Know About Living Wills, DNR and POLST

By Dr. Ferdinando Mirarchi


A 68-year-old male presents with a history of diabetes, hypertension, dyslipidemia, and CAD s/p CABG 10 years ago.  Patient is experiencing chest pain.  He is clammy.  He is in mild distress.  Vitals: T: 36C; P:60; RR:22; SaO2: 98%RA.  The family gives you his list of medications and living will.  Abruptly, the patient becomes unresponsive without palpable pulses.  The monitor shows ventricular fibrillation.  What next? Read the article, click here to look at the Will and take a two-question quiz.

Advance directives were created with the best of intentions, aiming to protect patient autonomy and honor end of life wishes.  Until recently, the risks posed to patient safety by the various incarnations of advance directives were unknown and thus, undisclosed. Often, these well-meaning documents have produced unintended consequences. The TRIAD studies (The Realistic Interpretation of Advance Directives) have disclosed this patient safety risk as reality and on a nationwide scale. The risk is attributable to variable understanding and misinterpretation of advance directives which then translates into over or under resuscitation. At present, this is an unreported safety concern and only by clarifying the terms of advance directives and developing systems to educate providers will we be able to respect our patients’ wishes while still protecting their safety.

The living will was first legalized in California in 1977 and was known as the Natural Death Act.1 It was created by an attorney and utilized to decline life saving measures, essentially intended to provide patients with greater autonomy in end of life decisions. 2 Unfortunately, it also resulted in increasing risks to patient safety. Further fueling this patient safety risk was the development of The Patient Self Determination Act 1990. 3 This mandate, which was never evaluated for safety, requires patients to be provided information regarding their right to execute an advance directive at institutions receiving Medicare/Medicaid funding.  With 90 million living wills in existence in the United States, 4 incorrect interpretation can lead to deleterious impacts on the care and safety of patients who summon 911 or experience a medical emergency in a healthcare setting. Clarification of terms, education of providers and implementation of safeguards are needed to protect the safety and autonomy of patients. In the TRIAD III nationwide study, high percentages of participants reported receiving training related to advance directives. However, those indicating receiving education produced no benefit. As health care providers, we need to work together on a national level to improve this education process. To further facilitate understanding, the following terms need to be defined and standardized:

Terminal Illness defined by law
Reversible & Treatable Condition
An “Effective” Living Will
An “Enacted” Living Will
DNR order
POLST Document

For purposes of clarification, the mere presence of a living will does not mean it should be followed.  It simply indicates that this document is “effective,” or that it is valid and legal.It should not be followed at this point to guide the care and treatment of the patient.

An “enacted” or “activated” living will is one that has been activated by the triggers in the document, most commonly a terminal or end stage medical condition or a persistent vegetative state. 5 This “enacted” living will now necessitates adherence to its instructions regarding the care of the patient.  A terminal or end stage medical condition has a legal definition which essentially states that a patient would be expected to die of their disease process despite sound medical treatment.  Therefore, the mere presence of a living will “does not” dictate the care of a critically ill patient who presents with a reversible and treatable condition such as CHF or COPD; rather it applies when that same patient is permanently unconscious and has exhausted all treatment options. A do not resuscitate order (DNR) refers to an actual physicians order that directs health care providers not to intervene with CPR if the patient is found pulseless or apneic.6,7

Otherwise it should have no implication on the care and treatment that the patient is to receive.6,7

Despite the legal and societal definition of DNR, research reveals in the TRIAD studies that medical providers understand DNR to be synonymous with an order to provide comfort and end of life care.8,9,10  A relatively new document called the Physicians Orders for Life-Sustaining Treatment (POLST) is different as it is an order set  to be followed that addresses the treatment options of a patient should they present in cardiac arrest as well as the patient’s preferences for care in a non-arrest situation.11

