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A New Nationwide Patient Safety Concern Related to Living Wills, DNR Orders, and POLST-Like Documents

Posted By Administration, Wednesday, September 3, 2014
Updated: Friday, October 24, 2014
On the need for a patient safety checklist to ensure that we avoid overtreatment or undertreatment—in all care settings.

By Ferdinando Mirarchi, DO, FAAEM, FACEP

Joe is a 59-year-old male who presents to a local emergency room with chest pain. He is pale and sweaty. The emergency medicine physician reviews his EKG, which shows Joe is actively having a heart attack. Joe’s heart becomes irritable and erratic, and he goes into full-blown cardiac arrest. Saving him will require shocking his heart. Joe has a living will, which the nurse gives to the physician. What should occur next? Does Joe get shocked and live, or does Joe not get shocked and die? What treatment is right for Joe?

These are questions that had never been asked or answered through research prior to the TRIAD (The Realistic Interpretation of Advance Directives) studies (Mirarchi et al. 2012), which showed widespread misunderstanding among clinicians about advance directives. We now know that this area represents a nationwide patient safety issue.

Advance directives, or advance care planning documents, most commonly living wills, do not resuscitate orders (DNR), and documents like POLST (physician orders for life-sustaining treatment) are tools utilized for care planning and until recently have not appeared to be a patient safety risk. These documents are well meaning and intended; however, they have in fact led to unintended consequences. These documents are often created in legal jargon and then interpreted by health care professionals who have had no or very little training in what they are, how they should be interpreted, and when they are to be followed.

This issue affects all populations, especially the elderly and those who have a critical illness, and has the potential to impact the entire care continuum from pre-hospital and inpatient to the various post-discharge settings. We have made these documents and orders available to travel with patients or be retrieved when needed, but have not adequately researched their impact on safety. I have unfortunately experienced this risk both as a practicing physician and as the son of a critically ill parent.

The TRIAD series of studies disclosed that this new patient safety risk exists on a nationwide scale. The risk stems from variable understanding and misinterpretation of living wills, DNR orders, and POLST-like documents, which then translates into overtreatment or undertreatment, both of which are medical errors.

When patients present to an emergency room and are critically ill, they may undergo what is called “resuscitation.” Resuscitation is a very important term to clarify, as it once related only to the cardiac arrest scenario. It now pertains to many aspects of patient care. Resuscitation is a “process” whereby we implement care measures quickly to aggressively treat a medical condition. Examples of resuscitation are when patients experience a heart attack, trauma, stroke, or virtually any medical condition that causes an abrupt decompensation.

Emergency departments in particular are settings where the patient is under the care of a physician who is often unaware of any predetermined documents or discussions regarding end-of-life care. Additionally, emergency department physicians must decide quickly how to treat patients who are critically ill. This situation creates a significant safety risk for the patient. If we treat and over-resuscitate the patient, then we have ignored their predetermined wishes, committed a medical error, and have over utilized very expensive resources. If we don’t treat and under-resuscitate, we have also committed a medical error and the patient may in fact die as a result. A standardized patient safety checklist known as the Resuscitation Pause, or Advance Directive Pause, is a communication tool that can be utilized during the patient encounter to design an individualized plan of care that will maintain the patient’s wishes and minimize patient safety risk.

Living wills are legal documents and are often part of an estate plan to begin the advance care planning process. Living wills are created to accept or refuse life-saving medical care in the event that the patient is no longer competent and has a terminal condition or has entered a state of permanent unconsciousness (also written as a persistent vegetative state, or PVS). These are effective documents when they are created and they are determined to be valid and legal. A living will should not be followed, however, unless it has been enacted by the triggers in the document, which include loss of competency and having a terminal condition or being in a state of permanent unconsciousness. Living wills should not impact patient care just because they are present with the patient. And they do not say, “don’t treat me if I am critically ill.”

A do not resuscitate order (DNR) is different from a living will. A DNR is an actual physician’s order that directs medical providers not to intervene with CPR if a patient is found with no pulse or is not breathing. Otherwise this order is to have no impact on the care and management of the patient.

