2016 Advance Directive Update For questions contact: Weddy Balmaceda, MSN, RN-BC, CCRN, CCDS Professional Development Ext. 5241

Source: RBMC policy and procedures

PolicyName:

Department:

AdvanceMedicalDirective

Nursing

Version: 3 StartDate: 9-19-2016 ApprovalDate: 9-19-2016

Approvers:

1. JoanHarewood

3. RosalieGrantoza

2. Dr.Ciencewicki

4. DebbieMahoney

PrimaryOwner: JoanHarewoodandDr.Ciencewicki Owners: 1. Dr.Ciencewicki

3.

2. DeniseGalasso

4.

5. JoanHarewood

6.

ContributingDepartments: 1. 2.

3. 4.

AdvanceMedicalDirective AdministrativePolicy

DocumentNumber: MHS-ADMIN-01-1046Revision #: v3 DocumentOwner:RiskManagementDate LastUpdated: 12/03/2015 Author:SeniorVPandChiefRiskOfficerStatus: ApprovedandReleased

GeneralDescription Purpose: 1. Tohonortherightofpatientswiththecapacitytomakehisorherownmedical

treatmentdecisions,includingdecisionsthataremadeprospectivelyintheform ofanAdvanceMedicalDirective (LivingWill). 2. Toprovidebothanatmosphereandaprocessforpromotingapatient'srightto self-determinationregardinghisorherhealthcareandtreatmentcourse, includingtherighttoacceptorrefusetreatment. 3. ToassistinestablishinguponAdmission/Registration,orassoonaspractical thereafter, futuretreatmentguidelinesintheeventthatapatientisnolongerable tomakehealthcaredecisionsforhim/herself.

Scope: AllsitesandfacilitiesofMeridianHealthanditssubsidiarycompanieswhere

inpatient/observationandoutpatientmedicalservicesareprovided, including MeridianHospitalsCorporationanditsdivisionalhospitals.

Policy: ItisthepolicyofMeridianHealthtorespecttherightofeachpatienttoparticipatein

healthcaredecisionsandtodirecttreatmentdecisionsthroughpreparationofan AdvanceMedicalDirective (AMD)or "LivingWill."Therefore,itisthepracticeat allMeridianHealthfacilitieswhereinpatient/observationandoutpatientmedical servicesareprovided,toinquireastowhetherornotanadultpatient, 18yearsofage orolder,hasanAMD.PatientswhodonothaveanAMDwiththemupon registrationoradmissionwillbeofferedinformationaboutAMDsandassistance

shouldtheydecidetoprepareone.AvalidAMDmaybeutilizedbycaregiversand surrogatedecisionmakerstodeterminethewishesofapatientregardingmedical treatmentdecisionswhentheAMDisonthemedicalrecordandwhenthepatientno longerhasthecapacitytomakesuchdecisions. PROCEDURE A.InpatientRegistration/Admission 1. Atthetimeofanadultinpatient/observationregistrationand/oradmission,the MeridianTeammembercompletingtheregistrationand/oradmissionassessment, willinquireanddocumentwhetherornotthepatienthasanAMD.Allpatients willbeprovidedwritteninformationabouttheirrighttocompleteanAMDand describingMeridianHealth'spolicywithregardtoAMDs.

2. IfthepatienthasanAMDandacopyisavailable, itwillbeplacedinthemedical record. 3. IfthepatienthasanAMDbutacopyisnotavailable,thepatientand/orfamily memberwillbeinformedthatinordertobecomeoperative,thedocumentMUST beaffixedtothemedicalrecordandthatacopyoftheAMDshouldbeprovided Ifacopyisnotprovideduponinitialrequest, asecondrequestwillbemadeof thepatientand/orfamilymember.Nursingstaffand/orpatientrepresentatives willberesponsibleforthiseffort. 4. IfthepatienthasanAMDbutthecopyisintheMedicalRecordsDepartment fromaprioradmissionandnochangeshavebeenmadebythepatientsubsequent tothatadmission,acopyoftheAMDshallbemadeandplacedinthecurrent medicalrecord.Nursingstaffand/orpatientrepresentativewillberesponsiblefor thiseffort.ThemostcurrentAMDshouldreflectthepatient'scurrentwishes shouldhe/shelosethecapacitytomakemedicaltreatmentdecisions. 5. IfthepatienthasanAMDbutacopycannotbeobtained,thepatientwillbe offeredtheopportunitytoprepareanewAMD. 6. IfthepatientdoesnothaveanAMD,orwishestomakeanewAMD,he/shewill beadvisedoftheprocesswherebyassistancemaybeobtainedtoformulatean AMD. 7. TheAMDwillremainapermanentpartofthemedicalrecordforeachadmission. 8. Theadvancedirectiveinquirywillbedocumentedinadesignated, central locationinthemedicalrecordtoensureallclinicianshavereadyknowledgeof theexistenceofanadvancedirectiveandreadyaccesstothedocument,if provided.