POLST is a national paradigm and its philosophy is being rapidly embraced on both a national and state level.  Unfortunately, it is now being nicknamed the Pink DNR form. This nickname needs to be quickly clarified and resolved as patients can be designated as a Full Code or a DNR through the use of this form. This again is a situation where good intentions can have unexpected consequences. SafeGuards are created to promote patient safety. I would like to introduce the SafeGuard known as the Rescuscitation Pause (RP). The RP is a process similar to the surgical pause (time out is the correct term) which is already widely utilized to correctly identify patients and eliminate wrong site surgery. Resuscitation takes on many forms and is not limited to the cardiac arrest situation. Resuscitation takes place when a patient presents critically ill and requires active interventions for conditions such as respiratory distress, sepsis or GI bleeding, etc. Resuscitation takes place with conditions that require immediate evaluation and intervention such as trauma, cardiac and stroke system activations to define care and facilitate treatment. A Pause is a moment to quickly assess and reassess the situation to assure you are defining the appropriate care and treatment. Through the use of a secure, HIPPA protected and interactive educational platform, QuantiaMD, ( we have been able to educate over 24,000 medical providers and empower them with the RP as a patient safety tool. We have been able to confirm that the medical community nationwide supports the TRIAD concerns that there is a real and present risk to patient safety; they found the education and tool to be useful and have empowered it into their clinical practice.

Advance directives in their various forms have never been evaluated with regard to patient safety though they directly affect well over 90 million patients. This is a medical error and resolution of the issue will require increased awareness and education among medical providers of all disciplines. The Resuscitation Pause holds significant promise as a way to protect patient safety and autonomy. The importance of this issue cannot be overstated as understanding advance directives not only allows us to appropriately provide or withhold life-saving care, but also ensures that we safely honor our patient’s wishes in the process.


How to Interpret a Living Will <>
What Do DNR Orders Really Mean? <>
POLST: Physician Orders for Life-Sustaining Treatment <>
Understanding Your Living Will; What you need to know before a medical emergency

Towers B. The Impact of the California Natural Death Act. J Med Ethics. 1978;4:96-8.
Kutner Luis. The Living Will: a proposal. Indiana Law Journal. 1969;44(1):539-554
Patient Self Determination Act
Source: U.S. Census Bureau, 2044 Population Estimates, Census 2000, 1990 Census (
Mirarchi FL. Understanding Your Living Will. Addicus Books 2006
Do Not Resuscitate (DNR) Protocols within the Department of Veterans Affairs. Section 30.02
Code of Medical Ethics Opinion 2.22 Do-Not-Resuscitate Orders.
FL, Hite LA, Cooney TE. TRIAD I – The Realistic Interpretation of Advanced Directives. J Patient Saf. 2008;4:235-40.
Mirarchi FL, Kalantzis S, Hunter D. TRIAD II: Do Living Wills Have an Impact on Pre-hospital Life Saving Care?  J Emerg Med.2009;36:105-15
Mirarchi FL, Costello E, Puller J, Kottkamp N. TRIAD III: Nationwide Assessment of living Wills and DNR orders. J Emerg Med. 2012 May;42(5):511-20.
Physicians Orders for Life-Sustaining Treatment (POLST)


No Comments

Annals podcasts

The Annals podcasts are available here:


The highlights for October are:


-What predicts ‘drug-seeking’ or prescription misuse among ED patients?

-hydromorphone 1+1 opiate dosing

-metoclopramide vs ketorolac for ED headaches

-Cost-effectiveness of helicopter EMS

-Attitudes toward sickle cell crisis management

And much much more…

No Comments



I’ve noticed something.

At tertiary care hospitals, such as Level 1 trauma centers, there are all manner of specialists on call for the emergency department.  In fact all specialties are represented.  There’s no need to transfer patients to a higher level of care.  It makes sense.  After all, these hospitals are affiliated with medical schools, have residency programs, carry on teaching and research and act as referral centers for a certain geographical area.

