triad viii: nationwide multicenter evaluation to determine … · 2018. 6. 21. · triad viii:...

ORIGINAL ARTICLE

TRIAD VIII Nationwide Multicenter Evaluation to DetermineWhether Patient Video Testimonials Can Safely Help Ensure

Appropriate Critical Versus End-of-Life Care

Ferdinando L Mirarchi DO FACEP Timothy E Cooney MS Arvind Venkat MD FACEPdagger

David Wang MDDagger Thaddeus M Pope JD PhDsect Abra L Fant MD|| Stanley A Terman PhD MDparaKevin M Klauer DO EJD FACEP Monica Williams-Murphy MDdaggerdagger Michael A Gisondi MD||

Brian Clemency DO MBA FACEPDaggerDagger Ankur A Doshi MDsectsect Mari Siegel MD|||| Mary S Kraemer MD||||Kate Aberger MD FACEPparapara Stephanie Harman MDDagger Neera Ahuja MDDagger Jestin N Carlson MDMelody L Milliron DO Kristopher K Hart DO FACOEPdaggerdaggerdagger Chelsey D Gilbertson DOdaggerdaggerdagger

Jason W Wilson MD MA FAAEMDaggerDaggerDagger Larissa Mueller MDDaggerDaggerDaggerLori Brown MDDaggerDaggerDagger and Bradley D Gordon MDsectsectsect

Objective End-of-life interventions should be predicated on consensusunderstanding of patient wishes Written documents are not always under-stood adding a video testimonialmessage (VM) might improve clarityGoals of this study were to (1) determine baseline rates of consensus inassigning code status and resuscitation decisions in critically ill scenariosand (2) determine whether adding a VM increases consensusMethods We randomly assigned 2 web-based survey links to 1366 fac-ulty and resident physicians at institutions with graduate medical educationprograms in emergency medicine family practice and internal medicineEach survey asked for code status interpretation of stand-alone PhysicianOrders for Life-Sustaining Treatment (POLST) and living will (LW) docu-ments in 9 scenarios Respondents assigned code status and resuscitationdecisions to each scenario For 1 of 2 surveys a VM was included to helpclarify patient wishesResults Response rate was 54 and most were male emergency physi-cians who lacked formal advanced planning document interpretation train-ing Consensus was not achievable for stand-alone POLST or LWdocuments (68ndash78 noted ldquoDNRrdquo) Two of 9 scenarios attained consen-sus for code status (97ndash98 responses) and treatment decisions (96ndash99) Adding a VM significantly changed code status responses by 9to 62 (P le 0026) in 7 of 9 scenarios with 4 achieving consensus Resus-citation responses changed by 7 to 57 (Ple 0005) with 4 of 9 achievingconsensus with VMs

From the UPMC Hamot Erie Pennsylvania daggerAllegheny General HospitalAllegheny Health Network Pittsburgh Pennsylvania DaggerStanford University Schoolof Medicine Stanford California sectUniversity of Minnesota Center for BioethicsMitchell Hamline School of Law Minneapolis Minnesota ||Northwestern Univer-sity Feinberg School of Medicine Chicago Illinois paraCaring Advocates CarlsbadCalifornia Michigan State University College of Osteopathic MedicineKnoxville Tennessee daggerdaggerUniversity of Alabama at Birmingham HuntsvilleCampus and Huntsville Hospital Birmingham Alabama DaggerDaggerState Universityof New York at Buffalo Buffalo New York sectsectUniversity of Pittsburgh Schoolof Medicine Pittsburgh Pennsylvania ||||Temple University School of Medi-cine Philadelphia Pennsylvania paraparaSt Josephs Regional Medical CenterNewYorkMedical College Paterson New Jersey Saint VincentHealth SystemAllegheny Health Network Erie Pennsylvania daggerdaggerdaggerINTEGRIS SouthwestMedical Center Oklahoma State University Center for Health SciencesOklahoma City Oklahoma DaggerDaggerDaggerUniversity of South Florida Tampa Floridaand sectsectsectUniversity of Minnesota Medical School Minneapolis MinnesotaCorrespondence Ferdinando L Mirarchi DO FACEP Department of

Emergency Medicine UPMC Hamot 201 State St Erie PA 16550(e‐mail mirarchiflupmcedu)

The authors disclose no conflict of interestSupplemental digital content is available for this article Direct URL citations

appear in the printed text and links to the digital files are provided in theHTMLtext of this article on the journalrsquos Web site (wwwjtraumacom)

Copyright copy 2017 Wolters Kluwer Health Inc All rights reserved

J Patient Saf bull Volume 00 Number 00 Month 2017

Conclusions For most scenarios consensus was not attained for codestatus and resuscitation decisions with stand-alone LW and POLST docu-ments Adding VMs produced significant impacts toward achievinginterpretive consensus

Key Words patient safety living willPhysicians Orders for Life Sustaining Treatment do not resuscitatepatient video message TRIAD

(J Patient Saf 201700 00ndash00)

With the aging population and concomitant rise in elderly pa-tients with chronic illness there is a critical need for clarity

in establishing goals of care in patients presenting for emergencyor other acute care In this time-sensitive setting patient wishesmust be represented and interpreted in a rapid and accurate fash-ion Without effective communication patients may receive un-ethical and potentially ineffective care in the form of eitheroveraggressive or underaggressive treatments

To promote patient autonomy and communication of advancecare planning the Federal Government enacted the Patient SelfDetermination Act (1990) mandating hospitals to ask individualspresenting for acute care whether they had an advance directive orliving will (LW) document1 Living wills contain conditionalstatements (eg if end-stage or permanently unconscious thenhellip)steering medical treatments in the event the patient loses decision-making capacity Yet their conditionality calls into question theapplication of LWs in the acute care setting To address thislimitation the Physicians Orders for Life-Sustaining Treatment(POLST) paradigm was developed to allow patients or surrogatesto enact actionable medical orders delineating their goals of careSince 1991 POLST forms and variations (medical orders for lifesustaining treatment medical orders for scope of treatment physi-cian orders for scope of treatment transportable physician ordersfor patient preferences) have been adopted in 26 states2

Both POLSTand LWs are subject to interpretation error Previ-ous research has demonstrated that healthcare providers conflatedo-not-resuscitate (DNR) code status with ldquodo not treatrdquo whenpatients present in nonarrest situations3ndash6 A recent retrospectiveanalysis revealed a nearly doubled perioperative mortality inDNR versus non-DNR vascular surgery patients despite similarcomorbidities and perioperative complication rates This suggestsa difference in the approach to perioperative care in DNR patientspreviously denoted ldquofailure to rescuerdquo7 A similar propensity wasidentified in a trauma registry with preadmission DNR being

wwwjournalpatientsafetycom 1

Mirarchi et al J Patient Saf bull Volume 00 Number 00 Month 2017

independently predictive of a 5-fold mortality increase after con-trolling for other variables8

