The Patient Self-Determination Act: An Early Look at Implementation

The Patient Self-Determination Act has provoked a proliferation of print and electronic materials to assist facilities to implement it. Numerous articles have appeared in medical, nursing, and health care administration journals. Organizations such as the American Hospital Association and Choice In Dying have prepared materials to assist patients, health care facilities, and community groups.[1] Despite existing guidelines, facilities have enormous latitude as to how they implement the PSDA. They may use the act to improve patient decisonmaking, patient satisfaction, and quality of care. On the other hand, facilities may choose "paper compliance" with the act, thus having little or no influence on patient decision-making. If poorly implemented, the PSDA actually has the potentail to affect patient decisionmaking and quality of care negatively, especially for ethnic and racial minorities, the poor, the old, and those with dementia. Three themes have emerged with regard to how facilities implement the PSDA. These are: advocacy (the degree to which institutions seek to encourage the execution of advance directives), assignment of duties (who is responsible for implementing the PSDA), and centrality (the extent to which the PSDA is central to an institution's mission to deliver quality care).[2] Using these three themes as a basis of comparison, we report here on the experiences of voluntary hospitals and nursing homes in implementing the PSDA. In addition to reviewing the literature and speaking with people in several cities, in-depth interviews were conducted at each of seven facilities representing the five boroughs of New York City. Examination of the similarities and differences in the practices of these facilities is instructive in helping to frame the ongoing discussion as to the benefits and concerns surrounding the PSDA. Advocacy Advocacy has been described as the extent to which a facility encourages patients to execute advance directives.[3] Advocacy is a continuum that can include something as simple as giving all patients health care proxy forms and living wills, to a comprehensive education program aimed at encouraging patients to complete advance directives. The institution's intent in this regard is communicated in its overall mission statement, in its protocols for advance directives, and in the structure it selects for implementation of the PSDA. Institutions vary substantially in the degree to which they advocate for completion of advance directives. Facilities distinguish between advocating for effective patient education and advocating in favor of executing directives. We observed one hospital which both philosophically and operationally advocates in favor of executing a health care proxy. Another hospital was committed to assuring that the "patient's point of view" is heard. Still other hospitals provided extensive patient education but stopped short of advocating that patients execute a directive. Lastly, several facilities we examined, while in compliance with the PSDA, have chosen to provide minimum levels of patient education and not to advocate in favor of advance directives. Example 1. Anticipating the PSDA, the Patient Representative Department in Hospital A, a large medical center, conducted a pilot study to encourage patients to complete a health care proxy. When the PSDA was implemented, hospital administration endorsed the medical center's policy to "follow not only the letter of the law, but the spirit as well." Within forty-eight hours of admission, every patient (with the exception of certain units such as obstetrics, pediatrics, and psychiatry) is visited by one of twelve patient representatives. Patient representatives explain the proxy and offer assistance in complementing a proxy document. The representative makes copies of the proxy for the hospital record, the patient, and the family. Nurses, social workers, and physicians are taught to make referrals to patient representatives and can witness proxies on their own. …