title: TRIAD II: do living wills have an impact on pre-hospital lifesaving care?
abstract: BACKGROUND
  Living wills accompany patients who present for emergent care. To the best of our knowledge, no studies assess pre-hospital provider interpretations of these instructions.
  
  
  OBJECTIVE
  Determine how a living will is interpreted and assess how interpretation impacts lifesaving care.
  
  
  METHODS
  Three-part survey administered at a regional emergency medical system educational symposium to 150 emergency medical technicians (EMTs) and paramedics. Part I assessed understanding of the living will and do-not-resuscitate (DNR) orders. Part II assessed the living will's impact in clinical situations of patients requiring lifesaving interventions. Part III was similar to part II except a code status designation (full code) was incorporated into the living will.
  
  
  RESULTS
  There were 127 surveys completed, yielding an 87% response rate. The majority were male (55%) and EMTs (74%). The average age was 44 years and the average duration of employment was 15 years. Ninety percent (95% confidence interval [CI] 84.6-95.4%) of respondents determined that, after review of the living will, the patient's code status was DNR, and 92% (95% CI 86.5-96.6%) defined their understanding of DNR as comfort care/end-of-life care. When the living will was applied to clinical situations, it resulted in a higher proportion of patients being classified as DNR as opposed to full code (Case A 78% [95% CI 71.2-85.6%] vs. 22% [95% CI 14.4-28.8%], respectively; Case B 67% [95% CI 58.4-74.9%] vs. 33% [95% CI 25.1-1.6%], respectively; Case C 63% [95% CI 55.1-71.9%] vs. 37% [95% CI 28.1-44.9%]), respectively. With the scenarios presented, this DNR classification resulted in a lack of or a delay in lifesaving interventions. Incorporating a code status into the living will produced statistically significant increases in the provision of lifesaving care. In Case A, intubation increased from 15% to 56% (p < 0.0001); Case B, defibrillation increased from 40% to 59% (p < 0.0001); and Case C, defibrillation increased from 36% to 65% (p < 0.0001).
  
  
  CONCLUSIONS
  Significant confusion and concern for patient safety exists in the pre-hospital setting due to the understanding and implementation of living wills and DNR orders. This confusion can be corrected by implementing clearly defined code status into the living will.
authors.affiliation: Department of Emergency Medicine, Hamot Medical Center, Erie, Pennsylvania 16550, USA.
authors.forename: Ferdinando L
authors.initials: FL
authors.lastname: Mirarchi
authors.forename: Stella
authors.initials: S
authors.lastname: Kalantzis
authors.forename: Daniel
authors.initials: D
authors.lastname: Hunter
authors.forename: Emily
authors.initials: E
authors.lastname: McCracken
authors.forename: Theresa
authors.initials: T
authors.lastname: Kisiel
mesh_terms: D000328:Adult; D000368:Aged; D015331:Cohort Studies; D003625:Data Collection; D003657:Decision Making; D004634:Emergency Medical Technicians; D005260:Female; D006801:Humans; D016224:Living Wills; D008297:Male; D008875:Middle Aged; D010414:Pennsylvania; D011361:Professional Competence; D016414:Resuscitation Orders; D028761:Withholding Treatment; D055815:Young Adult