More than 200 events reported to the Pennsylvania Patient Safety Authority in part show that healthcare providers, patients and their family members may not understand the different meanings and consequences of living wills and DNR (do not resuscitate) orders which may pose patient safety risks according to analysis provided in the 2008 December Pennsylvania Patient Safety Advisory.Potential patient safety risks related to the misinterpretation of living wills and DNR orders may inadvertently result in the delivery of unwanted care or the withdrawing or withholding of otherwise appropriate care that should have been given to the patient.

According to the Authority data: 93 reports regarding living wills or DNR orders indicated that a DNR order may have been misinterpreted as a directive to withdraw or withhold care, suggesting the healthcare providers may not have understood the narrow scope of a DNR order.

"Our data shows that more education must be given to healthcare providers, patients and their families to ensure everyone involved understands that a living will does not become effective automatically certain conditions must be met according to Pennsylvania law first," Dr. John Clarke, clinical director of the Pennsylvania Patient Safety Authority said. "Also, in regard to DNR orders, healthcare providers and patients need to know that these particular orders only apply to a patient's wishes not to be resuscitated if they have a heart attack or stop breathing. A DNR order does not mean 'do not treat.'"

Clarke explains that a living will is a document signed by an individual that is intended to convey that person's preferences regarding end-of-life healthcare decisions when he or she cannot express them personally to a physician or other healthcare provider.

A living will is considered a type of advance directive. An advance directive refers to a number of different documents executed by an individual intended to convey that individual's preferences about healthcare. However, a DNR is a medical order issued by a physician or other healthcare practitioner authorized to issue medical orders that directs clinicians not to provide cardiopulmonary resuscitation (CPR) in case of a heart attack or the patient stops breathing.

According to Authority data: 37 of the reports related to advance directives have involved a patient receiving potentially unwanted interventions.

"From the data we analyzed there appears to be patients who received unwanted care and were brought back to life and others who did not receive the appropriate care to save their lives," Clarke said. "The issue is very complicated and protocols vary from facility to facility in regard to DNR orders, while what constitutes a living will becoming effective is determined by Pennsylvania statute."

Clarke added that patients and their families must know that due to the varying degrees of DNR orders in facilities, a DNR order in one facility does not automatically carry over to another facility if that patient is transferred. Also, DNR orders are only effective per hospital visit. DNR orders do not remain effective after the patient leaves the hospital.

According to the Authority data: 71 of the reports show some form of communication breakdown related to advance directives. Of the issues reported, the majority of reports involve the lack of understanding of the meaning of the documents by families, lack of communication of the presence of a DNR order between healthcare providers, misidentification of patients and the failure to identify patients with DNR orders.

"The definitions of a living will and other advance directives must be clearly understood for a patient's wishes to be accurately conveyed," Clarke said. Further, a DNR order is much different than a living will. They are not interchangeable.

"Each has its own meaning and circumstance in order to be carried out by the healthcare provider," Clarke added. "The issues surrounding both are not being understood clearly by patients, family members or healthcare providers according to the data we received."

Clarke cited recent studies that show the issue is not just in Pennsylvania. In a survey to determine the level of understanding of a living will among doctors, patients and their families the results show 71% of patients, 42% of family members and 27% of physicians did not understand when a living will becomes effective. Another study showed that patients with living wills poorly understood the meaning of "life-sustaining therapies" and the implications of other advance directives. Of 755 patients admitted to a community teaching hospital during the study period, 264 study participants were surveyed regarding their understanding of CPR. Of these, 82 (31%) had living wills. Most (76%) created their living will with a lawyer or family member; only seven percent involved a physician. After the patients were provided an explanation of the meaning of CPR, 37% of patients with living wills indicated they actually did not want CPR. Their living wills did not accurately reflect their treatment preferences.

The Authority suggests key elements needed for healthcare providers to implement to a successful advance directive program and that may be applied to the process of obtaining a DNR order. The Authority also offers tips for consumers to ensure they are educating themselves and their families about their exact preferences for end-of-life care.

For more information on living wills, DNR orders and Pennsylvania law go to "Understanding Living Wills and DNR Orders" of the 2008 December Pennsylvania Patient Safety Advisory at

The Authority's quarterly 2008 December Advisory contains other articles developed from data submitted through real events that have occurred in Pennsylvania's healthcare facilities. The articles also provide advice and prevention strategies for facilities to implement within their own institutions. Highlights include:

€¢ Pressure Ulcers: Reports Show More Information and Education Necessary: Reports of pressure ulcers in Pennsylvania show that nearly 13 percent in 2007 were categorized as the worst kind, stage III or IV. This article highlights the lack of information provided in reports to prevent the progression of a pressure ulcer as well as the financial burden to treat them. It also provides facilities with the latest information found to reduce stage III and IV pressure ulcers.

€¢ Medication Errors with Bar Code Technology: While bar coding systems used for medications can help improve patient safety and reduce medication errors, reports in PA-PSRS show that some errors occur because healthcare providers fail to use the technology appropriately. This article discusses the process behind the errors and gives guidance to address the problems associated with bar-code medication administration (BCMA) systems.

€¢ Dangers associated with Tubular Dressing Retainers: Tubular dressing retainers are often used to apply and hold dressings, creams and other devices in place when treating an injury. However, if used incorrectly, these devices can cause patients harm. This article gives strategies healthcare providers can use to ensure the retainers are used correctly to prevent further harm. A quick reference card based on information in this article is available for practitioners to carry with them.

€¢ Surgical Site Markers: How Well Do They Perform?: While the Authority conducted its wrong-site surgery project by visiting facilities to inquire about their protocols for wrong-site surgery, several facilities asked about the performance and sterility of surgical site marking pens. This article examines the issue and encourages facilities to examine their surgical site marking pens for possible problems.

€¢ Strategies to Reduce MDROs (multidrug-resistant organisms): Multidrug-resistant organisms are resistant to one or more classes of antibiotic. The challenges infectious disease practitioners and the infection control community face are discussed in this article with guidance for implementing a successful transmission prevention program.

€¢ Wrong-Site Surgery Quarterly Update: This update article of the wrong-site surgery initiative includes preliminary results of a one-year analysis of wrong-site surgery errors that occurred in Pennsylvania. Also available is a brochure to help consumers understand why healthcare providers ask so many of the same questions before they have to go into surgery. Consumer tips for preventing wrong-site surgery are also on the Authority's website.

For a copy of the 2008 December Patient Safety Advisory or more information on the Pennsylvania Patient Safety Authority, visit the Authority's website at

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