Skip to main content

Can your Emergency Physician find your Advance Directive?




by: Ryan Van Wert, MD

Providing high quality emergency care to individuals with serious, life-limiting illness starts with an understanding of their treatment goals and care preferences above all else.  Speaking as a critical care physician, this is absolutely essential information to have at the time of an emergency. It helps me to formulate a plan to provide the best possible care for an individual in the context of their wishes. It also helps to frame care recommendations when speaking to families, and to support them through the difficult task of speaking for a loved one who cannot be heard. So I was very interested to see two recent publications in the Journal of Palliative Medicine relating to accessibility of advance care planning (ACP) documents in the emergency department (ED).

The first study from Angelo Volandes’ group looked at 104 elderly individuals presenting to the ED at an academic medical center. Participants were asked about whether they had completed any ACP documents, and the electronic chart was then reviewed for the presence of these documents or current code status in the chart. Fifty-nine (59) percent of participants reported completing some form of ACP document.  The majority were living wills (52%) and healthcare power of attorney (54%), with fewer having DNR (38%) or MOLST (6%) forms.

Did the ED provider have access to these documents? The short answer is no. Only 8% of participants had a current code status in the chart, and only 13% had any form of advance care documentation locatable in the EHR. Of the 13 people who said they had given a copy of ACP documents to the hospital previously, only 31% could be found in the EHR, and of the 69 participants whose primary care provider was affiliated with the institution only 19% had current code status or ACP documentation available in the EHR.

The second study comes from Rebecca Sudore and colleagues, who conducted a survey of 86 ED providers at an academic medical center and county hospital about ACP documentation. First to note, this survey had an 81% response rate, which is impressive (note the compensation for participating was a $5 gift card) and I think speaks to the importance of this topic to ED providers. Not surprisingly, 95% of ED providers agreed or strongly agreed that ACP documentation is important for patient care. Seventy-four (74) percent of ED clinicians reported needing access to this information once or more a week, and 43% reported needing it five or more times per week. Only 31% of providers said they agreed or strongly agreed with the statement “I am confident I can find patients’ ACP documentation in the current EMR when it exists”. And if they could find it only 55% thought the ACP information could be used to provide patient care. The respondents were also permitted to make suggestions on how to improve ACP document availability. These included having ACP information in one consolidated place, and highly visible “on the main screen” avoiding having to “sift through notes.”

These publications give us a window into the use and availability of ACP documentation in EDs. Those of us providing front line emergency and critical care are likely not surprised by the results, but the quantitation is valuable. There are clear barriers to the accessibility of ACP documents, and in a healthcare provider’s ability to utilize the information effectively.  Let’s now take a step back for a moment and think about the process of advance care planning. This is no easy task for individuals or families. The decisions are difficult, emotional, and require an individual to be vulnerable and brave. Once documented, an individual should find comfort and solace in the fact that an ED physician will know their preferences and provide care that is consistent with these wishes. The fact that we are not providing our patients with this assurance is the most troubling aspect of these findings. This is a patient safety issue, and a true disservice to our most vulnerable patients.


Comments

I very much applaud the blog and the focusing of the accessibility of advance directives for ED physicians. So let's ask the question, what happens when the documents are actually present? The answer is risk to patient safety in the form of both "over" & "under" Resuscitation.

The TRIAD series has shown this in 8 independent and unfunded studies.
We need to focus on the quality of discussions and the right documents for patients.

This whole process requires a name change to Emergency & EOL planning. It also requires a non biased quality oversight process.

There is one think that is certain, documents create confusion and translate into risk to patient safety.

Popular posts from this blog

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 …

Dying without Dialysis

There is a terrific article in this weeks Journal of Pain and Symptom Management by Fliss Murtagh of King's College in London about the epidemiology of symptoms for patients with advanced renal failure who die without dialysis.  This study is important because while we know that patients with advanced renal failure have a limited life expectancy and the average age of initiation of hemodialysis is increasing, we know little about the alternatives to hemodialysis.  Specifically, we know nothing about symptoms affecting quality of life among patients who elect not to start dialysis (so called "conservative management" - is this the best label?).  This article provides a terrific counterpoint to the article in last years NEJM showing that nursing home residents who initiated hemodialysis tended to die and decline in function (see GeriPal write up here). 

The study authors followed patients with the most advanced form of chronic kidney disease (the new name for renal failu…

Survival from severe sepsis: The infection is cured but all is not well

Severe sepsis is a syndrome marked by a severe infection that results in the failure of at least one major organ system: For example, pneumonia complicated by kidney failure. It is the most common non-cardiac cause of critical illness and is associated with a high mortality rate.

But what happens to those who survive their hospitalization for severe sepsis? An important study published in JAMA from Iwashyna and colleagues provides answers and tells us all is not well. When the patient leaves the hospital, the infection may be cured, but the patient and family will need to contend with a host of major new functional and cognitive deficits.

Iwashyna examined disability and cognitive outcomes among 516 survivors of severe sepsis. These subjects were Medicare enrollees who were participants in the Health and Retirement Study. The average age of patients was 77 years.

When interviewed after discharge, most survivors were left with major new deficits in their ability to live independently. …