Innovations in End-of-Life Care
an international journal of leaders in end-of-life care

This document comes from the appendix to Chapter 10 of the RYC Training Manual and is not copyrighted.

DISTRIBUTION: All Dept ANU Bud Hammes Risk Mgt

OBJECTIVE:

1. To respect the known wishes of patients who have become incapable of making their health care decisions.
2. To better define the obligations of health care professionals with regard to advance directives.
3. To assure that advance directives are available to physicians in a timely manner.

POLICY:

The desires of an adult patient who is capable of making his or her own health care decisions supersede the effect of an advance directive at all times. If an adult patient is incapable of making his or her health care decisions, then the patient's advance directive is presumed to be valid.

GUIDELINES:

1. Definitions:
1. An adult patient is any person at least 18 years old.
2. An advance directive is any written document representing the wishes and values of an adult, either while a patient or prior to becoming one, that: a) designates another person(s), i.e., surrogate(s), to make health care decisions on behalf of the patient if the patient is unable to make decisions for himself or herself, b) gives instructions to a health care professional as to the patient's desires about health care decisions; or c) both designates a surrogate and gives instructions.

   To meet this definition, for the purposes of this policy, an advance directive need not comply with any particular form or formalities, as long as it is in written form and it appears to be authentic. (IT SHOULD BE NOTED THAT ADVANCE DIRECTIVES THAT DO NOT MEET THE STATUTORY REQUIREMENTS OF WISCONSIN'S CHAPTER 154 OR 155 MAY NOT PROVIDE THE LEGAL PROTECTION AS SPECIFIED IN THOSE STATURES).

3. A primary physician is the attending physician who is responsible for the patient's care.
2. Notification of Entrance or Removal of a Written Advance Directive:

Before an advance directive can be entered into, or removed from a patient's chart, an authorized staff person from Gundcrsen Clinic or Lutheran Hospital-La Crosse must be notified. Authorized staff included: anyone on the medical staff; a patient service representative from Gundersen Clinic; or a person designated by a member of the medical staff who is also either a physician assistant, nurse practitioner or a certified advance directive counselor.

The authorized staff must acknowledge notification by making his or her signature on the appropriate line of the patient's advance directive record.

3. Effect:

An advance directive should be followed to the extent that it does not require a physician to perform any c act, does not violate that physician's personal or professional ethical responsibilities, or does not violate accepted standards of professional practice. If a physician is unwilling to honor an advance directive because it violates his or her personal ethical beliefs, then transferring the care of the patient to another physician should be discussed with the patient or the patient's surrogate(s).

Advance directives relevant to patient care, e.g., "no resuscitation indicated', will be written by the attending physician on the Hospital order sheets.

4. Validity:

In all cases in which an advance directive is to be disregarded, persuasive and credible evidence must exist that:

1. the patient was not competent at the time the directive was made;
2. the directive is a forgery; or
3. the directive has subsequently been revoked by the patient.
5. Review:

Ordinarily, there should be no need to seek review of the enforceability of an advance directive any more than there ought to be routine review of a patient's oral wishes. However, when doubts or conflicts arise, such as when there is conflict between the advance directive and the wishes of the patient's family, or when there is a substantial doubt as to the authenticity of the advance directive, a consultation should be sent to the Hospital Ethics Committee for its recommendation.

6. Procedures for Entering and Removing:

A written advance directive will be kept in the front of the patient's active chart in a green plastic folder. The folder will contain a patient's advance directive record that is clearly marked "Advance Directive Record" and the record will have the patient's name, clinic number, and birth date. When a directive is entered the authorized staff who is notified will sign and date the advance directive record. The entrance of the directive will also be noted on the master sheet with the date, the phrase "Advance Directive Entered", and the name of the authorized staff who signed the record. When an advance directive is not personally delivered by the patient, a written confirmation of its entrance into the chart will be sent to the patient.

An advance directive will be removed at the patient's oral or written request. When a directive is removed the authorized staff who is notified will sign and date the advance directive record. The advance directive will be returned to the patient. The patient's written request will remain in the correspondence section of the chart. The removal of the advance directive will be provided to another

1. health care facility if a patient is being transferred to that facility from Lutheran Hospital-La Crosse or,
2. health care facility or physician caring for the patient if requested by the patient or the patient's physician.

The responsibility to transfer advance directives, as described in circumstance 1, will fall to the social worker assigned to the nursing unit caring for the patient.

To be noted on the master sheet with the date, the phrase "Advance Directive Removed", and the name of the authorized staff who was notified.

7. Transferring Advance Directives:

A copy of an advance directive will

8. Questions and Information:

If a patient, family members, or Hospital staff have questions or need information about advance directives, the on call chaplain will be available to address these questions and needs.

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