At community hospitals, i.e. those that are not designated as tertiary care or Level 1 or Level 2 trauma centers, there is almost never a full complement of specialists.  Often there is no neurosurgery, no cardiothoracic surgery , sometimes no plastics, maxillofacial or vascular services.  In many of these hospitals, though a significant portion of the emergency population is children, there is no pediatric ICU.

In other words, in many hospitals in the USA, patients with serious medical and/or surgical problems have to be stabilized by the emergency physician and then transferred to a higher level of care.

Who manages these critical care emergency patients?  Who manages the trauma patients, until they are transferred out?  The emergency physician, of course.  All this requires great skill and competence.  Ask anyone who’s done it.

Who manages these types of patients at the Level 1 trauma center?  The on-call specialists do.

It is believed, by some, that ACEP Legacy physicians are not competent enough to work in tertiary care hospitals and certainly not capable of teaching medical students and residents.

It is also believed, by some, that Emergency Medicine Residency-Trained (EMRT) doctors are more competent than their non-EMRT counterparts.

So, if the EMRT doctors are more competent, why aren’t they working in the community hospitals where a higher level of skill is required?

Why aren’t the non-EMRT docs working at the trauma centers, where all the back-up is available?  If we’re less competent, don’t we need all the help we can get?

If the EMRT docs are more competent, shouldn’t they be working at the hospitals where there is less back-up, fewer resources?

Has someone got this whole thing bass-ackwards?

Why are only EMRT docs working at the tertiary care hospitals?

I’m just asking.


Marlene Buckler, MD, FACEP, CCFP(EM), DABUCM

Official Blogger for ACEP Emergency Medicine Workforce Section







Is it any easier now for ACEP Legacy Physicians to get jobs in American hospitals?

For the past 5 years I have been doing locum work abroad; in Canada, New Zealand and England and I’m currently looking at Australia.  I haven’t applied for any jobs in US hospitals during that time.  I live in Florida, have keep my medical license active and am considering exploring the possibility of working in Florida again in the near future.

Some of you might remember that previously I ran into problems applying for work in The Sunshine State, because I was not EM residency-trained nor ABEM-boarded.  In spite of ACEP offering verbal support to the idea that Legacy physicians are an important part of the workforce and thus should be given consideration on merit and performance, in hiring situations, the reality was that most hospitals, especially those in desirable locations, were off-limits to doctors like me.

Numerous ads for ER jobs come into my email daily.  A few years ago almost all of them “required” ABEM certification. Some even stipulated that applicants must be EM residency-trained, which, by the way, would exclude a number of ACEP past-presidents.

Lately there seem to be more than a few hospitals that will settle for certification in any primary care specialty, e.g. family medicine, internal medicine, etc.  So, is the landscape changing?  Are the realities of the workforce finally being realized by hospitals that find themselves in need of emergency doctors?

Do I have any hope of getting a job in a decent hospital in the Sarasota, FL area?

Is it any easier now for ACEP Legacy Physicians to get jobs in American hospitals?

I’m just asking.


Marlene Buckler, MD, FACEP, CCFP(EM), DABUCM

Official Blogger for ACEP Emergency Medicine Workforce Section

1 Comment

A Different Corner

She was young, pretty, and dead.  Another victim of a head-on collision on a stretch of winding road outside of town where we get the great majority of MVC’s in the rural hospital in which I work.  We knew it was going to be bad when we heard the ambulance traffic call out the “Code Three with one” as it was en route from the accident site.

She was resuscitated, but after an hour we knew that nothing more could be done for her.  After calling the code, my attention turned to the sometimes worst part of our job, notifying the next of kin.  She had a cell phone in her bag, and on it “Mommy.”

I can still hear her voice as she cheerily answered “Hi!  Good morning!”  Had I been in a different frame of mind, I would have taken the time to try to figure out how to find the actual number in her contact list.  But, Monday morning quarterbacking aside, I did what my instincts told me to do at that moment.

