Position Statement: Nursing and the Patient Self-Determination Acts - 11/18/91
Effective Date: November 18, 1991
Status: New position statement
Originated by: Task Force on End of Life Decisions
Adopted by: ANA Board of Directors
Related Past Action:
1. Code for Nurses with Interpretive Statements, 1985
2. Guidelines on Withdrawing or Withholding Food and Fluid, 1988
The American Nurses Association (ANA) believes that nurses should play a primary role in implementation of the Patient Self-Determination Act, passed as part of the Omnibus Budget Reconciliation Act of 1990. It is the responsibility of nurses to facilitate informed decision-making for patients making choices about end-of-life care. The nurse's role in education, research patient care and advocacy is critical to implementation of the Patient Self-Determination Act within all health care settings.
The Patient Self-Determination Act, passed as part of the Omnibus Budget Reconciliation Act of 1990, becomes effective December 1, 1991. The federal law applies to all health care institutions receiving Medicaid funds and requires that all individuals receiving medical care must be given written information about their rights under state law to make decisions about medical care, including the right to accept or refuse medical or surgical treatment. Individuals must also be given information about their rights to formulate advance directives such as living wills and durable powers of attorney for health care. Patients must be made aware of their rights to make decisions about these issues upon admission (in the case of hospitals or skilled nursing facilities), enrollment (in the case of health maintenance organizations), on first receipt of care (in the case of hospices) or before the patient comes under an agency's care (in the case of home health personal care agencies).
ANA supports the patient's right to self-determination and believes that nurses will and must play a primary role in implementation of the law. Ideally, decision about advance directives should be made by the patient with the family and the primary provider prior to admission. The formation of advance directives is an important decision and will inevitably involve nurses who are the most omnipresent professionals in health care facilities. It is imperative that the decision making that will fall to patients and their families as they make choices about end of life care be facilitated by nurses.
Each nurse should know the laws of the state in which she/he is practicing pertaining to advance directives, and should be familiar with the strengths and limitations of the various forms of advance directive.
The nurse is one of several health care professionals who has a responsibility for ensuring that the advance care directives initiated by the patient are current and reflective of the patient's choices. Facilitating self-determination of patients with respect to end of life decisions is a process that includes evaluating changes in the patient's perspective and health state. The nurse has a responsibility to facilitate informed decision making, including but not limited to advance directives.
ANA recommends that these questions about advance directives be part of the nursing admission assessment: Do you have basic information about advance care directives including living wills and durable power of attorney? Do you wish to initiate an advance care directive? If you have already prepared an advance care directive, can you provide it now? Have you discussed your end of life choices with your family and/or designated surrogate and health care team worker?
The role of the nurse is critical in implementation of the Patient Self-Determination Act and includes public education, research, patient care, advocacy, education of the profession and inservice education of other health care providers.
Interpretive Statement: What's an Advance Medical Directive?
Advance medical directives are of two types: treatment directives, often referred to as "living wills," and appointment directives, often referred to as "power of attorney" or "health proxies."
A LIVING WILL -- states what medical treatment you choose to omit or refuse in the event that you are unable to make those decisions yourself and are terminally ill.
A DURABLE POWER OF ATTORNEY FOR HEALTH CARE -- appoints a proxy -- usually a relative or trusted friend to make medical decisions on your behalf if you can no longer decide for yourself. It has broader applications than a living will and can apply to any illness or injury that could leave you incapacitated.
An advance directive does not need to be written, reviewed signed by an attorney. It must be witnessed by two people (in many states witnesses may not be your heirs, relatives or physicians). An advance directive applies only if your are unable to make your own decisions because you are incapacitated or if, in the opinion of two physicians, you are otherwise unable to make decisions for yourself. It can be changed or canceled at any time.
An advance directive is intended to help others make decision for you. It may be as simple or as complex as you feel necessary. For example, a simple statement indicating that in the case of an incurable illness or catastrophic injury you do not wish to be kept alive by artificial means such as CPR, artificial respiration or tube-feeding is an advance directive. A copy of the advance directive should be given to your family, physician and anyone you designate as a proxy. In addition, you should bring a copy of it with you if you are admitted to a hospital or nursing home.
The Patient Self-Determination Act (PSDA), effective December 1, 1991, does not require patients to have or fill out an advance directive. It does require hospitals and other health care organizations to tell patients that they have the right to do in accordance with existing state law. PSDA is not applicable in federal facilities such as Veterans Administration Hospitals that do not receive Medicare or Medicaid funds.
- Choice in Dying, 250 West 57th St., New York, NY 10107 -- 212/ 246-6973
- AARP Legal Counsel for the Elderly, 601 E St., NW, Washington, DC 20049 -- 202/ 434-2277
- American Bar Association, 1800 M ST., NE, South Lobby, Washington, DC 20036
- Alzheimers Association, 70 East Lake St., Suite 600, Chicago, IL 60601 -- 1-800-621-0379
- Association for Death Education & Counseling, 638 Prospect Ave., Hartford, CT 06105 -- 203/ 232-4825
- Children of Aging Parents, 2761 Trenton Rd., Levitttown, PA 19056 -- 215/ 945-6900
Information and advice regarding the law in your state may be obtained from the following:
- State Department of Health
- State Office on Aging
- State or Regional Hospital Association
- State Bar Association
- University Centers on Aging