Patient Rights and Organizational Ethics Documents

RI - Patient Rights and Organizational Ethics

RI001P	Withholding and Withdrawing Life-Sustaining Treatment Policy
Facility Type: Tertiary Referral Teaching Hospital - 376 Beds	Last JCAHO Survey: November 1997
Related Documents: Limited Treatment Plan Order Form
Downloadable or Viewable Documents: Withholding and Withdrawing Life-Sustaining Treatment Policy -Download in Word 97 format zipped in a self extracting file: RI001P.exe Limited Treatment Plan Order Form: RI001F.pdf
WITHHOLDING AND WITHDRAWING LIFE-SUSTAINING TREATMENT STATEMENT OF RATIONALE Your Hospitals has the capacity to provide patients with high quality, state-of-the-art, life-sustaining treatments. However, these treatments do not benefit all patients, nor do all patients desire such treatments. Therefore, it is necessary to establish a policy at Your Hospitals for withholding and withdrawing life-sustaining treatments. STATEMENT OF PURPOSE The purpose of this document is to describe the policy of Your Hospital with regard to withholding and withdrawing life-sustaining treatments and the procedure to be followed when life-sustaining treatments are withheld or withdrawn. GENERAL PRINCIPLES When decisions are made to withhold or withdraw life-sustaining treatment, the following principles shall apply: 1. Respect for patient autonomy is the primary basis for withholding and withdrawing life-sustaining treatment. Patients with decision-making capacity must be consulted about decisions to withhold or withdraw life-sustaining treatment, and they have a right to accept or refuse such treatment. While patients with decision-making capacity have a right to accept or refuse life-sustaining treatment, they do not has a right to receive treatment which falls outside the accepted standards of medical practice. 2. If a patient lacks decision-making capacity, the instructions written in a patient's advance directive, either a Living Will or Medical Power of Attorney, are to be followed provided they are consistent with accepted standards of medical practice. 3. When a patient who lacks decision-making capacity has completed a Medical Power of Attorney, the designated representative should serve as the surrogate decision-maker for the patient (i.e., the person to make decisions on the patient's behalf). When a patient lacks decision-making capacity and has not completed a Living Will or Medical Power of Attorney, a surrogate decision maker should be identified according to the WV Health Care Surrogate Act of 1993 to help make decisions on the patient's behalf regarding life-sustaining therapy. The attending physician is responsible for selecting a surrogate from among close family and friends according to criteria listed in the Checklist for Surrogate Selection farm. If the surrogate knows the patient's values and/or wishes, these decisions should be based on substituted judgment. If the patient's values and/or wishes are unknown, surrogate decision-making should be based on the patient's best interests. 4. A consideration of best interests (the balance of benefits and burdens offered by a treatment) is the primary basis for withholding or withdrawing life-sustaining treatment when the patient is a non-mature minor - an infant or child. In the case of an infant or child, it is presumed that the parents or legal guardians are the primary decision-makers on behalf of their child and will act according to the infant or child's best interests. If there is uncertainty or disagreement about what constitutes the child's best interests, it is recommended that the Hospital Ethics Committee be consulted. Parents do not have an unqualified right to refuse clearly beneficial treatment for their minor children or to require treatments that fall outside the accepted standards of medical practice. If the minor is emancipated or is determined to be mature, they should be the primary decision-maker concerning life-sustaining treatment. (See Policy 111.010 Informed Health Care Decision Making by Patients or Patient Surrogates and Policy IV.055 Do Not Resuscitate (DNR) 5. A physician's decision to withhold or withdraw life-sustaining treatment because it is of no expected benefit to the patient must be discussed with the patient, or the patient's surrogate, or the patient's parent/legal guardian if the patient is a minor, before it is implemented. If the patient or surrogate disagree with withholding or withdrawing treatment, the patient or surrogate must be given an opportunity to request a second opinion or to transfer his/her care to another physician. AT Hospital, respect for the values of each patient or parent/legal guardian in defining benefits is of utmost priority; however, there are limits to what reasonably may be considered to be beneficial. There is no ethical obligation for Your Hospitals to provide life-sustaining treatment if such treatment falls outside the bounds of accepted medical practice even if requested by a patient or surrogate. 6. Your Hospital subscribes to the consensus in the medical literature that there is no ethically relevant difference between withholding and withdrawing a life-sustaining treatment. 7. When the balance of benefits to burdens of a life-sustaining treatment for a particular patient is not clear, a time-limited trial of life-sustaining therapy is appropriate. Such a trial of therapy will allow the physicians and nurses to observe the patient's response to this treatment and will provide the patient or surrogate with a better understanding of what the treatment involves. At the completion of time-limited trial, physicians and patients or surrogates may be in a better position to assess the efficacy and desirability of the treatment and decide whether to continue or withdraw it. 8. The ultimate responsibility for implementing this policy rests with the patient's attending physician. DEFINITIONS Life-sustaining treatment: The term "life-sustaining treatment" includes all health care interventions that have the potential to sustain life in situations where death otherwise is expected to occur. Life-sustaining treatments include cardiopulmonary resuscitation, mechanical ventilation, dialysis, antibiotics, artificial nutrition and hydration, anti-arrhythmics, blood pressure support medications, blood and blood products, and other medications and procedures, which are capable of sustaining life. Decision-making capacity: A patient has decision-making capacity a he or she is at least is years of age or is a mature minor or an emancipated minor and the following conditions are satisfied: 1) the patient understands the nature of his/her condition and prognosis, expected benefits, and expected risks of each treatment alternative including non-treatment; 2) the patient is able to weigh the alternatives and make a reasoned decision among them based on his/her values; and 3) the patient is able to communicate his or her decision. A patient may have the capacity to make health care decisions while lacking the capacity to make other decisions, e.g., financial ones. Emancipated minor: Usually an emancipated minor is one who (a) lives apart from his or her parents, (b) has independent sources of support, and (c) is free from parental control or discipline. Generally, a minor who is or has been married or who has been declared emancipated by a court is emancipated. (See Policy 111.010) Mature minor: Regarding the determination of maturity in a minor, the Supreme Court of Appeals of Your State wrote in the Belcher vs. CAMC case, "Whether the child has the capacity to consent depends upon the age, ability, experience, education, training, and degree of maturity or judgment obtained by the child, as well as upon the conduct and demeanor of the child at the time of the procedure or treatment. The factual determination would also involve whether the minor has the capacity to appreciate the nature, risks, and consequences of the medical procedure to be performed, or the treatment to be administered or withheld." (See Policy 111.010) Time limited trial: The initiation for a pre-determined length of time of a therapy with the agreement that the therapy will be stopped when the anticipated benefits are not realized. Surrogate: An individual (usually a close family member or friend) selected by the attending physician to make health care decisions on behalf of a patient who lacks capacity to make his or her own health care decisions and has not completed an advance directive (either a medical power of attorney or a living will). The physician selects the individual who knows the patient's wishes, has regular contact with the patient and demonstrates care and concern, visits the patient regularly during the illness, engages in face-to-face contact with the caregivers and is able to participate fully in decision-making. (See Policy 111.010 and the Checklist for Surrogate Selection Form) Best Interests: The determination of whether a life-sustaining treatment ought to be withheld or withdrawn based on the proportion of benefits and burdens that it offers. This is the primary basis for decisions made on behalf of infants and children, adults who have never had capacity to make decisions, or previously competent adults whose previous wishes are unknown. PROCEDURE A. Patients with Decision-Making Capacity 1. For patients with decision-making capacity including mature or emancipated miners, decisions to withhold or withdraw life-sustaining treatment should be the result of shared decision-making between the patient and the attending physician. To facilitate shared decision-making and to enable patients to exercise their right to accept or refuse life-sustaining treatments, physicians must disclose relevant information to patients. Relevant information includes the potential benefits and burdens (harms, discomforts, and side effects) of each treatment option as well as the probability of each potential outcome, if known. 