Skip to main content

Should Failure to Follow Preferences be a Medical Error? #NHDD Question

Today is National Healthcare Decisions Day. The day was created as “an initiative to encourage patients to express their wishes regarding healthcare and for providers and facilities to respect those wishes, whatever they may be.” Much of what will be going on today at various outreach programs will be focused on the first part of this initiative: educating the public on the importance of advance care planning.  I'd like to take a second though and pose the following question to our audience:
Should the failure to follow end-of-life preferences be considered a medical error?

This question is derived from a recent JAMA Internal Medicine editorial by GeriPal contributors Theresa Allison and Rebecca Sudore.  In it they make a persuasive argument that the disregard of patients' preferences is indeed a medical error.  Here is an excerpt:
"Discussions about goals of care and code status constitute a medical procedure every bit as important to patient safety as a central line placement or a surgical procedure. Much as we have developed systems to improve patient safety in surgical procedures, we need to develop systematic approaches to discussing patient values and goals of care."

The Importance of this Question on National Healthcare Decisions Day

To understand the importance of this question, one needs to only turn to the study that accompanies the editorial by Allison and Sudore.  The study, conducted by Heyland and colleagues, involving 278 patients and 255 family members in 12 Canadian hospitals.  To be included, patients needed to be age 80 years or older and have either advanced pulmonary, cardiac, or liver disease, or metastatic cancer, or be to be someone whose death within the next 6 months would not be a surprise to any member of his or her care team.

Of these elderly patients who were at high risk of dying in the next 6 months, 76% reported that they thought about what kind of life-sustaining treatments they would or wouldn't want prior to hospitalization.  And what did they want?
  • Few (12%) wanted aggressive use of heroic measures and artificial life-sustaining treatments, including CPR with a goal of life prolongation 
  • A little more (18%) wanted “Full medical care” but no CPR in the event their heart or breathing stopped 
  • Most (31%) would want their care either focused on 1) comfort if their health deteriorated including avoiding CPR and other life-sustaining technologies, 2) trying to fix problems but if not getting better, switch to focusing comfort even if it hastens death
The good news is that most individuals discussed their preferences with someone (88%).  The bad news is that most patients just talked to their family members about these wishes.  Only 30% had talked to their family physician, and only about half (55%) had talked to any member of their health care team.

The other good news is that nearly half of patients (48%) reported having completed a written advance care plan, and 73.3% had documented who they would like to be their surrogate decision maker.  The other bad news though is that only one in four (25%) of these patients were asked about these prior discussions or written documents on admission to the hospital.

The most unfortunate finding of this study was that more than two-thirds of patients’ preferences were either not documented at all or documented incorrectly in the medical record.  When the authors of the study looked at the 199 patients who expressed a preference for care and for whom a written goals-of-care order was present in the patient’s records, they found:
  • only a 30% agreement between patients’ expressed preferences and the documented goals-of-care order in the medical record 
  • 28.1% of patients (56 of 199) preferred comfort measures only, but this preference was documented in only 4.5% (9 of 199) of stated goals (Figure 2A). 
So, the question I have for you on this National Healthcare Decisions Day is whether you agree with Drs Allison and Sudore that this failure to document end-of-life preferences should be considered a medical error?

by: Eric Widera (@ewidera)


Bruce Scott said…

My indoctrination must be really complete, since I cannot fathom how the answer could be "no".
Eric Widera said…
When was the last time you saw or heard of someone doing an incident report on a failure to respect or ask about end-of-life preferences?
Failure to follow EOL preferences is not just a medical error, it is also the basis for civil and administrative sanctions. I outline these in this forthcoming article.
Susan Joseph, MD said…
Most definitely a serious medical error and to my observation the cause of much resulting harm; these interventions often start a cascade of events and further interventions which are deleterious.
Anonymous said…
If States complied with the provisions of the 1991 PSDA and if the federal government clarified the provisions of the PSDA as to BOTH the choice to die by electing to refuse life-extending treatments and the right to live by accepting life-extending treatments, of course, it would be a serious LEGAL error and violation of patients rights if either CHOICE were violated.