9. Theattendingphysicianshallbemadeawareoftheexistenceofanadvance directive & healthcarerepresentativeviatheabovedocumentationinthemedical recordorviaanindependentinquiryprocess.Asdeemedappropriate, the attendingphysiciancanmakeanindependentaffirmativeinquiryofthepatient,

hisfamilyorothers, concerningtheexistenceofanadvancedirective & documentsameinthemedicalrecord. B.InpatientImplementation 1. AnAMDbecomesoperativeonlywhenthepatientlacksdecisionmaking capacitytomakeinformedhealthcaredecisions.

2. TheAttendingPhysicianshallmakeanassessmentofthecapacity, andifthe patientisdeterminedtolackcapacity,itwillberecordedinthemedicalrecord. TheAttendingPhysicianwillnotifythepatient'ssurrogatedecisionmakerand/or familyofthisdetermination. Whencapacityisindoubt,thedeterminationshould beconfirmedbyanotherphysician. 3. IftheAttendingPhysiciandeterminesthatapatientlackscapacitybecauseofa mental,psychologicalordevelopmentalimpairmentordisability, theassessment shallbeconfirmedbyoneormorephysicianswithspecializedtraininginthese areas (e.g.;psychiatristorneurologist) andthedeterminationwillberecordedin themedicalrecord.

4. Aphysiciandesignatedassurrogatedecisionmakerbythepatient'sAMDmay notparticipateinadeterminationofcapacity. 5. Ifitisdeterminedthatthepatientdoeslackcapacity,theAttendingPhysician mustinformthepatientthathe/shehasbeendeterminedtolackcapacitytomake healthcaredecisions. 6. IfasurrogatedecisionmakerhasbeendesignatedpursuanttoanAMD,the physicianwillalsoadvisethesurrogatethatthepatienthasbeendeterminedto lackcapacity. Thesurrogatedecisionmakerwillthenbecontactedforallmedical decisionsuntilsuchtimeasthepatientmayregaincapacity.Ifthereisan instructiondirectiveintheAMD,theinstructiondirectivewillbereviewedwith thesurrogateandappropriatetreatmentimplementedwiththesurrogate’s informedconsent.Ifnosurrogatehasbeendesignated, itisprudenttonotifythe patient'sfamily,ifany,aswell. 7. Ifthepatientdesignateshis/herspouseordomesticpartnerasahealthcare representative, itshallberevokedupondivorceorlegalseparationortermination ofthedomesticpartnership. 8. ApatientmaysuspendanAMDorally,inwritingorbyanyotheractevidencing intenttorevokethedocumentandmayreinstatetheAMDinthesameways. 9. WhenanAMDbecomesoperative, theAttendingPhysicianwillstrivetofollow theinstructionsofthepatientasindicatedintheAMD.Ifanethicalconflict develops, theAttendingPhysicianmustinformthesurrogatedecisionmaker (and patient'sfamilyifappropriate) oftheconflict(s).Ifaseriousconflictdevelops, thephysicianmaywithdrawfromcareofthepatientaftereffectingtransferof caretoanotherphysician.

10Whenthereisnosurrogatedecisionmakerorfamilytoconsult, treatmentbased solelyonthepreferencesexpressedintheAMDwillbenotedinthemedical record.

C.InpatientConflictResolution 1. Intheeventofanydisagreementamongthepatient,family,surrogatedecision maker/healthcarerepresentative/proxy,healthcareproviderorattending physician, concerningthepatient'sdecisionmakingcapacityortheappropriate interpretationandapplicationofthetermsofanAMDtothepatient'scourseof treatment, thesepartiesshouldseektoresolvethedisagreementbymeansof communicationamongsteveryoneinvolved.Considerationshouldbegivento consultingtheBioethicsCommitteeasameansoffacilitatingresolutionofthe conflict(s). RefertoPolicyonEthicalIssuesinPatientCare.) (

2. ABioethicsCommitteeconsultationcanberequestedbyanypatient,family member,surrogate, nurse,physicianorbyotherdirectpatientcareproviders. 3. Healthcareprofessionalsmaydeclinetoparticipateinwithholdingor withdrawingoflifesustainingmeasuresonthebasisofsincerelyheldpersonalor professionalconvictions. Insuchcases, thehealthcareprofessionalshallfacilitate theappropriate, respectfulandtimelytransferofthepatient'scareinorderto respecteveryone's concerns. D.OutpatientAdvanceMedicalDirectives Inquiry/Documentation

1. Inquirywillbemadeofadultindividualsreceivingoutpatientcareinthe EmergencyDepartment, surgicalServices, Hemodialysis (excludingchronic dialysis), oranydepartmentadministeringAnesthesia (excludingminor conductionblock) regardingtheexistenceandlocationofanadvancedirective. 2. TheMeridianstaffmemberconductingtheinquirywilldocumentinthemedical recordifthepatienthasanadvancedirective. Ifthepatienthasacopyofthe advancedirective,itwillbeplacedinthemedicalrecord.

