Liverpool Care Pathway – Gang Aft Agley

Be Careful What You Wish For…

In The Journal of Emergency Medicine, Volume 42, Issue 5, May 2012, Pages 511-520, Ferdinando L. Mirarchi, Erin Costello, Justin Puller, Timothy Cooney and Nathan Kottkamp have published the following study which reaches a troublesome conclusion.

TRIAD III: Nationwide Assessment of Living Wills and Do Not Resuscitate Orders

• Ferdinando L. Mirarchi, DO, FAAEM, FACEP, 
• Erin Costello, DO, 
• Justin Puller, MD, FACEP, 
• Timothy Cooney, MS, 
• Nathan Kottkamp, JD, MA (Bioethics)

• University of Pittsburgh Medical Center (UPMC) Hamot, Erie, Pennsylvania

• Received 22 April 2011. Accepted 13 July 2011. Available online 17 November 2011.   

Abstract 

• Background

  Concern exists that living wills are misinterpreted and may result in compromised patient safety.

  Objective

  To determine whether adding code status to a living will improves understanding and treatment decisions.

  Methods

  An Internet survey was conducted of General Surgery, and Family, Internal, and Emergency Medicine residencies between May and December 2009. The survey posed a fictitious living will with and without additional clarification in the form of code status. An emergent patient care scenario was then presented that included medical history and signs/symptoms. Respondents were asked to assign a code status and choose appropriate intervention. Questions were formatted as dichotomous responses. Correct response rate was based on legal statute. Significance of changes in response due to the addition of either clinical context (past medical history/signs/symptoms) or code status was assessed by contingency table analysis.

  Results

  Seven hundred sixty-eight faculty and residents at accredited training centers in 34 states responded. At baseline, 22% denoted “full code” as the code status for a typical living will, and 36% equated “full care” with a code status DNR. Adding clinical context improved correct responses by 21%. Specifying code status further improved correct interpretation by 28% to 34%. Treatment decisions were either improved 12–17% by adding code status (“Full Code,” “Hospice Care”) or worsened 22% (“DNR”).

  Conclusion

  Misunderstanding of advance directives is a nationwide problem. Addition of code status may help to resolve the problem. Further research is required to ensure safety, understanding, and appropriate care to patients.

Forward-thinking people thinking they may plan for every exigency and whatever circumstance their lives may confront them with are not at all accommodated by the very nature of existence that it is all quite uncertain and unpredictable! 

The best laid schemes… 

It may well prove to be accurate, it may not, but diagnosis is always a medical opinion. For those who have chosen and decided upon what course they will follow given that diagnosis, that is for them.

But God help those who are placed on the Liverpool Care Pathway for their course has been decided for them: it is both determination and termination!