Poorly Advanced Directives || AHRQ WebM&M: Morbidity & Mortality Rounds on the Web

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AHRQ WebM&M: Morbidity & Mortality Rounds on the Web

Poorly Advanced Directives

Commentary by Wendy G. Anderson, MD, MS


Cared for at home by his wife and family, an 82-year-old man with multiple chronic medical conditions described his overall health as declining recently. He saw a primary care physician, received home nurse visits, and had recently been referred to a geriatrician. The primary physician realized the need for end-of-life discussions but always ran of out of time due to the complexity and acuity of the patient's medical conditions.

One afternoon, the patient presented to the emergency department (ED) and was admitted to the hospital for delirium, an underlying infection, and acute kidney injury. During the hospitalization, the primary team engaged the patient and his family in advanced directive discussions, and the patient ultimately decided (with his family's blessing) on a do-not-resuscitate/do-not-intubate (DNR/DNI) order. After treatment for his infection, he returned to his baseline health status and was discharged home. The change in code status was communicated to the patient's primary physician.

Two days later, the patient returned to the same ED with altered mental status and impending respiratory failure. En route, the paramedic asked the distraught family members about advanced directives and they expressed a desire that "everything be done" to save their loved one. Despite the previously documented DNR/DNI order, the patient was intubated and remained on mechanical ventilation for 3 days. The family ultimately decided to withdraw life-sustaining interventions, and the patient died peacefully soon afterward.