UPMC POLICY AND PROCEDURE MANUAL POLICY: HS-PS0507 * INDEX TITLE: Physician SUBJECT: Advance Directives for Medical/Physical Health Care DATE: December 4, 2015 I. POLICY It is the policy of UPMC to provide quality medical care to its patients and residents with the objective of sustaining life and practicing in conformity with current legal, ethical and medical standards. While maintaining the presumption in favor of providing treatment to all patients, UPMC recognizes the right of certain patients (as described in more detail below) to make their own decisions about their health care (including through advance written directives) and to continue, limit, decline, or discontinue treatment, whether lifesustaining or otherwise. Links to policies referenced within this policy can be found in Section VIII. II. PURPOSE A. The federal Patient Self-Determination Act recognizes the rights of adults under state laws, including the Pennsylvania Living Will Act, Healthcare Agents and Representatives Act, and Out-of-Hospital Nonresuscitation Act, to control decisions relating to their own medical care in general and through the proper execution and implementation of advance directives. B. This policy sets forth general procedures by which patients and residents of UPMC institutional providers are informed of their right to formulate advance directives and procedures by which the existence of executed advance directives shall be determined and confirmed. More detailed, facility-specific procedures consistent with this policy are available from the applicable facility. C. This policy also outlines the manner in which advance directives become operative, how they may be revoked or countermanded, and the responsibilities of health care providers with respect to implementing advance directives. D. This policy should be read in conjunction with the policy of the UPMC concerning Patient Informed Consent, Policy HS-RI1302, UPMC s Guidelines on Life-Sustaining Treatment, Policy HS-PS0506, and relevant facility-specific policies and procedures.
PAGE 2 Please refer to UPMC policy HS-PS0506, Guidelines on Life Sustaining Treatment for discussion concerning out-of-hospital do-not-resuscitate orders. POLST - Pennsylvania Orders for Life Sustaining Treatment (Overview, Education, Policy, Resources, Patient and Family Communications, Transition of Care and Advance Directives and Code Status) Please refer to UPMC policy HS-PS0508, Mental Health Advance Directives for discussion concerning this type of advance directive. III. SCOPE This policy applies to all patients receiving care at United States based UPMC hospitals, Ambulatory Surgery Centers, UPMC long-term care facilities, or through a UPMC home health provider. IV. DEFINITIONS The following terms shall be defined as provided by Pennsylvania law: A. Advance directive means, for purposes of this policy, a living will, health care power of attorney, or any written combination of both, relating to the provision of medical/physical health care. B. Competent means a condition in which an individual, when provided appropriate medical information, communication supports and technical assistance, is documented by a health care provider to do all of the following: (1) Understand the potential material benefits, risks and alternatives involved in a specific proposed health care decision. (2) Make that health care decision on his own behalf. (3) Communicate that health care decision to any other person. This term is intended to permit individuals to be found competent to make some health care decisions, but incompetent to make others. For purposes of this policy, the term competent shall be synonymous with having decision making capacity. C. End stage medical condition means an incurable and irreversible medical condition in an advanced state caused by injury, disease or physical illness that will, in the opinion of the physician to a reasonable degree of medical certainty, result in death, despite the introduction or continuation of medical treatment. Except as specifically set forth in an advance health care directive, the term is not intended to preclude treatment of a disease, illness or physical, mental, cognitive