You must know that Medicare already doesn't reimburse physicians/hospitals for medical errors and non-beneficial overtreatments.
Anonymous said…
Are you aware that The American Bar Association (ABA) has already offered their opinion to Congress/Medicare that the Patient Self Determination Act of 1991 (PSDA) does NOT have to be clarified and that CMS Medicare/Medicaid do NOT have to reimburse for treatments that are in violation of patients' advanced directive made under the provisions of the PSDA and state laws? It would be understood, of course, that the hospitals/physicians would have to eat the costs and the patients couldn't be billed.

Wouldn't the problem of overtreatment for profit be solved if all physicians were mandated to SEEK consent from elderly/disabled patients with late stage disease for either curative care or palliative care/transition to hospice?

If the provision of palliative care/hospice required informed consent from patients to forfeit their rights to life-extending and/or life-saving treatments to be eligible for palliative care/Hospice, would this be legal and constitutional under the PSDA and existing law?

Isn't this why physicians (especially the specialists) are often NOT seeking informed consent for one standard of care or the other? Isn't this why unilateral covert and overt DNRs become the solution to lack of reimbursement from Medicare and the private insurers?

Popular posts from this blog

The Future of Palliative Care: A Podcast with Diane Meier

There are few names more closely associated with palliative care than Diane Meier.  She is an international leader of palliative care, a MacArthur "genius" awardee, and amongst many other leadership roles, the CEO of the Center to Advance Palliative Care (CAPC).  We were lucky enough to snag Diane for our podcast to talk about everything we always wanted to ask her, including:
What keeps her up at night?Does palliative care need a national strategy and if so why and what would it look like?The history of CAPC and the leadership centersAdvice that she has for graduating fellows who want to continue to move palliative care forward as they start their new careersWhat she imagines palliative care will look like in 10 or 15 years?What is the biggest threat facing palliative care? So take a listen and if you want to dive a little deeper, here are two articles that we discussed during the podcast:
A National Strategy For Palliative Care. Health Affairs 2017Palliative Care Leadership…

Advance Care Planning before Major Surgery: A Podcast with Vicky Tang

This week's podcast is all about the intersection of geriatrics, palliative care, advanced care planning and surgery with our guest Dr. Vicky Tang.  Vicky is an assistant professor and researcher here at UCSF.  We talk about her local and national efforts focused on this intersection, including:
Her JAMA Surgery article that showed 3 out of 4 older adults undergoing high risk surgery had no advance care planning (ACP) documentation. Prehab clinics and how ACP fits into these clinicsThe Geriatric Surgery Verification Quality Improvement Program whose goal is to set the standards for geriatric surgical care including ACP discussions prior to surgeryHow frailty fits in and how to assess it (including this paper from JAGS on the value of the chair raise test) So take a listen and check out some of those links.  For those who want to take a deeper dive into how GeriPal and surgery fit together, check out these other podcasts: Zara Cooper on Trauma Surgery, Geriatrics, and Palliative Car…

The Dangers of Fleet Enemas

The dangers of oral sodium phosphate preparations are fairly well known in the medical community. In 2006 the FDA issued it’s first warning that patients taking oral sodium phosphate preparations are at risk for potential for acute kidney injury. Two years later, over-the-counter preparations of these drugs were voluntarily withdrawn by the manufacturers.  Those agents still available by prescription were given black box warnings mainly due to acute phosphate nephropathy that can result in renal failure, especially in older adults. Despite all this talk of oral preparations, little was mentioned about a sodium phosphate preparation that is still available over-the-counter – the Fleet enema.

Why Oral Sodium Phosphate Preparations Are Dangerous 

Before we go into the risks of Fleet enemas, lets spend just a couple sentences on why oral sodium phosphate preparations carry significant risks. First, oral sodium phosphate preparations can cause significant fluid shifts within the colon …