Learn how to handle advance directives
Policies keep staff and patients well-informed
An otherwise healthy 40-year-old patient comes in for her routine testing for her D&C one morning. Preparing this patient should be simple and straightforward, correct? But not so fast — she throws you a curve by asking for information on advance directives and asking that one be placed in her chart.
Do your staff know how to handle questions related to advance directives? Does your accreditation organization require you to address advance directives? Do you know if you are required by federal or state law to provide information?
The Joint Commission on Accreditation of Healthcare Organizations in Oakbrook Terrace, IL, has standards that address advance directives. While the hospital accreditation standards are more specific and more detailed in terms of withholding resuscitative treatment and life-sustaining treatment, the ambulatory care standards simply state that "patients receive assistance in formulating advance directives," says Charlene Hill, media relations director for the Joint Commission.
The Accreditation Association for Ambulatory Health Care in Wilmette, IL, doesn’t specifically address advance directives, but it does have a standard that addresses patients’ right to participate in decisions involving their own health care, says Adrian Hochstadt, director of public affairs and communications.
While the Patient Self-Determination Act of 1990 requires hospitals and hospital-based outpatient surgery programs to offer assistance to patients in developing and honoring advance directives, freestanding surgery centers don’t have to meet the same requirements, says Raymond Grundman, vice president of operations for Aspen Healthcare. Aspen Healthcare is a surgical center development and management firm in Boulder, CO. Grundman also is administrator of The Ambulatory SurgiCenter at FMC, a same-day surgery center associated with Flagstaff (AZ) Medical Center.
In Arizona, the state requires all health care facilities to offer patients information about advance directives and have policies to handle administration of the directives. To meet this requirement, Grundman’s facility has an information packet that includes forms for advance directives and a brochure explaining how advance directives work.
The information for these packets can come from health departments or other state departments that are responsible for patient advocacy, as well as national organizations such as Choice in Dying, says Mary L. Meyer, vice president of special projects. Choice in Dying is a Washington DC-based national not-for-profit organization that helps patients and their families participate in decisions about end-of-life medical care. (See policy tips, p. 115.)
Typically, same-day surgery patients are healthy people who aren’t concerned with do-not-resuscitate (DNR) orders and advance directives prior to entering an outpatient surgery admissions area. There is, however, an increased awareness of advance directives and their importance among the general public.
Not only do patients know more about advance directives, but there is a growing awareness among surgeons as well, says Gerald O. Strauch, MD, FACS, director of the trauma and assembly departments of the American College of Surgeons (ACOS) in Chicago.
The increased emphasis on medical ethics and the need to fully inform patients have made it necessary for surgeons to be aware of advance directives and offer patients assistance in developing or modifying directives when appropriate, Strauch says. Although most surgeons think in terms of critically ill patients when discussing advance directives, it is important for surgeons to talk to same-day surgery patients, especially in terms of modifying an existing directive.
"More complex procedures are being performed in nontraditional settings, so more complicated technology that might be excluded from use in an advance directive is used," he explains.
Intravenous fluids, breathing assistance, and medications that stimulate the heart are some of the items that strict adherence to an advance directive might preclude, he adds.
In a statement approved by ACOS in 1994, the college recommends that the surgeon follow a policy of "required reconsideration" of previous directives for some patients, says Strauch.1 While the ACOS statement does not specifically address same-day surgical procedures, the policy of informing patients that an advance directive related to items such as ventilators or DNR may need to be modified prior to surgery applies, he adds.
"The policy in our center is to have the patient waive advance directives for the duration of the surgery and recovery period because there are too many items used during surgery or medications that are similar to items excluded in advance directives," says Grundman. (See waiver, inserted in this issue.)
"Our pre-op nurses call all patients 48 hours before surgery to gather pre-admission information and to give final instructions," Grundman says. "During this call, the nurse asks if the patient has an advance directive and explains our policy that requires [the patient] to waive it during surgery and recovery in our center. We will place a copy of the directive on the medical record, but we also include the waiver in the record."
"Because an untoward event in our setting is most likely something that we can easily treat, we choose not to honor a DNR request, and we inform the patient of this fact prior to surgery," explains Grundman. If a patient doesn’t sign the waiver, the surgery is canceled. The surgeon can reschedule for another day, which gives the surgeons additional time to discuss the issue with the patient, or the surgeons can schedule the surgery at another facility, he adds.
The Flagstaff center opened in 1999 and has not had to cancel any surgical cases because a patient didn’t want to waive an advance directive, says Grundman.
Even without federal, state, or accreditation requirements, same-day surgery programs should have a policy that clearly states how staff will handle advance directives, says Meyer.
"The most important thing a same-day surgery center can do is be prepared when a patient has an advance directive," she says. "Develop a policy that states whether or not you will honor a DNR request and document the method by which you inform the patient of your policy."
Reference
1. American College of Surgeons. Statement on advance directives by patients: "Do not resuscitate" in the operating room. Bulletin of the American College of Surgeons 1994; 79:29.
Sources
For information about advance directives and same-day surgery, contact:
• Gerald O. Strauch, MD, FACS, Director of Trauma and Assembly Departments, American College of Surgeons, 633 N. Saint Claire St., Chicago, IL 60611-3211. Telephone: (312) 202-5455. Fax: (312) 202-5005.
• Raymond Grundman, Vice President of Opera-tions, Aspen Healthcare, 603 S. Broadway, Suite B, Boulder, CO 80303. Telephone: (303) 499-4984. Fax: (414) 529-3597. E-mail: grundman @execpc.com.
ReSource
Booklets that explain advance directives are available from Choice in Dying for $3.50 per booklet. Special prices for bulk orders are available. For information about the booklets or other materials on advance directives, contact:
• Choice in Dying, 1035 30th St. N.W., Washing-ton, DC 20007. Telephone: (800) 989-9455 or (202) 338-9790. Fax: (202) 338-0242. Web site: www.choices.com.
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