TRIAD II: do living wills have an impact on pre-hospital lifesaving care?
BACKGROUND: Living wills accompany patients who present for emergent care. To the best of our knowledge, no studies assess pre-hospital provider interpretations of these instructions.
OBJECTIVES: Determine how a living will is interpreted and assess how interpretation impacts lifesaving care.
DESIGN SETTING: Three-part survey administered at a regional emergency medical system educational symposium to 150 emergency medical technicians (EMTs) and paramedics. Part I assessed understanding of the living will and do-not-resuscitate (DNR) orders. Part II assessed the living will's impact in clinical situations of patients requiring lifesaving interventions. Part III was similar to part II except a code status designation (full code) was incorporated into the living will.
RESULTS: There were 127 surveys completed, yielding an 87% response rate. The majority were male (55%) and EMTs (74%). The average age was 44 years and the average duration of employment was 15 years. Ninety percent (95% confidence interval [CI] 84.6-95.4%) of respondents determined that, after review of the living will, the patient's code status was DNR, and 92% (95% CI 86.5-96.6%) defined their understanding of DNR as comfort care/end-of-life care. When the living will was applied to clinical situations, it resulted in a higher proportion of patients being classified as DNR as opposed to full code (Case A 78% [95% CI 71.2-85.6%] vs. 22% [95% CI 14.4-28.8%], respectively; Case B 67% [95% CI 58.4-74.9%] vs. 33% [95% CI 25.1-1.6%], respectively; Case C 63% [95% CI 55.1-71.9%] vs. 37% [95% CI 28.1-44.9%]), respectively. With the scenarios presented, this DNR classification resulted in a lack of or a delay in lifesaving interventions. Incorporating a code status into the living will produced statistically significant increases in the provision of lifesaving care. In Case A, intubation increased from 15% to 56% (p < 0.0001); Case B, defibrillation increased from 40% to 59% (p < 0.0001); and Case C, defibrillation increased from 36% to 65% (p < 0.0001).
CONCLUSIONS: Significant confusion and concern for patient safety exists in the pre-hospital setting due to the understanding and implementation of living wills and DNR orders. This confusion can be corrected by implementing clearly defined code status into the living will.
Published In/Presented At
Mirarchi, F. L., Kalantzis, S., Hunter, D., McCracken, E., & Kisiel, T. (2009). TRIAD II: do living wills have an impact on pre-hospital lifesaving care?. The Journal of emergency medicine, 36(2), 105–115. https://doi.org/10.1016/j.jemermed.2008.10.003
Medicine and Health Sciences
Department of Emergency Medicine