With potential misinterpretation of advanced planning docu-ments andor DNR status in the acute care setting there is a needto evaluate newmodalities for ensuring both concordant and accu-rate interpretation of LWs and POLST Our objective is to evaluatewhether video testimonials augment ldquoconcordantrdquo interpretationof LWs and POLST when considering clinical scenarios in theacute care setting We hypothesize that the addition of video testi-monial would lead to more accurate interpretation of such docu-ments when compared with written documents alone

METHODSWe conducted an anonymous multicenter randomized

internet-based survey involving resident and attending physicianswho are hospitalists or emergency family or internal medicine(IM) physicians at 13 teaching institutions across the UnitedStates (Table 1) The survey introduction gave a brief explanationof the purpose of the study listed inclusion criteria and empha-sized voluntary participation A total of 1366 residents and facultymembers were identified and solicited to participate in this study

The survey began with 3 questions that asked for the appropri-ate code status for a POLST document specifying DNRfull treat-ment and a LW document declining all lifesaving interventions(Figs 1 2) This was followed by a question that prompted the ap-propriate care for a ldquoDNRrdquo order Nine clinical scenarios werethen presented involving patients who arrest with either a POLSTor an LW (Table 2) Specific orders on the POLST form varied in-cluding cardiopulmonary resuscitation (CPR) or DNR and levelof treatment support (ldquofullrdquo ldquolimitedrdquo or ldquocomfort measures onlyrdquo[CMO]) Respondents were asked to choose the appropriate codestatus of the patients and make resuscitation decisions At the con-clusion of the scenarios demographic information was collectedincluding information about specialty (emergency medicine[EM] hospitalist IM family practice) experience (both in yearsand in terms of attending versus resident physician status) andprevious training in the use andor interpretation of POLST andLW documents We also assessed respondent perceptions of theadequacy of the informed consent process for POLST and LWdocuments by asking for respondent comfort level in withholdingcare whenwhether patients presented with these documents Phy-sician specialty experience previous training and comfort levelwith informed consent were considered secondary factors thatmight influence coding or treatment decisions This survey was

TABLE 1 Participating Sites

Site

UPMC HamotUniversity of Pittsburgh School of MedicineTemple University School of MedicineStanford University School of MedicineAllegheny General Hospital Allegheny Health NetworkUniversity of Alabama at Birmingham Huntsville Campus and HuntsvilleSaint Vincent Health System Allegheny Health NetworkState University of New York at BuffaloNorthwestern University Feinberg School of MedicineUniversity of South FloridaUniversity of Minnesota Medical SchoolINTEGRIS Southwest Medical Center Oklahoma State University CenterSt Josephs Regional Medical Center New York Medical College

2 wwwjournalpatientsafetycom

designated ldquosurvey ArdquoAvariant of this ldquosurvey Brdquowas identicalin content but used patient video testimonialsmessages (VMs)intended to clarify patient wishes The following 3 VMs wereevaluated full aggressive treatment (full code) aggressive carewith a trial of CPR for 3 minutes when in cardiac arrest andend-of-life (EOL) care with no CPRallow natural death (CMOTable 2) Surveys were created in SurveyMonkey with a uniqueweb-based link generated for each Scenario content was validatedbymedical and legal peer review To preclude a sequence or order-ing effect the order of the scenarios with each survey was ran-domized The reliability of these surveys has been addressed inprevious studies45 Consistency in responses was assessed by com-paring concordance of responses to duplicate scenarios (E I) usingChronbach α a measure of reliability

Rosters of teaching faculty and residents were generated fromeach participating institution and forwarded to one of the study in-vestigators who randomized survey assignment to 1 of the 2 sur-vey links Randomization was conducted for all participants onan institution-by-institution basis using a web-based site (httpwwwgraphpadcomquickcalcsrandomize1) Rosters with ran-domizations were then returned to collaborating investigators atparticipating academic centers Collaborators e-mailed a standard-ized solicitation letter to each prospective participant along withthe survey link corresponding to their group assignment and senta reminder notification 2 weeks after the initial e-mail requestThe study design underwent both medical and legal peer reviewand was evaluated by the coordinating center institutional reviewboard and granted exempt status Each institutions institutionalreview board also reviewed and approved this study

Survey responses were analyzed not for ldquocorrectrdquo responses butconsensus We interpreted consensus to infer clarity of understand-ing For this study consensus reflected a supermajority of 95 orgreater concordant responses As an example if 95 of the cohortdesignates DNR as the appropriate code status for a patient depictedin a scenario this level of agreement indicates consensus and byinference clarity in the information provided about the patientspreferences With the critical issue of fidelity to patient wishesand safety we submit that this is the minimum level of clarity re-quired for decision making about life-sustaining treatment (LST)

Responses rates were contrasted across survey groups to de-termine whether video testimonials improved agreement andled to greater consensus Secondary factors were also consideredincluding physician specialty (EM versus IMfamily practicehospitalist) experience (attendings versus residents) previoustraining in POLST LW document interpretation and comfort

Location

Erie PennsylvaniaPittsburgh PennsylvaniaPhiladelphia Pennsylvania

Stanford CaliforniaPittsburgh Pennsylvania

Hospital Birmingham AlabamaErie PennsylvaniaBuffalo New YorkChicago IllinoisTampa Florida

Minneapolis Minnesotafor Health Sciences Oklahoma City Oklahoma

Paterson New Jersey

copy 2017 Wolters Kluwer Health Inc All rights reserved

FIGURE 1 Physician Orders for Life-Sustaining Treatment document

J Patient Saf bull Volume 00 Number 00 Month 2017 TRIAD VIII Mirarchi Nationwide Survey

with the informed consent process leading to document executionfor their impact on responses These factors were screened usingunivariate χ2 tests to examine differences in rates of responsesLogistic regression was used to generate odds ratios for responsesin the context of a multivariate approach Potential predictorvariables included use of the video testimonial (plusmn) practice ex-perience (attending resident) previous POLST training (plusmn) previousadvance directives training (plusmn) comfort with the POLST consentingprocess (plusmn) and comfort with the LW consenting process (plusmn) Apower analysis indicated that a minimum of 59 respondents were re-quired per survey group (118 total) to have an 80 certainty of de-tecting a between-groups response difference of at least 25

The impact of missing datawas analyzed by identifying scenar-ios impacted by withdrawals or absent responses Dummy group-ing variables were created in these cases to represent responders


and nonresponders for each affected scenario These groups werethen compared for responses to questions unaffected or minimallyaffected by missing data We posited that if response rates weresimilar then withdrawals or failure to respond to specific scenar-ios did not unduly bias study outcomes We chose this methodto ascertain missing data effects because rates of missing datafor some of the scenarios were in excess of 20 and data imputa-tion was considered inappropriate

RESULTS

Participant DemographicsThere were 741 responses representing a response rate of

54 (7411366) Respondents were mainly males (63) and


FIGURE 2 Depiction of LW declining life-saving measures


EM physicians Approximately half were attending and board-certified physicians Most had no training in either POLST orLW documentation The mean (standard deviation [SD]) age ofthe cohort was 36(10)years Faculty experience in years was amean (SD median) of 127(153 80) Group demographics weresimilar suggesting homogeneity between survey groups (Table 3)

