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

Data on the frequency of unwanted CPR/intubation due to medical error are scarce. In the US, several lawsuits arising from unwanted CPR and intubation have achieved notoriety, but registries of legal cases⁶ probably underestimate the frequency of this harm. In a study of incorrect code status orders at Canadian hospitals, 35% of 308 patients with limited care preferences had full code orders in the chart.⁷ It is unclear how many of these expressed preferences also had legal documents available. There was considerable variability among hospitals, suggesting that local practices and culture were important factors.

Spot audits of 121 of our own patient charts (median age 77 years) on oncology, geriatrics, and cardiac units at our institution found 36 (30%) with AD/POLST that clearly limited life-sustaining treatments. Of these, 14 (39%) had discrepant full code orders. A review of these discrepant orders showed no medical documentation to indicate that the discrepancy was purposeful.

A root cause analysis (RCA) of cases of unwanted resuscitation, including interviews with involved nurses, medical staff, and operating room, hospitalist, and medical informatics leadership, revealed several types of error, both human and system. These pitfalls are probably common to several hospitals, and the solutions developed may be helpful as well (Table).

Haste leads to poor communication with the patient and family. Emergency departments and admitting services can be hectic. Clinicians facing time and acuity pressure may give short shrift to the essential activity of validating patient choices, regardless of whether an AD or POLST is available. Poor communication was the major factor allowing for discrepancy in the Canadian study.⁷ Avoiding prognostic frankness is a well-known coping strategy for both clinicians and patients^8,9 but in all these cases, that obstacle had been overcome earlier in the clinical course of disease, leaving inattention or haste as the most likely culprit.

“It is not our hospital culture to surveille for code status discrepancies, discuss appropriateness on rounds or at sign out.”

In all reviewed cases of unwanted resuscitation, numerous admitting or attending physicians failed to discuss LST meaningfully despite clinical scenarios that were associated with poor prognosis and should have provoked discussion about medical ineffectiveness. The admitting hospitalist in case 2 stated later that she had listed code choices for the patient who chose full code despite having a POLST stating otherwise. However, that discussion was not in depth, not reviewed for match to her POLST, and not documented.

Moreover, all the cases of AD/POLST and code status discrepancy were on nursing units with daily multidisciplinary rounds and where there had been twice-daily nurse-to-nurse and medical staff–to–medical staff sign out. Queries about code status appropriateness and checks for discrepant AD/POLST and code orders were not standard work. Thus, the medical error was perpetuated.

Analysis of cases of unwanted intubation in postoperative cases indicated that contrary to guidelines,^4,5 careful code status review was not part of the preoperative checklist or presurgical discussion.