The Journal of Emergency Medicine, Vol. 40, No. 6, pp.

629 632, 2011

Copyright 2011 Elsevier Inc.
Printed in the USA. All rights reserved
0736-4679/$see front matter

doi:10.1016/j.jemermed.2008.11.014

Clinical
Communications: Adults

A LIVING WILL MISINTERPRETED AS A DNR ORDER: CONFUSION

COMPROMISES PATIENT CARE
Antonios D. Katsetos,

DO

and Ferdinando L. Mirarchi,

DO, FAAEM

Department of Emergency Medicine, Hamot Medical Center, Erie, Pennsylvania

Reprint Address: Ferdinando L. Mirarchi, DO, FAAEM, Department of Emergency Medicine, Hamot Medical Center, 201 State Street Erie,
PA 16550

e AbstractBackground: Advance directives are becoming ever more commonplace in the United States. Correct
interpretation of living wills and do-not-resuscitate (DNR)
orders is essential if patient safety and autonomy are to be
preserved. Objectives: 1) To recount a case in which a living
will was misinterpreted as a DNR order; 2) To make known
the ramifications of this misinterpretation; 3) To advocate
for improved education of health care professionals regarding the interpretation and implementation of advance directives. Case Report: Mr. S. is an 89-year-old nursing
home resident who agreed to the terms of a living will. This
living will was subsequently misinterpreted as a DNR order
by the patients physician. This misinterpretation set off a
cascade of events that led to the completion of an out-ofhospital DNR order and a compromise of patient care.
Conclusion: This case study underscores the potential for
misunderstanding of an advance directive and the consequent
effect on patient care. Likely this is the result of a fundamental
lack of understanding about the terminology and definitions
inherent in an advance directive document. 2011 Elsevier
Inc.

wills and do-not-resuscitate (DNR) orders is essential if

patient safety and autonomy are to be preserved. We
present a case in which a physicians misunderstanding
of a living will led to the eventual completion of an
out-of-hospital DNR order. This cascade of events and
lack of communication between physician and patient
led to a breach of patient autonomy and a compromise of
patient safety.
Details of our case have been altered to protect patient
confidentiality and the identity and location of the physicians and health care facilities involved.

CASE REPORT
Mr. S. is an 89-year-old male nursing home resident
with a history of unilateral blindness, hypertension,
hearing loss, and remote bladder cancer (status postcystectomy 26 years ago) who presented to the Emergency Department (ED) with a 1-day history of slurred
speech and hypotension. The nursing home face sheet
indicated that the patient had an out-of hospital DNR
order and that Emergency Medical Services (EMS)
should not be activated (Figure 1). Therefore, he was
transported to the ED by private vehicle (facility van).
Included in the records sent by the nursing home was
a living will, in which the patient appointed a health
care proxy and indicated his wishes regarding medical

e Keywordsadvance directives; living wills; DNR orders; geriatrics; end-of-life care

INTRODUCTION
Advance directives are becoming more commonplace in
the United States. An estimated sixty million Americans
have a living will (1). Correct interpretation of living

RECEIVED: 15 February 2008; FINAL

ACCEPTED: 8 November 2008

SUBMISSION RECEIVED:

17 September 2008;
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A. D. Katsetos and F. L. Mirarchi

evidence of any mood disorder. The patient explicitly

stated to the neuropsychologist, I know I am an old
man, but if the condition is treatable, I would like the
chance to be treated. The patient recovered to his baseline after further blood transfusions and upper endoscopy
(which was delayed until completion of the neuropsychological evaluation) and was discharged back to the
nursing home several days later.

DISCUSSION

Figure 1. A reproduction of Mr. Ss. nursing home face sheet

indicating that Mr. S. has an out-of-hospital DNR order and
that EMS should not be activated.

treatment should he be in a terminal condition or a

persistent vegetative state (Figure 2).
In the ED, the patient was found to be profoundly
anemic, hypotensive, and hypoxic. Although he was
visually impaired and hard of hearing, his mental status
and neurologic examination were otherwise normal. Mr.
S. was judged to be competent, and, though critical, his
condition was not judged to be terminal. Therefore, the
emergency physician judged the patients living will to
be inapplicable. The emergency physician had a discussion with the patient regarding his wishes for further
treatment. The patient stated that he wanted all necessary
treatment; as such, he was resuscitated, emergently transfused, and admitted to the intensive care unit. He was
later diagnosed with an acute gastrointestinal (GI) bleed.
While hospitalized, the patient reiterated to both his
attending physician and a consulting intensivist that he
wished to receive all necessary treatment. Both physicians indicated in dictated reports that the patient was
DNR and that he wished to reverse his code status. The
intensivist discussed code status at length with both the
patient and his daughter, who was designated as his
health care proxy and durable power of attorney. The
intensivist did not feel confident that the patient understood the implications of his decision to be a full code.
Therefore, he recommended a neuropsychological evaluation to assess the patients competence. The patient
received appropriate medical therapy for GI bleeding,
including packed red blood cell transfusions and proton
pump inhibitors while awaiting neuropsychological evaluation, which occurred the following day. The assessing
neuropsychologist found the patient to be competent to
make decisions regarding his code status and found no

