for use of LST even when patients designated it as unwanted. Two cases, chosen from several similar ones, are highlighted, demonstrating both human and system errors.

During the time of these events, the hospital policy required admission orders to contain a “code status” designation in the electronic medical record (EMR). All active and historical code status orders were listed chronologically and all AD and POLST documents were scanned into a special section of the EMR. Hospital policy, consistent with professional society guidelines,^4,5 stated that patients with AD/POLST limiting EOL support should have individualized discussion about resuscitation options in the event of a periprocedural critical event. Automatic suspension or reinstatement of limited code orders was not permitted.

A 62-year-old woman with refractory heart failure was admitted with recurrence. The admitting code order was “initiate CPR/intubation” even though a POLST order written 10 months earlier indicating “do not intubate” was visible in the EMR. A more recent POLST indicating “No CPR/No intubation” accompanied the patient in the ambulance and was placed at bedside, but not scanned. There was no documented discussion of code status that might have explained the POLST/code order disparity. Notably, during two prior admissions within the year, “full code” orders had also been placed. On the fifth hospital day, the patient was found in respiratory distress and unresponsive. A “code” was called. ICU staff, after confirming full code status, intubated the patient emergently and commenced other invasive ICU interventions. Family members brought the preexisting POLST to medical attention within hours of the code but could not agree on immediate extubation. Over the next week, multiple prognosis discussions were held with the patient (when responsive) and family. Ultimately, the patient failed to improve and indicated a desire to be extubated, dying a few hours later.

A 94-year-old woman was admitted from assisted living with a traumatic subcapital femur fracture. Admission code orders were “initiate CPR/intubation” despite the presence in the EMR of a POLST ordering “no CPR/no intubation.” The patient underwent hemiarthroplasty. There was no documented discussion of AD/POLST by the surgeon, anesthesiologist, or other operating room personnel even though the patient was alert and competent. On postoperative day one, she was found to be bradycardic and hypotensive. A code was called. After confirming full code status in the EMR, cardiac compressions were begun, followed by intubation. Immediately afterward, family members indicated that the patient had a POLST limiting EOL care. When the healthcare proxy was reached hours later, she directed the patient be extubated. The patient died 16 minutes later.