Code Status of Stand-Alone Documents andInterpretation of Care for DNR

Of the respondents 683 (95 confidence interval [CI]649ndash717) selected DNR as the code status of a POLST doc-ument (formatted DNRfull TX [treatment]) and 784 (95 CI754ndash814) of an LW Almost half (461) equated DNRwithcomfort careEOL care (95 CI 425ndash497) beyond an arrestevent the remaining responses were equally split between fullcare and unsureuncertain Group differences for these initial 3questions were negligible (le3) Neither group evidenced con-sensus in responses (Table 4)

Code Status Decisions by GroupFor survey A (documents only) 2 of the 9 scenarios evi-

denced consensus Ninety-seven percent coded DNR for scenarioC (POLST DNRCMO) Ninety-seven percent selected full codefor scenario H (POLST attempt CPRfull TX) For the remainingscenarios DNR was most frequently selected representing 64to 88 of the code status decisions (Table 4)

For survey B adding a video testimonial significantlychanged code status responses by 9 to 62 (P le 0026) in 7of the 9 scenarios Four of the 9 scenarios attained (or nearlyattained) code status consensus the 2 previously mentioned (sce-nario C + H) along with scenario D a patient with terminal lungCa a LW and a ldquono CPRallow natural deathrdquo VM (94 re-sponded DNR) and scenario F a patient with advanced stageParkinson and a ldquono CPRallow natural deathrdquo VM (95 re-sponded DNR) For the remaining scenarios full code was the


most common response representing 44 to 68 of the codestatus decisions

Treatment Decisions by GroupFor survey A (documents only) 2 of the 9 scenarios reached

treatment consensus Ninety-six percent selected ldquodo not intu-baterdquo for scenario C (terminal lymphoma) and 99 would intu-bate in the case of scenario H For the remaining scenariosapproximately half would have resuscitated in scenario A for allother scenarios (BndashI) withholding resuscitation was the mostcommon choice (58ndash87 Table 4)

Adding a VM (survey B) significantly changed resuscitationresponses by 7 to 57 (P le 0005) with the following 4 of the 9attaining consensus scenarios C (96 do not intubate) scenario D(94 do not intubate) scenario F (95 do not defibrillate) andscenario H (99 intubate) For the remaining scenarios (A BE G I) resuscitationwas themost common response (76ndash86)

Internal Consistency (Reliability)Chronbach α value for coding responses was 0776 and for

treatment responses 0859 representing ldquosubstantial agreementrdquo9

Effect of Secondary Factors on ResponsesFor survey A physician specialty did not exert a significant

effect on code status or treatment responses Physician experience(attending versus resident) affected 3 of the 9 scenarios with dif-ferences from 12 to 17 (P le 0048) Scenarios affected wereB F and G Attendings chose DNR less frequently and chose re-suscitation more often Neither POLST nor LW training exertedan effect Perception of comfort with POLST informed consent af-fected 3 of the 9 scenarios A E and F with differences of 11 to20 (P le 0031) Those who were ldquocomfortablerdquo with the ade-quacy of consent chose DNR more often and resuscitated lessPerception of comfort with LW informed consent affected 5 of


TABLE 2 Survey Content

Survey A Survey B

POLST document only code status POLST document only code statusLW document only code status LW document only code statusDNR = DNR = Scenario A POLST (DNRfull TX) 66-year-old manchest pain SOB and diaphoresis Vitals P 110 RR30 SaO2 97 RA T 37degC BP 13070 Abrupt VTVF

Scenario A + POLST+ VM full code with CPR

Scenario B (LW) 61-year-old man chest pain SOB diaphoresisVitals P 100 RR 24 SaO2 97 RA T 37degC BP 10070Abrupt VTVF arrest

Scenario B + LW + VM full code with CPR

Scenario C (POLST DNRCMO) 52 years oldterminal lymphoma chest pain SOB diaphoresisVitals P 110 RR 30 SaO2 97 RA T 37degC BP 13070Abruptly unresponsive arrests

Scenario C + POLST + VM no CPRallow natural death

Scenario D (LW) 62 years old terminal stage IV lung CAchest pain SOB diaphoresis Vitals P 120 RR 36 SaO2 94 RAT 37degC BP 15090 Abruptly unresponsive arrests

Scenario D + LW + VM no CPRallow natural death

Scenario E (POLST DNRLTD) 70 years oldDM HTN dyslipidemia and CAD sp CABG chest painclammy distress Vitals T 36degC P 60 BP 10060 RR 22SaO2 98 RA Abruptly unresponsive no pulse VT

Scenario E + POLST + VM trial of CPR for 3 min

Scenario F (LW) 79 years old Hx CAD emphysemadiabetic retinopathy and advanced stage Parkinsonchest pain clammy distress Vitals T 37degC P 69BP 9550 RR 31 SaO2 92 RAAbruptly unresponsive no pulse VT

Scenario F + LW + VM no CPRallow natural death

Scenario G (LW) 61 years old chest pain SOB diaphoresisVitals P 100 RR 24 SaO2 97 RA T 37degC BP 10070Abruptly unresponsive arrests

Scenario G + LW + VM full code with CPR

Scenario H (POLST CPRfull TX) 90 years oldSOB agitated confused severe respiratory distressVitals P 120 RR 46 BP 8460 T 37degC SaO272 on nonrebreather Abruptly arrests

Scenario H + POLST + VM full code with CPR

Scenario I repeat of scenario E (POLST DNRLTD) Scenario I repeat of scenario E

BP blood pressure CABG coronary artery bypass graft DM diabetes melitus HTN hypertension Hx history (medical) P pulse RAroom airRRrespiration rate SaO2oxygen saturation SOBshortness of breath Ttemperature VTventricular tachycardia


the 9 scenarios with differences of 13 to 27 (P le 0026)Again those comfortable with the consent process chose DNRmore often and resuscitated less (Supplementary Material TablesS1ndashS3 httplinkslwwcomJPSA77)

For survey B physician specialty exerted no effect on codestatus or treatment responses Physician experience (attending ver-sus resident) significantly affected only scenario (E) 11 moreattendings chose to intubate (P = 0048) Neither POLST norLW training had any impact Comfort with POLST consent pro-cess significantly affected 2 of the 9 scenarios Those uncertainabout the adequacy of POLST consent were also more uncertainabout a code status for scenario A (21 P = 0003) For scenarioF those comfortable with consent chose DNR 11 more often(P ~ 0017) Perception of comfort with LWinformed consent pro-cess significantly affected 1 scenario (B 16 difference in resus-citation decision P = 0020)