2. Patients are presumed to possess decision-making capacity unless there is good reason to doubt such capacity. Refusal of treatment that most patients would request does not necessarily imply that a patient lacks decision-making capacity. However, refusal in such circumstances may initiate an inquiry concerning the patient's decision-making capacity. Patients Who Lack Decision-Making Capacity 1. The assessment of decision-making capacity is a clinical judgment to be made by the attending physician. If the attending physician is uncertain about the patient's decision-making capacity, the attending should consult the psychiatry liaison service and/or the hospital ethics committee. Before implementation of a decision by a surrogate decision-maker to withhold or withdraw life-prolonging intervention, at least one other qualified physician or a licensed psychologist who has personally examined the patient must concur in the determination of incapacity of an adult. The determination of incapacity must be recorded in the patient's medical record by the attending physician, and, if one is required, by the second physician or licensed psychologist. The recording should state the basis for the determination of incapacity, including the cause, nature and expected duration of the patient's incapacity, if known. 2. If the patient has completed a Medical Power of Attorney, the wishes of the patient as stated by the patient's representative and/or written in the Medical Power of Attorney should be followed provided they are consistent with accepted medical practice. 3. If a patient lacks decision-making capacity and has not provided a written advance directive, the attending physician shall inquire of the identified surrogate whether the patient has expressed his/her wishes orally with regard to future health care. If the surrogate has knowledge of the patient's wishes, the surrogate shall make decisions with the attending physician based on a substituted judgment of what the patient would have wanted. 4. If the patient lacks decision-making capacity and has not expressed his wishes in advance for health care either verbally or in writing, the surrogate shall make decisions with the attending physician based on the patient's best interests. 5. If the attending physician cannot reach agreement with the surrogate in regard to the use, withdrawal, or withholding of a life-sustaining treatment for a patient who lacks decision-making capacity, consultation with the hospital ethics committee is strongly encouraged. 6. If a patient lacks decision-making capacity and there is no person who can be identified as an appropriate surrogate, consultation with the hospital ethics committee is strongly encouraged. When it is decided not to request judicial appointment of a surrogate, withholding or withdrawing life-sustaining treatment is ethically acceptable a each of the following conditions are satisfied: 1) reasonable efforts have been made to identify an individual to serve as a surrogate, and these efforts have been unsuccessful; 2) there is a consensus of the physicians involved in the patient's care that there is no expected benefit of life-sustaining treatment to the patient; and 3) conditions 1 and 2 above have been clearly documented in the patient's chart. in addition to these conditions, when a life-sustaining treatment is going to be withheld or withdrawn for such a patient, consultation with either the hospital ethics committee or a physician who is not otherwise involved in the patient's care is required to confirm the patient's best interests are served in the decision to withhold or withdraw life-sustaining treatment. Physician Responsibility 1. The attending physician is responsible for initiating a discussion of the appropriateness of life-sustaining treatments with patients who have decision-making capacity. When the patient lacks decision-making capacity, the attending physician is responsible for initiating a discussion of the appropriateness of life-sustaining treatments with the patient's Medical Power of Attorney representative or surrogate (whom the attending physician is responsible for selecting). 2. The attending physician is responsible for documenting in the hospital chart the substance of conversations about life-sustaining treatments. He/she shall document who participated in the conversation and the rationale for decisions. 3. If life-sustaining treatments are to be withheld or withdrawn, the attending physician is responsible for entering Limited Treatment Plan Orders in CHIP. (The attending physician may direct a resident responsible to him/her to write such orders.) It is the responsibility of the attending physician to ensure that this order and its meaning are discussed with all the physicians and nurses caring for the patient. 4. If, because of personal moral convictions, the attending physician cannot in good conscience honor a patient's or surrogate's request to withhold or withdraw a life-sustaining treatment, the attending physician shall arrange for the prompt and orderly transfer of the patient to the care of another physician. Nurse's Responsibility 1. The registered nurse is responsible for incorporating the Limited Treatment Plan Orders in CHIP into the plan of care and to communicate these orders at nursing report. 2. If, at any time, Limited Treatment Orders are rescinded, the registered nurse is responsible for updating the patient's plan of care and for reporting to other nurses involved in the patient's care changes in the patient's orders. 3. If the patient, patient's surrogate or parent/legal guardian, expresses the desire to have life-sustaining treatment withheld or withdrawn to other members of the health care team, e.g. RN, Social Worker, Chaplain, students, etc., this information should be communicated to the attending physician as soon as possible. Members of the health care team should be receptive to patient, surrogate or parent/legal guardian discussion regarding this issue, but the attending physician remains responsible for Limited Treatment Plan Orders. 4. If, because of personal moral convictions, the nurse objects to a particular Limited Treatment Plan Order, he/she should conscientiously withdraw from the care of the patient consistent with hospital policy V. 2.8. E. Limited Treatment Plan Orders in CHIP 1. To implement decisions to withhold or withdraw life-sustaining treatments, special Limited Treatment Plan Orders are available in CHIP. 2. The discussion and rationale resulting in the Limited Treatment Plan Orders in CHIP shall be documented in the progress notes of the hospital chart. 3. Attending physicians or their designees are responsible for entering Limited Treatment Plan Orders in CHIP. (The attending physician may direct a resident responsible to him/her to enter such orders). These orders may include but are not limited to the following: "Do Not Resuscitate", "Do Not Defibrillate", "Do Not Cardiovert", and "Do Not Intubate." Medications and/or treatments which may be limited include the following: Vasopressor drugs, inotropic agents, anti-arrythmics, hyperalimentation, tube feedings, dialysis, blood products, antibiotics, blood tests, x-rays, and other treatments and medications. 4. The Limited Treatment Plan Orders may be revoked at any time. The most common reason that might lead to a revocation of a Limited Treatment Plan is a change in the patient's medical condition such that the patient's prognosis is improved and the likelihood of response to treatment is increased. The attending physician is responsible for notifying the patient or the patient's surrogate of any significant changes in the patient's medical condition and for making decisions with the patient about revisions in the treatment plan. Changes in treatment orders should be consistent with E3 above. F. Patient or Surrogate Requests for Life-Sustaining Treatment with No Expected Benefit: 1. If the attending physician judges that a life-sustaining treatment is of no expected benefit to the patient, the physician shall recommend withholding or withdrawing a to the patient or surrogate or parent/legal guardian. If the patient, surrogate, or parent/legal guardian agrees, the physician shall enter Limited Treatment Plan Orders in Chip. If the patient, surrogate, or parent/legal guardian does not accept the physician's recommendation for withholding or withdrawing life-sustaining treatment, the physician has the following options: 1) the physician may seek a second opinion; 2) the physician may consult the hospital ethics committee; and/or 3) the physician may seek a transfer of the patient to another physician and/or institution. 2. If a transfer is not feasible and if, after consultation with another physician and/or the hospital ethics committee, the physician believes that provision of a life-sustaining treatment requested by the patient or surrogate is contrary to the accepted standards of medical practice, the physician may complete Limited Treatment Plan Orders in CHIP after notification of the patient, surrogate, or parent/legal guardian. Since this action, while medically and ethically correct, may place the physician at risk of litigation, the physician contemplating this action may wish to consult with the hospital ethics committee (if he/she has not already done so) and/or hospital Health Sciences Center Office of Risk Management. Physicians at Your Hospital have the responsibility to provide treatments within the standards of accepted medical practice which are in their scope and practice when such treatments are available at Your Hospitals and requested by patients or their surrogates. While patients have the right to accept or refuse any and all life-sustaining treatments recommended to them by their attending physicians, they do not have the right to receive life-sustaining treatments which are judged by attending physicians at Your Hospitals to offer no expected benefit to them. G. Resolution of Disputes About the Use, Withholding or Withdrawal of Life-Sustaining Treatment 1. Consultation with the Hospital Ethics Committee is strongly encouraged if physicians, other members of the health care team, patients, family members, and/or other surrogates disagree about whether to use, withhold, or withdraw life-sustaining treatment. A consultation may be requested by any of these parties. Consultation by the Hospital Ethics Committee shall be performed according to hospital policy, Hospital Ethics Committee Consultation, Section 111.027, which shall be appended to this policy. 2. Recourse to the courts should be reserved for occasions when adjudication is clearly required by state law or when concerned parties have disagreements over matters of substantial import that they cannot resolve and that cannot be resolved in consultation with the Hospital Ethics Committee. Relationship to Existing Hospital Policies This policy is cumulative with other hospital policies regarding life-threatening emergencies. Nothing in this policy is meant to abrogate consent procedures in emergency situations (See Section 111.010)

