When Technology Fails Patients at the End of Life

Before my current role at MyDirectives, I was a practicing nurse, working directly with patients every day. A few years ago, I helped a patient complete a Do Not Resuscitate (DNR) order. They had been clear and courageous about their wishes: no resuscitation if their heart stopped. But after being transferred to a skilled nursing facility, something tragic happened.

The DNR stayed in our local electronic health record (EHR), but it didn’t travel with the patient. When their heart stopped, staff at the new facility attempted resuscitation, leading to a hospital readmission. The patient died there, receiving the exact interventions they had explicitly declined.

This wasn’t a failure of compassion. It was a failure of systems.

We need better-connected healthcare ecosystems — ones that protect patients’ choices no matter where they go. Most people don’t receive all their care from one organization, and their records shouldn’t be trapped there either. That’s why health information exchanges (HIEs) were developed, to make medical histories available wherever care happens.

But here’s the problem: advance care planning (ACP) documents like DNRs, living wills, healthcare powers of attorney, or mental health advance directives are too often missing from those exchanges.

Now imagine an ecosystem where:

• All providers can create and store standardized digital ACP documents
• Patients can contribute their own digital directives
• All documents are available through a statewide HIE
• Emergency orders (like POLST or out-of-hospital DNRs) are automatically pushed to 911 and first responders

In this system, every stakeholder is aligned to honor patients’ values. The results?

✔️ Higher rates of ACP completion
✔️ Better comprehension of what ACP documents mean
✔️ Reliable access to documents across all care settings
✔️ Fewer unwanted — and often wasteful — interventions
✔️ Reduced readmissions and lower in-hospital mortality

This isn’t hypothetical. It’s already happening in several states. And I couldn’t be more excited to be part of it.

Americans are mobile. Healthcare is fragmented. It’s time our technology caught up to protect people across both realities. If you’re building — or dreaming of — systems like this, let’s talk. I really want to be in that conversation.

About the Author
Jessica Zan, RN, BSN, MAMFC, is Vice President of Clinical Implementations and Success at MyDirectives, where she leverages her expertise in advance care planning (ACP) to guide health systems in implementing effective, patient-centered ACP programs. With a background in clinical nursing and healthcare IT, she helps MyDirectives' customers navigate workflows, training, governance, and technical considerations to ensure seamless ACP adoption.

A passionate advocate for empowering individuals to take an active role in their healthcare, Jessica believes in the power of transparent conversations, well-structured documentation, and improved access to ACP records. Before joining MyDirectives in 2024, she pioneered a groundbreaking ACP program for a major health system in Oklahoma, which led to her leadership role in Epic applications. Her unique blend of clinical expertise, ACP innovation, and technical proficiency enables her to support organizations in integrating ACP solutions that enhance patient care and operational efficiency.

Jessica is a sought-after speaker on successful ACP implementation and continues to drive advancements that prioritize patient autonomy and meaningful healthcare decisions.