DEPARTMENT: Social Services EFFECTIVE: APPROVED BY: REVISED: ,

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1 SUBJECT: Advance Directive Protocol Page 1 of 7 POLICY: It is the policy of Helen Newberry Joy Hospital and Health Care Center, in accordance with Michigan Law, of maintaining the rights of every competent adult 18 years of age and older, to make decisions regarding healthcare to accept, refuse or discontinue care, treatment or services. It is also the policy of Helen Newberry Hoy Hospital and Healthcare Center to provide a consistent and orderly method of notifying patients of their rights to make decisions concerning their medical care, including the right to accept or refuse medical treatment and to formulate advance directives. (Federal Omnibus Budget Reconciliation Act of 1990, P.L ). PURPOSE: To assure that medically indicated treatment decisions correspond with the wishes of individual patients, whether expressed by patients or made by surrogates acting in the patient's behalf. To assure that decision making regarding treatment options is done in keeping with current ethical, legal and clinical standards. DEFINITIONS: All advance directive documents must be read for specific instructions within the document. The following definitions are of different documents that you may see. Advance Directive: Advance directives are documents which state a patient s choices about his/her medical treatment or name someone to make decisions about his/her medical treatment, if he/she is unable to make these decisions or choices for his/her self. They are called advance directives because they are signed in advance to let doctors and other health care providers know the person s wishes concerning medical treatment. Through advance directives, a patient can make legally valid decisions about future healthcare. Using an advance directive a person may select another person to act on his/her behalf in the event that he/she becomes incapacitated to make decisions. Durable Power of Attorney: A competent adult may assign someone to represent him/her, in case he/she becomes incapacitated or are otherwise unable to make decisions for his/her self. This is done through a Durable Power of Attorney document. Financial Durable Power of Attorney: This is for financial matters only. A person with a FDPOA cannot make medical decisions. General Durable Power of Attorney: This is for financial matters. There are some DPOA documents that have limited stipulations regarding medical decisions. A medical decision that needs to be made must be specified within the DPOA document. For example, if a DPOA needs to place an incapacitated person in a nursing home, the DPOA papers must specify this as a power in the document. Medical Durable Power of Attorney: This may also be referred to as a Durable Power of Attorney for Healthcare or a Patient Advocate or a

2 SUBJECT: Advance Directive Protocol Page 2 of 7 Healthcare Durable Power of Attorney or a Healthcare Proxy. This is for medical decision-making only. Power of Attorney: This is for a specific, finite situation. It is intended for financial decisions but there are some documents which have statements regarding the ability to make medical decisions. A Power of Attorney is invalid when the person becomes incapacitated. A Durable Power of Attorney continues after the person becomes incapacitated. Guardianship: A guardian is an agent who is appointed by a probate court proceeding. Guardianships include those for incapacitated adults, individuals with developmental disabilities and guardianships for minor children. The specific powers that a guardian has are outlined in the guardianship papers from the probate court. Specific powers granted may vary based on the needs of that adult or child. Guardianships do not always provide the power for the guardian to make financial decisions on behalf of the adult or child. Conservatorship: A conservator is an agent who is appointed by a probate court proceeding. It is specifically, and only, for financial matters of the ward. Conservators do not have the power to make medical decisions. In the event of death, Advance Directives Documents are no longer valid. Procedure Subject Responsibility Action Informing patients of decision-making rights and options Admitting Clerk Ask patient if he/she has an Advance Directive during the admission process. If the patient says no, give the patient a copy of the Michigan Advance Directive booklet. A patient s refusal of information or to execute an advanced directive has no affect on care, treatment and services. SW- LTC If the patient is admitted to LTC the LTC SW will review the documents and place them in the record. A copy will be sent to HIM to be scanned into the record. Prior to scanning, HIM will forward said copy to the CAH SW/Patient Advocate to review and

3 SUBJECT: Advance Directive Protocol Page 3 of 7 Admitting Nurse initial. SW will send initialed copy to HIM for scanning. Ask patient if he/she has an Advance Directive. If the patient says no, give a copy of the Michigan Advance Directive Booklet. Explain and confirm patients understanding. SW - CAH A patient s refusal of information or to execute an advanced directive has no affect on care, treatment and services. The CAH SW or LTC SW may be consulted when a patient wants assistance filling out an Advance Directive. The SW will provide education about Advance Directives and assist patients/residents as requested in completing same. The SW will document, in the medical record, the status of the process of the patient/resident completing the Advance Directive while currently a patient/resident. If the patient/resident is discharged prior to the SW receiving the referral, the SW will attempt to contact the patient/resident via phone twice to provide Advance Directive education and will document the outcome in the medical record. Documentation of presence and acceptance of the Advanced Directive Patient and or Advocate CAH SW will initial the right bottom corner of the document to indicate that it has been reviewed and will forward the copy to HIM to be scanned. The CAH SW will be consulted whenever there are any questions regarding the Advance Directives. Presents the Advance Directives to the Admitting Nurse. On subsequent visits the patient should be given opportunities to review and update the document. Provide a copy of the Advance Directive and

