Saturday, July 6, 2013

Advanced Directives and Patient Safety

Are Advanced Directives a Patient Safety Issue?

A great man died this week.  Most people won’t know him.  He was a member of the congregation I have belonged to for over 25 years.  He was diagnosed with cancer that quickly took his life in a matter of months after the diagnosis.

According to the Society to Reduce Diagnosis in Medicine there are an estimated 40,000 – 80,000 deaths annually in the Unites States from diagnosis errors.  Diagnostic error is responsible for billions of healthcare dollars for inappropriate care, and is the leading cause of medical malpractice claims.

As the patient, a prominent and well loved member of a close community, quickly became sicker and weaker, his wife was forced to start making decisions.   What doctors are the “best”, what hospital should they use that would support their wishes of care and as things progressed quickly, what to do now that he had to leave the hospital;  nursing home, rehab or hospice?   Does he need at home care or should he be in a facility that he could get care?  What could they afford and now that he is weaker, what would he want?  What could his wife live with?  Could she really take him home to overwhelm her life and home?  What does it all mean and why, oh why couldn’t his lovely wife just sit at his side and hold his hand as the end of his life comes to a close?  

How do we make these decisions before we need it?

How do we want our end of life care to be?

Is this a patient safety issue? 

I put the question out there because I struggle myself to explain how advanced directives or living wills fall under the heading of “patient safety”.  Patient safety, as described by the corporate world is very different than that of the advocate / activists side. 

According to an 18 page paper by some of our patient safety leaders;  What Exactly is Patient Safety; quality is described as three parts, underuse, overuse and misuse.  The term misuse became the term for conceptualizing patient safety as a component of quality.

Patient safety is a discipline in the health care sector that applies safety science methods toward the goal of achieving a trustworthy system of health care delivery. Patient safety is also an attribute of health care systems; it minimizes the incidence and impact of, and maximizes recovery from, adverse events. 

The National Patient Safety Foundation  describes patient safety as the avoidance and prevention, of adverse outcomes or injuries stemming from the processes of healthcare.

I asked members of a patient safety advocate Facebook page what they thought of advanced directives and end of life care being part of patient safety.

The response is an obvious “yes”.  Advanced directives is a patient safety issue.  Here are just some of the comments:
  • When unwanted or unnecessary medicines and procedures are done at the end of life (or any other time for that matter) they bring risks.
  • Root-causing the failure to die in peace underscored for me, even beyond our personal experiences, that safety is more than physical. It's existential.

Although one can argue that advanced directives and making your wishes known is a human rights issue or encourages patient empowerment and makes healthcare more patient centeredness and does not fall into a patient safety category.  But, if we think of advanced directives as “informed consent” of which it really is, it surely becomes a patient safety issue.

I would love to know your thoughts.

Here are some things on the topic you don’t want to miss:

Bart Windrum Dying in Peace                                                  

Institute of Medicine Committee on Approaching Death: Addressing Key End of Life Issues: Second Meeting

Decide now who will be your agent and speak for you if you can't speak for yourself and ask yourself, do they know what I want?

CBS News on Medical Misdiagnosis