RI002P	Life Sustaining Treatment Policy
Facility Type: Acute Care - A 3 facility system made up of an acute care teaching facility with an ADC of 207; an acute care facility with an ADC of 17-25; a rural facility with a ADC of 40	Last JCAHO Survey: September of 1997
Comments: This is an organization-wide policy which is used at the 3 facilities listed above. We received no recommendations or suggestions related to these policies during our survey.
Related Documents: None
Downloadable or Viewable Documents: Life Sustaining Treatment Policy Download in Word 97 format zipped in a self extracting file: RI002P.exe
Life-Sustaining Treatment I. STATEMENT OF POLICY Adult patients with decision-making capacity, after being given adequate information about treatment and after having received a recommendation about treatment from their primary physician or consultant, shall be the final decision maker about whether they wish to accept or refuse any or all treatment that their primary or consulting physician believes is medically appropriate for their condition. A surrogate shall be identified for adult patients who lack decision-making capacity and the surrogate shall consent to or refuse treatment for the patient in accordance with any advance directive given by the patient and under the same conditions as the adult patient with decision-making capacity who gives consent or refusal. Minors (children and adolescents) should be encouraged to participate in their treatment decisions to the extent that they have the capacity to do so. Medically appropriate life-sustaining treatment shall be provided to any patient (including a minor) who requests it. II. DEFINITIONS (A word or phrase appears in italics throughout the policy if it is defined in this section.) A. Adequate information. Patients should receive all information in a language they can understand and in terms meaningful to them. They should be informed about risks and benefits of treatment and alternative forms of treatment, and any other information (which may include costs of care) that are necessary for them to make reasoned decisions about accepting or refusing treatment. Information about burdens or risks should not be minimized or omitted on the grounds that it might affect the patient's decision, unless patients have specifically requested they not receive full information. B. Advance Directive. Any written document that states patient wishes about treatment or about a surrogate decision maker and that comes into effect at such time as the patient has lost decision-making capacity. Advance directives include durable powers of attorney for health care, natural death act declarations or directives, and living wills. C. Decision-making capacity. A patient has decision-making capacity if he/she is able (1) to understand the need for treatment, the implications of receiving and of not receiving treatment, and alternative forms of treatment that are available, and (2) is able to relate that information to his/her personal values, and then to make and convey a decision. Diagnosed mental illness in itself does not justify a determination of lack of decision-making capacity. Capacity determinations are specific only to the particular decision that needs to be made. Competence and capacity are often used interchangeably in the health care setting, but, as a matter of law, all adults are competent unless they have been determined incompetent by a court. Therefore, incompetency is a legal determination, whereas capacity and incapacity are usually medical determinations. If there is a disagreement about a patient's capacity, a court determines whether the patient lacks competency. D. Medically appropriate treatment. After consultation with appropriate team members regarding available treatment for a medical condition, it is proper for the physician to determine what are medically appropriate treatments for the patient. Medically appropriate treatment has the reasonable possibility of achieving a definable goal of medicine, such as restoration of function, prolongation of life that is currently meaningful to the patient, and relief of pain and suffering. Medically inappropriate treatment is one that lacks reasonable possibility of reaching such goals, or where the burden of the treatment outweighs its benefit to the patient. E. Medically futile treatment. Medical futility has quantitative and qualitative aspects: physician may regard any treatment as futile that either through experience or clinical studies has shown no reasonable possibility of achieving definable goals of medicine in substantially all cases, or merely preserves permanent unconsciousness or cannot end dependence upon medical treatment available only in an intensive care unit. A physician may refuse to provide medically futile treatment. A patient may pursue alternate treatment from another physician or facility (see III E, N and IV B6 below). Examples of circumstances in which certain treatments could be deemed futile or inappropriate may include: 1. Persistent vegetative state of greater than one year's duration 2. Terminal cancer refractory to accepted treatment modalities 3. NYHA Class IV CHF in non-transplant candidates 4. End stage lung disease in non-transplant candidates 5. Advanced irreversible dementia 6. Multi-organ/system failure 7. End stage cirrhosis and/or hepatorenal syndrome 8. Cardiovascular collapse and inability to wean from pressors 9. End stage AIDS F. Primary Physician. The attending physician whose responsibility it is to make most major medical decisions with the patient and who, in most cases, has an ongoing relationship with the patient and would follow the patient after hospital discharge. G. Surrogate. The person designated to make decisions for the patient who lacks decision-making capacity. Family members or significant others often act as the surrogate for a patient. The order of preferred surrogates is: 1. The parent or guardian of a minor. 2. The person named as attorney-in-fact in a Durable Power of Attorney for Health Care. 3. The previously-named conservator of the patient, if as conservator he/she has authority to make health care decisions. 4. The person whom the patient previously chose in a written or verbal declaration to the physician or family. 5. The patient's spouse or significant other. 6. The individual whom family members/friends close to the patient agree can best speak for the patient, or the family itself if members wish to act as a group as surrogate. If there is disagreement about who should be the surrogate, the physician should consult the ethics committee. H. Treatment. Any intervention or procedure that is ordered by a physician that will sustain the patient's life, including artificially-supplied nutrition and hydration. III. PRINCIPLES A. Health care professionals have an obligation to respect patient autonomy and confidentiality, to do good and not to do harm, and to treat similar cases similarly. These are the values underlying decisions to undertake or to forego life-sustaining treatment. B. Physicians have a duty to determine treatment options that have a reasonable probability of providing benefit that can be perceived or appreciated by their patients with respect to prolonging life, restoring function, and relieving pain and suffering. C. Physicians must provide accurate and adequate information to their patients about their disease, prognosis, and appropriate treatment options, including the efficacy of each treatment alternative and its risks and benefits, so that patients can make informed decisions. D. Physicians should ascertain the patient's treatment goals and provide patients with a considered recommendation of which treatment option will best serve the patient's goals. E. Physicians need not provide treatment that they consider medically inappropriate or futile (See III.N.). Recognizing a distinction between medically appropriate and futile treatment means that some patients or surrogates will not be offered treatment that they might want. For example, the physician may choose not to offer CPR as a treatment option when the patient presents with widespread metastatic end stage cancer. In another example, once a medical determination has been made that a patient is in a persistent vegetative state of greater than one year's duration, no further medical treatment need be offered because it is qualitatively futile. In some instances medically futile treatment is provided for psychological or compassionate reasons: continuing for a brief time to ventilate a patient who has been found to meet the neurological criteria for death, in order to allow family members to come to terms with the patient's death. F. Patients' informed decisions about treatment that is offered to them will be respected, as will treatment directions made in advance directives to the extent that those decisions and directives are consistent with medically appropriate treatment. (See III.N.). G. When patients lack decision-making capacity, physicians will provide the same information to the patient's surrogate and grant them the same authority as they would have provided to the patient. H. When a surrogate acts for the patient, he/she shall act in conformity with the patient's previously expressed desires and values whether expressed formally in writing or informally and orally. If such information is unknown, surrogate and physician shall determine together what is in the best interests of the patient. I. Minors should be encouraged to participate in all treatment decisions to the extent that they have the capacity to do so. J. Life-sustaining treatment need not be continued solely because it was begun. Continued use of any treatment must always be justified in terms of the patient's goals and be consistent with medical appropriateness. K. Life-sustaining treatment that may be foregone encompasses all medical treatment including artificially supplied nutrition and hydration. L. Hygienic care shall always be provided and means of alleviating pain shall always be offered to the patient. Procedures or medications necessary to alleviate pain should not be withdrawn or withheld without the patient's (or surrogate's, if appropriate) explicit consent. M. Analgesia sufficient to eliminate pain and discomfort may be used even knowing that it may tend to hasten death, as long as the health care professional's intention is to treat or prevent pain. Medication shall not be used with the intent to cause or hasten the patient's death. N. Physicians have the right to refuse to participate in continuing or foregoing life-sustaining treatment if they have objections of conscience in a specific case. In such instances, physicians are obliged to transfer the care of the patient to another qualified physician. When other health care professionals have objections of conscience, their preferences not to participate in a patient's care should be respected to the extent that is consistent with their terms and conditions of employment. O. Providing good medical care requires the joint effort of an entire health care team, including physicians, nurses, social workers, and chaplains. Physicians should consult with and enlist the support of other appropriate members of the team throughout the treatment process, and especially when decisions that may be disputed are being considered. IV. PROCEDURES A. Determining Decision-making Capacity 1. The attending/primary physician shall have responsibility for determining each patient's decision-making capacity and shall draw upon the knowledge of those who have the most extensive contact with the patient. 2. A determination of the patient's decision-making capacity shall be made independently of whether the patient is consenting to or refusing treatment. 3. If the physician is uncertain about the patient's decision-making capacity, the physician shall request a consultation from a psychiatrist. 