title: A living will misinterpreted as a DNR order: confusion compromises patient care.
abstract: BACKGROUND
  Advance directives are becoming ever more commonplace in the United States. Correct interpretation of living wills and do-not-resuscitate (DNR) orders is essential if patient safety and autonomy are to be preserved.
  
  
  OBJECTIVE
  1) To recount a case in which a living will was misinterpreted as a DNR order; 2) To make known the ramifications of this misinterpretation; 3) To advocate for improved education of health care professionals regarding the interpretation and implementation of advance directives.
  
  
  METHODS
  Mr. S. is an 89-year-old nursing home resident who agreed to the terms of a living will. This living will was subsequently misinterpreted as a DNR order by the patient's physician. This misinterpretation set off a cascade of events that led to the completion of an out-of-hospital DNR order and a compromise of patient care.
  
  
  CONCLUSIONS
  This case study underscores the potential for misunderstanding of an advance directive and the consequent effect on patient care. Likely this is the result of a fundamental lack of understanding about the terminology and definitions inherent in an advance directive document.
authors.affiliation: Department of Emergency Medicine, Hamot Medical Center, Erie, Pennsylvania 16550, USA.
authors.forename: Antonios D
authors.initials: AD
authors.lastname: Katsetos
authors.forename: Ferdinando L
authors.initials: FL
authors.lastname: Mirarchi
mesh_terms: D000369:Aged, 80 and over; D006801:Humans; D016224:Living Wills / Q000331:legislation & jurisprudence; D008297:Male; D005791:Patient Care; D010820:Physicians; D012151:Resuscitation; D016414:Resuscitation Orders / Q000331:legislation & jurisprudence