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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, 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


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: [see in context]


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