Source: https://www.wsha.org/our-members/projects/end-of-life-care-manual/section-1-advanced-directives-law/
Timestamp: 2020-02-26 09:11:18
Document Index: 299392692

Matched Legal Cases: ['§ 1395', '§ 1395', '§ 489', '§ 482', '§ 489', '§ 483']

Section 1: Advanced Directives Law - Washington State Hospital Association
Section 1: Advanced Directives Law
Specifically, the PSDA requires providers to inform patients of their rights, under state law, to make decisions about their medical care and the right to formulate advance directives. The PSDA defines an advance directive as a, “written instrument, such as a living will or durable power of attorney for health care, recognized under state law? relating to the provision of such care when the individual is incapacitated.” (2)
In Washington State, an individual’s right to control decisions involving their health care and to make an advance directive is codified in two places:
An individual’s right to control decisions involving health care via an advance directive is codified in the Natural Death Act in chapter 70.122 of the Revised Code of Washington.(3)
An individual’s right to control decisions involving mental health care by making a mental health advance directive is codified in chapter 71.32 RCW, concerning mental health advance directives.(4)
provide written information to each such individual concerning the individual’s rights under state law (whether statutory or recognized by the state’s courts) to make decisions concerning medical care including: the right to accept or refuse medical or surgical treatment, the right to formulate advance directives, and the hospital’s policies respecting the implementation of such rights;
document in the individual’s medical record whether or not the person has executed an advance directive;
educate staff on the facility’s policies and procedures concerning advance directives; and
provide for community education. The educational materials must inform the public of their rights under state law to make decisions about their medical care, the right to formulate advance directives, and the facility’s implementation policies concerning an individual’s advance directive.
If an individual is incapacitated at the time of admission or is otherwise unable to articulate whether or not he or she has executed an advance directive, information about advance directives may be given to an individual’s family or surrogate.
A: If an individual is incapacitated at the time of admission and is unable to receive information or articulate whether or not she or he has an advance directive, the facility should give advance directive information to the patient’s family or surrogate to the extent that it gives other materials about policies and procedures to an incapacitated person’s family, surrogate, or other concerned person in compliance with state law.
A: Yes, both the hospital and the nursing home would be required to provide information on advance directives to the individual. The hospital discharge planner may provide the information on behalf of the nursing home, including the nursing home’s policies regarding advance directives, in the course of coordinating the transfer, but the nursing home would still be responsible for ensuring the individual received the information and to mark in the individual’s medical record whether or not she or he has an advance directive.
A: No. In fact, the PSDA specifically prohibits providers from conditioning care on whether or not an individual has executed an advance directive. The regulations make clear that the PSDA’s main intent is to ensure patients receive information about the right to accept or refuse medical or surgical treatment and about the right to formulate an advance directive.
Q: What constitutes minimally sufficient educational efforts in meeting the PSDA’s community education requirements?
A: The PSDA allows great flexibility in the level of community education it requires. At a minimum, a provider must be able to document its community education efforts. For example, photocopying a brochure or pamphlet that meets the community education requirements and was distributed to the public may be sufficient to show the community education requirement was met. Community education does not necessarily require the distribution of written materials and may be carried out in a variety of formats at the provider’s discretion (workshops, seminars, etc.).
A: No. A provider must meet it obligation to provide community education on advance directives. Under state law, a provider may conscientiously object to implementing an advance directive. However, a provider’s conscientious objection must be included in the provider’s policy and mentioned in both its community education materials and the materials distributed to individuals upon their admission to the facility.
In 2006 the legislature passed a statute directing the Department of Health to establish and maintain a statewide online health care declarations registry.(5) A person can upload directives onto a secure website and these directives will then be accessible to patients, personal representatives, and health care providers. Individuals may submit a health care directive, durable power of attorney for health care, mental health advance directive, or a POLST form.(6) The Department of Health’s website for the registry is located at http://www.doh.wa.gov/livingwill. A power point presentation for hospitals describing the website and how it works can be found at: WSHA Webcasts.
According the enacting legislation, the legislature intends the registry be consulted by providers in instances where there may be a question about the patient’s wishes and the existence of an advance directive might clarify the patient’s intentions. The registry does not create any new or distinct obligations for a provider or facility to ascertain the existence of a directive.(9) A provider is not subject to criminal or civil liability or sanctions for unprofessional conduct if the provider provides, does not provide, withdraws, or withholds treatment:
according to a patient’s health care declaration stored in the registry.(10)
These requirements apply to all Medicare or Medicaid participating hospitals. This includes: short-term, acute care, surgical, specialty, psychiatric, rehabilitation, long-term, children’s, and alcohol/drug treatment facilities, whether or not they are accredited. This rule does not apply to Critical Access Hospitals (see Social Security Act Section 1861(e)). Critical Access Hospitals and long-term care facilities are addressed later in this section.
In 1999 an interim final rule, called the “Patients’ Rights” Conditions of Participation for hospitals, became effective.(12) The Conditions of Participation for patients’ rights address hospitals’ obligations regarding advance directives and end-of-life care. The Centers for Medicare and Medicaid Services (CMS) finalized changes to the Conditions of Participation for Patients’ Rights standards in January 2007. The sections pertaining to advance directives, end-of-life care, and right to participation in treatment decisions are unaltered from the 1999 language.