Discussions with Mr. S.s family and review of nursing

home records revealed that he had, upon admission to the
nursing home, signed a living will as presented in Figure 2.
When questioned about the living will during the abovementioned neuropsychological evaluation, Mr. S. stated
that he signed the document because I had to. Mr. Ss
attending physician during a previous hospitalization reviewed the living will, and because it declined all lifesustaining measures, apparently misinterpreted it as a
DNR order. A DNR order was then entered into the
patients chart. To the best of our knowledge, this DNR
order was written without consultation with the patient or
his family. Upon returning to the nursing home from the
previous hospitalization, a case manager noted that
Mr. S. had a DNR order while hospitalized and arranged
for an out-of-hospital DNR order to be written by the
nursing home physician. This out-of-hospital DNR order
again was apparently written without discussion with the
patient or his family. As a result of the out-of-hospital
DNR order, EMS was not summoned when Mr. S. again
became ill, and, though unstable, he was transported to
the ED by nursing home staff in the facility van.
Mr. Ss case demonstrates that there is confusion
regarding the meaning and application of living wills and
DNR orders. Mr. S. had an effective living will at the
time of both hospital admissions discussed. An effective
living will is one that is valid and legally binding but that
has not been activated. In contrast, an enacted living will
is one that has been activated because the patients condition meets the terms of the living will (most often a
terminal condition or persistent vegetative state) (2). The
attending physician during the first hospital admission
misinterpreted Mr. Ss living will as a DNR order. This
error set off a cascade of events that resulted in Mr. S.
being denied EMS care despite being hemodynamically
unstable secondary to a GI bleed. Upon admission to the
hospital for GI bleed, both the admitting physician and
the consulting intensivist interpreted the patients acceptance of blood transfusions and other resuscitative measures as a reversal of his presumed DNR status. Although
a DNR order directs health care providers not to resuscitate a pulseless or apneic patient, it should not affect

Living Will Misinterpreted as DNR

631

Figure 2. A reproduction of Mr. S.s living will. Note that the patient has declined all interventions.

any other treatment decisions (3). EMS activation and

maximal therapy short of cardiopulmonary resuscitation are allowable for patients with DNR orders (4 9).
Therefore, regardless of Mr. S.s DNR status, EMS
activation and transfusion of blood products would
have been appropriate.
Misinterpretation of advance directives is an emerging and troubling problem (2). Recent surveys of physicians, nurses, and EMS providers demonstrated that a
significant percentage of providers at all levels interpreted a valid (but not enacted) living will as an order not
to resuscitate (2). Furthermore, survey results revealed
that DNR orders often are misconstrued as orders to
provide only comfort care (2). Several studies have
shown that patients with DNR orders are more likely to
have treatment withheld, even in non-terminal conditions;
such patients are less likely to receive aggressive nursing
care (4,10). Furthermore, nurses are less likely to notify
physicians of status changes in patients with DNR orders
(4). Such patients are also less likely to receive adequate
resuscitation and critical care interventions (11,12). In fact,
the appropriateness of Mr. S.s admission to the intensive
care unit was debated, initially, by the admitting physician
on the basis of the patients presumed DNR status.

Valid living wills do not equal DNR orders unless the

patient is in a terminal condition or persistent vegetative
state and the patient has indicated that he or she would
not want to be resuscitated if in such a state. Furthermore, DNR orders must not be misinterpreted as orders
not to treat conditions other than cardiac or respiratory
arrest. Staff misinterpretation of Mr. S.s out-of-hospital
DNR order led to his being denied EMS care despite
being critically ill. Re-wording of the nursing home face
sheet to read do not activate EMS in case of cardiac or
respiratory arrest might prevent a similar error in the
future.
Physicians spend little time discussing end-of-life issues with patients and their families. Tulsky et al. revealed that when the subject of advance directives was
broached, the conversation lasted 6 min, on average,
with the physician speaking two-thirds of the time (13).
Adequate communication between physicians, patients,
and family members is essential if patients wishes regarding end-of-life care are to be carried out appropriately. Lack of communication in both the hospital and
nursing home led to Mr. S. being made DNR without his
knowledge or consent. Similar cases of patients being
designated DNR without discussion or consent have

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A. D. Katsetos and F. L. Mirarchi

been reported previously (14,15). Such a failure to communicate represents a disregard for patients autonomy and
potentially can lead to compromises in patient care and
safety.

CONCLUSION
The case presented demonstrates a lack of understanding
among several physicians and other health care providers
regarding the implementation, activation, and implications of advance directives. This lack of understanding
potentially compromises patient care, safety, and autonomy. At the very least, greater vigilance is needed to
understand the terms and conditions by which an advance directive becomes activated. Better understanding
is needed at all levels of care because each can adversely
affect subsequent decisions and efforts.
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