Welcome Medicare Nation! Today my guest is Dr. Fernando Mirarchi, who is the Medical Director of the University of Pittsburgh Medical Center. He is the principal investigator of the TRIAD report. His research has led to a spiral report that presents the confusion and risk around Living Wills and DNR orders. Dr. Mirachi has written a book and several articles about this topic.
Dr. Mirarchi practices Emergency Medicine, but he is also the Chairman of the Medical Ethics Committee, so he has a special insight into end of life care and the breakdown around it.
Having confusion around a Living Will and DNR is a real possibility to the general public and it is a reality that many will be dealing with in the future.
What is a Living Will?
A way for a patient to document, in writing, their wishes for their end of life care. The problem with this definition is, in medicine, everything can be terminal, if not properly treated. The difference between an Effective and an Enacted Document are also misperceived as to when a document becomes enacted. “The Living Will” will not prevent care from being provided, in order to save your life.
What is a DNR (Do Not Resuscitate)?
A document that says that medical providers will not administer CPR, in the event that you are found not breathing and with no pulse. The name of the document causes confusion, because people think it means you aren’t going to get treatment for a medical condition. In legal terms, it only means the CPR will not be administered if you are found without a pulse and not breathing. In order to refuse all types of care if you are critically ill, then you would have to sign a document indicating you don’t want any care administered. Period.
What is a POLST Order?
This is enacted when you would be in cardiac arrest, and a Provider would have to use this document to immediately chart the treatment for the cardiac arrest. There are multiple options and this can also cause some confusion as to when it can supersede a DNR. This process can also cause conflicts because it is a metric by which insurance companies are rewarding Providers financially.
What caused you to do the TRIAD (The Realistic Interpretation of Advanced Directives) Studies?
Dr. Mirarchi had a situation first hand, where he was being faced with paperwork that was being misinterpreted, and almost caused him not to save a life. Luckily, another Physician was around nearby, who understood what the paperwork meant and intervened for a good outcome for the patient. This and a few other circumstances caused him to write the book, Understanding Your Living Will. (available on Amazon and Atticus Books)
One of the criticisms of the book was that there was no research backing up the claims in the book. This thought was what led Dr. Mirarchi to start the TRIAD Studies.
Dr. Mirachi views these decisions as a Patient Safety issue, rather than an end of life decision.
He created a checklist to help facilitate the conversation about these decisions from a Medical perspective and also from the patient perspective. There is a checklist of the Medical Provider and also for the lay person. Each checklist provides the ABCD for each role.
A - Announcing your end of life documents
B - Be clear with regard to treatment with regard to the document.
Understanding whether the issues are terminal or chronic illnesses.
C - Communicate and coordinate with family members.
D - Discussing the next steps and designing the plan for the patient.
You can download the checklist and cut it out and place it in your wallet (link)
There is a company called My Directives, which has digitized all of the end of life paperwork, so you can carry the paperwork with you at all times.
The checklist for the lay person basically spells out the same information, but in terms that anyone can understand.
The aging population is being unintentionally targeted in an effort to control healthcare costs, so it is important that every patient understand their options and having the ability to make it a two-sided conversation.
Resources discussed in the show:
National Patient Safety Article
Dr. F. Mirarchi’s book
“Understanding Your Living Will: What you need to know Before an Emergency”
Advanced Care Directives
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