The Conditions of Participation for Patients’ Rights relevant to end-of-life care and advance directives state that:
The CMS issued interpretive guidelines regarding the Conditions of Participation for Patients’ Rights.(14) These guidelines stress that, whenever possible, the hospital should inform a patient of her or his rights in a language the patient understands. The interpretive guidelines also state that hospitals must be sensitive to the communication needs of its patients. Hospitals must also comply with Civil Rights laws that ensure it will provide alternative communication techniques or aides for those who are deaf or blind, or take other steps as needed to effectively communicate with the patient. To comply with these guidelines hospitals may need to use large print materials, specialized programs to inform those who are deaf or blind, or utilize interpreters.
The Joint Commission addresses advance directives, end-of-life care, and surrogate decision-making in its Ethics, Rights, and Responsibilities Standards (RI). End-of-life care is also addressed in the Provision of Care, Treatment, and Services Standards (PC). The elements of performance that accompany the standards direct hospitals to provide patients with information about their right to accept or refuse medical treatment, including forgoing or withdrawing life-sustaining treatment or withholding resuscitative services. Specifically, information must be provided upon admission on the extent to which the hospital is able, unable, or unwilling to honor advance directives. Information should be conveyed in a way that is appropriate to the patient’s age, understanding, and language.
The Joint Commission defines an advance directive to include living wills, durable powers of attorney, do-not-resuscitate orders, right to die, or similar documents listed in the Patient Self-Determination Act which express the patient’s preferences. Though the Joint Commission’s accreditation standards do not specifically address mental health advance directives, these directives fall under the obligations laid out in the Patient Self-Determination Act.
document the existence or absence of a patient’s signed advance directive;
document and honor, within the limits of the law or hospital capacity, a patients’ wishes concerning organ donation;
Development of a plan for care, treatment, and services is individualized and appropriate to the patient’s needs, strengths, limitations, and goals.
Washington Administrative Code 388-97-065, entitled “Advance Directives,” outlines requirements for nursing homes. These requirements are similar to those under the Patient Self-Determination Act, discussed at the beginning of this section. The term “advance directive” in this chapter of the WAC refers to any document indicating a resident’s choice with regard to a specific service, treatment, medication, or medical procedure option that may be implemented in the future. Examples of advance directives include a durable power of attorney for health care, a health care directive, a limited or restricted treatment order, and a DNR. Though mental health advance directives are not specifically referenced, nursing homes are directed to carry out the WAC in accordance with applicable state law. As mental health advance directives are state law, they are probably included in nursing homes’ obligations regarding advance directives.
inform the resident in writing and orally, at the time of admission and as necessary thereafter, in language and words the resident understands, of the resident’s right to make health care decisions and the nursing homes policies and procedures concerning implementation of advance directives;
review the resident’s advance directive at the resident’s request, when the resident’s condition warrants review, and when there is a change in condition.
A resident’s advance directive might conflict with nursing home procedures and policies (which must be consistent with state and federal law). If this occurs, WAC 388-97-065 requires the nursing home to inform the resident of the procedures or policies that would preclude the home from implementing the resident’s advance directive. The resident must be provided with written policies and procedures that explain the circumstances under which the resident’s directive will or will not be implemented by the nursing home. The nursing home should meet with the resident, discuss the conflict, and implement a plan to carry out the resident’s wishes to the fullest extent possible. This plan should be attached to the advance directive and placed in the resident’s chart. If the resident chooses to seek care elsewhere where his or her directive will be fully honored, the nursing home must assist the resident in locating other appropriate services.
fully inform residents in advance, in language and words they understand, about care and treatment and of any changes in care or treatment that may affect residents’ well-being; and
document any refusal of care in the resident’s comprehensive plan of care.
Patient Self-Determination Act, 42 U.S.C. § 1395cc (2000).
42 U.S.C § 1395cc(f)(3).
A health care advance directive (aka a living will) expresses a competent individual’s preferences regarding the withholding or withdrawal of life-sustaining treatment if terminally ill or permanently unconscious, see RCW 70.122. A durable power of attorney for health care appoints an agent to provide informed consent for health care decisions on behalf of the individual who executed the directive, see RCW 11.94.
A mental health advance directive expresses a competent individual’s preferences and instructions regarding his or her mental health treatment in the event of incapacitation. The directive may also appoint an agent to make decisions on behalf of the person who executed the directive.
Refer to 42 C.F.R § 489.102 for details regarding hospitals’ obligations to educate patients and the community, have written policies, ensure compliance with state law, make timely inquiries regarding whether a patient has an advance directive.
42 C.F.R § 482.13(b).
“For the purpose of this part, advance directive means a written instruction, such as a living will or durable power of attorney for health care, recognized under State law (whether statutory or as recognized by the courts of the State), relating to the provision of health care when the individual is incapacitated.” 42 C.F.R § 489.100.
CMS State Operations Manual, Appendix A – Survey Protocol, Regulations and Interpretive Guidelines for Hospitals (Rev. 1, 05-21-04) A-0038 – A-0052.
Washington’s Natural Death Act allows health care facilities or personnel to refuse to participate in the withholding or withdrawing of life-sustaining treatment due to moral or ethical objections. Patients must be informed of this policy or practice when the provider or facility becomes aware of the existence of a directive. RCW 70.122.060(2) & (4). Washington’s Mental Health Advance Directive law also allows providers and facilities to decline to follow a patient’s directive, but this must be clearly conveyed at the time the provider or facility receives the directive. RCW 71.32.150(5)(a). Refer to Section Two on Mental Health Advance Directives for further information.
42 C.F.R § 483.10.
CMS State Operations Manual, Appendix PP – Guidance to Surveyors for Long-Term Care Facilities (Rev. 22, 12-15-06) and Appendix W – Survey Protocol, Regulations and Interpretive Guidelines for Critical Access Hospitals (CAHs) Swing-Beds in CAHs (Rev. 02-21-04).