4 SUBJECT: Advance Directive Protocol Page 4 of 7 Admitting Nurse file in the chart. Give back the original document to the patient for their records. Make a copy of the Advance Directive and file in the chart. Give back the original document to the patient for his/her records. Activation of DPOA Documents Patient Advocate When a patient becomes competent after activation of the DPOA. Attending Health Information Management Attending physician Health Information Management Document if the patient has Advance Directives. Notify the Attending physician of the Advance Directives. Reviews the Advance Directive documents. If the patient becomes or presents in an incompetent state, the attending physician and one other physician or a physician and a licensed psychologist may deem the person incompetent and activate the Advance Directive by signing and dating the Activation of Patient Advocate/Medical Durable Power of Attorney Attending s Statement. The Activation form is then forwarded to the CAH SW to be reviewed and initialed. It is then forwarded to the Health Information Management Department where it will be scanned. The HIM department will scan the Activation form to the ADV DIR document type in the Orders tab in the Patient Chart. The description will be changed to reflect the activation date. The LTC SW will provide a copy of the Activation form to the LTC Desk Nurse who will document said Activation status in the Optimus system. If a person is deemed incompetent for an acute process and then becomes competent again, the physician will document the patient s competence in the chart, sign the Deactivation of Patient Advocate/Medical Durable Power of Attorney Attending s Statement and communicate that to the CAH SW/LTC SW. The Deactivation form is then forwarded to the CAH SW to be reviewed and initialed. It is then forwarded to the Health Information

5 SUBJECT: Advance Directive Protocol Page 5 of 7 Revocation of Durable Power of Attorney (DPOA) Documents Compliance with provisions of an Advance Directive Patient Hospital staff/ltc staff Nursing, SW - CAH/ or Health Information Management and Hospital staff/ltc staff Management Department where it will be scanned. The HIM department will scan the Deactivation form to the ADV DIR document type in the Orders tab in the Patient Chart. The description will be changed to reflect the deactivation date. A patient may revoke an Advance Directive at anytime without regard to their mental condition. Revocation is effective upon communication with the physician or to any health care provider. If a patient makes his/her wishes known and wants to revoke his/her Advance Directives, the hospital staff member must immediately inform the attending physician. The staff member will notify SW or the charge nurse to make sure that the process of Revocation is complete including notification of medical records. The Nurse, SW or documents revocation in current medical record including date, time and witness to the revocation and the name of the person accepting the revocation. The SW, Nurse or marks the paper copy of the Advance Directives with one line and writes the word revoked and the date at the top of the document. The SW, Nurse or communicates with the staff and the Advocate if available that the patient no longer has an Advance Directive and that a new one must be executed if desired. The HIM staff will change the scan description from ADV DIR to INACTIVE. Will follow the instructions set forth in the Advanced Directive EXCEPTION Will not follow instructions to withhold or withdraw any treatment from a pregnant person that would result in the death of that person per Michigan Law

6 SUBJECT: Advance Directive Protocol Page 6 of 7 Conflict Resolution Patient Competency, patient, hospital staff/ltc staff, SW - CAH Patient Hospital staff/ltc staff, attending physician Will not comply with any request for assisted suicide or voluntary euthanasia Must comply with Advance Directives which qualify for DPOAHC under Michigan Law. If a physician cannot comply with the Advance Directive as a matter of conscience, the physician must transfer the patient to a physician who will comply with the directives and document this in the medical record. May request a referral to the Ethics Committee for assistance in exploring alternatives in an effort to resolve conflicts between and among patient, family and caregivers regarding compliance with the Advance Directive. May seek legal counsel May consider legal appointment of a guardian: 1. When the parties cannot resolve differences in application of provisions of the advanced directives 2. When the authenticity of the Advance Directive is in question 3. When there is no patient advocate or family member available 4. When the patient is incompetent Makes own decisions as long as the patient is competent Will evaluate competency by evaluation of 2 physicians or 1 physician and 1 licensed psychologist. If the patient is deemed incompetent to make own decisions, the attending physician will acknowledge that the DPOA has been activated. Results of the evaluation will be recorded in the patient record. Patients who have not Patient If mentally competent the patient will make

7 SUBJECT: Advance Directive Protocol Page 7 of 7 executed an Advance Directive Annual Review of LTC residents Advance Directives Hospital Staff SW - CAH decisions about own care treatment and services If a patient presents to the hospital for services and in a condition that compromises decision making capacity regarding care, treatment and service, staff immediately will determine if there is an Advance Directive, a guardian or if family members are available If no decision maker is available, pursues the appointment of a guardian through the Probate Court Assists with petitions for guardianship as needed. LTC SW will review all resident Advance Directives quarterly as well as track "Activation" status and maintain documentation of said review. Accessing in Centriq Hospital: Hospital Module Documents Tab Scanned Images Change the filter to MPI Double click "open book" icon (image will populate to the screen) Review or print as necessary. Multiple documents may be scanned for one patient. Review carefully. If you are unsure of what document to use contact the SW or nursing supervisor. In addition, several documents may be current at one time. Read the document and if conflict exists contact SW or the charge nurse. Make the physician aware that a conflict exists in the advanced directive documents.