POLST is the physician orders for life-sustaining treatment. It is a national paradigm that has been adopted in various forms and under various names in more than 22 states, and its adoption is growing at a pace that precludes the ability to appropriately educate health care professionals before they encounter it. The intent of POLST is not to limit care, but to guide care in both cardiac arrest and non-cardiac-arrest settings. Unlike living wills or DNRs, a POLST is an activated medical order set, meaning clinicians should follow its instructions when they encounter the document. It is transferrable among the many health care settings (pre-hospital, hospital, nursing home). POLST requires a physician’s signature, though some states allow the form to be signed by a nurse practitioner or a physician assistant, however, POLST forms are most commonly completed by trained nonmedical personnel when a patient is admitted to the hospital or visits the outpatient setting. When you compare the level of understanding of a nonmedical person requesting informed consent from the patient with a physician’s understanding of disease and what would and would not benefit from treatment, it raises scrutiny of the process and whether the patient was provided with the ability to actually give informed consent or not. Additionally, the POLST form is not standardized, and states can make changes to the document and the form that can have deleterious effects on understanding and exacerbate the patient safety risk.

In emergency departments across the nation, the aging and critically ill populations are at greatest risk to experience medical errors related to both over-resuscitation and under-resuscitation. These are real life-or-death situations in which health care professionals have seconds to minutes to act to save a life or allow someone to die. In the face of this risk, an opportunity presents itself to create a patient safety checklist. The components of a safety checklist already exist as stipulated by the American Bar Association’s POLST legislative guide (NPPTF 2014), which specifically recommends that POLST documents be reviewed periodically and specifically when:

  1. Patients are transferred from one care setting or care level to another
  2. There is a substantial change in patients’ health
  3. Patients’ goals or treatment preferences change

These requirements could easily apply to all types of advance directives, ensuring that patients’ wishes are met.One tool that can be used to ensure that this is done is a checklist called the Resuscitation Pause, or the Advance Directive Pause, which was created to accomplish this pivotal safety goal (Mirarchi and Cammarata, in press).

 

The Resuscitation Pause
ABCDE’s of the Living Will, DNR, or POLST

 

A:  Ask the patient or surrogate to be clear about their intentions in their advance directive (Living Will, DNR order, or POLST form).
B:  Be clear about whether this is a terminal condition despite sound medical treatment, PVS (persistent vegetative state) vs. treatable critical illness.
C:  Communicate clearly whether you believe the condition is reversible and treatable, and whether with a good or a poor prognostic outcome.
D:  Design a plan and discuss next steps. For example, “Your mom is critically ill. We can give her a trial of instituting life-sustaining care for 48 to 72 hours, and if there is no benefit, we can withdraw the life-sustaining treatment and provide comfort.”
E:  Explain that it is okay to withhold or withdraw life-sustaining treatment and provide comfort so long as it is in keeping with the perceived wishes of the patient. Also, take a moment to explain the benefits of palliative care and hospice.

 

How does one operationalize this vital patient safety checklist? At our organization, we embed the Resuscitation Pause checklist into our initial assessments of critically ill patients who require resuscitation. This ensures that a discussion occurs at the patient’s bedside to individualize a plan of care for that patient.

Society has a desperate need to fund research, standardized training, and education about living wills, DNR, and POLST order utilization for the health care profession. The Resuscitation Pause is a simple checklist, and the process that can be incorporated into resuscitations when confronted with all types of advance care planning documents or orders. A safeguard such as the Resuscitation Pause allows the health care team to clarify the intent of the living will, DNR, or POLST and design an individualized plan of care to make sure we get it right for each patient and every time. 

 



Ferdinando L. Mirarchi, DO, is the medical director of University of Pittsburgh – Hamot’s Emergency Department and chairman of the UPMC Hamot Physician Network Governance Council. He is a fellow of the American College of Emergency Physicians as well as a fellow of the American Academy of Emergency Medicine. Dr. Mirarchi is the author of Understanding Your Living Will: What You Need to Know before a Medical Emergency, published by Addicus Books. He serves as a consultant for Emedicine.com, and has been published nationally and internationally in the field of emergency medicine and featured in national publications, including USA Today, the New York Times, the Associated Press, and ABC News. Contact him at mirarchifl@upmc.edu



 

References and Additional Reading

Mirarchi FL, Cammarata C, Zerkle S, Cooney T. In press. TRIAD VII – Pennsylvania Pre-hospital Experience with POLST. J Emerg Med.

Mirarchi FL, Doshi A, Zerkle S, Cooney T. In press. TRIAD VI – Pennsylvania ACEP’s Experience with POLST. J Emerg Med.

Mirarchi F, Cammarata C. Letter to the Editor. In press. RE: Schmidt TA, Olszewski EA, Zive D, Fromme EK, Tolle SW. The Oregon physician orders for life-sustaining treatment registry: a preliminary study of emergency medical services utilization. J Emerg Med. [see in context]

Mirarchi FL, Ray M, Cooney T. 2014. TRIAD IV: Nationwide Survey of Medical Students’ Understanding of Living Will’s and DNR orders. J Patient Saf. Feb 27 [Epub ahead of print]. DOI: 10.1097/PTS.0000000000000083.

