PRACTICE POLICIES AND PROCEDURES ADVANCE DIRECTIVES
and “DO NOT RESUSCITATE” in the ASC

June 3, 2009
Approval Date and Approving Manager or Board

Original Issue Date: 7/2009
Revision Dates: 10/1/09

POLICY TITLE:  ADVANCE DIRECTIVES

POLICY:  Patients generally have a right to execute advance directives and have those directives honored; however, for moral and professional reasons, IPM&R/Ambulatory Surgery Center (ASC) will take reasonable action to stabilize or revive patients who have suffered a life threatening condition, including the use of CPR or other artificial life sustaining treatment.  Accordingly, IPM&R/ASC will not honor advance directives to the extent that such directives would otherwise prohibit life sustaining treatment.

PROCEDURE.

1.            Advance Directives.  Patients generally have the right to make informed decisions concerning their treatment.  Advance directives are written instructions that declare a patient’s treatment decisions or appoint a representative to make treatment decisions for the patient if the patient becomes incapacitated.  Idaho statutes recognize the following forms of advance directives:

            a.            Living Will.  A living will allows a patient with a terminal condition to specify certain treatment options if the patient becomes incapacitated, including the withdrawal or withholding of certain types of life sustaining treatment.  Idaho Code § 39-4510 to -4514 sets forth the requirements for valid living wills.

            b.            Durable Powers of Attorney for Health Care.  A durable power of attorney for health care appoints a personal representative who may make health care decisions for the patient if the patient becomes incapacitated.  Idaho Code § 39-4510 to -4514 sets forth the requirements for a valid durable power of attorney.

            c.            Physician’s Orders for Scope of Treatment (“POST”).  A POST is a physician order executed on a standardized form issued by the state of Idaho that directs the care to be provided to the patient under certain circumstances, including the withdrawal or withholding of life sustaining treatment.  Idaho Code § 39-4511 to -4514 sets forth the requirements concerning POSTs.  If a patient requests a POST, their physician must help the patient complete the POST and periodically review the POST.  Once completed, a valid POST is effective in any facility.  See I.C. § 39-4512A to -4514.

            d.            Do Not Resuscitate Orders (“DNRs”).  DNRs are physician orders that specify treatment to be provided in the event that the patient suffers a life threatening condition.

            e.            Other Advance Directives; Technical Defects.  Although the foregoing are the advance directives expressly recognized by statute, Idaho law confirms that they are not the only way to effectively communicate a patient’s treatment wishes.  I.C. § 39-4509.  Any authentic expression of a patient’s lawful treatment wishes should be honored.  Id.  Accordingly, IPM&R physicians may honor advance directives that clearly document the patient’s wishes even if they contain technical defects.

2.            Resuscitation; No “Do Not Resuscitate” Directives.  Idaho allows physicians to decline to honor a living will, POST, or other advance directive due to ethical or professional reasons.  I.C. § 39-4513(2).  It is IPM&R’s ASC policy to take reasonable action to revive patients who have suffered a life threatening condition, including the use of artificial life sustaining treatment.  Accordingly, IPM&R Ambulatory Surgery Center will not honor advance directives to the extent that such directives would otherwise require the withholding or withdrawal of such life sustaining treatment, including POSTs and living wills.

3.            Written Notice to Patients.  Consistent with federal requirements, IPM&R will provide written notice to ASC patients concerning their right to execute advance directives and IPM&R’s/Ambulatory Surgery Center’s policy concerning advance directives, including IPM&R’s/ASC policy not to honor directives for the withholding of life sustaining treatment.  Such notice shall be provided prior to obtaining informed consent for treatment.  Such notice shall be provided so that the patient receives and may review the policy at least one day prior to any scheduled ASC procedure. 

4.            Advance Directive Forms.  If the patient requests a copy of Idaho’s approved POST or living will/durable power of attorney form, state laws and federal regulations require that IPM&R provide the forms to the patient.  The living will/durable power of attorney form is located in Idaho Code § 39-4510, which can be accessed at http://www2.state.id.us/ag/living_wills/LivingWill_DurablePowerOfAttorney.pdf.  The POST form is available at www.sos.idaho.gov/general/hcdr.htm.  To request a password to obtain the POST form, send an e-mail with the physician or facility name and license number to idahopost@dhw.idaho.gov.  Idaho law requires that the attending physician assist the patient with completing a POST form.  See I.C. § 39-4512A.  For more information on POST form requirements or completing the POST form, see the attached POST Form Instructions for Physicians.

5.            Documenting Advance Directives.  IPM&R must document the existence of any advance directives in the patient’s medical record.  The documentation must be placed in a prominent part of the medial record where it will be readily noticeable by clinical staff providing services to the patient.  If a patient in the ASC is transferred to another health care facility (e.g., if there is an emergency transfer to a hospital), the ASC must ensure a copy of the advance directive is sent with the medical record.

6.            Patient With Advance Directive That Prohibits Life Sustaining Treatment.  If the patient presents with an advance directive that requires life sustaining treatment contrary to IPM&R/ASC’s policy, IPM&R personnel must explain IPM&R’s/ASC policy to the patient and do the following:

            a.            Document Consent to Life Sustaining Treatment.  If the patient agrees to waive or suspend operation of the advance directive, IPM&R/ASC personnel shall document in the medical record that they discussed IPM&R’s policy with the patient and that the patient consents (1) to receive life sustaining treatment consistent with IPM&R’s/ASC policy, and (2) to waive or suspend the conflicting provisions in the advance directive.

            b.            No Consent; Referral to Another Provider.  If the patient will not consent to life sustaining treatment and/or will not waive or suspend the conflicting provisions of their advance directive, IPM&R/ASC personnel shall explain to the patient that they cannot provide treatment to the patient; shall make a good faith effort to assist the patient in transferring their care to another willing provider; and shall document the circumstances and communications in the patient’s record.

RELATED POLICIES.                             

Informed Consent

Notice of Patient Rights