Education Corner – Advance Care Planning Documents & The Donation Process

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Advance care planning documents have almost no role in the initial aspects of resuscitative care.

Misperceptions with Regards to Advance Care Planning Documents

  • Nationwide living wills (LW) are inappropriately considered “do not resuscitate” (DNR) orders (misperception held 78% of the time).
  • DNR orders are inappropriately equated to comfort care / end-of-life care (misperception held 64% of the time).

Danger of these misperceptions Lack of Action!

Challenges with EOL Care Documents

  • Living wills – not read and understood, lack of clarity of who the Attending is, lack of clarity on definition of “terminal”, and do not address donation.
  • Physician Orders for Life-Sustaining Treatment (POLST) – DNR checked most often on POLST and does not equate to do not treat, e.g. intubation, ventilation, feeding, etc., and does not address donation.
  • DNRs—sometimes inappropriately placed without informed consent from patient and/or family, LW confused as DNR orders, often misinterpreted as “do not treat” and does not address donation.

DNR

Resuscitation

action


 

**Patient safety checklist – see Alliance organ donation toolbox. “Checklists & Forms” category

Organ Donation & Advance Care Planning Documents

  • Advance care planning documents typically do not address donation.
  • A previous declaration to donate supersedes any advance care planning document (unless it specifically addresses donation).
  • If a document does not address the question of organ donation:
    • It does not mean it is not an option—directives should not hinder the donation process.
    • Follow CMS guidelines and hospital policies on maintaining patients for purposes of determining donation potential (see reference).
  • Question whether DNR is being interpreted correctly.

Summary Points:

  1. A LW is not a DNR..
  2. DNR is not “do not treat”.
  3. A LW and POLST are not the same.
  4. Use the patient safety checklist** every time to individualize care and clarify the discussion regarding donation.

**Patient safety checklist – see Alliance organ donation toolbox. “Checklists & Forms” category

Taken from a webinar presentation by Ferdinando L. Mirarchi, DO, FAAEM, FACEP (UPMC Hamot). A special thanks to Dr. Mirarchi for his contributions in this inservice.

Editor: Hedi Aguiar RN, MSN, Director of Programs and Communications, The Alliance, haguiar@odt-alliance.org.
This Education Corner is available for downloadThe Alliance grants permission for the distribution and reproduction of this educational communication.

 

References:

Mirarchi FL, Doshi AA, Zerkle SW, Cooney TE. TRIAD VI: How Well Do Emergency Physicians Understand Physicians Orders for Life Sustaining Treatment (POLST Forms? Journal of Patient Safety. 11(1): 1-8.
http://journals.lww.com/journalpatientsafety/Abstract/2015/03000/TRIAD_VI___How_Well_Do_Emergency_Physicians.1.aspx

Mirarchi FL, Cammarata C, Zerkle SW, Cooney TE, Chenault J, Basnak D. TRIAD VII: Do Prehospital Providers Understand Physician Orders for Life-Sustaining Treatment Documents? Journal of Patient Safety. 11(1): 9-17.
http://journals.lww.com/journalpatientsafety/Abstract/2015/03000/TRIAD_VII___Do_Prehospital_Providers_Understand.2.aspx

Additional references:

CMS Conditions of Participation: §482.45(a)(5)

How to Interpret a Living Will? http://secure.quantiamd.com/player/yabhqcxpi?u=yxjzuqjvk

Physicians Orders for Life Sustaining Treatment. http://secure.quantiamd.com/player/ywebdxfnf?u=yxjzuqjvk

Understanding Your Living Will; What You Need to Know Before a Medical Emergency. http://www.addicusbooks.com/show_title.cfm?isbn=1886039771

What Do DNR orders Really Mean? http://secure.quantiamd.com/player/yafruujyt?u=yxjzuqjvk

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