Mirarchi FL, Costello E, Puller J, Cooney T, Kottkamp N. 2012. TRIAD III: Nationwide Assessment of Living Wills and Do Not Resuscitate Orders. J Emerg Med. 42:511-20. [see in context]

Mirarchi FL, Kalantzis S, Hunter D, McCracken E, Kisiel T. 2009. TRIAD II: do living wills have an impact on pre-hospital lifesaving care? J Emerg Med. 36:105-15.

Mirarchi FL, Hite La, Cooney TE, Kisiel TM, Henry P. 2008.TRIAD I – The realistic interpretation of advanced directives. J Patient Saf. December 4(4);235-240. doi: 10.1097/PTS.0b013e31818ab16f

Mirarchi F. 2006. Understanding Your Living Will: What You Need to Know before a Medical Emergency. Omaha, NE: Addicus Books.

National POLST Paradigm Task Force (NPPTF). 2014. POLST Legislative Guide. Accessed 25 Aug. 2014. Available at: http://www.polst.org/wp-content/uploads/2014/02/2014-02-20-POLST-Legislative-Guide-FINAL.pdf. [see in context]

 

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High Reliability: A Strategy to Support a Safe Environment and Commitment to Safety

Posted By Administration, Wednesday, July 23, 2014
Updated: Tuesday, September 2, 2014
Comments on the session “The High Reliability Chassis: Improving Patient and Employee Safety” at the 2014 NPSF Patient Safety Congress in May (Orlando).

By Lorri Zipperer, MA

 

I have been intrigued by high reliability and organizations that foster it as a direction for patient safety improvement since reading Weick and Sutcliff’s classic business text Managing the Unexpected (2001). Building on that interest, I have since led and participated in efforts to apply high-reliability concepts to my consulting interests, professional development, and local community building (Zipperer 2006, 2014; Attaining High Reliability 2014).

 

So naturally I wanted to take in the session at the 2014 NPSF Congress related to high reliability and workforce safety (Johnson and Deck 2014). Speakers Kerry Johnson of HealthCare Performance Improvement and Marcia Deck, MD, of WellStar Health System, introduced the essential characteristics of high reliability as defined by Weick and Sutcliff into their session in a fresh way. With a mix of theory, success stories from non–health care, high-consequence industries we are all accustomed to hearing about in our safety work (aviation and nuclear industry safety), and implementation advice, they focused their comments on the importance of: 
  • Seeing safety as a science to enable the application of high-reliability principles to achieve the safety we seek
  • Recognizing the criticality of senior leader champions as a high-reliability attainment strategy
  • Understanding that safety is a dynamic “non-event” that all in health care have a role in creating
  • Establishing safety as a core value for medical staff
  • Acknowledging that humans err, and that serious incidents resulting in patient harm are almost always the result of system failure
  • Enabling all health care workers to consistently apply error prevention strategies in their daily work
Obviously each bullet here could have been the topic of its own session. Johnson and Deck wove these ideas into their discussion through an emphasis on how a foundational culture needs to be in place to allow these elements to take hold and be meaningful to those in health care: from patients to executive leadership.
 
The example of WellStar, a 5-hospital, 1321 bed, safety net, health care system in the southeastern United States, anchored the discussion. Their experience provided a real-world glimpse of how the often-considered “academic” approach to establishing a hospital as a high-reliability organization (HRO) can work. Their illustration underscored the importance of aligning HRO elements with a systems-level quality agenda and tactics. It also reinforced the value of implementing programs that support commitment to both patient and worker safety improvement as being part of the cultural fabric of the organization. WellStar initiatives such as a peer coach program, an error prevention toolkit, and daily leadership huddles were established to help engage staff as team members to provide diagnostic assessments of safety gaps in the system. The safety culture enabled an environment to brainstorm, envision, and implement a range of interventions that resulted in reductions in workman’s compensation claims by almost 50% and improved employee satisfaction (see figure).