4. If the attending/primary physician (with or without consultation) determines that the patient lacks decision-making capacity, the patient shall be informed if that is possible. a. If the patient disagrees, a second evaluation shall be conducted by one or more different physicians. If the second evaluation concludes that the patient lacks decision-making capacity and the patient continues to disagree, then the matter shall be referred to court for a competency determination. b. If the patient cannot be informed of this judgment, the patient's surrogate shall be informed. If the surrogate, family members, or significant others disagree with the physician's determination of the patient's lack of capacity, a second capacity evaluation shall be conducted by a different physician. If the second evaluation concludes that the patient lacks decision-making capacity and the surrogate continues to disagree, then the matter shall be referred to court for a competency determination. c. If neither patient nor family disagrees with the physician's evaluation of the patient's incapacity, the identified surrogate shall become the decision maker for the patient. (See II F. above, for surrogate identification). B. Responsibilities of the Physician 1. The attending/primary physician is responsible for ensuring that every adult patient or surrogate receives adequate information to make treatment decisions. In so doing, he/she should consult with and enlist the support of appropriate team members. Adequate information includes the need for treatment, various treatment alternatives, including the alternative not to receive treatment, risks and benefits of all medically appropriate treatment options, and probable results of receiving no treatment. This discussion is to be documented in the medical record. 2. Physicians should provide this information to the patient, even if family members request that it not be given, unless the patient has specifically said that he/she does not wish to receive information and wishes the family to be given information instead. 3. The attending/primary physician, either alone or in conjunction with consulting physicians, shall recommend to the patient or surrogate the course of treatment that best meets the patient's goals and explain to the patient or surrogate why he/she believes this is the best alternative. 4. Physicians shall, to the best of their ability, ensure that the patient or surrogate understands the choices that are available to him/her. 5. If discontinuing life-sustaining treatment requires withdrawal of a medical device, such as a ventilator, the patient's physician is responsible for discontinuing this medical device. If a staff member cannot honor this decision for personal, ethical reasons, an attempt will be made to relieve him or her from that case responsibility. 6. If a physician concludes that any form of life-sustaining treatment is medically inappropriate or futile, that treatment does not need to be offered, provided, or continued although it may need to be discussed (See 1. above). If the physician is aware that there is a possibility of obtaining the treatment through other physicians or at other facilities, the physician shall explain to the patient/surrogate why the treatment(s) is not appropriate and shall document this discussion in the medical record. If the patient/surrogate wishes to pursue this treatment(s), the physician shall assist in transferring the patient's care to those who will provide the treatment. (For conflicts between team members or between team and patient/surrogate about claims that treatment is medically inappropriate or futile, or in instances in which no other physician/facility will provide treatment considered medically inappropriate or futile (See E. below, Conflict Resolution.) 7. If a physician has a long-standing, conscientious belief with respect to this/her unwillingness to participate in either providing or not providing any form of standard medical treatment the physician has a moral obligation to inform patients as soon in the establishment of the doctor/patient relationship as is reasonable. 8. If the patient or surrogate chooses a course of action that violates the ethical or religious beliefs of the physician, the physician may decline to participate when another physician who is willing to be guided by the patient's or surrogate's wishes will accept care of the patient. The physician who has the objections of conscience must cooperate in transfer of the patient's care to the new physician. Such transfer should be made only after serious efforts have been made to reconcile the views of the physician and patient or surrogate and after adequate notice has been given to the patient or surrogate that the physician will have to withdraw from the case. The physician may also consult the ethics committee for assistance in resolving his/her inability to comply with the patient's wishes. C. Decision-making When Patients Have Decision-making Capacity. 1. The patient shall provide either informed consent or informed refusal to treatment and the physician shall document this process and the patient's choice in the medical record. 2. If the patient's choice is a very unusual one and one that the physician would not usually recommend, the physician shall ascertain the reasons for the patient's choice and shall ensure that the patient holds this view consistently over a period of time. This must be documented in the medical record. 3. To ensure patient confidentiality, no decision or other information obtained by the physician during the processing of decision-making shall be conveyed to family/friends of the patient or any other parties without first obtaining the patient's consent for this disclosure. 4. Adult patients with decision-making capacity shall be asked about their wish to complete an advance directive and shall be given information about the purpose and value of such a document, as well as referral to institutional resources if they wish to complete one. 5. The treatment decisions of an adult patient with decision-making capacity shall be respected. If an adult patient has refused treatment with full knowledge and understanding, the treatment previously refused will not be provided on an emergency basis should the patient lose decision-making capacity unless there is strong evidence that the change in circumstances would have led to the patient's making a different decision than that he/she previously expressed. Any such change must be documented in the medical record. D. Decision-making When Patients Lack Decision-making Capacity. 1. Adult patients Who Lack Decision-making Capacity a. When treatment decisions are made for the adult patient who lacks decision-making capacity, physicians shall act toward the patient's surrogate as they would to the patient him/herself. b. The surrogate shall make decisions by the following priority of standards: 1) As the patient has written, if there are applicable written instructions, 2) As the patient has said, if he/she has given applicable oral instructions, 3) As the surrogate believes the patient would have chosen, given his/her knowledge of the patient's values and concerns (if the surrogate can make such a judgment). 4) As appears to maximize the benefits or minimize the burdens to the patient, (best interests standard). (Standards 3 and 4 are only approximations of what the patient's own choices might be.) c. If the physician and surrogate disagree about the decision or the appropriate decision-making standard, the surrogate shall be informed about the availability of social service and the hospital ethics committee to facilitate further discussion of the decision. The surrogate shall also be informed of the possibility of transferring the patient's care to another physician who is more sympathetic to the surrogate's views. The attending/primary physician or the medical staff office shall, if necessary, assist the surrogate in finding another physician. d. If the surrogate named by the patient requests a course of action that is not consistent with the patient's previously expressed wishes or with the physician's assessment of the patient's best interests when the patient's wishes are not known, and attempts to resolve the differences in judgment are unsuccessful, treatment shall be provided and replacement of the surrogate through legal action should be pursued. 2. Adult Patients Who Lack Decision-making Capacity and Have No Identifiable Surrogate a. When the patient has no family or friends in attendance or when the patient is unidentified, the institution shall attempt to identify the patient, and social services shall make a serious effort to identify family or friends who are willing to act as the patient's surrogate. b. If no surrogate can be identified or if the patient's identity cannot be determined, decisions shall be made in the following manner: 1) If all members of the healthcare team agree as to the appropriateness of providing continued treatment, treatment shall be provided. 2) If all members of the healthcare team agree that life-sustaining treatment should be withheld or withdrawn, that decision shall be reviewed and approved by a staff physician who has not been personally involved in the patient's previous care. 3) If members of the healthcare team disagree about the appropriateness of providing continued treatment, a consultation with the chief of service (or chief of medical staff) shall be held. 4) If disagreement about providing treatment continues after this consultation, the ethics committee shall be requested to facilitate discussion about continuing treatment. 5) If no consensus arises in the course of the ethics committee consultation, treatment shall be provided. Alternatively, the institution may pursue conservatorship proceedings or request the court to permit treatment to be foregone. 3. Minors, Excluding Newborns a. Parents or guardians are the responsible legal decision makers for those under the age of 18, except for those minors who, under current law, may consent on their own behalf (e.g., self-sufficient minors, married minors, emancipated minors, minors in the armed forces). b. Minors who have the capacity to participate in decision-making should be encouraged to participate in all treatment decisions. As with adult patients, capacity should be addressed with respect to the particular decision that needs to be made. c. Physicians should discuss with minor patients who have the capacity to engage in such discussions their attitudes about life-support treatment if there is reason to suppose that decisions about that treatment may need to be made in the future. d. Medically appropriate treatment should not be foregone for a minor patient if the minor patient wants treatment continued or instituted. E. Conflict Resolution 1. If members of the healthcare team disagree about provision or non-provision of any life-sustaining medical treatment, they shall first request a team meeting and attempt to gain consensus about appropriate treatment. If a team meeting is not possible or if consensus is not achieved, any member of the team may consult the hospital ethics committee for assistance in resolving the disagreement. 2. If patient/surrogate/family disagree with the physician or healthcare team about the provision or non-provision of any life-sustaining treatment, then the opinion of a medical consultant should be obtained. Following this they may consult with the hospital ethics committee for assistance in resolving the disagreement. 3. If a physician, in consultation with the healthcare team, has concluded that a form of life-sustaining medical treatment is medically inappropriate or futile and thus will not be offered, provided, or continued, and the patient/surrogate/family wish the treatment to be provided but no other physician or facility is willing to provide the treatment, the hospital ethics committee shall be consulted before any action is taken to forego treatment. Patients/surrogates/families shall be permitted adequate time to consult with the ethics committee or to appeal to the courts if they wish to pursue that course and life-sustaining treatment shall not be withheld or withdrawn during that reasonable period of time.

