PRACTICE ISSUES RELATED TO PARIENT SELF DETERMINATION

Objectives:
1. Identify the nursing roles and responsibilities related to informed consent.
2. Identify legal and ethical elements of informed consent.
3. Describe autonomy and paternalism as it relate to self determination.
4. Enumerate and identify the different types of advance directives.

What is informed consent?
- A process by which fully informed patients can participate in choices about their health care.
- It originates from the legal rights of patients to direct what happens to them and from the ethical duty of the doctor
to involve the patient in their health care

GOAL

Provide information, explanation and comprehensive understanding of the clinical situation, and the timely
exercise, by the patient, of active choices regarding the circumstance, so the patient has an opportunity to be an
informed participant in his health care decisions.

The most important goal of informed consent is that the patient have an opportunity to be an informed participant
in his health care decisions.
In order for the patient's consent to be valid, he must be considered competent to make the decision at hand and
his consent must be voluntary. It is easy for coercive situations to arise in medicine. Patients often feel powerless
and vulnerable. To encourage voluntariness, the physician can make clear to the patient that he is participating in a
decision, not merely signing a form. With this understanding, the informed consent process should be seen as an
invitation to him to participate in his health care decisions. The physician is also generally obligated to provide a
recommendation and share her reasoning process with the patient. Comprehension on the part of the patient is
equally as important as the information provided. Consequently, the discussion should be carried on in
layperson's terms and the patient's understanding should be assessed along the way.
Basic consent entails letting the patient know what you would like to do and asking them if that will be all right.
Basic consent is appropriate, for example, when drawing blood. Decisions that merit this sort of basic informed
consent process require a low-level of patient involvement because there is a high-level of community consensus.

Types of Consent

1. Implied. Examples include routine tests such as blood tests, x-rays and urinalyses. While implied consent
to such tests is a variation of consent, it is rarely informed.
2. Express. A patient may state thoughts or feelings in words for examination and treatment. Differing
recollection may lead to conflicting testimony at a trial.
3. Informed. For complete written consent the doctor must discuss the treatment or procedure with the
patient and obtain a signed consent.


The Elements of Consent

1. Patient must have capacity to consent
Determine the patient's capacity to consent to the proposed treatment.
Capacity is defined as mental capacity.
The physician is entitled to assume that a patient is capable unless there are reasonable grounds to believe
otherwise.
The physician may not assume a patient is incapable just because of age, disability or a psychiatric or
neurological diagnosis, although such factors may be relevant in the assessment of capacity.
The legislation states:
A person is capable with respect to a treatment, admission to a care facility or a personal assistance service if the
person is able to understand the information that is relevant to making a decision about the treatment, admission
or personal assistance service, as the case may be, and able to appreciate the reasonably foreseeable
consequences of a decision or a lack of decision.
A person who is capable of providing consent is also capable of withdrawing consent to treatment.

2. Consent must be related to treatment

'Treatment' is defined in the legislation as: "anything that is done for a therapeutic, preventive, palliative,
diagnostic, cosmetic or other health-related purpose, research [and] includes a course of treatment or plan of
treatment"
Nature of the disease or condition
Nature of proposed diagnostic steps and/or treatment(s)
Material elements of the proposed treatment
Probability of success
Nature of the risks involved and potential benefits
Recommend alternative treatments (including the choice of no treatment).
Prognosis without treatment
Any other important factors

3. Consent must be informed
The patient's decision to consent to (or refuse) treatment must be informed; that is, the patient must receive
information about the nature of the proposed treatment, its expected benefits, the material risks, special risks or
material side effects associated with it, alternative courses of action and likely consequences of not having the
treatment.
The information provided to the patient about such matters must be the information a reasonable person in the
same circumstances would require in order to make a decision about the treatment. As well, the person must have
received responses to his or her requests for additional information about those matters.

4. Consent must be voluntary
Freedom to choose medical alternatives without coercion or manipulation.

5. Consent must not be obtained through fraud or misrepresentation

Legal age
With thorough understanding of procedure or treatment, its risks and benefits and alternative procedures
Opportunity to have all questions answered satisfactorily
Treatments/care must be specified
Voluntary consent (without force or undue pressure)

Evidence of Consent

Although the Act states that consent to treatment may be express or implied, physicians are strongly advised to
obtain express consent from the patient and to document the process of doing so.
Physicians should be aware that the critical element of the consent process is the explanation given to the patient
and the dialogue between physician and patient around the proposed treatment.
Signed consent forms are simply documentary confirmation that the consent process has been followed, and the
patient has agreed to the proposed treatment.
Documentation of consent discussions in the patient's chart by the physician is also important evidence that the
process has been followed.