 

  
 WellStar Health System’s workers’ compensation costs, 2007–2011
WellStar Health System’s workers’ compensation costs, 2007–2011
As the Lucian Leape Institute’s report Through the Eyes of the Workforce highlighted for us all, creating a culture that brings joy and meaning to work in health care is an effective strategy for safety improvement. The experience reported by Johnson and Deck provided an active example that attention to employee safety is valuable and effective. Partnering to embrace the elements of reliability can help health care staff to feel safer which, in turn, empowers clinicians and the staff that support them, to provide safe care to the patients, families, and communities they serve.
Are you also intrigued with how high-reliability principles might be applied in your organization? Does your organization recognize worker safety as part of that effort or as a part of the overall patient safety program? 
Lorri Zipperer, MA, is the principal at Zipperer Project Management in Albuquerque, NM, specializing in knowledge management efforts and bringing multidisciplinary teams together to envision, design, and implement knowledge sharing initiatives. Among her publications, Ms. Zipperer recently served as editor for two texts, Knowledge Management in Healthcare and Patient Safety: Perspectives on Evidence, Information and Knowledge Transfer, both published earlier this year by Gower Publishing (UK).

References

Attaining High Reliability and Safety for Patients – Collaborating for Change. March 6–7, 2014. Conference presented by the Patient Safety Collective of the Southwest, Albuquerque, NM. http://healthinsight.org/images/docs/NMConfPlan_general_agenda_fnl_forweb.pdf [see in context]

 

Johnson K, Deck M. May 16, 2014. The High-Reliability Chassis: Improving Patient and Employee Safety. Presentation at NPSF Patient Safety Congress, Orlando, FL. [see in context]

 

Lucian Leape Institute. 2013. Through the Eyes of the Workforce: Creating Joy, Meaning, and Safer Health Care. Boston, MA: National Patient Safety Foundation. [see in context]

 

Weick KE, Sutcliffe KM. 2001. Managing the Unexpected: Assuring High Performance in an Age of Complexity, 1st edition. San Francisco, CA: John Wiley & Sons. [see in context]

 

Zipperer, L. ed. 2014. Knowledge Management in Health Care. London, UK: Gower. [see in context]

 

Zipperer L. October 2006. High reliability, information work and patient safety. National Network 31:4–5, 7. http://hls.mlanet.org/wordpress/wp-content/uploads/2011/03/v31n2.pdf [see in context]

 

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The Doctors Company Foundation Young Physicians Patient Safety Awards

Posted By Mark Alpert, Wednesday, June 4, 2014
Updated: Friday, June 6, 2014
The Doctors Company Foundation Young Physicians Patient Safety Award is conferred in partnership with the National Patient Safety Foundation’s Lucian Leape Institute. The award recognizes young physicians for their deep personal insight into the significance of patient safety work. Awards are given for the best essays on the most instructional patient safety event that was a personal, transformational experience during the third or fourth clinical year in medical school or the first year in residency. Essays are judged by a distinguished panel of experts in patient safety.

Awardees for 2014 are:

  • Maria Czarina Acelajado, MD, University of South Alabama College of Medicine
  • Jennifer Bruno, BS, University of South Florida, Morsani College of Medicine
  • Daniel Leifer, BS, University of California Davis School of Medicine
  • John Nguyen, MD, University of Arizona College of Medicine
  • Samantha Wang, BA, Yale University School of Medicine
  • Emily Yue Wu, BS, Baylor College of Medicine
NPSF is proud to publish the 2014 essays on the P.S. Blog. For assurance of privacy, names of individuals and organizations have not been associated with the individual essays.


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Health Disparities Increase Safety Risks

Posted By Mark Alpert, Tuesday, April 29, 2014
Updated: Friday, June 6, 2014
April is National Minority Health Month. In recognition of the month, NPSF has teamed up with the Partnership for Patients Patient and Family Engagement Network to publish blog posts by patient advocates who can speak to the patient safety implications of health disparities. This is the first in the series of three posts.

By Alicia Cole

This year, the population of the United States reached a new record of more than 317 million people, according to the U.S. Census Bureau. We are the third most populous country on the planet, behind only China (1.35 billion) and India (1.23 billion)–yet we are the most diverse.

Americans have long been proud of this diversity. We have welcomed immigrants from many different countries, races, and religions, all hoping to find within our borders freedom, opportunity, and a better way of life. It is this diversity that makes America what it is and, at the same time, creates the challenges it faces. Nowhere is this more evident than in health care.

While health indicators such as life expectancy and infant mortality have improved for most Americans, minorities still experience a disproportionate burden of preventable disease, death, and disability compared to our non-minority neighbors. These are known as health disparities, a common example of which is breast cancer. Did you know that African American women are 34 percent more likely to die of breast cancer than caucasian women? Sadly, black women are more likely to be diagnosed with larger and more aggressive tumors.