PAGE 3 or intellectual condition, even if incurable and irreversible and regardless of severity, if both of the following apply: (1) The patient would benefit from the medical treatment, including palliative care. (2) Such treatment would not merely prolong the process of dying. D. Health care agent means an individual designated by a patient in an advance health care directive. E. Health care power of attorney means a writing made by a patient designating an individual to make health care decisions for the patient. Health care powers of attorney may be executed by individuals of sound mind who are 18 years of age or older, have graduated from high school, have married, or are emancipated, and must be witnessed by two individuals 18 years of age or older. F. Health care representative means an individual designated by a patient in a signed writing other than an advance directive or by personally informing the health care provider, who is authorized to make health care decisions for a patient. In the absence of such a designation or if no designee is reasonably available, a health care representative may be selected as provided in Addendum C of UPMC Policy HS-PS0506 Guidelines on Life-Sustaining Treatment. G. Incompetent means a condition in which an individual despite being provided appropriate medical information, communication supports and technical assistance, is documented by a health care provider to be: (1) unable to understand the potential material benefits, risks and alternatives involved in a specific proposed health care decision; (2) unable to make that health care decision on his own behalf; or (3) unable to communicate that health care decision to any other person. The term is intended to permit individuals to be found incompetent to make some health care decisions, but competent to make others. For purposes of this policy, the term incompetent shall be synonymous with the term lack of decision-making capacity. H. Living will means a writing that expresses a patient s wishes and instructions for medical/physical health care and health care directions when the patient is determined to be incompetent (lacking decision making capacity) and has an endstage medical condition or is permanently unconscious. Living wills may be executed by individuals of sound mind who are 18 years of age or older, have
PAGE 4 graduated from high school, have married, or are emancipated, and must be witnessed by two individuals 18 years of age or older. I. Permanently unconscious means a medical condition that has been diagnosed in accordance with currently accepted medical standards and with reasonable medical certainty as total and irreversible loss of consciousness and capacity for interaction with the environment. The term includes, without limitation, an irreversible vegetative state or irreversible coma. V. NO PRESUMPTIONS FROM PRESENCE OR ABSENCE OF ADVANCE DIRECTIVES An advance directive for medical care does not imply "Do Not Resuscitate" status. Moreover, the absence of an advance directive should not give rise to any assumption as to the intent of any patient to consent to or refuse any treatment. VI. PATIENT NOTIFICATION AND DOCUMENTATION REQUIREMENTS A. Introductory Information for Inpatients, Same Day Surgical Services Patients, Skilled Nursing Facility Residents, Patients of Personal Care Services, Hospice Patients, and recipients of home health services. 1. Written information shall be provided to adult hospital inpatients, Same Day Surgical Services patients (patients who arrive at a UPMC facility on the day of their scheduled procedure), skilled nursing residents, patients of personal care services, hospice patients, and home health patients and shall describe the following: a. an individual's rights under Pennsylvania law to make decisions concerning medical care, including the right to accept or refuse treatment and the right to formulate advance written directives with respect to such treatment; b. the written policies of the UPMC institutional provider concerning the implementation of such rights (such as UPMC Policy HS-HR- PR-01 Patients Bill of Rights and Responsibilities); c. the availability of interpreting service for the deaf and for patients who cannot read or speak English. 2. Patients/residents who do not have a medical advance directive will be offered information on advance directives at the time of admission.
