Case Presentation:

A 65 year-old man with end-stage renal disease was brought to the Emergency Department (ED) when he developed confusion and shortness of breath at a skilled nursing facility (SNF).  He had a recent prolonged hospitalization for pelvic osteomyelitis and was discharged to the SNF 3 days before presentation.  In the ED, the providers felt that intubation was indicated for severe respiratory distress. The transferring Emergency Medical Technicians (EMTs) stated that the patient was full code. The team looked through the paperwork sent with the transfer and found no Physician Orders for Life Sustaining Treatment (POLST), a type of Advance Directive (AD).  There was an AD from 2013 indicating full code status, but a recent note from a SNF physician showing DNR/DNI. With ambiguity regarding goals, the patient unable to make decisions, and no surrogate decision-maker present, the patient was intubated.

Subsequently, it was discovered that a POLST was completed just days earlier. On the prior discharge, the form was not scanned into the electronic medical record (EMR).  The form itself was sent to the SNF, where a different AD is used as institutional policy.  The POLST was lost, and the outdated AD on file for this patient inadvertently used instead. On the day of his readmission, the SNF physician called a local ED to specify his DNR/DNI status prior to transport. That ED subsequently diverted ambulance traffic, and the patient arrived at our hospital. The transporting EMT had asked a SNF provider about code status, but the covering provider at the bedside was unaware of the details.  Lacking definitive documentation, the patient was signed out to the ED as full code, and the EMR showed only an anonymous “code 3” with an automatically populated “Full/Prior” code status, which is standard procedure for high acuity ambulance patients. Ultimately, the family was contacted, his true code status discovered, and the decision made to extubate with comfort measures.  He died four hours later.


Hospitalists commonly face ambiguity regarding goals of care. Designed to be portable, the POLST remains a paper form that can be lost in a digital world, creating potential for error. Medical errors are preventable adverse outcomes that occur during care, and they fall into two categories: latent errors embedded in systems, and active errors resulting from specific acts by individuals. The latent errors in this case include complex systems for updating ADs, lack of AD standards and interoperability, and anonymous charts for ambulance patients.


Digital health has the potential to address many of the latent errors in healthcare through improved systems, but as this case highlights, also introduces new latent errors built into the EMR. Hospitalists can help reduce these errors through coordinated efforts to make care transitions safer. Without standards and interoperability, the EMR may expose patients to latent errors that could violate even their most basic wishes.