RI003P	No Code/Do Not Resuscitate (DNR) Order
Facility Type: Acute Care - A 3 facility system made up of an acute care teaching facility with an ADC of 207; an acute care facility with an ADC of 17-25; a rural facility with a ADC of 40	Last JCAHO Survey: September of 1997
Comments: This is an organization-wide policy which is used at the 3 facilities listed above. We received no recommendations or suggestions related to these policies during our survey.
Related Documents: None
Downloadable or Viewable Documents: Policy: No Code/Do Not Resuscitate (DNR) Order - Download in Word 97 format zipped in a self extracting file: RI003P.exe
GOAL: To provide guidance and standards for the Medical Staff, in the writing of orders exempting a patient from the automatic invocation of Cardiopulmonary Resuscitation. To provide guidance for other health care professionals in instituting the "No Code" or "DNR" order. A specific order is necessary if Cardiopulmonary Resuscitation is not to be instituted. The writing of any order which has the effect of precluding such resuscitative measures is the subject of this policy. POLICY: 1. In all cases where a patient is found by any clinical staff to have lost vital function, Cardiopulmonary Resuscitation (CPR) will be immediately started unless a "No Code" or "DNR" order has been written by the Attending Physician or appropriate designee such as on-call physician or resident in the patient's chart. 2. A "No Code" or "DNR" order will be considered appropriate when one or more of the following conditions exists: a. CPR is refused by the patient (or patient's surrogate) after following the process of informed consent. b. The patient has a terminal and irreversible illness. c. The patient is in a terminal or pre-terminal condition which is the inevitable result of a decision by the patient to decline recommended treatment or supportive measures. d. The patient is in a terminal condition, the result of an election to decline treatment in accordance to the California Natural Death Act. (See CHA Consent Manual) or advanced directives . e. The patient is in a terminal condition as a result of an action undertaken to discontinue life supports in accordance with accepted ethical guidelines. (see policy #12.08 Life Sustaining Treatment) 3. Consent for execution of the decision not to resuscitate should be regarded as comparable to that required for an invasive procedure, and is required as follows: a. Competent Patient: Consent should be obtained from the fully informed patient. b. Incompetent Patient: When the patient has been judged incompetent by a court of competent jurisdiction, consent is given by the patient's legal guardian or conservator. c. Patient incapable of understanding or communicating: Consent decision is made by judgment of the Attending Physician, after appropriate medical consultation. It is desirable to include discussion and agreement with immediate family members who are reasonably accessible; however, agreement is not always possible and the physician may make a decision on his or her established relationship with that patient and what her or she feels is in the best interest of the patient. d. Minor children, under the age of 18 years: Consent should be obtained from the parents or legally appointed guardian. In the event of parental divorce, the parent with legal custody is empowered to grant consent, although it is advisable to discuss the decision with both parents where available. 4. The Attending Physician should ensure that suitable documentation of the circumstances and reasoning process leading to the "No Code" or "DNR" order be included in the chart. This should be written in the progress notes, or dictated, and should include: a. A summary of the medical situation leading to the terminal prognosis. b. Reference to consultation with another physician, if such documentation is deemed appropriate. c. A statement of the discussions of the prognosis and agreement of the patient, family, conservator or legal guardian. 5. On approval of an academic attending physician, a resident may write a "No Code" or "DNR" order for a 24 hour period. If extension beyond 24 hours is desired, an attending or on -call physician must write such an order. 6. It is the right of an individual physician to decline to issue an order not to resuscitate. In exercising this right, the physician should, where the expressed wishes of the patient differ, take appropriate steps to transfer the care of the patient to another qualified Attending Physician. 7. If a health care worker feels the physician is not honoring the wishes expressed by the patient or noted in an advance directive he or she may request Bioethics Committee review. PROCEDURE: 1. The Attending Physician having determined that a "No Code" or "DNR" order is reasonable, should obtain suitable consent and agreement, and document the decision in writing or by dictation in the patient record. At times, the on-call physician may assume this role. A written order should be originated and signed by the attending or on-call physician. 3. Where necessary, when the decision has been previously discussed with the patient, and when the Attending or on call Physician is sufficiently aware of the patient's current medical status, his or her telephone order may be received for "No Code" or "DNR", by a RN/LVN or a physician, and recorded for subsequent signature and required documentation by the ordering Physician within 48 hours. 4. A "No Code" or "DNR" order shall remain in effect for 72 hours, and will automatically be discontinued thereafter, unless another duration is specified in the order, or the order is renewed by the attending physician. A telephone order not countersigned within 48 hours shall be discontinued automatically. 5. A physician may also write the "No Code" or " DNR" order for the duration of the hospital stay. 6. The nursing staff may request verification of a telephone order by a second qualified person (e.g. Nursing Supervisor, another RN, etc.). 7. The nursing staff shall execute the order by not instituting Cardiopulmonary Resuscitation upon discovery of cessation of vital function. 8. A "No Code" or "DNR" order is revocable by the patient, and may be effectively rescinded by the patient as long as such recession is communicated to the medical staff. 9. When a patient on "No Code" or "DNR" status requires surgical intervention, at least one physician (surgeon, anesthesiologist, or attending physician of record) must engage in discussion with the patient or agent regarding how the "No Code" or "DNR" order is to be handled. Significant parts of the physician-patient discussion should be documented in the progress notes section of the patient’s medical record. 10. In the event that a patient has designated a "No Code" or "DNR", then goes into surgery, the "No Code" or "DNR" policy will be suspended during the surgery and for 24 hours after the surgery is completed for post surgical observation. The "No Code" or "DNR" order must be rewritten post-operatively. 11. In accordance with California Civil Code section 2443, an attempted suicide shall not be construed to indicate a desire that health care treatment be restricted or inhibited. In the Emergency Room, "No Code" or "DNR" orders are not considered effective when a patient is brought in who has apparently attempted suicide. Emergency measures are to be utilized unless there is a Durable Power of Attorney for Heath Care and an agent instructing to the contrary. 12. When the patient changes his or her level of care and the change requires rewriting of orders, the "No Code" or "DNR" order must be rewritten. DEFINITIONS: 1. Attending physician: The physician or designee primarily responsible for the management and treatment of the patient's illness. 2. On-Call physician: The physician covering for the attending physician or designee after hours or when the attending is unavailable. 3. Cardiopulmonary Resuscitation: The application of measures to restore vital functions, including external or internal cardiac massage, intubation and/or ventilation, electrical defibrillation, and administration of drugs necessary to support vital signs or control cardiac activity. 4. A "No Code Order" or a "Do Not Resuscitate Order (DNR)" is a written medical order stating that in the event of a Cardiac or Respiratory Arrest, Cardiopulmonary Resuscitative measures will not be initiated. 5. Durable Power of Attorney for Health Care (DPAHC) is a written instruction that relates to the provision of health care and the appointment of an agent when an individual is incapacitated and unable to make healthcare decisions. This document will only serve as a direction for DNR when clearly stipulated or when the agent so directs in consultation with the physician. 6. Chemical Code Only is resuscitation limited to the administration of medications only and does not include chest compression or ventilatory assistance.

