Interpretation of Advance Directives and Errors

Patient being rushed into the ER Many would agree that the execution of advance directives is a good thing, and that such documents can often clarify stressful, confusing situations. But, what happens when an advance directive is not interpreted correctly? And, how often does this happen? The answer is we don’t really know. What we do know is that the potential for errors in misinterpreting advance directives can be catastrophic.

I recently read an interesting article about an ER physician relaying his own personal experiences with advance directives and how, more often than not, he has had difficulty with them. In fact, he said that he “almost killed a patient” because he thought he was interpreting the document correctly. The physician, Ferdinando Mirarchi, DO, chairman of the emergency medicine department at UPMC-Hamot in Erie, PA, has since made it his own, personal crusade to see that these documents become safer, easier to interpret, and less prone to errors.

Dr. Mirarchi talked about the nature of advance directives and why they can be so prone to errors in interpretation. First, the language used in advance directives to express a patient’s wishes is often, simply, not clear. Second, add to that the fact that the documents often involve several people needing to interpret (and often act) in response to them: physicians, bedside nurses, and family members. Third, Dr. Mirarchi said that he has seen many health care providers assume that advance directives are synonymous with a DNR order –this is not the case. Fourth, there is a lack of standardization of advance directives –thus, every document can be written differently, using different language, format, etc –thus, truly increasing the need for interpretation with every document. Finally, I would like to add that advance directives are sometimes only learned about in moments of crisis when there may not be sufficient time to assess and discuss the document with others.

Dr. Mirarchi thinks that the lack of standardization and potential for misinterpretation of advance directives, and resulting errors, is so bad that it is a patient safety issue. What do you think? Do you have an advance directive? If so, are you confident that your family and caregiver(s) understand your wishes?

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