In last week’s Ftag of the Week post, we looked at part of the regulatory requirements for F578 surrounding the right to refuse treatment/s and the right to participate in/decline to participate in experimental research. In this post, we will review the regulatory requirements for advance care planning and look at some important topics that need to be addressed in a facility’s policies and procedures.
Advance Care Planning
“Advance care planning,” per the Interpretive Guidance (IG), refers to how individuals and their healthcare agents communicate to understand, discuss, and plan for future healthcare decisions in order to plan for a time when an individual may not be able to make his/her own healthcare decisions. This ongoing planning is incorporated into the comprehensive care planning process, and should be reevaluated routinely, as well as upon a change in a resident’s condition. A resident, along with family and/or the resident representative, can work with the interdisciplinary team to understand the resident’s goals and wishes should he/she become unable to make decisions or is actively dying. These goals and wishes may change over time, which is why it is important that they are continually reassessed
The IG defines “advance directives” to mean written instructions that are recognized by State Law related to the provision of healthcare when an individual is incapacitated.
There are multiple options for directives, including a living will, durable power of attorney, medical power of attorney, pre-existing medical orders for “Do Not Resuscitate” (DNR), Do Not Hospitalize (DNH) documents, as well as others.
Here are some key items to note from the IG:
- While a resident has the option to formulate one or more advance directives, the resident cannot be required to do so.
- Facility staff are required to communicate the resident’s wishes to the resident’s direct care staff and physician.
- Facility staff are not required to provided care that conflicts with an advance directive
Are Advance Directives Required?
While there are many directives that a resident can execute, the resident is not required to do so. The facility is prohibited from discriminating against a resident based on whether he/she has executed an advance directive, and also is prohibited from conditioning the provision of medical care based on the presence of an advance directive or not. However, it is also important to note that facility staff are not required to provide care that is conflict with an advance directive. In some circumstances, staff would not be required to implement an advance directive if State law allows the provider to conscientiously object to implementation and the provider is unable to implement the directive.
The facility is also responsible for informing the resident/ representative of his/her right to establish an advance directive. Facility staff must provide the resident with assistance if he/she wishes to execute one or more advance directives. Any discussions that are had related to this topic must be documented in the resident record, along with any advance directives that the resident decides on.
Policies & Procedures
Per the Interpretive Guidance, providers are required to have written policies & procedures (P&P) in place regarding a resident’s right to refuse medical or surgical treatment or formulate an advance directive, and must ensure staff follow the associated P&P. The facility’s P&P needs to address not only steps that occur during the admission process, such as determining if a resident has an advance directive or if he/she wishes to formulate one, but also outlines the procedures necessary to ensure a resident retains his/her rights throughout the course of his/her stay at the facility. This includes:
- Identifying the primary decision maker, whether it is the resident or another, if the resident has been assessed as unable to make healthcare decisions
- Periodically assessing the resident for decision-making capacity, and invoking the healthcare agent/ representative if the resident is determined to not have capacity
- Ensuring that information regarding the right to refuse medical or surgical treatment and to formulate an advance directive is provided in a manner that the resident and/or representative can understand
The process of advance care planning can be a daunting one for a resident and/or his/her family, and facility staff needs to use their knowledge as well as communication skills to assist the resident/resident representative in understanding his/her rights and options.
The process of advance care planning can be a daunting one for a resident and/or his/her family, and facility staff needs to use their knowledge as well as communication skills to assist the resident/resident representative in understanding his/her rights and options. It is also expected that the facility routinely ensures that the resident’s goals and wishes are reassessed so that they reflect the resident’s current preferences. The P&P should consider how:
- The resident’s choices will be reviewed and clarified, if necessary, as part of the overall care planning process, including whether existing care instructions are aligned with the resident’s current wishes
- Situations where healthcare decision making is required will be identified and how it may trigger a reassessment, such as when there is a significant change in the resident’s condition
- The resident’s choices will be documented and communicated to the interdisciplinary team and the staff responsible for the resident’s care to ensure the resident’s wishes are carried out
In the final part of CMSCG’s Ftag of the Week for F578, we will look at facility responsibilities regarding honoring residents’ preferences and executed advance directives, as well as some actual survey citations.
