Discrepant Advanced Directives and Code Status Orders: A Preventable Medical Error
© 2019 Society of Hospital Medicine
The EMR is a well-recognized source of potential medical error.10,11 Clinicians may rely on the EMR for code status history or as a repository of relevant documents. These are important as a starting place for code status discussions, especially since patients and proxies often cannot accurately recall the existence of an AD/POLST or understand the options being presented.9,12 In case 1, clinicians partially relied upon the erroneous historical code status already in the chart from two prior admissions. This is a dangerous practice since code status choices have several options and depend upon the clinical situation. In the case of paper AD/POLST documents, the EMR is set up poorly to help the medical team find relevant documents. Furthermore, the EMR clinical decision support capabilities do not interact with paper documents, so no assistance in pointing out discrepancies is available. In addition, the scanning process itself can be problematic since scanning of paper documents was not performed until after the patient was discharged, thus hiding the most up-to-date documents from the personnel even if they had sought them. Moreover, our scanning process had been labeling documents with the date of scanning and not the date of completion, making it difficult to find the “active” order.
ROOT CAUSE 4: WE DID NOT KNOW
Interviews with different clinicians revealed widespread knowledge deficits, including appreciation of the POLST as durable across different medical institutions, effective differences between POLST and AD, location of POLST/AD within the EMR, recommendations of professional society guidelines on suspending DNR for procedures, hospital policy on same, the need to check for updates in bedside paper documents, and whether family members can overrule patients’ stated wishes. Education tends to be the most common form of recommendation after RCA and may be the least efficacious in risk mitigation,13 but in this case, education reinforced by new EMR capabilities was an essential part of the solutions bundle (Table).
AD/POLST and similar tools are complex, and the choices are not binary. They are subject to change depending upon the medical context and the patient status and may be poorly understood by patients and clinicians.14 Accordingly, writing a goal-concordant code status order demands time and attention and as much nuanced medical judgment as any other medical problem faced by hospital-based clinicians. Though time-consuming, discussion with the patient or the surrogate should be considered as “standard work.” To facilitate this, a mandatory affirmative statement about review of LST choices was added to admission templates, procedural areas, and clinician sign outs (Table).
Unwanted, and therefore unwarranted, resuscitation violates autonomy and creates distress, anger, and distrust among patients and families. The distress extends also to frontline clinicians who are committed to “do no harm” in every other aspect of their professional lives.
Respecting and translating patients’ AD/POLST or similar tools into goal-concordant code status order is an essential professional commitment. Respect for patient safety and autonomy demands that we do it well, teach it well, and hold each other accountable.
Disclosures
The authors have nothing disclose.