RI004P

Access to the Case Review Subcommittee of the Bioethics Resource Committee by Patient, Patient Representative, Hospital Employee and/or Medical Staff

Facility Type: Acute Care - A 3 facility system made up of an acute care teaching facility with an ADC of 207; an acute care facility with an ADC of 17-25; a rural facility with a ADC of 40

Last JCAHO Survey: September of 1997

Comments: This is an organization-wide policy which is used at the 3 facilities listed above. We received no recommendations or suggestions related to these policies during our survey.

Related Documents: Bioethics Case Review Summary Form

Downloadable or Viewable Documents:
Policy: Access to the Case Review Subcommittee of the Bioethics Resource Committee by Patient, Patient Representative, Hospital Employee and/or Medical Staff - Download in Word 97 format zipped in a self extracting file: RI004P.exe
Bioethics Case Review Summary Form: Viewable or Downloadable in PDF Format: RI004F.pdf

GOAL: To establish a mechanism by which the patient, patient’s representative, hospital employee and/or medical staff may access the Case Review Subcommittee of the Bioethics Committee to resolve ongoing ethical issues concerning patient care.

PROCEDURE:

When there is an potential ethical issue to be clarified, the patient, patient’s representative, hospital employee and /or medical staff should complete the case review screening questionnaire (attached) to request a Bioethics Case Review.

When this questionnaire is completed, the person requesting a Bioethics Case Review should follow the procedures below:

During Regular Office Hours: Contact the Medical Staff Office at Your Hospital. Following review of the screening questionnaire, a medical staff representative will activate the case review subcommittee.

After Regular Office Hours:

Requests from Your Hospital: Contact the administrative nursing supervisor. After review of the screening questionnaire, the administrative nursing supervisor will facilitate the activation of the case review subcommittee by contacting the on-call Case Review Team Leader.

Requests from Your Care Center, Your A Hospital & Your B Hospital: Contact the administrative nursing supervisor at the requesting hospital. The administrative nursing supervisor at the requesting hospital will then contact the administrative nursing supervisor at Your Hospital who will facilitate the activation of the case review subcommittee.

The Case Review Team Leader shall notify the attending physician.

The case review shall commence as soon as possible, but no later than 24 hours after the request is received.

Immediately following the conference, a brief note will be made in the patient’s medical record by the Case Review Team Leader.

The Case Review Team Leader will complete a Bioethics Case Review Summary (Form Attached.) The summary form together with the screening questionnaire will be retained in the Medical Staff Office at Your Hospital and will not be part of the medical record. A brief review of the case will be presented by the Case Review Team at the next Bioethics Committee meeting.

YOUR HEALTH SYSTEM

BIOETHICS SCREENING QUESTIONNAIRE

1. What is the problem?

__________________________________________________________________
__________________________________________________________________

2. What is the interest of the patient that needs to be addressed?

__________________________________________________________________
__________________________________________________________________

3. What are the medical indicators?

diagnosis: ________________________________________________
prognosis: ________________________________________________

4. What do you believe is the patient's or surrogate's wish?

__________________________________________________________________
__________________________________________________________________

5. Is there a conflict with the patient's wishes and his/her personal support system? If so, please describe.

__________________________________________________________________
__________________________________________________________________

6. Who is the attending physician and have you discussed the problem with him/her?

__________________________________________________________________
__________________________________________________________________

7. Have you discussed the problem with your direct supervisor/department director "off duty" supervisor?

__________________________________________________________________
__________________________________________________________________

8. Is there disagreement among the members of the healthcare team? If so, please describe.

__________________________________________________________________
__________________________________________________________________

If you have answered all of the above and still feel that the

Bioethics Committee should be accessed, please call: xxx-xxxx

RI008P

Advance Directive Policy and Form

Facility Type: System involving 3 acute care hospitals, one with ADC of 220, one with ADC of 50-60 and one with ADC of 4.

Last JCAHO Survey: September 1997

Comments: This is a system wide policy. The form has not gone through a JCAHO survey in this format as we keep revising it - we simplify it more each time we make changes!!! Policy has had some minor changes since our survey in September of 1997.

Downloadable or Viewable Documents: Advance Directive
Download in Word 95 Format: RI008P.exe

AVANCE DIRECTIVE (PATIENT SELF-DETERMINATION ACT (PL101508))

GOAL:

Protect each patient’s right as defined by the Patient Self-Determination Act, OBRA 1990, to participate in health care decision-making to the maximum extent of his or her ability, to execute advance directives, and to prevent discrimination based on whether the patient has executed an advance directive for health care.

POLICY:

I. All YOUR Health System facilities ("the hospitals") shall provide to each individual, at the time of admission¹, written information describing:

A. An individual’s rights under California statutes and court decisions to accept or refuse medical or surgical treatment and to formulate advance directives; and

B. The hospitals’ policies regarding these rights to make health care decisions and to formulate advance directives, and the way such decisions and directives will be implemented in the hospitals.

II. For purposes of this policy, an advance directive means a written instruction that relates to the provision of health care when the individual is incapacitated, such as a Durable Power of Attorney for Health Care, a Declaration pursuant to the Natural Death Act, or a Living Will.

III. For the purposes of this policy, a surrogate decision maker is defined as an individual other than the patient to whom health care providers appropriately look for medical decision making regarding the patient’s care when the patient is incapacitated. This individual may be formally appointed (e.g., by the patient in a durable power of attorney for health care or by a court in a conservatorship or guardianship proceeding) or, in the absence of a formal appointment, may be informally authorized by virtue of a relationship with the patient (e.g., the patient’s next of kin or, in the absence of next of kin, a close friend).

Incapacitated is defined as a condition of the patient where the capacity to make informed decisions regarding care 1.) is temporarily lost (e.g., due to unconsciousness, being under the influence of mind-altering substances, or otherwise suffering from treatable mental disability); 2.) is permanently lost (e.g., irreversible coma, persistent vegetative state, or untreatable brain injury rendering understanding by the patient impossible); or, 3.) never existed (e.g., congenital retardation or severe brain injury as a child rendering understanding by the patient impossible).

IV. The hospitals shall comply with California statutes and court decisions regarding advance directives.

V. The hospitals shall not condition the provision of care or otherwise discriminate against an individual based on whether or not the individual has executed an advance directive.

VI. The hospitals shall provide education to staff and the community on issues that concern advance directives.

VII. The attending physician and hospital can not follow the terms of an Advance Directive until the contents are known and documented in the medical record. This can be done via a copy of the Advance Directive being placed in the medical record or the patient and/or surrogate documenting the wishes via the completion of the Advance Directive Acknowledgment form which is then placed in the medical record. The Advance Directive or Advance Directive Acknowledgment form becomes a permanent part of the medical record and is part of the patient’s treatment plan.

VIII. The patient has the right to change or revoke any Advance Directive document at any time. If hospitalized, the patient and/or surrogate needs to discuss the changes with the physician and complete an Advance Directive Acknowledgment form which is then placed in the medical record. Changes are shared with the staff involved in the patient’s care and the treatment plan is updated.

PROCEDURE:

I. In compliance with the Patient Self-Determination Act (PSDA), YOUR Health System has in place the mechanism for determining, during the admission process, whether the patient has an advance directive(s) or desires to formulate such directive(s). Individual staff responsibilities are outlined below.

A. Admission Staff Responsibility

1. The Patient Financial Counselor (PFC) is responsible for obtaining information regarding the advance directive(s), for providing the patient with the brochure "Your Right to Make Decisions about Medical Treatment" and/or instructing the patient/surrogate to bring in a copy of an existing directive.

2. The PFC documents the following information on the admission face sheet:

A. No, I have no Advance Directive (brochure given)

B. Yes, I have an Advance Directive (copy in chart)

C. Yes, I have an Advance Directive (but not available, patient has been advised to bring it in).

3. The PFC will complete the appropriate information on the Advance Directive Acknowledgment form. Original stays in medical record, one copy is given to the patient/surrogate and the second copy belongs to admitting.

4. If the patient has brought in an advance directive, the PFC will copy and document that it was received and include it with the admission papers being sent to the patient care unit. An Advance Directive sticker will also accompany the packet to the patient care unit when the advance directive exists.

5. If the patient indicates that the hospital has a copy of the advance directive from a previous admission, the PFC will document on the admission face sheet and Advance Directive Acknowledgment form accordingly.

6. If a copy of the advance directive is not provided at the time of admission, admitting staff will explain to the patient/surrogate that the physician and hospital can not follow the terms of an advance directive until the contents are known and documented in the medical record. Admitting will explain the methods available for documenting this information (e.g., placing a copy of the advance directive in the medical record or documenting those wishes on the Advance Directive Acknowledgment form which is then placed in the medical record).

7. If the surrogate brings an advance directive to the Admitting Department at any time during the patient’s hospitalization, admitting will forward it to the appropriate patient care unit.

B. Nursing Responsibility

1. If nursing admits the patient prior to the admission staff seeing them, nursing is responsible for obtaining information regarding advance directive, offering the brochure to patients and/or instructing the patient/surrogate to bring in a copy of the existing advance directive.

