This past Tuesday was the annual National Healthcare Decisions Day when patients are encouraged “to express their wishes regarding healthcare and for providers and facilities to respect those wishes, whatever they may be.” To be clear, this is not about getting people to agree to a Do Not Resuscitate order or agreeing to limit their treatment options if that is not what they want. It is presumably an opportunity for patients to take control of their care at a time when they otherwise would not be able to do so. For those of us for whom religious beliefs and values inform and undergird these decisions, it is about taking advantage of an open invitation from a health care system which so often seems oblivious to those beliefs to make them known and document them in relationship to care decisions.
In observing this day, Dr. Eric Widera offers a very provocative post on GeriPal. He cites a recent editorial by Theresa Allison and Rebecca Sudore in JAMA Internal Medicine and a related study by Heyland and colleagues investigating documentation of treatment preferences by a sample of elderly patients in Canada. One of the most dramatic and disturbing findings of the study was that, for those who had stated preferences, over two-thirds of those preferences were either not documented at all or documented incorrectly in the medical record. This finding calls into serious question the basic premise of advance directives. If one’s stated preferences are likely not to be observed, why even bother?
But Allison and Sudore up the ante even further when they state:
“Discussions about goals of care and code status constitute a medical procedure every bit as important to patient safety as a central line placement or a surgical procedure. Much as we have developed systems to improve patient safety in surgical procedures, we need to develop systematic approaches to discussing patient values and goals of care.”
Dr. Widera then raises the obvious question, “Should failure to follow preferences be a medical error?”
For those of us who are not physicians, this could be an invitation for doctor bashing. However, we need to all take seriously that patient safety is everyone’s responsibility. So if this is about patient safety, we are all culpable. But, even if this is not a patient safety issue, I would expect that all of us believe that patient’s wishes should be respected and every effort should be made to make that happen.
The newly released 3rd edition of the NCP Clinical Practice Guidelines contains the following criterion under Guideline 8.1. This criterion applies equally to all members of the treatment team.
“All expressed wishes, preferences, values, goals, plan of care, surrogate decision makers and advance care plans are routinely documented, including the completion of clinical orders such as inpatient resuscitation status, out of hospital do not resuscitate orders, and health care surrogate declaration documents for adult patients.”
So it seems to me the bottom line here is that all members of the treatment team are obliged, individually and as a group, to make sure that all stated treatment preferences and advance directives are well documented, well understood by the team, and observed. If the finding of this study turns out to be true more widely, all of us bear responsibility. Dr. Widera along with the authors of the editorial raise an interesting and provocative question. However, no matter whether consensus ever develops around the answer to that question or not, the findings of this study should galvanize us all to action. The findings point out that while getting patients to fill out their advance directives is a necessary first step, there is another necessary part to the process which may be seriously broken. Each of us needs to be committed to point out that brokenness each and every time we see it.
George Handzo, BCC, CSSBB
President, Handzo Consulting
Senior Consultant, HealthCare Chaplaincy