A living will misinterpreted as a DNR order: confusion compromises patient care.

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.

Objectives: 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.

Case Report: 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.

Conclusion: 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.