Multivariate Modeling of ResponsesThe effect of the identified factors on predicting a full-code

response showed that addition of a VM significantly affected 7of the 9 scenarios (Table 5) 5 of which evidenced increased like-lihood of selecting full code by up to 40 times (A B E G Ireflecting full-code video messages) and 2 decreased likelihood (DF reflecting DNR messages) Physician specialty was a predictor of


code status response in only 1 scenario (F the Parkinson patient withthe non-EM physician less likely to choose full code) Residentphysicians were less likely to choose full code for scenarios Band F Physicians who were uncomfortable with either POLSTor LW patient informed consent were more likely to choose fullcode for scenarios F B and G Previous training had no impacton coding decisions

Addition of a VM increased the likelihood of resuscitationdecisions (Table 6) in 5 of the 9 scenarios up to nearly 17 times(A B E G I full-code messages) and decreased likelihood in 2others (D F DNRmessages) Resident physicianswere less likelyto choose resuscitation in scenarios B F and G Physicians un-comfortable with patient informed consent for either POLST orLWwere roughly twice as likely to choose to resuscitate in scenar-ios B E to G and I

Overall addition of VM was the most consistent predictorof either code status determination or resuscitation choicesachieving consensus

Missing DataRates of missing data amounted to nomore than 26 for the

initial 3 survey questions (Table 2) Subsequent rates of missingdata for scenarios varied from 185 to 22 Differences betweenscenario ldquorespondersrdquo and ldquononrespondersrdquo were evident in 3


TABLE 3 Respondent Demographics

Variable Survey A Survey B P

Age mean (SD median) 369 (1035 330) 357 (964 320) 0290Years of practice mean (SD median) 125 (1029 100) 121 (1971 70) 0094Sex female n () 303 (37) 252 (37) 0930dagger

Specialty n 302 246 0648Dagger

EM 77 76IMhospitalist 20 20FP 3 5

Experience n 303 251PGY1 13 14PGY2 14 16 0600Dagger

PGY3 16 14PGY4 3 6Fellow 2 2Attending 53 48

Board certification yes n () 305 (51) 246 (46) 0231dagger

Previous training POLST documents n () 304 (41) 250 (37) 0431dagger

Hours of POLST training mean (SD median) 23 (432 10) 20 (258 10) 0565Previous training LW documents n () 299 (33) 246 (29) 0307dagger

Hours of LW training mean (SD median) 24 (279 18) 22 (278 18) 0963

Mann-Whitney U testdaggerFisher exact testDaggerχ2 test

EM emergency medicine FP family practice IM internal medicine PGY post graduate year


(125) of 24 sets of responses The magnitude of these differ-ences was approximately 10 (Supplementary Material TableS4 httplinkslwwcomJPSA77)

DISCUSSIONThe term EOL care and its associated costs have received in-

creased attention for the previous decade In 2014 the Instituteof Medicine released a report entitled ldquoDying in Americardquo whichadvised that the health care system is broken in need of reformand that the current US $170 billion in EOL expenditures will ex-ceed US $350 billion in 5 years10 Many recommend to have dis-cussions for EOL care early in the disease process11ndash18 As such itis imperative that we ensure that the discussions are safe unbiasedand with appropriate patient selection Both LWs and POLSThave already shown promise and proven benefits to help ensurepatient autonomy prevent perceived unwanted resuscitations re-duce in-hospital mortality and control medical expenditures atEOL19ndash21 More recent studies reveal that use of most POLSTforms is timely and may be a predictor of timing of death22 ThePOLST use has also resulted in 22 more out-of-hospital deathsthan for those with LWs23 Currently LWs are being increasinglyused24 but are also being challenged by the rapid proliferation ofPOLST across the United States and globally25

Thus would the POLST paradigm concurrently support pa-tient autonomy yet ensure appropriate safe care and is it readyfor nationwide use Previous research has questioned how wellmedical providers understand LWs DNR and POLST formsand have inferred that use of these documents could pose a pa-tient safety issue3421 More recently there has been a call for amore evidence-based evaluation of POLST processes before theincreased nationalization of POLST2627 At present the POLSTparadigm contends that there is more than even enough researchto support nationalization28 This contention is rebutted with the


concern that premature nationalization of POLST threatenspatient-centered medical decision making and that even if docu-ments accurately reflect patient wishes they still may produce inter-pretation errors on the part of medical professionals2629 A questionnot answered to date is whether nationalization of POLST evenwith errors in interpretation be better than the current state of prac-tice with LWand DNR orders

An example of significant concern in interpretation and appli-cation is how LWs DNR and POLSTorders may impact the clin-ical decision making in conditions that have high perception ofneurological devastation Just as there are guidelines to recom-mend early goals of care discussions there are also guidelines todelay those discussions until a condition can evolve and declareitself Two examples of such guidelines are for out of hospital car-diac arrest with return of spontaneous circulation and for intrace-rebral hemorrhage3031 Both guidelines emphasize the delay towithdraw lifesaving interventions for 48 to 72 hours Previous re-ports related to intracerebral hemorrhage have shown falsely ele-vated mortality rates related to early adoption of DNR orders32

A recent multicenter out of hospital cardiac arrest trial confirmedthat guidelines are followed in only 50 of eligible treatment op-portunities33 This could be impacted by multiple confounderssuch as medicines introduction to public reporting of outcomesand also the use of LWs DNR and POLST which have seen in-creased proliferation with the aging of the patient population andare taken to be representations of a desire to forego a trial of crit-ical care treatment and rehabilitation A secondary analysis of thistrial asserts that one third of the patients had a premature with-drawal of LST for perceived poor neurological prognosis34 Thosein this category include stable patients with pre-existing advancedirectives or health care agent perceived understanding of patientwishes The trial extrapolates that 2300 Americans die prema-turely each year and nearly 1500 might have had functional


TABLE 4 Differences in Survey Responses by Group

StatementScenario Response Choices Survey A Survey B Difference (AndashB) P

POLST DNRfull TX POLST code status n 367 374 minus1 0669DNR 68 69 +2FC 13 11 0

Unsure 20 20LW declining LST LW code status n 364 368 +3 0073

DNR 80 77 minus3FC 3 6 +1

Unsure 18 17What is the meaning of DNR DNR = n 361 361 +2 0924

FC 47 45 0CC 26 26 minus1

Unsure 28 29Scenario A POLST (DNRfull TX) Scenario A code status n 333 270 +48 lt00001

DNR 64 16 minus50FC 18 68 +2

Unsure 18 16Scenario A response n 332 271 minus33 lt00001

Defib 53 86 +33Do not defib 47 14

Scenario B (LW) Scenario B code status n 331 275 +49 lt00001DNR 69 20 minus50FC 18 68 +2

Unsure 14 12Scenario B response n 328 275 minus45 lt00001


Scenario C (POLST DNRCMO) Scenario C code status n 333 279 0 ~0026DNR 97 97 minus2FC lt1 3 +2

Unsure 2 lt1Scenario C response n 334 277 0 0834

Intubate 4 4 0Do not intubate 96 96

Scenario D (LW) Scenario D code status n 335 276 minus9 lt00001DNR 85 94 +3FC 7 4 +6

