ORIGINAL ARTICLE
TRIAD IV: Nationwide Survey of Medical Students’ Understanding of Living Wills and DNR Orders Ferdinando L. Mirarchi, DO, FAAEM, FACEP,* Matthew Ray, MA (Bioethics),Þ and Timothy Cooney, MSþ
Introduction: Living wills are a form of advance directives that help to protect patient autonomy. They are frequently encountered in the conduct of medicine. Because of their impact on care, it is important to understand the adequacy of current medical school training in the preparation of physicians to interpret these directives. Methods: Between April and August 2011 of third and fourth year medical students participated in an internet survey involving the interpretation of living wills. The survey presented a standard living will as a ‘‘stand-alone,’’ a standard living will with the addition an emergent clinical scenario and then variations of the standard living will that included a code status designation (‘‘DNR,’’ ‘‘Full Code,’’ or ‘‘Comfort Care’’). For each version/ scenario, respondents were asked to assign a code status and choose interventions based on the cases presented. Results: Four hundred twenty-five students from medical schools throughout the country responded. The majority indicated they had received some form of advance directive training and understood the concept of code status and the term ‘‘DNR.’’ Based on a stand-alone document, 15% of respondents correctly denoted ‘‘full code’’ as the appropriate code status; adding a clinical scenario yielded negligible improvement. When a code designation was added to the living will, correct code status responses ranged from 68% to 93%, whereas correct treatment decisions ranged from 18% to 78%. Previous training in advance directives had no impact on these results. Conclusion: Our data indicate that the majority of students failed to understand the key elements of a living will; adding a code status designations improved correct responses with the exception of the term DNR. Misunderstanding of advance directives is a nationwide problem and jeopardizes patient safety. Medical School ethics curricula need to be improved to ensure competency with respect to understanding advance directives. Key Words: resuscitation, DNR order, living will, advance directives, patient rights, medical education, patient safety, patient autonomy (J Patient Saf 2014;00: 00Y00)
A
dvance directives have national recognition and provide evidence of a person’s wishes with respect to life-sustaining treatments before becoming incompetent to make medical decisions. Two common forms of advance directives are the living will and DNR order. A living will is a legal document providing medical personnel and patients’ families’direction about initiating or withholding life-saving interventions when the patient enters a terminal condition or persistent vegetative state. Living wills are commonplace and frequently encountered in medicine. A living will is not a do-not-resuscitate (DNR) order. A DNR order is a
From the *Department of Emergency Medicine, UPMCYHamot, Chairman, UPMC- Hamot Physician Network, Governance Council; † Lake Erie College of Osteopathic Medicine; and ‡Manager, Basic Science Research, UPMC Hamot, Erie, Pennsylvania. Correspondence: Ferdinando L. Mirarchi, DO, FAAEM, FACEP, Department of Emergency Medicine, UPMC Y Hamot, Chairman, UPMCYHamot Physician Network, Governance Council, 201 State Street, Erie, PA 16550 (e
TRIAD IV: Nationwide Survey of Medical Students’ Understanding of Living Wills and DNR Orders Ferdinando L. Mirarchi, DO, FAAEM, FACEP,* Matthew Ray, MA (Bioethics),Þ and Timothy Cooney, MSþ
Introduction: Living wills are a form of advance directives that help to protect patient autonomy. They are frequently encountered in the conduct of medicine. Because of their impact on care, it is important to understand the adequacy of current medical school training in the preparation of physicians to interpret these directives. Methods: Between April and August 2011 of third and fourth year medical students participated in an internet survey involving the interpretation of living wills. The survey presented a standard living will as a ‘‘stand-alone,’’ a standard living will with the addition an emergent clinical scenario and then variations of the standard living will that included a code status designation (‘‘DNR,’’ ‘‘Full Code,’’ or ‘‘Comfort Care’’). For each version/ scenario, respondents were asked to assign a code status and choose interventions based on the cases presented. Results: Four hundred twenty-five students from medical schools throughout the country responded. The majority indicated they had received some form of advance directive training and understood the concept of code status and the term ‘‘DNR.’’ Based on a stand-alone document, 15% of respondents correctly denoted ‘‘full code’’ as the appropriate code status; adding a clinical scenario yielded negligible improvement. When a code designation was added to the living will, correct code status responses ranged from 68% to 93%, whereas correct treatment decisions ranged from 18% to 78%. Previous training in advance directives had no impact on these results. Conclusion: Our data indicate that the majority of students failed to understand the key elements of a living will; adding a code status designations improved correct responses with the exception of the term DNR. Misunderstanding of advance directives is a nationwide problem and jeopardizes patient safety. Medical School ethics curricula need to be improved to ensure competency with respect to understanding advance directives. Key Words: resuscitation, DNR order, living will, advance directives, patient rights, medical education, patient safety, patient autonomy (J Patient Saf 2014;00: 00Y00)
A
dvance directives have national recognition and provide evidence of a person’s wishes with respect to life-sustaining treatments before becoming incompetent to make medical decisions. Two common forms of advance directives are the living will and DNR order. A living will is a legal document providing medical personnel and patients’ families’direction about initiating or withholding life-saving interventions when the patient enters a terminal condition or persistent vegetative state. Living wills are commonplace and frequently encountered in medicine. A living will is not a do-not-resuscitate (DNR) order. A DNR order is a
From the *Department of Emergency Medicine, UPMCYHamot, Chairman, UPMC- Hamot Physician Network, Governance Council; † Lake Erie College of Osteopathic Medicine; and ‡Manager, Basic Science Research, UPMC Hamot, Erie, Pennsylvania. Correspondence: Ferdinando L. Mirarchi, DO, FAAEM, FACEP, Department of Emergency Medicine, UPMC Y Hamot, Chairman, UPMCYHamot Physician Network, Governance Council, 201 State Street, Erie, PA 16550 (e
