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Part 1: Limits of Advanced Directives and Educated Decision Making

Health Care Patient Safety

A four-part series by Myra Gerson Gilfix, Esq.

The focus of this paper is on what we can do to improve our health, safety, and well-being in medical settings.

Part 1: Limits of Advanced Directives and Educated Decision Making.

We routinely do Advance Directives for our clients. As you know, Advance
Directives enable you to name someone to make decisions for you when you are not able
to express what you want. These documents also allow you to include specific directions
to guide those decisions. Most of the time these decisions occur at the end of life or during
end stage dementia. Those occasions are rare.

What is not rare is that we get sick or injured, and we need to seek help from a
doctor or other medical professional. If we have to cope with chronic illness, that often
means dealing with a variety of professionals as well as institutions. It may also mean
that we need hospital care, surgery, or other medical interventions.

We need to know how to advocate for and protect ourselves and our loved ones
in healthcare settings. We need to learn how better to navigate the maze that is our health
care system. The more I've learned about health care delivery, the more I realized that
helping people with end-of-life decision-making is not enough. I want to focus on actions
that will help you literally live longer. I want to empower you so that you can avoid
reaching end-of-life prematurely.

Avoiding Medical Errors

Why do I say "prematurely"? Well, to answer that, here’s some information to
explain why I think it's more important than ever to participate directly and actively in our
own health care – and to help loved ones get the best possible care.

Johns Hopkins surgeon Dr. Marty Makary wrote in the Wall St. Journal: "When
there is a plane crash in the U.S., even a minor one, it makes headlines. And there is
always a thorough investigation from which the aviation industry learns how to do its job
more safely.”

He goes on: "The world of American medicine is far deadlier: Medical mistakes kill
enough people each week to fill four jumbo jets. But these mistakes go largely
unnoticed...and the medical community rarely learns from them. The same preventable
mistakes are made over and over again..."1

Medical errors pose a serious public health risk and are a leading cause of death
in the U.S.2 The estimated number of deaths in the United States resulting from
preventable medical error differs, but it is likely more than 200,000 per year. Preventable
medical error may be the third leading cause of death in the US – more than respiratory
disease, accidents, stroke, and Alzheimer’s. Countless others suffer illness or injury
because of medical error as well. Approximately 400,000 hospitalized patients suffer
some kind of preventable harm every year.3

There are myriad causes of errors, including, but certainly not limited to inadequate
staffing, faulty or inconsistent protocols, and communication issues. The point is not to
place blame; the goal is to do what we can to mitigate and prevent errors from happening
to us and to those we care about. They cause harm to real people. Let’s make sure you’re
not among them!

Improving Our Ability to Evaluate and to Avoid Unnecessary Care: What We Can Learn from Choosing Wisely™

Did you know that 20-30% of all medications, tests, and procedures are
unnecessary according to research done by medical specialists who surveyed their own
fields! This is reported by Choosing Wisely™, an initiative of the ABIM Foundation in
Philadelphia, Pennsylvania. The mission of Choosing Wisely™ is to promote
conversations between clinicians and patients by helping patients choose care that is
supported by evidence, is free from harm, and is truly necessary. It is also to ensure that
care does not duplicate other tests or procedures already received

Beginning in 2012, national organizations representing medical specialists asked
their members to identify tests or procedures commonly used in their field whose
necessity should be questioned and discussed. This call to action has resulted in
specialty-specific lists of questionable medical interventions. Note that unnecessary
interventions are not only likely preventable, but when done, they also create a risk for
more errors.

In short, do not assume that everything your doctor suggests will be best. Don’t
assume everything your doctor suggests is even necessary. What are some of the
reasons to question medical treatments or tests? They can be harmful. For example:

  • Imaging tests, such as CT scans and X-rays expose you to radiation, which in repeated amounts can cause cancer.
  • Antibiotics are greatly overused. When needed, they are a blessing, but they can also have serious side effects. Taking them when you don’t need them (like for a viral sore throat or a cold) can cause your body to resist them so they won’t work when you do need them.
  • False alarms from testing (called false “positives”) can lead not just to anxiety, but also to more and maybe increasingly invasive testing.

Wasted time and money are not to be underestimated as negative consequences
as well. Your awareness that some procedures, tests, and other interventions may not
help or even be harmful will add to your ability to work productively with your doctor.

Always ask your practitioner if you really need the test, treatment, or procedure.
There may be simpler, safer approaches. An appropriate evaluation focuses on whether
the potential harm exceeds benefit. To understand that, you need to ask your doctor what
the risks and side effects are, and you need to know what can happen if you do nothing.