Unsure 8 2Scenario D response n 335 276 +7 0005

Intubate 13 6 minus7Do not intubate 87 94

Scenario E (POLST DNRLTD) Scenario E code status n 330 277 +55 lt00001DNR 87 32 minus40FC 4 44 minus15

Unsure 9 24Scenario E response n 331 273 minus43 lt00001


(Continued next page)


copy 2017 Wolters Kluwer Health Inc All rights reserved wwwjournalpatientsafetycom 7

TABLE 4 (Continued)


Scenario F (LW) Scenario F code status n 325 262 minus22 lt00001DNR 73 95 +6FC 9 3 +16

Unsure 18 2Scenario F response n 326 263 +24 lt00001

Defib 29 5 minus24Do not defib 72 95

Scenario G (LW) Scenario G code status n 324 260 +48 lt00001DNR 64 16 minus53FC 21 74 +5

Unsure 15 10Scenario G response n (324) (260) minus42 lt00001


Scenario H (POLST CPRfull TX) Scenario H code status n 323 259 0 0821DNR 2 2 minus1FC 97 98 0

Unsure 1 1Scenario H response n 321 260 0 ~0415


Scenario I repeat of scenario E (POLST DNRLTD) Scenario I code status n 319 258 +62 lt00001DNR 88 26 minus41FC 4 45

Unsure 9 30 minus21Scenario I response n 321 257 minus57 lt00001


Data in bold denotes statistically significant change

defib defibrillate FC full code


recovery34 This concern is supported by theWorchester Heart At-tack Study which showed a 9-fold increase in mortality for thiscondition in the presence of a DNR order suggesting a prematurewithholding or withdrawing of treatment measures even in the ab-sence of an arrest event (44 versus 05)35

TABLE 5 Predicting Coding Response of Full Code

Factors A B C D

Group Group B+155

Group B+213

NS Grouminus76

Specialty (EM versus other) NS NS NS NS

Experience(attending versus resident)

NS Residentminus44

NS NS

Comfort with POLST consent NS NS NS NSComfort with LW consent NS NC +29 NS NSPOLST training NS NS NS NSLW training NS NS NS NS

NC not comfortable with LWPOLST consenting Non-EM services other


As practice aids evolve there is a growing body of literature re-vealing that video support tools can substantially improve medicaldecision making particularly about CPR3637 Video tools helppatients better understand their treatment choices by enablingthem both to envision future circumstances and to deliberate about

Scenarios

E F G H I

p B

Group B+396

Group Bminus70

Group B+13

NS Group B+367

NS Non-EMminus85

NS NS NS

NS Residentminus80

NS NS NS

NS NC +31 NS NS NSNS NS NC +18 NS NSNS NS NS NS NSNS NS NS NS NS

than emergency medicine NS not significant


TABLE 6 Predicting Resuscitation Decisions

Scenarios

Factors A B C D E F G H I

Group Group B+55

Group B+94

NS Group Bminus65

Group B+116

Group Bminus85

Group B+64

NS Group B+165

Specialty (EM versus other) NS NS NS NS NS NS NS NS NSExperience(attending versus resident)

NS Residentminus46

NS NS NS Residentminus51

Residentminus41

NS NS

Comfort with POLST consent NS NS NS NS NS NS NS NS NC +19Comfort with LW consent NS NC +28 NS NS NC +24 NC +21 NC +22 NS NSPOLST training NS NS NS NS NS NS NS NS NSLW training NS NS NS NS NS NS NS NS NS

EM emergency medicine NC not comfortable with LWPOLST consenting NS not significant


their decisions38 Most of this research focuses on using videos toinform patients and our study focuses on using videos to commu-nicate patient wishes back to clinicians Just as videos work suc-cessfully as patient decision aids they should also work ascommunication tools The nonverbal information in a patient-recorded video LW should help both the healthcare team and thefamily understand (and accept) the patients wishes For examplea videowill allow doctors to see facial muscles hear the inflectionof a persons voice and better understand nuances39 Contrastedagainst these factors written documents are subjected to degreesof interpretation with respect to current patient medical status andtheir desire for treatment The question is whether a video testimo-nial can help foster understanding of written patient prerogatives

If consensus reflects cohort understanding then written docu-mentation fails the litmus test The current data reveal that only2 (C andH) of the 9 scenarios achieved consensus Adding avideotestimonial significantly changed responses in 7 of these 9 scenar-ios and increased the number of consensus scenarios to 4 Logisticmodeling of either code status or resuscitation responses demon-strated that the use of video testimonials was the dominant predic-tor variable regardless of specialty or experience This suggeststhat the incorporation of a VM with a LWor POLST can increaseconsensus understanding of patient goals in times of acute medi-cal crisis

Our data also show the importance of health provider educationon the interpretation of LWs and POLST The data indicate that nomore than 41 had previous training in either POLSTor LW doc-uments with median training times of between 1 and 2 hours No-where is this substandard training more evident than in theresponses to scenario F In survey A participants viewed advancedParkinson disease as a terminal or end-stage condition choseDNR and elected not to institute LST In survey B they choseDNR elected not to institute LST but had the benefit of reviewingan EOLVM to support their decision making This points to eithera lack of education or as suggested by Turnbull et al40 the needfor continuing (refresher) education Ultimately regulatory over-sight might be required to ensure and set standards for educatinghealth care providers on LWs and POLST interpretation

Responses to scenario F should also raise concern related tounderstanding of neurologic disease and physical disability (egspinal cord injury) and the specter of personal bias This issueof personal bias may be related to the participants feelings as tohow they themselves would want to be treated41ndash43 or how theywere trained (paternalistic versus patient centered) rather thanhow patients perceive to have consented to their LW documentThis finding should prompt more research involving chronic


conditions and those with significant disabilities (eg neurologicand physical) and how documents such as LWs and POLST im-pact their care and treatment To date no study has evaluated thispotential safety concern

An area that requires clarification is how physicians describecardiac arrest and its outcomes For years we have pessimisticallyportrayed dismal outcomes in cardiac arrest44 Research has alsobeen published stating that after 30-minute resuscitation is futileMore recently research suggests that prolonged resuscitationsare not futile and even thosewith prolonged resuscitation can havegood functional outcomes45 What patients consent to as far ascardiac arrest may not be as clear Living wills do not say ldquoDonot treat me when in cardiac arrestrdquo In contrast POLST may ormay not choose that Further research is required to see that weget this right for patients Patient VMs can specifically provideclarity to ensure we get it right for individual patient choices andhave the ability to be integrated into electronic health recordsacross practice settings

