By John C. Wallin
Understanding and incorporating a patient’s right to make decisions about their plan-of-care plays an integral role in overall health care outcomes. Honoring end-of-life choices in ambulatory settings is complex, since determination whether a health care organization will venerate a patient’s choice may vary based on services provided and specific patient populations served. It is also challenging for health care organizations to balance patient rights against possible ethical challenges.
Protecting patients’ rights to advanced directives is not new. Decades ago, The Patient Self Determination Act of 199O highlighted patients’ rights by amending titles XVIII (Medicare) and XIX (Medicaid) of the Social Security Act. The amendment required hospitals, skilled nursing facilities, home health agencies, hospice programs and health maintenance organizations to inform patients of their rights, under state law, to make decisions concerning their medical care.1
Almost 20 years later, in 2009, Centers for Medicare and Medicaid Services (CMS) revised Conditions for Coverage (42 CFR § 416.50) progressing patients’ rights further by requiring ambulatory surgery centers (ASCs) to query all patients about advance directives and to provide information about their policies on advance directives and applicable state law. Furthermore, the document stated that ASCs must provide patients with official state advance directives forms, if requested.2
The Joint Commission defines an advance directive as a document or documentation allowing a person to give direction about future health care or to designate another person(s) to make health care decisions if the individual loses decision-making capacity. Advance directives may include:
- Living wills – generally describe an individual’s wishes regarding end-of-life care, should they become permanently unconscious at the end of a terminal illness. An advance directive, while similar to a living will, is not limited to a terminal illness. It may also apply to events, such as a stroke, dementia or coma which leave the individual unable to communicate their wishes.
- Durable powers of attorney – allow the individual to name an individual as a medical decision-maker on their behalf if they lose the ability to make their own decision.
- Do-not-resuscitate (DNR) orders – instruct medical staff not to enact life-saving measures, such as cardiopulmonary resuscitation or an automated external defibrillator.3
Patients receiving care in an outpatient setting may have completed one or more of these types of patient directive documents. Therefore, it is important that staff and practitioners providing care are familiar with various forms of advanced directives that may impact how care is provided within their settings. Because laws and regulations vary from state to state, ASCs should work closely with their legal counsel to determine what types of directives are available. Such decisions should be considered legal and enforceable.
Physicians must respect a patient’s wishes, since advance directives are legally recognized documents, however, they can refuse to comply if they consider the directives to be an objection of conscience or deem the patient’s wishes medically inappropriate. Health care organizations are required to create written policies that specify whether they will honor advance directives and provide those documents to patients, upon request.
Honoring end-of-life choices is particularly challenging in ambulatory surgery and procedural settings. Patients receiving care in these facilities are generally undergoing “elective” procedures which are often performed under moderate or deep sedation or anesthesia. Medications used during such procedures may induce side effects or adverse reactions that, if untreated, could potentially be life-threatening. However, such untoward reactions are often easily treated using non-invasive advances, such as the administration of reversal agents or short term ventilatory support.
Patients whose advance directives indicate that they do not want any life-saving measures enacted under any circumstance, force health care organizations and practitioners to determine whether they will comply with such choices. Therefore, informing patients of the health care organization’s advanced directives policies is a critical step in assisting a patient with the choice to proceed with a procedure or not. Discussions about advanced directives need to occur when the patient is most receptive to making an informed decision about whether to proceed with a procedure.
Other settings, such as dialysis centers caring for end stage renal failure patients or oncology infusion/radiation services, present different challenges. Often patients receiving care in these settings have chosen to forego any life-saving interventions should a life-threatening event occur while receiving care. Again, health care organizations should share written information about their policies with patients and their family members, including a description of applicable state health and safety laws, and if requested, official state advance directive forms.
In settings where a patient’s choice will be honored, staff should know the patient’s wishes and be prepared to support them, should such an event occur. Health care organizations may wish to consider organizing a support team to respond to such events. In addition to nursing, staff from social services, pastoral care, medical staff and leadership could be considered as members of such a team.
In summary, health care organizations must establish policies and procedures that address patient self-determination decisions that may impact the organization’s ability to provide care, treatment or services in a manner consistent with patient choice.
Understanding state-specific regulatory requirements and educating staff and practitioners is key to consistent, compliant advanced directive implementation. Health care organizations can take the following steps to ensure their facility is prepared:
- Involve nursing and medical leadership and staff responsible for regulatory and accreditation compliance in the development of advanced directive policy and procedures.
- Identify staff who are responsible for providing information to patients regarding their advanced directive rights.
- Communicate through identified staff the facility’s position on advance directives and explain to each patient whether theirs will be met.
- Work with legal counsel to determine both state and federal regulatory requirements.
For questions regarding Joint Commission accreditation requirements, please send standards-related questions via the online question submission process: http://web.jointcommission.org/sigsubmission/sigquestionform.aspx.
John C. Wallin is associate director of the Standards Interpretation Group at The Joint Commission
1 https://www.congress.gov/bill/101st-congress/house-bill/4449
2 https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/r56soma.pdf
3 https://www.nationwide.com/lc/resources/investing-and-retirement/artictles/advance-directive-vs-living-will
