TRIAD I-The Realistic Interpretation of Advanced Directives

Rationale: Living wills often accompany patients who present for emergent care. Despite evidence suggesting that misunderstanding could lead to inappropriate care, few studies have assessed underlying assumptions about these instructions and how care may be affected. Objectives: To determine if the living will implies a code status before clinical interaction and to assess how the term "do-not-resuscitate" is defined in terms of patient care. Methods: An intranet survey was administered to clinical departments at a 350-bed acute care and level II trauma center. There were 585 potential respondents including physicians, nurses, and first-responders. No age or experience restrictions or exclusions were applied, given that emergent care presumes neither minimum age nor previous experience. The survey presented a fictitious living will refusing lifesaving interventions and prompted respondents to assign a code status (do-not-resuscitate or full code) and define the level of care associated with the former. Clinical information was withheld to isolate responses to the advance directive. Results: Between 440 and 452 responses were made. Most were female (64%) and nurses (62%) with an average age of 38.2 years (range 18-68) and an average duration of employment of 13.3 years (range 0.3-40.9). Seventy-nine percent (347/440) indicated do-not-resuscitate and 70% (317/452) construed do-not-resuscitate with "comfort care/end-of-life care." Occupation hierarchy (pre-hospital, nurse, physician) was related to the likelihood of choosing full code or full care (P ≤ 0.001, odds ratios: 4.03 [95% bounds 1.70, 9.55]; 2.19 [95% bounds: 1.04, 4.65], respectively). Conclusions: A majority of caregivers at a level II trauma center construed a living will with a do-not-resuscitate order which, in turn, was equated with end-of-life care. Such understandings may unnecessarily put patients at risk when presenting for emergent care.