Accordingly each April, we observe National Minority Health Month to raise awareness about these health disparities. This year’s campaign theme is “Prevention is Power: Taking Action for Health Equity.”

The most effective way I know to achieve this goal is through patient and family engagement: being actively involved in your own care and that of your loved ones. No matter who we are in the multicultural mosaic, one thread runs central through us all – love of family. So this month I want to encourage everyone to think about how we can engage in “prevention” to keep our families and communities healthy.

Thanks to the Affordable Care Act, 10.2 million Latinos, 6.8 million African Americans, nearly 2 million Asian and Pacific Islanders, and over a half million American Indians and Alaska Natives have the opportunity to get health coverage. But it’s not enough just to have the opportunity for check-ups, screenings, and vaccinations; we must now advocate for our loved ones to utilize their access to these potentially lifesaving, preventive services. We must also learn to engage with our care providers and become proactive members of our health care team. Cultures that have traditionally been taught never to question authority have to be re-educated that it is okay to ask health care providers questions regarding our condition, medications, and plan of care. Where there are language differences between the provider and patient, there are also greater risk of patient safety incidents. Therefore patients, their families, advocates, and caregivers must be more involved in their care in order to help prevent medical errors.

By the same token, health care providers must be sensitive to providing care that is culturally and linguistically appropriate to each patient. One way this has begun is through the work of the Vulnerable Patient Populations Working Group of the Partnership for Patients. Our goal is to ensure that diversity and issues involving vulnerable patient populations are included in each weekly Learning Event or Master Class produced for health care providers across the country. It is one of the ways that patient advocates are working within the health care system to foster a more multicultural, multiethnic system of care.

Starting with personal engagement in our own care, followed by advocacy on behalf of our family and loved ones, we can begin to create a community of healthy people and reduce health care disparities. Partnering with our care providers, local hospitals, and health advocacy organizations we can create a healthier minority population and a safer health care system for all Americans.

Alicia Cole is a nationally-recognized speaker and patient safety consultant. She is a survivor of multiple near-fatal hospital-acquired infections and the founder of the Alliance for Safety Awareness for Patients (ASAP) www.PatientSafetyASAP.org.

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Advance Directives and Patient Safety

Posted By Mark Alpert, Wednesday, April 16, 2014
Updated: Friday, June 6, 2014
Are advance directives, living wills, health care proxies, and do-not-resuscitate instructions patient safety issues? The P.S. Blog asked two patient safety experts to weigh in on this topic. Ilene Corina, president, PULSE of NY, writes from the patient and family perspective. Paul Gluck, MD, Associate Clinical Professor OB GYN, University of Miami Miller School of Medicine, writes about what clinicians need to know.


By Ilene Corina

Jerry sat at his friend Larry’s bedside knowing that Larry would die in the next few days, weeks, or months. No one seemed to know for sure what Larry’s future was. He was weakening from age and had been suffering from Alzheimer’s. At 80 years old, he’d had a good life, was well loved by family and friends, and until recently had lived independently with the help of Jerry, who had been hired two and a half years ago as a daily companion by family living in another state.

Now, however, Larry had suffered a stroke that affected his mind and body, and his family, in consultation with his physicians, had decided it was time to let him go peacefully.
Just months earlier Jerry—half Larry’s age—would look forward to visiting daily with Larry and listening to his stories of his younger days when he was in the army, then worked for a hotel chain. Together the men would visit friends and museums, followed by lunch at a local restaurant. Now Jerry wondered why Larry wasn’t even being given nourishment.

Jerry didn’t know if Larry had advance directives, but he knew that Larry’s son was his health care proxy and would be making the decisions for Larry when he couldn’t make them for himself. The doctors would speak to Jerry, and Jerry would relay information to the family. Keeping him alive wasn’t an option for the family. But Jerry didn’t feel that Larry was safe. Not having nourishment and being permitted to starve to death just didn’t feel right.

So the question is: are advance directives, living wills, health care proxies and DNR instructions patient safety issues?

The living will is not a new concept. Luis Kutner, a Chicago lawyer, is known for inventing the living will in 1930 so that critically ill patients could forgo artificial life-support. Kutner is also known as co-founder, in 1961, of Amnesty International, a global movement working for human rights.

Federal law requires most health care institutions to offer patients information about advance directives. But advance directives are still not widely used. A living will can prevent unwanted care, especially aggressive medical treatment at the end of life, and can help guide decisions about the way in which a patient would like to be treated if he or she loses the capacity to communicate.

