Better Than Paper: MIDEO Offers the Next Step in Digital Advance Care Planning
In a recent article, Hospice News highlighted the benefits of advance care planning, but also revealed the truth that your plan only helps if clinicians can understand it quickly at the bedside during medical emergencies.
That’s the part Dr. Ferdinando Mirarchi, an emergency physician and founder of MIDEO Health, has been focused on for years. In the Hospice News piece, he warns that traditional documents can be misinterpreted, sometimes dramatically, because the structure, labeling, and context aren’t always clear at the bedside. Add in multiple clinicians across specialties, and the same advance directive form can be read in different ways, especially during time-pressured decisions.
The risk is that an advance directive can be misread as “do not treat”
Advance care planning is supposed to reduce unwanted care by making your wishes clear. The problem is that many clinicians don’t consistently interpret an advance directive the way patients think they will.
He points to a troubling pattern shown across multiple studies where physicians may look at an advance directive and misinterpret it as a do-not-resuscitate order.
“Many studies have shown that physicians will look at an advance directive and because of a structure, format, and labeling, it gets misinterpreted as a do-not-resuscitate order 80% of the time,” explains Dr. Mirarchi.
In other words, a document meant to guide treatment choices can be mistakenly read as a signal to withhold treatment, and unfortunately, that happens more often than being read correctly.
Let’s be clear: The misread isn’t usually malicious. It’s often about the structure and labeling of the advance care planning document, combined with time pressure and the shortcuts humans take when they’re trying to make fast decisions. So, if a form is vague, checkbox-heavy, or framed in a way that sounds like end-of-life-only language, some providers may mentally collapse it into “comfort-only,” even when that isn’t what the patient intended.
But Dr. Mirarchi also warns that the mistakes that happen can also result in patients being over treated and prevented from dying naturally when that was their true intention.
There are times at hospital and medical care settings where too many clinicians are involved, and each may interpret the same advance healthcare directive differently. For example, a neurologist, a family medicine doctor, and an emergency physician may all read the same advance directive form through different clinical assumptions.
In practice providers may not always stop to confirm the patient’s intent with the patient or the health care agent and they may assume their interpretation is the right one. “Medical professionals often assume that what they’re thinking is the best thing to do for that particular patient,” Dr. Mirarchi says.
This doesn’t mean that you shouldn’t complete an advance directive form. It’s actually the opposite. You should have an advance directive, but it must be done in a way that it becomes impossible to misread and safe for you.
When an advance directive isn’t there when it’s needed
Okay…so you have a perfectly written advance directive that can’t be mistaken in any setting. That’s great! So, you’re all good, right?
Wrong!
Even the best-written advance directive can’t guide care if nobody can find it when it’s most needed.
The truth is that clinicians are often unaware that an advance directive exists, or they can’t access it quickly because it’s still on paper or stored outside the workflow of the electronic medical record.
Dr. Ferdinando Mirarchi points out that this “missing document” problem is common because so many advance directive forms are in a folder at home, a lawyer’s office, or a facility binder that doesn’t travel with the patient from healthcare center to medical facility.
These are exactly the settings where paper advance directives aren’t as effective. Just consider how care happens across settings. It could start with a hospital admission, become a transfer to rehab, mix in a return to the ED, followed up by a new specialist visit.
Because there was so much shuffling around, the care team may not have the right advance healthcare directive in front of them (or any advance directive form at all).
This highlights why “completing the form” isn’t the finish line. An advance directive form that works during medical emergencies has to be both understandable and retrievable. The truth is that healthcare systems can’t reliably follow what it can’t reliably access.
Why the same advance directive gets read differently
As we mentioned above, multiple healthcare specialists are often providing care for the same patient, and each can interpret the patient’s advance directive in a different way.. In emergency situations, it can change what gets done, what gets delayed, and what gets debated.
Different clinicians bring different mental models. Some may view an advance healthcare directive primarily through prognosis and long-term outcomes. While others, especially in emergency room settings, are forced to make rapid decisions with limited context. Under that time pressure, a vague phrase or checkbox on an advance directive form can get translated into a bigger conclusion than the patient ever intended.
Some of this falls on the healthcare provider. Too often, they don’t ask the patient or their health care agent to clarify the intent around their wishes. Instead, they may assume their interpretation is correct. But it is in those assumptions why inconsistency happens.
So what does that mean when you are going about creating your personal advance directive. Ask yourself if multiple specialists read your directive if they could come away with different conclusions. If so, your current document isn’t doing its job.
Training helps, but it won’t solve the problem by itself
Improved education for medical professionals matters when it comes to advance directive interpretation, but its impact only matters so much. Most medical and nursing students get little to no meaningful exposure to advance care planning or goals-of-care conversations during training. So yes—better education is needed.
Research suggests education gains are modest, somewhere on the order of a 5% to 8% improvement. That’s meaningful, but it also means the majority of the problem still remains because people are human and clinical environments never stop moving.
While improving education is great, it doesn’t fully remove the core risk that an advance directive will be misinterpreted or inaccessible.
This is why advance care planning has to be more than theoretical. It needs to be something that can actually be used at bedside
So, the goal isn’t to choose between education and better tools. The goal is both.
What is a “resuscitation pause,” and how can it provide a safeguard to protect patient wishes?
A “resuscitation pause” can be used as the final safety check before a high-stakes decision, similar to how surgical teams pause to confirm the right patient, procedure, and site.
In this case, the pause is a deliberate moment for the team to ask: “Is there an advance directive?” “Is there a health care agent?” and “Do we have anything that clarifies the patient’s goals of care?”
This matters because in the ER, medical teams often default to “what feels safest clinically,” even if it isn’t aligned with the patient’s preferences. A resuscitation pause creates space in just a few seconds to confirm whether there is an advance healthcare directive, where it is, and who can speak for the patient. Done consistently, it reduces the chances that decisions get made without the appropriate knowledge.
The challenge, of course, is that a pause only works if the information is actually retrievable. If the advance directive form is in a binder at home, buried in an old chart, or unclear enough that it sparks debate, the healthcare team is still left improvising.
It’s not enough to ask whether the document exists. The system also needs a reliable way to access and understand it in real time.
Why technology has to solve advance directive clarity and access
While advance care planning improves outcomes, the weak link is still the document itself. If health care systems can’t reliably build operational safeguards into clinical emergencies, then we need technological safeguards that perform better than paper.
The truth is, paper advance directives aren’t enough. “You have got to have a better option than paper in the 21st Century,” Dr. Mirarchi insists
A modern advance healthcare directive has to do more. It has to be:
- Clear enough to reduce interpretation
- Fast enough to influence decisions in real time
- Portable enough to travel across settings and transitions
- Consistent enough that the patient, proxy, and clinicians are all looking at the same version
This is exactly what MIDEO was built for. It takes the legally compliant advance directive form and strengthens it by using the patient’s own voice and intent, delivered in a digital format clinicians can access quickly when the stakes are highest.
The best time to create your advance directive is before you need one
When you choose MIDEO for your video advance directive, you still complete the legally compliant documentation, but you also record your wishes in your own words so clinicians aren’t forced to interpret your intent. And because it’s accessible from a smart phone, Ipad, or any digital device when it counts, your advance healthcare directive is available in seconds.
If you’ve been meaning to create an advance directive, don’t wait for a hospital admission, a rehab transfer, or a family emergency to force the issue. Create it now while you are in control.