Study LimitationsOne limitation of our study is that we did not control for how

states define DNR In some states DNR is for patients bothpulseless and apneic and in other states the definition is pulselessor apneic46ndash48 How we defined consensus also represents a limi-tation We equated consensus with a super majority value of 95some readers may find this value too stringent and unacceptableOthers may find it not stringent enough because it accepts a 5error rate and these are life or death decisions Similarly thisstudy made no attempt to specify correct treatment choices Weleave this to the discretion of the reader to interpret the scenariosand use their own judgment to self-evaluate how they would re-spond in a similar clinical situation The use of a VM itself mayalso pose limitations We only evaluated 3 messages The messag-ing asking for a trial of CPR could also have been created to de-cline a trial of CPR with the POLST DNRLTD Now that thestudy is completed we expect that a message crafted to withholdthe application of CPR would have shown similar benefits andpossibly prevented the unsure code status responses in POLSTDNRLTD scenarios Finally we are unaware of any data to daterevealing a correlation between responses to hypothetical writ-ten scenarios versus decisions during actual emergent conditionswith critically ill patients it is possible that physicians more ac-curately interpret these scenarios in actual practice Howeverpublications of case series as well as actual patient events support



the safety concerns we describe and support the need forfurther research294950

CONCLUSIONSEthical and financial pressures are mounting to change how we

care for patients at EOL Living wills and POLST have provenbenefits They are much needed and can be effective in helpingto ensure that patient wishes are honored At present this processof how to interpret and act on documents requires a need for safeguards to ensure we ldquoget it rightrdquo for patients who wish to acceptor decline lifesaving interventions Our results show that additionof a VM produced statistically significant changes toward consen-sus in code status interpretation as well as the decision to resusci-tate and reinforces the decision towithhold LST Video messaginghas the potential to ensure the safe interpretation of LWs andPOLST documents and ensure that these documents are faithfulto the wishes and goals of the patient producing benefits for allstakeholders in the health care system

ACKNOWLEDGMENTThe authors thank Nathan A Kottkamp partner of

McGuireWoods LLP and founder and chairman of NationalHealthcare Decisions Day for providing a legal review of theliving will documents to ensure their validity

REFERENCES1 Silveira MJ Kim SY Langa KM Advance directives and outcomes of

surrogate decision making before death N Engl J Med 20103621211ndash1218

2 Hickman SE Keevern E Hammes BJ Use of the physician orders forlife-sustaining treatment program in the clinical setting a systematic reviewof the literature J Am Geriatr Soc 201563341ndash350

3 Mirarchi FL Costello E Puller J et al TRIAD III nationwide assessmentof living wills and do not resuscitate orders J Emerg Med 201242511ndash520

4 Mirarchi FL Doshi AA Zerkle SW et al TRIADVI how well doemergency physicians understand Physicians Orders for Life SustainingTreatment (POLST) forms J Patient Saf 2015111ndash8

5 Mirarchi FL Cammarata C Zerkle SW et al TRIADVII do prehospitalproviders understand Physician Orders for Life-Sustaining Treatmentdocuments J Patient Saf 2015119ndash17

6 Smith CB Bunch ONeill L Do not resuscitate does not mean do nottreat how palliative care and other modalities can help facilitatecommunication about goals of care in advanced illness Mt Sinai J Med200875460ndash465

7 Siracuse JJ Jones DW Meltzer EC et al Impact of ldquoDo Not Resuscitaterdquostatus on the outcome of major vascular surgical procedures Ann VascSurg 2015291339ndash1345

8 Jawa RS Shapiro MJ McCormack JE et al Preadmission Do NotResuscitate advanced directive is associated with adverse outcomesfollowing acute traumatic injury Am J Surg 2015210814ndash821

9 Viera AJ Garrett JM Understanding interobserver agreement the kappastatistic Fam Med 200537360ndash363

10 Institute of Medicine Dying in America Improving Quality and HonoringIndividual Preferences Near the End of Life National Academies ofSciences Engineering Medicine September 17 2014 Available at httpwwwnationalacademiesorghmdReports2014Dying-In-America-Improving-Quality-and-Honoring-Individual-Preferences-Near-the-End-of-Lifeaspx Accessed January 3 2016

11 Mack JW Cronin A Keating NL et al Associations between end-of-lifediscussion characteristics and care received near death a prospective cohortstudy J Clin Oncol 2012304387ndash4395


12 American Society of Clinical Oncology (ASCO) and Conquer CancerFoundation ASCO Recommends Palliative Care as a Part of CancerTreatment Cancernet February 6 2012 Available at httpwwwcancernetresearch-and-advocacyasco-care-and-treatment-recommendations-patientsasco-recommends-palliative-care-part-cancer-treatment AccessedAugust 3 2015

13 Obermeyer Z Powers BW Makar M et al Physician characteristicsstrongly predict patient enrollment in hospiceHealth Aff (Millwood) 201534993ndash1000

14 Hui D Bansal S Park M et al Differences in attitudes and beliefs towardend-of-life care between hematologic and solid tumor oncology specialistsAnn Oncol 2015261440ndash1446

15 Mori M Shimizu C Ogawa A et al Medical oncologists attitude towardend-of-life discussions effects of their experience perceptions and beliefs[Abstract] American Society of Clinical Oncology Annual Meeting (May29ndashJune 2 2015) Chicago Illinois J Clin Oncol 201533 20Supple20503

16 Temel JS When more is not better how to integrate goals of care inconversations about stopping chemotherapy [Abstract] Oral presentationat American Society of Clinical OncologyAnnualMeetingMay 29 2015Chicago Illinois

17 Society of Critical Care Medicine and European Society of Intensive CareMedicine Surviving Sepsis Campaign International Guidelines forManagement of Severe Sepsis and Septic Shock 2013 Available athttpwwwsurvivingsepsisorgsitecollectiondocumentsimplement-pocketguidepdf Accessed January 3 2016

18 Grady KL DracupKKennedyG et al Teammanagement of patients withheart failure a statement for healthcare professionals from TheCardiovascular Nursing Council of the American Heart AssociationCirculation 20001022443ndash2456

19 Nicholas LH Langa KM Iwashyna TJ et al Regional variation in theassociation between advance directives and end-of-life Medicareexpenditures JAMA 20113061447ndash1453

20 Fromme EK Zive D Schmidt TA et al Association between physicianorders for life-sustaining treatment for scope of treatment and in-hospitaldeath in Oregon J Am Geriatr Soc 2014621246ndash1251

21 Vearrier L Failure of the current advance care planning paradigmadvocating for a communications-based approach HEC Forum 201628339ndash354

22 Zive DM Fromme EK Schmidt TA et al Timing of POLST formcompletion by cause of death J Pain SymptomManage 201550650ndash658

23 Pedraza SL Culp S Falkenstine EC et al POST forms more than advancedirectives associated with out-of-hospital death insights from a stateregistry J Pain Symptom Manage 201651240ndash246

24 Silveira MJ Wiitala W Piette J Advance directive completion by elderlyAmericans a decade of change J Am Geriatr Soc 201462706ndash710

25 National POLST Paradigm Task Force POLST State Status July 13 2016Available at httppolstorgwp-contentuploads20160820160713-POLST-State-Statuspdf Accessed August 29 2016

