The prevalence of medical error related to end-of-life communication in Canadian hospitals: results of a multicentre observational study

Abstract

BackgroundIn the hospital setting, inadequate engagement between healthcare professionals and seriously ill patients and their families regarding end-of-life decisions is common. This problem may lead to medical orders for life-sustaining treatments that are inconsistent with patient preferences. The prevalence of this patient safety problem has not been previously described.MethodsUsing data from a multi-institutional audit, we quantified the mismatch between patients’ and family members’ expressed preferences for care and orders for life-sustaining treatments. We recruited seriously ill, elderly medical patients and/or their family members to participate in this audit. We considered it a medical error if a patient preferred not to be resuscitated and there were orders to undergo resuscitation (overtreatment), or if a patient preferred resuscitation (cardiopulmonary resuscitation, CPR) and there were orders not to be resuscitated (undertreatment).ResultsFrom 16 hospitals in Canada, 808 patients and 631 family members were included in this study. When comparing expressed preferences and documented orders for use of CPR, 37% of patients experienced a medical error. Very few patients (8, 2%) expressed a preference for CPR and had CPR withheld in their documented medical orders (Undertreatment). Of patients who preferred not to have CPR, 174 (35%) had orders to receive it (Overtreatment). There was considerable variability in overtreatment rates across sites (range: 14–82%). Patients who were frail were less likely to be overtreated; patients who did not have a participating family member were more likely to be overtreated.ConclusionsMedical errors related to the use of life-sustaining treatments are very common in internal medicine wards. Many patients are at risk of receiving inappropriate end-of-life care.

Patient safety in marginalised groups: a narrative scoping review

“…Overview of marginalised groups and patient safety issues Figure 2 represents the distribution of patient safety issues and marginalised groups identified across included studies. Most patient safety issues (9/12) were repeatedly reported across more than one study except for four unique issues (culturally unsafe healthcare 1 [46], diagnostic delay [60], inpatient safety [47] and medical error [38]). Similarly, most marginalised groups (9/13) were studied in more than one study.…”

Advance care planning documentation strategies; goals‐of‐care as an alternative to not‐for‐resuscitation in medical and oncology patients. A pre–post controlled study on quantifiable outcomes

“…Clear, available and suitable ACP documentation, undertaken early in a patient's hospitalisation, will potentially lead to more appropriate and dignified care, improved communication through less ambiguity and the avoidance of non‐beneficial treatments . An inclusive GOC strategy, as attempted in our study, has been proposed as a mechanism to reduce the number of medical errors in ACP communication, as well as potentially alleviating treatment conflicts in patients transitioning through the final phase of life…”

“…Clear, available and suitable ACP documentation, undertaken early in a patient's hospitalisation, will potentially lead to more appropriate and dignified care, improved communication through less ambiguity and the avoidance of non-beneficial treatments. 7 An inclusive GOC strategy, as attempted in our study, has been proposed as a mechanism to reduce the number of medical errors in ACP communication, 4,25 as well as potentially alleviating treatment conflicts in patients transitioning through the final phase of life. 19 Despite a widespread educational campaign prior to, and during, the GOC (intervention) arm of this study, the uptake rate of GOC forms was limited (344.4 GOC forms per 1000 hospitalisations) and well below the rates reported in smaller studies conducted in publicly funded hospitals.…”

Patient-family agreement on values and preferences for life-sustaining treatment: results of a multicentre observational study

“…In the first two audit cycles, the questionnaire had included an additional option that contained a ‘mix’ of the above options but without an explicit statement about the inclusion of CPR or breathing machines. Consistent with previous analyses, due to perceived ambiguity, this ‘mix’ option was not included in the analyses for this paper 15. As with the questions about values, when asking about life support, we asked family members to indicate their own medical treatment preferences for the patient, not what they thought the patient would select.…”