2. The nurse completes the Advance Directive Acknowledgment form, with the assistance of the patient/surrogate as appropriate. Patient Care Unit will keep the original in the medical record, one copy is given to the patient/surrogate and the second copy is sent to the Admitting Department. Admitting will then update, as appropriate, the HIS system and issue a new face sheet for the medical record.

3. If a patient has an Advance Directive and a copy is not provided at the time of admission, nursing staff will explain to the patient/surrogate that the physician and hospital can not follow the terms of an advance directive until the contents are known and documented in the medical record. The nurse will explain the methods available for documenting this information (e.g., placing a copy of the advance directive in the medical record or documenting those wishes on the Advance Directive Acknowledgment form which is then placed in the medical record).

4. Nursing staff will follow-up with the patient/surrogate on the provision of a copy of the advance directive to the hospital once during the hospital stay.

5. Contents of the advance directive or the Advance Directive Acknowledgment form will be incorporated into the patient’s treatment plan.

6. If the patient indicates that the hospital has a copy of the advance directive from a previous admission, nursing will document this on the Advance Directive Acknowledgment form and place the existing copy of the advance directive in the current medical record.

7. The advance directive and the Advance Directive Acknowledgment form are located behind the Advance Directive divider in the medical record.

C. Utilization Review Responsibilities include the ongoing monitoring for compliance by concurrent review of each chart processed by Utilization Review.

II. Education

A. Employee Education

All new employees will be inserviced on advance directives during employee orientation. All hospital employees will be updated on advance directives annually through the Heath Education System (HES). A record of new employee orientation will be kept in Human Resources.

B. Patient Education

Should a patient have general or specific questions regarding executing an advance directive while in the hospital, the person who documents the need for education will instruct the patient to contact the Departments of Medical Social Services, Pastoral Spiritual Care, and/or Senior Services (located at YOUR Hospital) should they have questions or concerns.

C. Community Education

YOUR Health System will provide education to the community through the following mechanisms: Distribution of "Your Right to Make Decisions about Medical Treatment" brochure to all individuals admitted to the hospital; lectures to the community and articles in the quarterly "YOUR Health System" newspaper supplement. The Department of Senior Services will be responsible for providing community lectures on the Patient Self-Determination Act and for general information regarding advance directives. A record of community lectures provided will be documented and kept in the Department of Senior Services.

III. Special Circumstances

When a patient is admitted to YOUR Health System in such a condition that it is not practical to provide information regarding advance directives at the time of admission, such information will be provided as soon as reasonably feasible after admission (i.e.; patient’s condition has stabilized and patient is able to participate in conversation and answer questions appropriately).

When a person who lacks present decision-making capacity (as determined by the admitting physician in consultation with family members and/or close friends of the patient) is admitted to YOUR Health System, the person responsible for documenting the admission shall provide information (refer to Admission and/or Nursing Staff Responsibility) regarding advance directives and direct questions regarding the existence of an advance directive to the relative or friend accompanying the patient, if such a person is present. If the patient is unaccompanied at the time of admission, that information is documented on the Advance Directive Acknowledgment form. Information on advance directives and inquiry into the existence of an advance directive shall be directed to the patient’s surrogate decision maker, once a surrogate decision maker has been identified.

An advance directive initiated or changed while a patient is in a skilled nursing facility must be witnessed by the ombudsman to be valid.

__________________

1. Defined as both adult inpatient and outpatient admissions, excluding noninvasive outpatient procedures. These excluded areas will have Patient Self-Determination Act information available to them in the waiting areas. Adult patient is defined as any patient 18 and over being admitted as an inpatient or outpatient

YOUR HEALTH SYSTEM

ADVANCE DIRECTIVE ACKNOWLEDGMENT

ADVANCE DIRECTIVE PROCESS

The initial discussion on Advance Directive between the staff and the patient/surrogate needs to include the following:

it is not necessary to have an Advance Directive in order to receive medical treatment at YOUR Health System; and

the physician and hospital can not follow the terms of an Advance Directive until the contents are known and documented in the medical record.

1. Does the patient have an Advance Directive? o Yes Check Type o No (proceed to #3)

� Durable Power of Attorney for Health Care (DPAHC) o
� Other: __________________________________________ o

If "yes", copy of Advance Directive placed in medical record o Yes o No

If copy available in old chart, move it to the current medical record

2. THIS SECTION TO BE COMPLETED BY PATIENT/SURROGATE ONLY IF A COPY OF THE PATIENT’S EXISTING

ADVANCE DIRECTIVE IS NOT AVAILABLE:

A copy of the patient’s existing Advance Directive is not available at this time. I have been instructed to provide the hospital with a copy for the medical record. The contents of my (the patient’s) Advance Directive are as follows.

Surrogate’s Name/Phone Number ____________________________________________________

Special Wishes (written by patient or surrogate only) __________________________________________________________

Person Completing Section o Patient o Surrogate

Name (printed): ___________________________________________________________________

Signature:____________________________________________ Date: _________________

3. Patient desires further information on Advance Directives. o Yes o No
If "yes", Advance Directive information given to o patient o family o surrogate

4. The patient, due to special circumstances, is unable to provide Advance Directive information at this time and the family/surrogate is not available to provide information at this time (refer to Advance Directive policy #12.03 for details on special circumstances).

Document special circumstances: ___________________________________________________________

5. For Repeat Request for Advance directive, See MAR (day #2)

Staff Signature: __________________________ Date: ________________________

RI005P	Alternative Therapy
Facility Type: Acute Care - 352 Bed Full Service Facility	Last JCAHO Survey: January 1998
Comments: When we mentioned this as our current biggest challenge in the Joint Commission Pharmacy and Nutrition interview, they were very interested. The medical staff has tabled this issue after much discussion. Interested in feedback to the LISTSERV.
Downloadable or Viewable Documents: Policy: Alternative Therapy: RI005P.exe Alternative Therapy: Viewable or Downloadable in PDF Format: RI005F.pdf
Alternative Therapies Policy Statement: It shall be the policy at ---------- Hospital to promote the patient’s right to participate in planning his/her care with respect to alternative therapies while, at the same time, guarding against untoward effects or complications of any therapy. Purpose of Policy: The purpose of this policy is to provide guidelines for the appropriate use of "alternative therapies" in hospitalized patients. "Alternative therapies" includes, but is not limited to, massage therapy, acupuncture, aromatherapy, and herbal remedies. These therapies are practiced by individuals who are certified or licensed to perform them and/or require a physician prescription or order while the patient is hospitalized. Exempted from this policy are supplementary measures such as relaxation techniques, non-manipulative massage, or guided imagery which do not require manipulation/injection of body parts or administration of a substance and are conducted voluntarily by/with the patient. It is recognized that the public is increasingly interested in these areas and may have used/practiced these interventions prior to hospitalization. It is also recognized that an individual’s belief in the benefits of these therapies may contribute to the healing process. It is further recognized that alternative therapies have the potential to produce unknown and/or unwanted effects which may be detrimental to the "traditional" medical regime. For example, herbal remedies sold as "dietary supplements" are without backing or guidance from the FDA and may be impossible to be analyzed or recognized or determined to be free from contaminants. In general, "medication-like substances" will not be approved for use by in-patients. However, the patient’s attending physician may order these if, in his/her opinion, it is best for the patient. Guidelines for procedure: Generally, request for alternative therapy will come from the patient and/or family. Physicians may not, of their own volition, prescribe herbal therapies. Practitioners must carefully review each patient request individually based on the therapeutic benefit versus risk. Physician order for the therapy must be written A signed and legally defensible consent for participation in the specific therapy must be obtained in writing from the patient or the patient’s family or significant other.. If patient/family request a therapy and the MD will not approve, the Ethics Committee may be consulted. This committee is advisory in nature and will attempt to achieve consensus among parties. Any oral preparation will be administered by the patient or family with notification to the nurse caring for the patient. The nurse will document each "dose" administered by patient or family (in the nurse’s narrative note.) on the MAR once per shift under the statement "Patient/family administering own herbal therapy as prescribed". The Pharmacy will be notified of the substance which the patient is taking. The hospital Pharmacy will not stock or obtain these non-FDA approved agents. Patients will be required to provide the herbal product(s). If a practitioner of an alternative therapy will be providing treatment in the hospital, the following must occur after the MD order is written and prior to providing treatment. Health status approval must be obtained through the------------ Hospital Employee Health Service. Any applicable certificate or license should be presented for photocopying and placement in the patient’s medical record. A copy of the certificate or license, a copy of liability insurance voucher, and a copy of the health status approval should be forwarded to the Medical-Dental staff office. The "Agreement for Clinical Experience" will be modified for an alternative therapy practitioner. This states that ------ Hospital is not liable for what they do, that the health requirements must be met, and that, if they become injured on premises, they may present to the E.D. and their health insurance will be billed. If, at any time, it is believed that the alternative therapy is detrimental to the well being of the patient, the attending physician must be notified and the therapy discontinued until an evaluation can be completed.