PAGE 5 3. Information on advance directives may be provided by the patient's/resident s admitting or referring physician in advance of the admission, but this information does not take the place of information provided by the UPMC institutional provider at the time of the admission. 4. Assistance may be provided to any patient requesting help in writing an advance directive by nursing, social work, the attending physician and/or a representative of the institution s Ethics Committee. In all instances, where assistance is provided by someone other than the attending physician, the attending physician will be advised of the existence of the advance directive by the person providing the assistance. UPMC staff may not sign an advance directive on behalf of or at the direction of, nor serve as witnesses to an advance directive of, patients of UPMC facilities, nor is it the policy of UPMC to provide legal advice or services to patients considering or desiring to execute an advance directive. B. Documentation 1. It shall be documented in the medical record of each adult patient or resident, for each admission, whether such patient has formulated an advance directive. If the patient/resident or other individual is unable to provide this information, it shall be documented that this information is unknown. If available, a copy of the patient s/resident s advance directive shall be included in the medical record and placed in an appropriate section of the medical chart. 2. If the patient/resident has an advance directive but has not provided a copy to the UPMC institutional provider, the Social Worker/Registered Nurse or other appropriate staff member will be responsible for attempting to secure a copy. Information volunteered about the content of the advance directive will be documented. Any actions on the part of the Social Worker/Registered Nurse or other staff member to attempt to secure the advance directive should be documented in the medical record. 3. In UPMC hospitals, whenever an advance directive is provided to the Admitting Department prior to or at the time of admission by the patient or patient's physician, such advance directive shall be sent with patient registration materials to the inpatient or Same Day Services Unit. For Emergency Department patients, it will accompany the face sheet. 4. Advance directives may be revoked at any time as described in Section III.F hereof. Thus, advance directives obtained in connection with previous admissions shall be verified as current upon the current admission, and verification of this status shall be documented. If a previous advance directive has been revoked, this will be so noted in the
C. Ambulatory Services POLICY HS-PS0507 PAGE 6 medical chart, and patients/residents will be provided an opportunity to provide or create new advance directives. Advance Directives will be honored in the ambulatory setting to the extent permitted in each facility-specific policy or procedure. In all facilities that permit advance directives to be honored in the ambulatory setting, health care professionals will ask ambulatory patients if they want their advance directive to be implemented should the need arise. This discussion will be documented in the patient s medical record. Information about Advance Directive, specifically Five Wishes form, will be available to all patients. D. Special Situations 1. Pregnant Patients/Residents and End-of-Life Decision Making Pregnant patients/residents should be offered the same opportunity to give their advance directive to their care team, or to create one in accordance with this policy. However, there is specific legislation limiting the ability to implement advance directives for pregnant patients. This legislation may be found at 20 Pa.C.S.A. Section 5429. End-of-life decision making for pregnant patients is also discussed in UPMC Policy HS-PS0506 Guidelines on Life Sustaining Treatment. Cases involving the potential implementation of advance directives for pregnant patients can be legally and ethically complex. Orders regarding end-of-life care for pregnant patients should not be written without first consulting with the hospital ethics committee and the UPMC Corporate Legal Department. Physicians are not required to perform a pregnancy test on individuals prior to implementation of an advance directive unless the physician has reason to believe that the woman may be pregnant. 2. Minors The Living Will Act addresses the creation of advance directives by individuals who are 18 years of age or older, have been married, have graduated from high school, or are emancipated minors. (See UPMC s Policy HS-RI1302 Patient Informed Consent for additional information concerning emancipated minors). However, it is recognized that there may be individuals not fitting those criteria who, nonetheless, possess a degree of maturity warranting their right to self-determination. It is further recognized that circumstances may exist in which those mature minors wish to ensure that their preferences regarding aggressive medical