Once I said that her daughter had been in a serious accident, she immediately passed me off to the girl’s father “who was a doctor and would understand better.”  I steadied my voice as I informed him that his daughter had died.  I held the phone near my ear but somewhat away as the wails and cries filled the small space I was in.  Their grief carrying across the hundreds of miles that separated us.

They would come right away, he reassured me.  I told him to take his time and await our phone call.  There were other calls that had to be made.  To CHP.  To the donor network.  To the coroner.  After about an hour, my nursing supervisor told me the family was coming and would like to stop by the hospital to talk to me.

Several hours and a multitude of patients later, they arrived.  I spent some time with them explaining what I knew of the accident and about the resuscitation effort.  As a doctor, he had a lot of questions and wanted to know everything in detail.  Toward the end of the visit,  I found out she had only recently moved and was actually working at one of our local shops.

Then I remembered her.  A bright, smiling girl who helped me with a purchase not even a week ago.  I tried to wrap my head around that image and not of the broken patient who had been brought to my ED just hours earlier.  I’m still trying.


July Annals audio now posted!

We’re posted for July! Highlights include:
-Validation of a decision rule for SAH
-Effects of a health information exchange on xray ordering
-Ocular fundus photography in the ED
-Renal impairment: a risk factor for ACS among chest pain patients?
-Training and real time A-V feedback effects on CPR success
-Clinical Policy: Management of Asymptomatic Hypertension in the ED
-Antibiotic stewardship: A review of mechanisms
-Cost-effectiveness of rapid flu testing

Email any time with comments or questions about the audio/podcast.


No Comments

Track It Down in Seattle

Fellow ACEP Members,

For those who made the trip to Denver this past October, hopefully you were able to “add more science to your Scientific Assembly experience” by visiting the ACEP Research Forum.  The forum included both oral and poster presentations highlighting cutting-edge research in our field.  The Forum featured an expert panel discussing abstracts that have significant implications for emergency medicine practice or research.  Last year marked the first for the ACEP Research Forum Scavenger Hunt.  In order to bring additional interest, and add a little fun to the Research Forum, a scavenger hunt was created with collaboration from the researchers themselves.

The scavenger hunt consisted of a set of questions for each day of the forum for non-researchers reviewing the posters to complete.  The answers could be found in the poster presentations and each question was followed by a clue to guide you along the way.  Questions for the hunt were contributed by over forty of the presenting researchers.  The contributors were enthusiastic about the scavenger hunt, stating “It’s a great idea!! Very excited about it.” Another researcher appreciated that “It helped me not wait until the last minute to do my poster.”  Summing up the goal of the scavenger hunt well, another contributor commented, “Thanks for increasing the awareness of the research projects.

Those who completed the scavenger hunt were submitted into a drawing for prizes: Virtual ACEP membership and ACEP bookstore gift certificates.  One participant who completed the Scavenger Hunt commented, “It forced you to get a look at the whole range of research EM physicians are involved in, instead of gravitating only to your area of interest.”

Cutting edge research is presented every year at the research forum by hard working practitioners in our field.  Efforts to increase awareness and participation by non-researchers in the forum should be continued.  The Scavenger Hunt is again being planned for the upcoming conference, ACEP13 in Seattle. Be on the lookout for a new and improved Scavenger Hunt with improved convenience and ease of access.  Of course, don’t forget about the exciting ACEP prizes for those cunning enough to navigate the hunt!

Alicia Glynn, MD
Resident, EM-3
Case Western Reserve University/Metro Health Medical Center/Cleveland Clinic
Cleveland, Ohio

1 Comment

In All My Career…Stories from the ED






Please send your stories to Tracy Napper ( today!