3. Patientsandfamilieswillbemadeawareoftheirrightsregardingadvance directivesviawritteninformationprovidedtothem. 4. Uponrequest,thehospitalwillprovideresourcesforassistancewithformulating advancedirectives.

5. Twiceduringacalendaryear, (i. e.JanuaryandJuly)areviewofallexisting AMD willbemade. ThosepatientswhohaverequestedtochangetheirAMDwillbe broughttotheattentionofthepatient'sphysician. ThePhysicianwillberequested toreviewthesechangeswiththepatient.Thechangesarethentobedocumentby thePatient'sPhysician.

HonoringAdvanceDirectives

1. Thehospitalwillhonoradvancedirectivesintheoutpatientsettingwiththe exceptionofanyareaprovidingAnesthesiaServices (excludingminor conductionblock). 2. Thepatient/familymustprovideavalidcopyoftheadvancedirectiveatthetime ofservices.

ImplementationinApprovedOutpatientAreas 1.IfanAMDisavailabletothetreatingphysician/staff,and,ifthereisadequatetime toreviewtheAMDwithoutendangeringorneglectingthepatient,thephysicianand staffwillreviewtheAMDand,asmuchasisreasonablypossible,complywiththe patient'sexpressedpreferences. 2.Ifthepatientbecomesaninpatientfollowingoutpatientservices, inpatient procedures applyasoutlinedinthispolicy.

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Requirements PatientSelfDeterminationActof1990 (federal) NJAdvanceDirectiveforHealthCareAct,NJSA26:2H-53etseq. Title9.HealthandSeniorServicesChapter43G.HospitalLicensing Stnadards (N.J.A.C.8:43G). June2012 Relevant Knowled CentersforMedicareandMedicaidServicesFinalrulelNovember ge: 19,2010,42CFR482.13 TheJointCommissionChapterUpdate: RightsandResponsibilities oftheIndividual, StandardRI.01.05.01 (2012)l

2008ComprehensiveAccreditationManualforHospitals, Section1,PatientRights andOrganizationEthics

MeridianHealth Definitio AllMeridianHealthfacilitieswheremedicalservicesareprovided. ns:

ValidAdvanceMedicalDirective

Adatedwritingsignedordirectedbyapatientinthepresenceof twoadultwitnesseswhoshallattestthatthepatientisofsound mindandfreeofduressandundueinfluence. AnAMDisalsovalid ifthedocumentissignedandacknowledgedbeforeaNotary Public. AnAMDisnotvalidifitiswitnessedbyapersondesignated tomakehealthcaredecisionsforthepatient. AdvanceMedicalDirective (AMD) AwritingexecutedinaccordancewiththerequirementsoftheNJ AdvanceDirectiveforHealthCareAct.Itisawritteninstruction statingapatient'sspecificwishesregardingtheprovision, withholdingorwithdrawalofanyformofhealthcare,includinglife sustainingtreatment. AnAMDmayincludeone,oracombination ofthefollowing: a.InstructionDirective - Awritingprovidinginstructionsand directionsregardingthepatient'swishesforhealthcare. b.ProxyDirective (alsoknowasaDurableMedicalPowerof Attorney) - Awritingwhichauthorizesahealthcare representative/proxy/surrogatedecisionmaker,tomakehealth caretreatmentdecisionsforapatientintheeventthepatient subsequentlylacksmedicaldecisionmakingcapacity. DecisionMakingCapacity Apatient'sabilitytounderstandandappreciatethenatureand consequencesofahealthcaredecision, includingthebenefitsand risksofeachandalternativestoanyproposedhealthcareinorder tomakeaninformeddecision.

SurrogateDecisionMaker/HealthCareRepresentative/Proxy Theindividualdesignatedtomakehealthcaredecisionsona patient'sbehalfinaccordancewiththetermsandorderofpriority statedinanAdvanceMedicalDirective, LivingWill,orwiththe patient'spreviouslyexpressedwishes.

RelatedDocuments Thefollowingisalistofotherdocumentsrelatedtothecurrentdocument. Changesyoumaketothecurrentdocumentmayaffectthedocumentslisted. External N/A Related

Docume nts

RevisionHistory Revision #:

v2 09/11/2009 Startnewrevisionlevel. Revision #:

v3 09/21/2009 Startnewrevisionlevel. Revision #:

v4 01/08/2013 Edited Revision #:

v5 01/09/2013 policyreleased Revision #:

v3 12/03/2015 Startnewrevisionlevel.

ContributingAuthors Thefollowingaresubjectmatterexpertswhocontributedtothisdocument:

AssociateGeneralCounsel

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