Paperwork Confusion Can Affect Life-saving Care in the ED

By Lynn Hetzler via Multibriefs

A recent study published in The Journal of Post-Acute and Long-Term Care Medicine (JAMDA) shows that paperwork confusion can affect life-sustaining treatment in the emergency department (ED), leading some patients to receive undesired life-saving care.

Honoring patient preferences is an essential element in quality end-of-life care. Clinicians and other healthcare professionals often rely on the Medical Orders for Life-Sustaining Treatment (MOLST) to help them discuss, understand and convey a patient's wishes regarding life-sustaining treatment.

Patients fill out the MOLST form and place a checkmark next to choices such as "CPR Order: Attempt Cardio-Pulmonary Resuscitation" or "DNR Order: Do Not Attempt Resuscitation (Allow Natural Death)," where each of the options is accompanied by a short explanation of what services healthcare professionals will or will not render in each case.

MOLST forms help practitioners honor the wishes of terminally ill or elderly patients who cannot speak for themselves. While MOLST and other forms like it help initiate the conversation between patients and their healthcare providers, it is often difficult to know what patients intend when they make healthcare choices and whether the patients understand the meaning of the medical orders.

Patients do not always fill out the forms completely and this can result in confusion about their preferences regarding advanced order at the most critical time in their care. What many patients and their families do not realize is that when ED doctors do not understand the patient's end-of-life wishes, the default option is the most aggressive treatment available.

Lead author of the study Brian Clemency, DO, MBA, and colleagues collected and analyzed MOLST forms that accompanied 100 patients transported to the ED. The scientists compiled the information into various data categories that included age, gender, whether the patients themselves completed the form, medical orders for life-sustaining treatment — including intubation, ventilation, artificial fluids or artificial nutrition — and wishes for future hospitalization or transfer to extended-care facilities.

The researchers calculated the frequencies of variables and determined the associations between them using chi-square. The researchers then developed a presumptive list of combinations of contradictory medical orders.

Contraindications with orders for CPR included the choice of one or more of the following:

• Comfort care
• Limited intervention
• Do not intubate
• No rehospitalization
• No IV fluids
• No antibiotics

Contradictions with DNR orders included the choice of one or more of the following:

• Intubation
• No limitation on interventions

Contradictions with orders for comfort care included:

• Send to the hospital
• Trial period of IV fluids
• Antibiotics

The researchers used crosstabs to calculate the frequencies of coexisting-but-contradictory medical orders. They found at least one section left blank on 69 percent of the forms. They also noted inconsistencies in patient wishes in 14 percent, where the patient express a desire for "comfort measures only," contradicted the desire to go to the hospital and receive IV fluids and/or antibiotics.

Patients and their proxies might believe that documenting some, but not necessarily all, of their wishes on an MOLST form is enough for directing end-of-life care. Making some, but not all choices clear can lead to undesired, extraordinary or invasive care.

Lynn Hetzler has been a freelance writer for more than 15 years. She has extensive experience in a variety of specialties, including transplantation, oncology, fertility, negligible senescence, laboratory science, addiction, general research and more. Lynn specializes in creating informative and engaging medical content for readers of all levels, from patients to researchers and everyone in between.