MVA Alex

Late on April 21, 2006 I received a call from my son’s cell phone; it was not him, it was a social worker at the University of Michigan’s ED who picked up Alex’s phone and hit redial. “Do you have a son named Alex? He’s been in a bad car accident, can you come right down?” Countless times I have been on the other side of that phone call. I always imagined what it must be like to receive it; now I know. As emergency physicians we try to never tell someone over the phone that their loved one has died. Get the family to the ED first. This knowledge served to increase the fear and anxiety that Marion and I felt rushing to get up, rushing to the hospital and brings tears to my eyes just in the recollection. When we got to the ED a number of the attendings and students recognized me and their discomfort was palpable as they themselves seemed to vicariously feel what it was like to be on the other side. We found Alex intubated and on a ventilator. By then his injuries had started to be catalogued: Intracranial bleed, diffuse axonal shearing, fractured C3, sinus and orbital floor fractures, blood loss from major scalp and facial lacerations. Alex was having decerebrate posturing which seemed to increase as time went by.

Talk with the neurosurgery resident of a ventriculostomy was put on hold when Alex seemed to show some subtle improvements but I could not stop myself from thinking about how I could possibly cope when they ask me for organ donation signatures. Twenty years of hopes and dreams seemed to be shattered. During the next two days in the trauma ICU we dealt with a steady stream of grieving friends and an uninjured, responsible, teenage driver who sobbed and cried by Alex’s bedside for almost 24 hours before we insisted he leave to get rest. The second night Alex showed some purposeful movement and then the next morning, he woke up. Completely. He was extubated, pulled his own feeding tube, sat up, and demanded to go home. The following morning he was indeed discharged, not from the ICU, but from the hospital. He walked the two blocks to the car himself. Decerebrate to walking home in less than three days! Now at home, I cannot minimize his discomfort as he contends with bruises and broken bones and the inevitable feeling of self sorrow, but…my God…he can feel!

My family and my son were astoundingly lucky, to the point of giving meaning to the word “miracle.” I was able to see and feel what we as providers do from the perspective of our patients and their families.

Used with permission by EPMB.
Charles Grassie, MD

1 Comment

Annals Audio/Podcast for June 2013 is posted and available!

June 2013 is up and running. Short and sweet, you can access it here!

-ED Crowding is associated with increased mortality, costs, and inpatient length of stay
-Characteristics of high performing hospitals on ED quality markers
-Physician email and phone contact after visits increases satisfaction
-Impact of Computerized Provider Order Entry in the ED
-Administrator views on barriers and opportunities to Palliative Care in the ED
-Improving Palliative Care in the ED – Notes from the early adopters
-Disaster triage – what method is best?

Email us at, let us know what you think.
Talk soon,

No Comments

ACEP News Plans New Editorial Direction

Dr. Kevin Klauer

In January 2014, Dr. Kevin Klauer will take over as the medical editor-in-chief of ACEP News.

The American College of Emergency Physicians is set to undertake a new editorial direction for our monthly news magazine, ACEP News, which coincides with a new publishing contract with Wiley Periodicals Inc. beginning in 2014.

Kevin Klauer, DO, EDJ, FACEP will take over as medical editor-in-chief in January 2014, helping to set the tone and editorial direction of the publication. In June, Dr. Klauer will resign as editor-in-chief of Emergency Physicians Monthly, a position he has held since 2008.

Robert Solomon, MD, FACEP, ACEP News’ current medical editor, has served in this role for almost eight years. Under his leadership, the magazine has grown from a small, insider newsletter to a robust and trusted source of up-to-date clinical information, valued articles on practice trends, and entertaining features on emergency physicians worldwide. Dr. Solomon will continue as ACEP News’ medical editor through December 2013.

ACEP would like to thank Dr. Solomon for his tireless dedication and the progress he has helped ACEP achieve with ACEP News.

Dr. Klauer will bring a new voice to ACEP News that will resonate with the 31,000 ACEP members and additional 8,000 emergency physicians who read the publication each month. He has a following in the emergency medicine community, where he is a respected, popular and dynamic faculty member at emergency medicine educational conferences. He will augment the current 21-member ACEP News Editorial Advisory Board with different perspectives and additional columnists.


1 Comment