Video Messages Clarify Patients' Wishes for Critical versus End-of-Life Care
Wednesday Feb 15th, 2017
Adding a patient-created video testimonial to a living will or "POLST" form can help to prevent errors of interpretation regarding the choice between life-sustaining treatment or allowing natural death in critically ill patients, according to a study in the March Journal of Patient Safety. The journal is published by Wolters Kluwer.
"Interpretation errors are common with living wills and POLST forms," commented Dr. Ferdinando L. Mirarchi of University of Pittsburgh Medical Center (UPMC) Hamot, in Erie, Pa., lead author of the new report. "Our study shows that medical professionals are more likely to reach a consensus after viewing a video testimonial, proving that we can do better than paper forms alone."
Video Testimonials Improve Consensus Regarding Patients' WishesWritten documents such as living wills (LWs) seek to direct medical treatments in the event the patient loses decision-making capacity. A newer type of document—called Physician Orders for Life-Sustaining Treatment, or POLST—provides a one-page format for seriously ill patients to indicate their treatment preferences.
"Both living wills and POLST are very much needed and effective," Dr. Mirarchi explained. "However, they are prone to medical errors related to provider misinterpretation of what is documented and appropriate patient selection." He notes three ways in these medical errors can cause harm: by taking a life inappropriately, by preventing the natural dying process, or by leading to overuse of costly medical resources.
In a nationwide internet survey, 741 physicians at 13 hospitals were presented with clinical scenarios involving critically ill patients who had either an LW or POLST. Doctors were randomly assigned to interpret the patients' wishes based on the LW or POLST alone, or with the addition of a scripted video testimonial in which patients talked about their treatment choices.
Responses were compared to see if the video testimonials led to more accurate interpretation of the patient's intentions. Choices included full aggressive treatment including CPR; aggressive care with a brief attempt at CPR; or no CPR/'allow natural death.'
The results suggested that doctors reached a higher level of agreement in interpreting the patients' wishes when they viewed the video testimonials. Based on the LW or POLST documents only, doctors reached a consensus (95 percent agreement) in two out of nine clinical scenarios.
Adding the video testimonials produced statistically significant changes in the responses of seven scenarios—in five of these, physicians were more likely to choose full aggressive treatment. Overall, the addition of a video testimonial was the most consistent predictor of resuscitation choices achieving interpretive consensus.
While end-of-life treatment should be predicated on consensus understanding of patient wishes, there is concern about how LW or POLST documents might affect patient-centered, medical decision making. Previous studies have raised questions as to how well medical providers understand these documents—including the simplified POLST form. Twenty-six states have adopted the POLST or similar forms so far, and that number is expected to increase.
At present both LWs and POLST forms "fail the litmus test" of achieving consensus among physicians, the results suggest. "Video testimonials can ensure the safe interpretation of LWs and POLST documents and ensure that these documents are faithful to the wishes and goals of the patient producing benefits for all stakeholders in the health care system," Dr. Mirarchi and colleagues conclude.
The study also raises concerns related to medical provider bias with respect to chronically ill or disabled people who have an LW or POLST. "This population should be carefully managed and researched to ensure their safety and decision making," Dr. Mirarchi commented.
(doi: 10.1097/PTS.0000000000000357)
About Journal of Patient Safety is dedicated to presenting research advances and field applications in every area of patient safety. While Journal of Patient Safety has a research emphasis, it also publishes articles describing near-miss opportunities, system modifications that are barriers to error, and the impact of regulatory changes on healthcare delivery. This mix of research and real-world findings makes Journal of Patient Safety a valuable resource across the breadth of health professions and from bench to bedside.
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