A New and Safer Approach to End-Of-Life Care
Rushing with electric paddles towards a 55-year-old woman in cardiac arrest, Dr. Ferdinando Mirarchi, a young intern, was stopped by a nurse flashing a piece of paper. “No, don’t shock her. She’s a DNR, she’s a DNR,” the nurse shouted. DNR means Do Not Resuscitate.
“I thought I was a good intern, but I became paralyzed, and didn’t know what to do,” Dr. Mirarchi remembered.
“A cardiologist who was walking through the ICU and saw the commotion pushed me aside and shocked the woman’s heart,” Dr. Mirarchi said. “She came to and started talking to us. Had the cardiologist not been there, and I was left alone, she would have died.”
The woman, in fact, had a living will, instead of a “do not resuscitate” order, but the documents confused the staff and Dr. Mirarchi.
Fast forward a few years to a level 1 trauma center in Pittsburgh, where Dr. Mirarchi was a resident in emergency medicine attending to a 60-something unresponsive man. “The paramedics said he had an AD (advance directive) living will, but I wasn’t going to repeat the mistake I made as an intern, so I resuscitated him,” Dr. Mirarchi related. “I placed him on a ventilator and set up IV catheters.”
Dr. Mirarchi was preparing to transport the patient to the ICU, when a slightly built old woman appeared and announced her husband was an end-stage cancer patient. “She could no longer care for him at home since he was in great pain,” she explained. She needed help and she could tell he was dying.
“The woman in cardiac arrest when I was an intern wanted to be treated, but this man wanted to die naturally because of his pain from advanced cancer. Everyone involved at the hospitals assumed they were on top of each situation, but the patients couldn’t speak for themselves, and we were wrong. That often happens, which is very troubling,” Dr. Mirarchi added.
When ‘Medical Strangers’ Make Decisions About Your Life
Now an emergency and palliative medicine physician, Dr. Mirarchi categorized his two previous encounters as “medical stranger dangers.” Our doctors are often no longer in the hospital advocating for us, he stressed. Instead, we see “medical strangers.”
“No one is going to know what that patient wants anymore. It’s frightening,” Dr. Mirarchi said.
Living wills and other ADs are written, legal instructions regarding your medical care preferences if you can’t make choices for yourself. They’re supposed to help guide decisions for doctors and caregivers if you’re terminally ill, seriously injured, comatose, in the late stages of dementia, or at the end of life.
But – and this is a BIG BUT – Dr. Mirarchi revealed that these directives are “often misinterpreted because they approach patients’ medical care preferences from a negative perspective.” They’ll state under what conditions a patient doesn’t want to receive care, which can be understood differently by different health care providers.
As the lead investigator with TRIAD – a patient safety research series that studies the realistic interpretation of advance directives – Dr. Mirarchi learned that a living will can often lead to inappropriate and unsafe medical care on both sides of this care equation. Sometimes too much care; sometimes too little. If you’ll remember back to the start of this article, that almost happened when he was a resident.
The statistics are staggering:
When medical providers look at ADs, 80% of the time they’ll assume these written directives mean Do Not Resuscitate. It’s almost 90% with nurses and above 90% with paramedics, multiple TRIAD studies repeatedly showed.
“If you’re critically ill, can the clinical staff taking care of you properly assess how your AD relates to your distinct situation?” Dr. Mirarchi asked. Based on his studies, it’s highly unlikely it can.
Aiming to eliminate the disparity between ADs and the actual treatment patients receive when critically ill or at the end of life, Dr. Mirarchi created MIDEO Health, a video-based advance care planning platform. “I knew I had to approach the solution from a technological perspective,” he added.
Making Sure to Honor Your End–Of–Life Wishes
MIDEO advance care plans on video are easily created in consultation with physicians. The videos are designed to eliminate confusion and prevent misinterpretation of care directives so our wishes concerning critical illness (desiring care) and end-of-life care (wanting a natural death) are honored.
“MIDEO is patient centered. We analyze each person’s current state of health and provide disease specific advance care planning. By customizing every plan, we ensure that what’s right, safe, and effective for patients is clearly understood by the ‘medical strangers’ viewing the videos. This is a non-traditional approach,” Dr. Mirarchi stressed. Most systems simply want you to prepare documents, and have you become comfortable with death. MIDEO wants to assure you will avoid being harmed because a medical stranger misinterpreted your documents.
To ensure a seamless process, MIDEO creates a prescription for your care and gives you a script to read when you film your video with its phone app.
The video is one component of the service. You’ll receive three MIDEO ID cards, one with a magnet. The cards contain identifying information, including your date of birth, the name and phone number of your healthcare proxy, and your “code status,” which is how you’d want to be treated.
You keep one card in your wallet with your driver’s license and give one to your healthcare proxy. The card with the magnet is for the side of the refrigerator, where paramedics often are trained to look for advance directives when they can’t communicate directly with the patient.
The MIDEO fulfillment team also coordinates with your primary care physician and hospital’s medical records department to insert your info into their electronic medical records online. And, if you have an attorney who created an estate plan for you, MIDEO will contact him or her.
“We now have patients in 43 states and five countries and are seeing really good results with patients using our system,” Dr. Mirarchi said. “And we’re constantly visiting hospital administrators to increase the MIDEO adoption rates, so it becomes the norm.” We do not charge health care systems to access your info or to use the MIDEO system.
Dr. Mirarchi stressed that MIDEO isn’t trying to remove your existing directives or medical orders, but to make sure they clearly reflect your current wishes. Paper-based legal documents or medical orders do not adequately perform the job.
The MIDEO Process,, Price,, and Practicality
The MIDEO Package, designed for those with multiple medical problems or aged 60 and above, is $349, which is covered by Medicare. A year after your information is in the system a $10 annual fee guarantees that your video is secured in MIDEO’s servers 24/7 365 days a year.
The MIDEO Package includes:
- A guided process and healthcare evaluation by a trained physician.
- Education and counseling according to your unique needs.
- A customized MIDEO statement- the prescription for your care – that is recorded and validated for quality, safety, and compliance.
- Step-by-step instructions from a live concierge to assist with the MIDEO software before, during and after the consultation.
Once you’re in the MIDEO system, your file is entered into a cycle, and the company decides when to see you again based upon your risk assessment. “We don’t need to see you back if there are no changes in your status, but we still need to periodically update your file,” Dr. Mirarchi explained.
Dr. Mirarchi advises creating a MIDEO advance care plan on video any time you experience a life-changing event, including marriage; having children; buying life insurance; being diagnosed with an illness, and having a stroke.
Don‘t let a “medical“ stranger” decide how you‘ll live. A Mideo advance care plan on video ensures you‘re treated precisely how you wish.
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