The limitations of living wills

Although living wills are legal documents, they aren’t always interpreted correctly. In one case, a 45-year old man hospitalized for pneumonia had a living will which stated he never wanted to be intubated. "He said that and wrote it, but he probably didn’t mean that," says Gregory Larkin, MD, FACEP, chair of ACEP’s ethics committee and director of research for the department of emergency medicine at Mercy Hospital in Pittsburgh, PA. "The spirit of what he wrote was, I don’t want to be a ventilator all my life, but that’s not what he said."

As a result, the man died of respiratory distress. "He would have been on a ventilator a week at the most, but he died at 45 years of age, which was a crime and a shame," says Larkin. "The family insisted he didn’t want to be on a ventilator, and they couldn’t be convinced it would have been temporary."

Ideally, patients should give a trusted person durable power of attorney for health care, enabling them to help make treatment decisions on the patient’s behalf. "Living wills aren’t optimal. Durable power of attorney for health care is what I’d prefer to see, coupled with written directives about certain things," says Larkin. "That helps us to make decisions on the patient’s behalf."

Living wills have limitations, he explains. "These pieces of paper are generally less effective than a person who knows the patient’s attitudes, values and goals," says Larkin. "It’s more flexible and can be customized to whatever situation you find yourself in. If there is a particular procedure you don’t want to have no matter what, then a living will is fine, but it can be interpreted the wrong way just as often as the right way."

Even when patients put their wishes in writing, there is room for interpretation. "One study showed that dying patients in ICUs who had advanced directives for treatment were largely ignored, which suggests that the power of those pieces of paper is somewhat limited," says Larkin. "That doesn’t mean they’re worthless, but there is often a lot of disagreement, and they’re not always followed to the letter."

An individual with durable power of attorney for health care may not forego life-sustaining treatment or emergency treatment that is clearly in the best interests of the patient. "You may have someone who’s waiting to collect on a big insurance policy, in which case you’d have to get a court-appointed guardian for the patient, but most of time these are reasonable people," says Larkin. "In an emergency situation, you do what is in the best medical interest of the patient."

Another benefit is that durable power of attorney for health care can always be transported across state lines. "The living wills are much more restricted state by state," Larkin says. "Many are portable, but some of them aren’t, which can be an issue."

Even ‘safe’ EDs eed security

Areas once thought to be safe havens, immune to the violence that plagues "big cities," are now realizing that they too must prepare for the worst and EDs in rural or low-crime areas are increasing their security.

"Everybody is affected by this problem, no matter what community you’re in," says Joni Taylor, RN, CEN, director of emergency services at South Coast Medical Center in Laguna Beach, CA. "Relatively speaking, we’re a safe community, but I don’t think anybody’s really immune from violence."

Still, security needs vary depending on your community. "The patient populations of a downtown L.A. ED vs. one in a little farm community are radically different," says Rob McFarland, a health care safety and security consultant based in Orange County, CA.

As a rule, rural areas need less security, but there are exceptions. "One ED in a farming community in central California had a ferocious problem with drunk and violent patients," recalls McFarland. "There was an extremely high unemployment and welfare rate, which spilled over into the ED and [people] got violent."

South Coast’s ED recently underwent a security assessment when planning a physical redesign with the goal of preventing violence before it occurs. "We now have security doors with a really good controlled access system for separating the waiting room entrance area from the actual ED," Taylor says. "We have the ability to entirely close and contain the ED from the rest of the hospital and the outside."

Cameras allow the registration clerk to observe all waiting areas. "There was initially going to be a solid wall between the main waiting room and an extension waiting room, but we built in windows so our clerks can observe areas of the waiting room that normally wouldn’t be visible," she explains.

Establish rapport with police

Establishing a good relationship with law enforcement personnel is essential in small communities. "We have developed a good rapport with local police, so we have immediate assistance when we need it," Taylor says. "As a small community, we’ve always supported their service and have given them recognition luncheons during the holidays to show our appreciation for them." A prehospital room is available with refreshments for police to do their paperwork.

Police have responded by being extremely responsive to the ED’s needs. "Often, when patients are brought in by police for evaluation and we’re not sure what the disposition will be, they will need close observation in the meantime," says Taylor. "While we’re treating other people with life-threatening emergencies, those patients can be very disruptive or walk out and disrupt the community. The local police have been very supportive of us by staying in the department when we needed them to."

Many EDs in relatively low-crime areas are keenly aware of the potential for violence. That point was brought home at South Coast when one of the ED’s patients went on a shooting spree locally. "He easily could have come in here, and that was the kind of situation we took into consideration when we planned for our new ED," Taylor says. "We need to protect our staff and patients the best way possible, without going overboard with bulletproof glass and metal detectors—there is a limit."