advance directives and POLST with videoOver 1,300 physicians across the U.S. were asked to interpret patient preferences for end-of-life care in theoretical cases. Physicians rarely reached consensus about patient preferences when they were given only living wills and POLST documents to interpret. The addition of a patient video testimonial helped physicians make better care decisions that reflected their patients’ wishes. Will video become the new national standard for advance care planning?

Consider this case scenario

A 79 year-old male patient with heart disease and advanced Parkinson’s Disease presents to the emergency department with chest pain. He is hypotensive, bradycardic, tachypneic, and hypoxic. A living will in the patient’s electronic medical record is several years old and unsigned — only the words “no CPR/allow natural death” are circled.

How do you resuscitate the patient dying in front of you?

Do you understand the patient’s preferences for resuscitative and end-of-life care?

The patient’s wife and four adult children arrive, along with their spouses and several grandchildren. They crowd around the bed, understandably emotional. It is loud. They inform you that another sibling holds power-of-attorney for the patient and is the designated decision maker, however she is currently out of town and is not answering her phone. The children argue about “what dad would really want” and tell you that the living will in the computer “must belong to someone else.” The patient’s wife perseverates on “how much he suffers every day.” Shortly after arrival, he becomes unresponsive and develops pulseless ventricular tachycardia.

Now what do you do???

Background

Scenarios like this are common in U.S. hospitals. Physicians are left to make decisions about life-sustaining treatments with little information and little time. All physicians want to provide care that is consistent with the authentic wishes of their patients. However, it is sometimes unclear what those exact wishes are. The TRIAD VIII study published in the Journal of Patient Safety, led by Dr. Ferdinando Mirarchi of UPMC Hamot, imagines a potential new future: the addition of a patient video testimonial.

Let’s reconsider our case, now with the addition of a patient video message:

A 79 year-old male patient with heart disease and advanced Parkinson’s Disease presents to the emergency department with chest pain. He is hypotensive, bradycardic, tachypneic, and hypoxic. A living will in the patient’s electronic medical record is accompanied by a video testimonial that he filmed last year in his primary care provider’s office. In the video, the patient appears weak and frail. He moves and speaks slowly, consistent with his Parkinson’s. The patient talks of a full and wonderful life that he shared with his wife. He is clear that he wants “comfort care only” at the end of his life, stating the words “do not intubate me or perform CPR on me… and tell my children that I love them.” Shortly after arrival, he becomes unresponsive and develops pulseless ventricular tachycardia. You turn off the monitors and declare a time of death. A quiet room of family members views the video, in comfort.

The TRIAD VIII study surveyed over 1,300 physicians at 13 teaching hospitals across the U.S., including attending and resident physicians from emergency medicine, internal medicine, and family medicine.1 Subjects were asked to consider 9 patient cases similar to the one described above, choose the appropriate code status for the patients presented, and make resuscitative decisions. Some subjects reviewed cases that included only a POLST document (Physician Order for Life-Sustaining Treatment) [sample PDF] or a Living Will to interpret, while other subjects reviewed the same materials plus a patient video testimonial/message that clarified the patient’s wishes. The hypothesis of the study was that the addition of the video testimonial would improve physician interpretation of patient wishes.

Not surprisingly, the subjects in this study generally did not agree on code status and resuscitative treatment decisions. Advance directives (example) and POLSTs are subject to interpretation errors by providers, as has been demonstrated in other TRIAD studies. The addition of patient video testimonials in this study significantly improved physician interpretations of patient wishes for end-of-life care. Logistic regression of the data demonstrated that the video testimonial was the dominant predictor variable for correct interpretation of advance directives and POLST, regardless of the specialty or experience of the physician.

Video testimonials led to a higher consensus about code status determination and treatment decisions among respondents. However, despite the addition of video messages, the subjects’ performance was not perfect. Think for a moment about that. Physicians who viewed a short video of a patient describing their end-of-life treatment preferences still could not reach a 100% consensus to get this life or death decision right for patients. This speaks to 2 critically important confounding issues:

  1. The overwhelming ethical and legal concerns of physicians that dominate (and sometimes negatively influence) their decision making process
  2. The remarkable lack of training for physicians in the interpretation of advance directives and POLST.

In this study, only 41% of subjects had previous training in the interpretation of living wills or POLST documents, with a median training time of less than 2 hours. There remains an imperative to improve the education of providers in palliative and end-of-life care topics, especially advance care planning, prognostication, and goals of care.

The TRIAD VIII study may prompt the next major paradigm shift in advance care planning– the addition of patient video testimonials to clinicians. Further research and significant policy work will be needed in order to make video testimonials a legal option for patients and providers in the future.

Summary

  • Advance care documents and POLST are subject to significant interpretation error.
  • Video testimonials improve physician interpretation of patient preferences for code status and resuscitative treatments.
  • Physicians report inconsistent training in the interpretation of advance care documents.
1.
Mirarchi F, Cooney T, Venkat A, et al. TRIAD VIII: Nationwide Multicenter Evaluation to Determine Whether Patient Video Testimonials Can Safely Help Ensure Appropriate Critical Versus End-of-Life Care. J Patient Saf. February 2017. [PubMed]
Michael Gisondi, MD

Michael Gisondi, MD

Associate Professor of Emergency Medicine
Residency Program and Medical Education Fellowship Director
Northwestern University
Editor, ALiEM EM Match Advice series
Abra Fant, MD

Abra Fant, MD

Assistant Residency Director
Department of Emergency Medicine
Northwestern University
Director of Patient Safety and Quality Improvement
McGraw Medical Center of Northwestern University
Fred Mirarchi, DO

Fred Mirarchi, DO

Medical Director
Department of Emergency Medicine
University of Pittsburgh Medical Center Hamot
Principal Investigator of TRIAD VIII