Your physician should have the expertise to help you figure out what your options are,
given your condition and situation. Regardless of what a doctor may think is the medically
best option, you are the expert about your concerns and priorities.
What will the intervention cost? Do not fail to ask. Surprisingly often, doctors will
not know. Health care costs are remarkably non-transparent, and that’s a major issue. However, the more often we ask the question, the more likely the answers will become
increasingly forthcoming.

How COVID-19 has Highlighted the Importance of Avoiding Unnecessary,
Unhelpful Interventions

A “silver lining” of the COVID-19 pandemic has been that health care institutions
and providers have become even more incentivized to prioritizing high value care, and to
eliminate protocols and procedures that are of marginal or no value to patients.
With each test, intervention, procedure, and treatment, clinicians must carefully
consider harms and benefits not only to the patient, but they must also consider the
danger of exposing themselves and other health care workers (HCWs) to SARS-CoV-2,
the virus causing this disease. For example, in “ordinary” times, unnecessary chest
computed tomography (CT) to help diagnose COVID-19 comes with the usual risks to the
patient including radiation.4

COVID-19 has added to the risk/benefit calculation: that CT comes with more than
just the usual risk (which may or may not have been factored into the decision about
whether to employ a CT). During the pandemic, clinicians have become accustomed to
weighing the benefits and harms of each test and treatment carefully with consideration
of both the patient and the staff involved.

The initial unnecessary chest CT may expose a surprising number of individuals –
besides the patient – to risk. These include the transporter, the staff in the hallways and
elevator en route to testing, the radiology staff operating the CT scanner, and the
maintenance staff who must clean the room and scanner afterward. Potential harms to
staff include exposure of the pulmonary and interventional radiology consultants, as well as the staff who perform repeat imaging after the biopsy.5 And don’t forget, the patient is not only at risk of radiation and possible false positives (a finding that leads to further
testing, but was not dangerous), the patient is also exposed to risk of infection.

Choosing Wisely™ helped develop even more specific guides for use during the
pandemic. Partnering with patient and clinician associations, the multi-institutional group
from the High Value Practice Academic Alliance of Choosing Wisely™ proposed a Top 5
list of overuse practices in hospital medicine that can lead to harm of both patients and

HCWs in the COVID-19 era.

The following recommendations apply to all patients in the hospital setting whether
they have SARS-COVID-19 or not. These recommendations build on already existing

For example, here’s an original Society of Hospital Medicine Choosing Wisely™
recommendation: Don’t perform repetitive complete blood count and chemistry testing in
the face of clinical and lab stability.6

Aside from patient harms such as pain and hospital-acquired anemia, the risk of
exposure to health care workers (HCWs) who perform phlebotomy (phlebotomists,
nurses, and other clinicians), as well as staff who transport, handle, and process the
bloodwork in the lab, had to be minimized. Most prior interventions to eliminate
unnecessary bloodwork focused on the number of lab tests,7 but some also aimed to
batch nonurgent labs together to effectively reduce unnecessary needlesticks (“think
twice, stick once”).8 The COVID-inspired more specific guideline: Do not obtain
nonurgent labs in separate blood draws if they can be batched together.

Another example of recommendations sharpened as a result of the pandemic that
offers future benefits to patients and their loved ones: Avoid in-person evaluations in favor
of virtual communication unless necessary.

Clearly, this helps to minimize Health Care Workers’ exposure to COVID-19 and
optimize infection control – and not just against COVID-19. Appropriate changes in
reimbursement and coverage have also followed. Medical professionals are learning how
to effectively use telemedicine as well as to minimize unnecessary face-to-face
interactions with patients. Telemedicine also allows for virtual family meetings. These
kinds of consultations can save time, energy, and help avoid infectious exposure to a variety of microbes. In other words, maybe it’s not even necessary to drive to the hospital or doctor’s office to begin with.

In summary, our challenge is not just to obtain information about proposed medical
treatments, tests, and procedures, it is to ensure that we really need them to begin with.
Do not automatically defer to every recommendation made by healthcare professionals.
We do need to trust and rely on the judgment of our physicians. Asking informed
questions, however, will not erode your doctor – patient relationship. It will enhance your
quality of care. And, it is all the better if your practitioner is aware of and on board with
the Choosing Wisely™ initiatives.

The next (second) part of this series will emphasize the role of a health care patient

  2. 3
  6. Bulger J, Nickel W, Messler J, et al. Choosing Wisely in adult hospital medicine: five opportunities for improved healthcare value. J Hosp Med. 2013;8(9):486-492
  7. Eaton KP, Levy K, Soong C, et al. Evidence-based guidelines to eliminate repetitive laboratory testing. JAMA Intern Med. 2017;177(12):1833-1839.
  8. Wheeler D, Marcus P, Nguyen J, et al. Evaluation of a resident-led project to decrease phlebotomy rates in the hospital: think twice, stick once. JAMA Intern Med. 2016;176(5):708-710.
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