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The Realistic Interpretation of Advanced Directives

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Although more and more, people are preparing Living Wills or other advance health care directives, these documents may not live up to what we expect of them. Differences in state laws and miscommunication between attorneys, patients and their health care providers can cause the documents to have little or no meaning when an end of life situation occurs.

Also, physicians may ignore an advanced directive, simply because they do not believe it adequately reflects the patient’s wishes or because they do not understand what is desired by the patient. Misinterpretation of the directive could be due to the use of legalese rather than actual medical codes, which codes would make more sense to health care personnel in a medical situation. Some physicians may mistakenly believe living will or other advance directive is the same as a DNR (do not resuscitate) code order.

Code orders have specific meaning for health care personnel, and although they can be interpreted differently, they can also help to clarify the patient’s wishes, when discussed with their doctor. There are several codes: full code, which means that the medical personnel should do everything necessary to keep a patient alive; hospice care/comfort care, indicates that nature should be allowed to take its course, and while medical personnel should make the patient comfortable and relieve pain, the patient should be allowed to die naturally; slow code, applies when a patient will not benefit from further medical care, and once again medical personnel will provide comfort, until the patient dies; no code/DNR, are similar, although there can be confusion in a no code situation, but they are generally meant to imply that health care personnel are not to attempt to resuscitate a patient who is near death and whose heart or breathing have stopped; chemical code, this implies that the patient wishes only to have medication administered, but to have no invasive procedures performed; and DNI, which stands for do not intubate.

As can be seen, there can still be some confusion among these codes. Therefore, prior to the completion of a living will, it is wise for the patient to discuss all these options with their physician. The patient should fully understand what the choices they have made mean, and also when these choices may be used in a health care situation. The document itself should outline the parameters for its enactment in the case of medical emergency.

Once a patient has provided their physician with an advance directive, they may also prepare a POLST (Physician Orders for Life Sustaining Treatment). This document should be used in conjunction with an advance directive. Again, this should be fully discussed with the physician, and its effectiveness can depend upon the understanding of all the health care personnel who are treating the patient.

Ideally, the advance directive, in order to be as effective as possible, should include all of the following: primary information, pertinent medical information, a resuscitation choice, a do not transfer order, and a hold harmless statement. Further, the document should be portable, follow all state laws, and require the confirmation of a second physician in a case of a terminal condition or persistent vegetative state. It is also wise for the patient to choose “safe” codes, such as full code or hospice/comfort care, rather than other codes which can be misinterpreted.

Obviously, as these documents are so open to confusion, it is best to make sure that the patient’s wishes are effectively communicated to the physician, other health care personnel and any proxy appointed by the patient, prior to the document’s enactment.

Special Sources To Note:

Understanding Your Living Will (Addicus Books, 2006) http://www.addicusbooks.com/show_title.cfm?isbn=1886039771

Mirarchi,Ferdinando Does a Living Will Equal a DNR? Is Patient Safety Compromised?, Journal of Emergency Medicine, Vol. 33, No.3, pp299-305, 2007.

Mirarchi, Ferdinando L “Living Wills & DNR: Is Patient Safety Compromised?”. Human Life Review. . FindArticles.com. 23 Sep. 2008. http://findarticles.com/p/articles/mi_qa3798/is_200710/ai_n24394969

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