PAGE 7 intervention are known to their health care providers. In such cases, the minor may issue a written statement which, although not endowed with the same legal weight of an advance directive, would provide evidence of the patient s wishes, and direction to family and health care providers should the patient be in a condition which would, if the patient were an adult, cause the advance directive to become operative. Written statements made by a minor patient may be included in the medical record and should be discussed with the patient, family and staff caring for the patient. E. Implementation of Advance Directives 1. Living Wills. A valid living will becomes operative when all of the following conditions are met: a. The attending physician or, in the case of home health, the ordering physician reviews the advance directive. b. The attending/ordering physician determines that the patient/resident is incompetent (lacks decision making capacity) and has an end-stage medical condition or is permanently unconscious, documents this determination and that the living will is operative in the medical chart, and issues the appropriate order in accordance with UPMC Policy HS-PS0506 Guidelines on Life Sustaining Treatment. 2. Health Care Powers of Attorney. Unless otherwise specified in the health care power of attorney, a health care power of attorney becomes operative when all of the following conditions are met: a. The attending physician or, in the case of home health, the ordering physician reviews the health care power of attorney. b. The attending/ordering physician determines that the patient is incompetent (lacks decision making capacity). The physician must document this determination in the medical chart. Unless otherwise provided in the health care power of attorney, the health care power of attorney becomes inoperative during such time as, in the determination of the attending physician, the patient is competent (has decision making capacity). 3. Discussion of Advance Directives with Patient Once an advance directive becomes operative, and before it becomes operative if circumstances that would make it operative are reasonably
PAGE 8 foreseeable (such as determination of an end stage medical condition or when a patient/resident is transferred from one health care setting to another), the physician should discuss the patient's advance directive with the patient/resident (or authorized surrogate(s) if discussion with the patient/resident is not feasible). (Please refer to UPMC Policy HS-PS0506 Guidelines on Life-Sustaining Treatment and UPMC Policy HS-RI1302 Patient Informed Consent for additional guidance concerning surrogates). 4. Emergency Situations In emergency situations, prior to when an advance directive becomes operative as provided above, the physician responsible for the medical care of the patient/resident at the time should exercise his or her best judgment, and act accordingly. F. Revocation of Advance Directives and Countermand 1. A patient/resident may revoke a living will or countermand a health care decision made by a substitute decision maker that would withhold or withdraw life-sustaining treatment at any time and in any manner without regard to the patient s mental or physical condition. The patient s/resident s family may not revoke the patient s living will. A revocation is effective upon communication to the attending physician or other health care provider by the patient or a witness to the revocation. 2. A patient/resident of sound mind may revoke a power of attorney or countermand any health care decision made by a health care agent or representative in writing or by personally informing the physician, health care provider, or health care agent or representative of such revocation. 3. In the case of a revocation of any type of advance directive, the attending physician or other health care provider should document the revocation in the medical record. If not aware, the attending physician will be notified of the revocation. G. Patient/Resident Consultation UPMC shall respond to requests by patients/residents, families, and concerned others relating to advance directives and/or refusal or withdrawal of lifesustaining treatment in accordance with applicable guidelines and procedures of UPMC, or of the facility involved.
PAGE 9 Requests relating specifically to whether to provide or withhold treatment for the patient should be referred to the patient's/residents attending physician. Requests for an ethics consultation shall be referred as applicable to the appropriate Medical Ethics Committee in accordance with the procedures of such Committee. H. Attending Physician Unwilling to Comply If the attending physician is unwilling in good conscience to comply with an advance directive for medical care or a decision of a health care agent or representative, the procedure set forth in UPMC Policy HS-PS0506 Guidelines on Life Sustaining Treatment, Addendum B, should be followed. I. Education UPMC and its facilities shall provide and/or participate in the provision of education to staff and the community as to issues concerning advance directives. VII. NONDISCRIMINATION UPMC shall not condition the provision of care or otherwise discriminate against an individual based on whether the individual has executed an advance directive. VIII. POLICIES REFERENCED WITHIN THIS POLICY HS-RI1302 HS-PS0506 Patient Informed Consent Guidelines on Life-Sustaining Treatment POLST - Pennsylvania Orders for Life Sustaining Treatment (Overview, Education, Policy, Resources, Patient and Family Communications, Transition of Care and Advance Directives and Code Status) HS-PS0508 Mental Health Advance Directive HS-HR-PR-01 Patients Bill of Rights and Responsibilities
PAGE 10 SIGNED: Steven Shapiro, MD. Executive Vice President, UPMC Chief Medical and Scientific Officer President, Health Services Division ORIGINAL: October 14, 2005 APPROVALS: Policy Review Subcommittee: November 12, 2015 Executive Staff: December 4, 2015 PRECEDE: December 1, 2014 SPONSOR: Executive Vice President, UPMC Chief Medical and Scientific Officer President, Health Services Division * With respect to UPMC business units described in the Scope section, this policy is intended to replace individual business unit policies covering the same subject matter. In-Scope business unit policies covering the same subject matter should be pulled from all manuals.