RI006F	Informed Consent for Blood Transfusion
Facility Type: Acute Care - 139 Beds	Last JCAHO Survey: November 1998
Related Documents: None	Comments: JCAHO Surveyors reviewed and approved of the content of the informed consent
Downloadable or Viewable Documents: Informed Consent for Blood Transfusion Viewable or Downloadable in PDF Format: RI006f.pdf Download in Word 95 Format: RI006f.exe
Patient:__________________________________ Date:___________ Time:_________ o AM / o PM Blood Transfusion: It has been explained to me that I need or may need a blood transfusion and/or blood products for the following reason: _________________________________________________________. I understand in general what a transfusion is and the procedures that will be used. Risks: It was also explained to me that there are possible risks involved with this blood transfusion including, but not limited to, transfusion of infectious hepatitis, acquired immune deficiency syndrome (AIDS), or certain other diseases, unexpected blood reactions, such as immunization or allergic reactions. Alternatives: Alternatives to blood transfusion and/or blood products, including the risks and consequences of not receiving this therapy, have been explained to me. Patient consent: I accept all the risks explained and hereby authorized the administration of such transfusion or transfusions of blood or blood products to me in connection with my medical and surgical care as may be deemed advisable in the judgment of my attending physician or said physician’s associates or assistants. No Guarantee: While extensive testing is performed on all blood used for transfusions, no testing is 100 percent (100%) reliable. I acknowledge that no guarantees have been made to me about the outcome of the transfusion. If you have any questions as to the risks or hazards of blood transfusions, or any questions concerning the proposed procedure or treatment, ask your physician NOW, before signing this consent form. Do not sign unless you have read and thoroughly understand this form. Consent Form will be valid for 30 days or one admission, whatever comes first. Witness Signature_____________________ Patient Signature _______________________ The patient is unable to consent because:__________________________________________________ I, therefore, consent for this patient. Relative/Guardian/Representative __________________ Relationship to Patient ________________ As the physician ordering the transfusion/s, I have explained the risks, benefits, and alternatives of blood or blood product transfusions to this patient. Physician Signature ____________________________ Refusal of Consent for Transfusion: I, ______________________________________________, do refuse to consent to the transfusion of blood and/or blood products described on this consent form. The risks attendant to my refusal have been fully explained to me, and I hereby release the YOUR Medical Center, its nurses and employees, together with all physicians in any way with me as a patient, from liability for respecting and following my express wishes and direction. Witness ____________________________ Patient or Responsible Person ___________________ Date/Time _____________________ Relationship to Patient ________________

RI007O	Patient Responsibilites
Facility Type: Not submitted	Last JCAHO Survey: Not submitted
Related Documents: None	Comments: The print is kept purposefully large for easy reading. It is not posted as are the patient rights but are attached to patient handbooks distributed upon admission.
NOTICE OF PATIENT RESPONSIBILITIES Health care organizations are entitled to reasonable and responsible behavior on the part of the patient and his/her family. The facility identifies the responsibilities of patients and their families and educates them accordingly. Such responsibilities may include, but need not be limited to the following: Provision of information- the patient/family is responsible for providing, to the best of their knowledge, accurate and complete information about present complaints, past illnesses, hospitalizations, medications and other matters relating to the patient’s health. The patient/family is responsible for reporting unexpected changes in the patient’s condition to the responsible practitioner. Compliance with instruction- the patient/family is responsible for following the treatment plan they develop with the health care provider. The patient should express any concerns regarding his/her ability to comply with a planned course of treatment, and every effort should be made to adapt the treatment plan to the patient’s specific need and limitations. Where such adaptation to the treatment plan is clinically indicated, the patient/family is responsible for understanding the consequences of the treatment alternatives and of noncompliance with the proposed course of treatment. Refusal of treatment- the patient/family is responsible for the outcome if the patient/family refuses treatment or does not follow the practitioner’s instruction. Rules and regulations- the patient/family is responsible for following the health care organization’s rules and regulations affecting patient care and conduct. Respect and consideration- the patient/family is responsible for being considerate of the rights of other patient’s and organization personnel and for assisting in the control of noise, smoking and distractions. The patient/family is responsible for being respectful of the property of other persons and the health care organization.

RI011F	Interim Care Directive
Facility Type: Health Care System	Last JCAHO Survey: January - July 1999
Related Documents: None
Comments: Have had multiple JCAHO/CALSurveys in our system Jan-July 1999 ... the patient rights standard that requires documenting per RI.1.2.4: "In the absence of the actual advance directive, the substance of the directive is documented in the patient's medical record." This form was our attempt to help codify this documentation .... I bounced it off two separate surveying teams and they both liked it ..... hope this helps others
Downloadable or Viewable Documents: Interim Care Directive - View or Download in Adobe Acrobat Reader Format: RI010F.pdf Download in Word95 format zipped in a self extracting file: RI011F.exe For Windows 95 hold down the shift key as you click on the file. After downloading the file, double click on the file to cause the files to self inflate.
*INTERIM CARE DIRECTIVE [DRAFT]* I _____________________________________, have a "Durable Power of Attorney for Healthcare" (DPA) or other advance directive, but it is not physically present at the time of my admission. During this admission, until my directive is available, I would like the following to be considered as an Interim Care Directive. The following, as indicated by an initialed box and my signature, reflects my wishes. I do not want life sustaining treatment to be provided or continued if I am in an irreversible coma or persistent vegetative state, and/or if I am terminally ill and the application of life sustaining procedures would serve only to artificially delay the moment of my death. I want the hospital and my Health Care Agent to provide comfort and pain relief measures should such measures be indicated. I want life sustaining treatment to be provided even if I am in an irreversible coma or persistent vegetative state, and/or if I am terminally ill and the application of life sustaining procedures would only serve to artificially delay the moment of my death Other: ___________________________________________________________________ My designated Health Care Agent is _______________________________________ Telephone Number (___)__________________ Address: ____________________________________________________________ This Interim Care Directive does not replace, modify or cancel my existing DPA or other advanced directive. This interim directive is only applicable until such time as my DPA or other directive becomes available to hospital personnel. At that time, this interim directive is to be cancelled. ___________________________ Name (Printed) Signature Date ___________________________ Witness Name Signature Date

RI012P	OR Observers Policy
Facility Type: Acute Care	Last JCAHO Survey: Not submitted
Comments: Submitted by Warren Hospital, Phillipsburg, NJ (Facility Acknowledgement by Request)
Downloadable or Viewable Documents: Downloadable or Viewable Documents: Viewable online and Downloadable in Adobe Acrobat Reader Format: RI012P.pdf Click on the file to view; right-click on the file to download Downloadable in a self-extracting executable file in Word97 format: RI012P.exe

RI009F	Advance Directives Worksheet
Facility Type:	Last JCAHO Survey:
Related Documents: None
Because some documents cannot be included in a suitable format for web page viewing, this file is only viewable or downloadable in Adobe Acrobat Reader format. Downloadable or Viewable Documents: Advance Directives Worksheet - View or Download in Adobe Acrobat Reader Format: RI009F.pdf

RI010F	Organ Donor/Post Mortem Documentation Form
Facility Type:	Last JCAHO Survey:
Related Documents: None
Because some documents cannot be included in a suitable format for web page viewing, this file is only viewable or downloadable in Adobe Acrobat Reader format. Downloadable or Viewable Documents: Organ Donor/Post Mortem Documentation Form - View or Download in Adobe Acrobat Reader Format: RI010F.pdf

RI013P	Compliant Resolution Policy
Facility Type: Acute beds 108, LTC beds 134	Last JCAHO Survey: February 1998
Comments: Distinguishes between what is not a complaint (a concern,