26 Moore KA Rubin EB Halpern SD The problemswith physician orders forlife-sustaining treatment JAMA 2016315259ndash260

27 Halpern SD Toward evidence-based end-of-life care N Engl J Med 20153732001ndash2003

28 Tolle SWMoss AH Hickman SE Assessing evidence for physician ordersfor life-sustaining treatment programs JAMA 20163152471ndash2472

29 Smith E Grieving daughters ldquoDo Not Resuscitaterdquo nightmare BostonHerald January 28 2016 Available at httpwwwbostonheraldcomnewslocal_coverage201601grieving_daughters_do_not_resuscitate_nightmare Accessed January 28 2016

30 Sandroni C Cariou A Cavallaro F et al Prognostication in comatosesurvivors of cardiac arrest an advisory statement from the European



Resuscitation Council and the European Society of Intensive CareMedicine Intensive Care Med 2014401816ndash1831

31 Hemphill JC 3rd Greenberg SM Anderson CS et al Guidelines for themanagement of spontaneous intracerebral hemorrhage a guideline forhealthcare professionals from the American Heart AssociationAmericanStroke Association Stroke 2015462032ndash2060

32 Zahuranec DB Morgenstern LB Saacutenchez BN et al Do-not-resuscitateorders and predictive models after intracerebral hemorrhage Neurology201075626ndash633

33 Stub D Schmicker RH AndersonML et al Association between hospitalpost-resuscitative performance and clinical outcomes after out-of-hospitalcardiac arrest Resuscitation 20159245ndash52

34 Elmer J Torres C Aufderheide TP et al Association of early withdrawal oflife-sustaining therapy for perceived neurological prognosis with mortalityafter cardiac arrest Resuscitation 2016102127ndash135

35 Jackson EA Yarzebski JL Goldberg RJ et al Do-not-resuscitate orders inpatients hospitalized with acute myocardial infarction the Worcester HeartAttack Study Arch Intern Med 2004164776ndash783

36 Volandes AE Paasche-Orlow MK Mitchell SL et al Randomizedcontrolled trial of a video decision support tool for cardiopulmonaryresuscitation decision making in advanced cancer J Clin Oncol 201331380ndash386

37 Wilson ME Krupa A Hinds RF et al Avideo to improve patient andsurrogate understanding of cardiopulmonary resuscitation choices in theICU a randomized controlled trial Crit Care Med 201543621ndash629

38 El-Jawahri A Paasche-Orlow MK Matlock D et al Randomizedcontrolled trial of an advance care planning video decision support tool forpatients with advanced heart failure Circulation 201613452ndash60

39 Volandes A End-of-life care needs an overhaul Boston Globe April 152015 Available at httpwwwbostonglobecomopinion20150415end-life-care-needs-overhaulGr2w1Iesb5dj1ddnbmipBJstoryhtml AccessedJuly 1 2016

40 Turnbull AE Hayes MM Hashem MD et al Interactive online modulefailed to improve sustained knowledge of the Maryland medical orders forlife-sustaining treatment form Ann Am Thorac Soc 201613926ndash932


41 Lim M Influence of physician bias on end-of-life care Virtual Mentor20035 virtualmentor200351jdsc1-0301

42 White T Study doctors would choose less aggressive end-of-life care forthemselves (blog) Posted May 28 2014 Available at httpscopeblogstanfordedu20140528study-doctors-would-choose-less-aggressive-end-of-life-care-for-themselves Accessed August 1 2016

43 Dzeng E Colaianni A Roland M et al Influence of institutional cultureand policies on do-not-resuscitate decision making at the end of life JAMAIntern Med 2015175812ndash819

44 Nehme Z Andrew E Bernard S et al Impact of cardiopulmonaryresuscitation duration on survival from paramedic witnessedout-of-hospital cardiac arrests an observational study Resuscitation 201610025ndash31

45 Rajan S Folke F Kragholm K et al Prolonged cardiopulmonaryresuscitation and outcomes after out-of-hospital cardiac arrestResuscitation 201610545ndash51

46 San Francisco Emergency Medical Services Agency Do Not Resuscitate(DNR) Policy Policy Reference No 4051 Effective Date January 12011 Available at httpsfdemorgsitesdefaultfilesFileCenterDocuments1558-405120Do20Not20Resuscitate_01-01-11pdfAccessed August 1 2016

47 Emergency Medical Services Authority and California Health and HumanServices Agency Do Not Resuscitate (DNR) and Other Patient-DesignatedDirectives EMSA 311 5th Revision ndash October 2014 Available at httpwwwemsacagovMediaDefaultPDFEMSA311DNRGuidelines_10_01_2014pdf Accessed July 20 2016

48 Out-of-Hospital Do-Not-Resuscitate (DNR) Orders A Guide for Patientsand Families Pennsylvania Department of Health Available at httpwwwhealthpagovMy20HealthEmergency20Medical20ServicesOut20of20Hospital20DNR20OrdersPagesdefaultaspxV3Vs16HD-Uk Accessed August 1 2016

49 Mirarchi FL Does a living will equal a DNR Are living willscompromising patient safety J Emerg Med 200733299ndash305

50 Katsetos AD Mirarchi FL A living will misinterpreted as a DNR orderconfusion compromises patient care J Emerg Med 201140629ndash632



independently predictive of a 5-fold mortality increase after con-trolling for other variables8

With potential misinterpretation of advanced planning docu-ments andor DNR status in the acute care setting there is a needto evaluate newmodalities for ensuring both concordant and accu-rate interpretation of LWs and POLST Our objective is to evaluatewhether video testimonials augment ldquoconcordantrdquo interpretationof LWs and POLST when considering clinical scenarios in theacute care setting We hypothesize that the addition of video testi-monial would lead to more accurate interpretation of such docu-ments when compared with written documents alone

METHODSWe conducted an anonymous multicenter randomized

internet-based survey involving resident and attending physicianswho are hospitalists or emergency family or internal medicine(IM) physicians at 13 teaching institutions across the UnitedStates (Table 1) The survey introduction gave a brief explanationof the purpose of the study listed inclusion criteria and empha-sized voluntary participation A total of 1366 residents and facultymembers were identified and solicited to participate in this study

The survey began with 3 questions that asked for the appropri-ate code status for a POLST document specifying DNRfull treat-ment and a LW document declining all lifesaving interventions(Figs 1 2) This was followed by a question that prompted the ap-propriate care for a ldquoDNRrdquo order Nine clinical scenarios werethen presented involving patients who arrest with either a POLSTor an LW (Table 2) Specific orders on the POLST form varied in-cluding cardiopulmonary resuscitation (CPR) or DNR and levelof treatment support (ldquofullrdquo ldquolimitedrdquo or ldquocomfort measures onlyrdquo[CMO]) Respondents were asked to choose the appropriate codestatus of the patients and make resuscitation decisions At the con-clusion of the scenarios demographic information was collectedincluding information about specialty (emergency medicine[EM] hospitalist IM family practice) experience (both in yearsand in terms of attending versus resident physician status) andprevious training in the use andor interpretation of POLST andLW documents We also assessed respondent perceptions of theadequacy of the informed consent process for POLST and LWdocuments by asking for respondent comfort level in withholdingcare whenwhether patients presented with these documents Phy-sician specialty experience previous training and comfort levelwith informed consent were considered secondary factors thatmight influence coding or treatment decisions This survey was