Problems and Issues

But there could be problems with advance directives, such as patients nominating a loved one without ever really discussing the patient’s wishes with that person.
According to an article in the Annals of Internal Medicine, many proxies either do not know patients’ wishes or do not pursue those wishes effectively (Perkins 2007). Thus, unexpected problems arise often to defeat advance directives
.
A living will may direct physicians to undertake no “aggressive” measures at the end of life or to treat a patient in a certain way when that patient is suffering from a “terminal” illness. This nonspecific language must be interpreted by the family and the medical team.

Living wills and advanced directives were widely discussed when the story of Karen Ann Quinlan made headlines in 1975. She had slipped into an irreversible coma. After making the decision to remove Karen Ann from life-support, the family had to petition the court. When the machines were finally removed, Karen Ann continued breathing on her own for nine years until she died from a pneumonia at the age of 31.

In the 1990s advanced directives were in the spotlight when 26-year-old Terry Schiavo fell into a coma following a cardio-respiratory arrest. Terry was put on a ventilator but was soon able to breathe on her own. She remained in a severely compromised neurological state and was provided a PEG tube to ensure the safe delivery of nourishment and hydration. In 1998 Terry’s husband, Michael, petitioned the state of Florida to remove her feeding tube—a decision that was challenged by her parents. On March 31, 2005, at 41, Terri Schiavo died of dehydration following more than 13 days without nutrition or hydration under Court order.

When patients, families, and medical professionals are asked about advance directives being a patient safety issue, there are mixed reviews.

Some patients and family members who were interviewed are quick to say they are. This can be because without a health care proxy or someone prepared to speak for the patients unable to speak for themselves, both patients and families may feel unsafe. Who will, after all, make sure patients are getting the best care possible?

Others feel it is an ethical concern or a patient’s rights issue, but not about safety.

When asked if advance directives are a patient safety issue, Gary Kaplan, MD, chairman and chief executive officer of Virginia Mason Hospital and Medical Center, said, “Yes….safety is about avoiding harm. This requires appropriate care. Appropriate care is respectful, cognizant of, and fulfilling of patients’ wishes. This would include end-of-life care, living wills, etcetera.”

Promoting the Discussion

The Conversation Project, developed in collaboration with the Institute for Healthcare Improvement (IHI) seeks to encourage and support people in expressing their end-of-life wishes for care. The Conversation Project does not promote a particular position, but instead, believes that patients and their families must be engaged in the decision-making.

Maureen Bisognano, president and chief executive officer of IHI, was asked about her thoughts on whether advance directives are a patient safety concern. She replied, “Yes, I’d consider them a safety issue. If [advance directives are] not transmitted to the providers, or not adhered to, care that is unwanted or unneeded may be delivered.”

Now in its seventh year, National Healthcare Decisions Day (www.nhdd.org) “exists to inspire, educate and empower the public and providers about the importance of advanced care planning. National Healthcare Decisions Day is an initiative to encourage patients to express their wishes regarding health care, and for providers and facilities to respect those wishes, whatever they may be.”
NHDD is celebrated on April 16 of each year. Nathan A. Kottkamp, chair of the National Healthcare Decisions Day initiative explains, “If a patient really doesn’t want to have chest compressions in the event of cardiac arrest and receives them anyway, thus breaking ribs and increasing pain, it would be a safety issue.”

Jim Conway, adjunct faculty, Harvard School of Public Health, explains his opinion: “The IOM in the Chasm report (IOM 2001) defines patient safety as ‘the prevention of harm to patients.’ AHRQ has defined the prevention of harm as ‘freedom from accidental or preventable injuries produced by medical care.’ So yes, I can easily imagine the failure to honor a patient’s advance directive as a patient safety event.”

The Long Island Patient Safety Advisory Council which began as part of my NPSF-AHA Patient Safety Leadership Fellowship training, focuses on patient safety education in the community. One of the focuses was having people discuss their advance directives. Recognizing that it is not an “old person’s” issue, the council worked with Hospice Care Network on Long Island and Nassau County Youth Board to develop information appropriate for everyone. There is now a brochure called Advanced Directives and Speaking to Young People. LIPSAC has partnered with Momma’s House on Long Island, and we talk to young mothers about advance directive and help them fill them out.

The National Patient Safety Foundation defines patient safety as the “avoidance and prevention of adverse outcomes or injuries stemming from the processes of health care.”
So we must ask ourselves: if there is no injury from not having an advance directive, is it a patient safety concern? Or is patient safety only an issue after a patient is harmed?

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