TABLE 1 Participating Sites

Site

UPMC HamotUniversity of Pittsburgh School of MedicineTemple University School of MedicineStanford University School of MedicineAllegheny General Hospital Allegheny Health NetworkUniversity of Alabama at Birmingham Huntsville Campus and HuntsvilleSaint Vincent Health System Allegheny Health NetworkState University of New York at BuffaloNorthwestern University Feinberg School of MedicineUniversity of South FloridaUniversity of Minnesota Medical SchoolINTEGRIS Southwest Medical Center Oklahoma State University CenterSt Josephs Regional Medical Center New York Medical College


designated ldquosurvey ArdquoAvariant of this ldquosurvey Brdquowas identicalin content but used patient video testimonialsmessages (VMs)intended to clarify patient wishes The following 3 VMs wereevaluated full aggressive treatment (full code) aggressive carewith a trial of CPR for 3 minutes when in cardiac arrest andend-of-life (EOL) care with no CPRallow natural death (CMOTable 2) Surveys were created in SurveyMonkey with a uniqueweb-based link generated for each Scenario content was validatedbymedical and legal peer review To preclude a sequence or order-ing effect the order of the scenarios with each survey was ran-domized The reliability of these surveys has been addressed inprevious studies45 Consistency in responses was assessed by com-paring concordance of responses to duplicate scenarios (E I) usingChronbach α a measure of reliability

Rosters of teaching faculty and residents were generated fromeach participating institution and forwarded to one of the study in-vestigators who randomized survey assignment to 1 of the 2 sur-vey links Randomization was conducted for all participants onan institution-by-institution basis using a web-based site (httpwwwgraphpadcomquickcalcsrandomize1) Rosters with ran-domizations were then returned to collaborating investigators atparticipating academic centers Collaborators e-mailed a standard-ized solicitation letter to each prospective participant along withthe survey link corresponding to their group assignment and senta reminder notification 2 weeks after the initial e-mail requestThe study design underwent both medical and legal peer reviewand was evaluated by the coordinating center institutional reviewboard and granted exempt status Each institutions institutionalreview board also reviewed and approved this study

Survey responses were analyzed not for ldquocorrectrdquo responses butconsensus We interpreted consensus to infer clarity of understand-ing For this study consensus reflected a supermajority of 95 orgreater concordant responses As an example if 95 of the cohortdesignates DNR as the appropriate code status for a patient depictedin a scenario this level of agreement indicates consensus and byinference clarity in the information provided about the patientspreferences With the critical issue of fidelity to patient wishesand safety we submit that this is the minimum level of clarity re-quired for decision making about life-sustaining treatment (LST)

Responses rates were contrasted across survey groups to de-termine whether video testimonials improved agreement andled to greater consensus Secondary factors were also consideredincluding physician specialty (EM versus IMfamily practicehospitalist) experience (attendings versus residents) previoustraining in POLST LW document interpretation and comfort

Location

Erie PennsylvaniaPittsburgh PennsylvaniaPhiladelphia Pennsylvania

Stanford CaliforniaPittsburgh Pennsylvania

Hospital Birmingham AlabamaErie PennsylvaniaBuffalo New YorkChicago IllinoisTampa Florida

Minneapolis Minnesotafor Health Sciences Oklahoma City Oklahoma

Paterson New Jersey








RESULTS























Survey A Survey B




























































FC 47 45 0CC 26 26 minus1


DNR 64 16 minus50FC 18 68 +2


















TABLE 4 (Continued)



















Factors A B C D

Group Group B+155

Group B+213

NS Grouminus76



NS Residentminus44

NS NS





Scenarios

E F G H I

p B

Group B+396

Group Bminus70

Group B+13

NS Group B+367

NS Non-EMminus85

NS NS NS

NS Residentminus80

NS NS NS





Scenarios


Group Group B+55

Group B+94

NS Group Bminus65

Group B+116

Group Bminus85

Group B+64

NS Group B+165


NS Residentminus46


Residentminus41

NS NS



















































































RESULTS























Survey A Survey B




























































FC 47 45 0CC 26 26 minus1


DNR 64 16 minus50FC 18 68 +2


















TABLE 4 (Continued)



















Factors A B C D

Group Group B+155

Group B+213

NS Grouminus76



NS Residentminus44

NS NS





Scenarios

E F G H I

p B

Group B+396

Group Bminus70

Group B+13

NS Group B+367

NS Non-EMminus85

NS NS NS

NS Residentminus80

NS NS NS





Scenarios


Group Group B+55

Group B+94

NS Group Bminus65

Group B+116

Group Bminus85

Group B+64

NS Group B+165


NS Residentminus46


Residentminus41

NS NS
































































































Survey A Survey B




























































FC 47 45 0CC 26 26 minus1


DNR 64 16 minus50FC 18 68 +2


















TABLE 4 (Continued)



















Factors A B C D

Group Group B+155

Group B+213

NS Grouminus76



NS Residentminus44

NS NS





Scenarios

E F G H I

p B

Group B+396

Group Bminus70

Group B+13

NS Group B+367

NS Non-EMminus85

NS NS NS

NS Residentminus80

NS NS NS





Scenarios


Group Group B+55

Group B+94

NS Group Bminus65

Group B+116

Group Bminus85

Group B+64

NS Group B+165


NS Residentminus46


Residentminus41

NS NS










































































































FC 47 45 0CC 26 26 minus1


DNR 64 16 minus50FC 18 68 +2


















TABLE 4 (Continued)



















Factors A B C D

Group Group B+155

Group B+213

NS Grouminus76



NS Residentminus44

NS NS





Scenarios

E F G H I

p B

Group B+396

Group Bminus70

Group B+13

NS Group B+367

NS Non-EMminus85

NS NS NS

NS Residentminus80

NS NS NS





Scenarios


Group Group B+55

Group B+94

NS Group Bminus65

Group B+116

Group Bminus85

Group B+64

NS Group B+165


NS Residentminus46


Residentminus41

NS NS













































































TABLE 4 (Continued)



















Factors A B C D

Group Group B+155

Group B+213

NS Grouminus76



NS Residentminus44

NS NS





Scenarios

E F G H I

p B

Group B+396

Group Bminus70

Group B+13

NS Group B+367

NS Non-EMminus85

NS NS NS

NS Residentminus80

NS NS NS





Scenarios


Group Group B+55

Group B+94

NS Group Bminus65

Group B+116

Group Bminus85

Group B+64

NS Group B+165


NS Residentminus46


Residentminus41

NS NS














































































Scenarios


Group Group B+55

Group B+94

NS Group Bminus65

Group B+116

Group Bminus85

Group B+64

NS Group B+165


NS Residentminus46


Residentminus41

NS NS











































