What are the elements of full informed consent?

the nature of the decision/procedure
reasonable alternatives to the proposed intervention
the risks, benefits, and uncertainties related to each alternative
assessment of patient understanding
the acceptance of the intervention by the patient

How much information is considered "adequate"?

How do you know when you have said enough about a certain decision? Most of the literature and law in this area
suggest one of three approaches:

1. Reasonable physician standard: What would a typical physician say about this intervention? Based upon
reasonable medical judgment of the doctor.
what would a typical physician say about this intervention? This standard allows the physician to
determine what information is appropriate to disclose. However, it is probably not enough, since most
research in this area shows that the typical physician tells the patient very little. This standard is also
generally considered inconsistent with the goals of informed consent as the focus is on the physician
rather than on what the patient needs to know.

2. Reasonable patient standard: What would the average patient need to know in order to be an informed
participant in the decision? This asks whether the doctor disclosed risks that a reasonable person would
find important for making an informed decision.
what would the average patient need to know in order to be an informed participant in the decision? This
standard focuses on considering what a patient would need to know in order to understand the decision at
hand.
3. Subjective standard: what would this patient need to know and understand in order to make an informed
decision?

what would this patient need to know and understand in order to make an informed decision? This
standard is the most challenging to incorporate into practice, since it requires tailoring information to each
patient.
The best approach to the question of how much information is enough is one that meets both your
professional obligation to provide the best care and respects the patient as a person with the right to a
voice in health care decisions.

What sorts of interventions require informed consent?
All invasive procedures including surgery and anaesthesia
For a wide range of decisions, written consent is neither required nor needed


When is it appropriate to question a patient's ability to participate in decision making?
Generally you should assess the patient's ability to:
understand his or her situation,
understand the risks associated with the decision at hand, and
communicate a decision based on that understanding.

Whenever this is unclear, a psychiatric consultation can be helpful

In most cases, it is clear whether or not patients are competent to make their own decisions. Occasionally, it is not so clear.
Patients are under an unusual amount of stress during illness and can experience anxiety, fear, and depression. The stress
associated with illness should not necessarily preclude one from participating in one's own care. However, precautions
should be taken to ensure the patient does have the capacity to make good decisions. There are several different standards
of decision making capacity. Generally you should assess the patient's ability to:
understand his or her situation,
understand the risks associated with the decision at hand, and
communicate a decision based on that understanding.
When this is unclear, a psychiatric consultation can be helpful. Of course, just because a patient refuses a treatment does
not in itself mean the patient is incompetent. Competent patients have the right to refuse treatment, even those treatments
that may be life-saving. Treatment refusal may, however, be a flag to pursue further the patient's beliefs and understanding
about the decision, as well as your own.
What about the patient whose decision making capacity varies from day to day?
Patients can move in and out of a coherent state as their medications or underlying disease processes ebb and
flow. You should do what you can to catch a patient in a lucid state - even lightening up on the medications if
necessary - in order to include him in the decision making process.

What should occur if the patient cannot give informed consent?
If the patient is incapacitated/incompetent, a surrogate decision maker must speak for him.
There is a specific hierarchy of appropriate decision makers defined by law.
If no appropriate surrogate decision maker is available, the physicians are expected to act in the best interest of the
patient until a surrogate is found or appointed.

If the patient is determined to be incapacitated/incompetent to make health care decisions, a surrogate
decision maker must speak for her. There is a specific hierarchy of appropriate decision makers defined by
state law (also see the DNR topic page). If no appropriate surrogate decision maker is available, the
physicians are expected to act in the best interest of the patient until a surrogate is found or appointed.

These include in a ranking order and act in a person's best interests:
1. Personal care guardian
2. Attorney for personal care
3. Representative appointed by Consent and Capacity Board
4. Spouse or partner
5. Child or parent or individual/agency entitled to give or refuse consent instead of parent
6. Parent with right of access only
7. Brother or sister
8. Any other relative
9. Public Guardian and Trustee
Is there such a thing as presumed/implied consent?
The patient's consent should only be "presumed", rather than obtained, in emergency situations when the patient
is unconscious or incompetent and no surrogate decision maker is available. In general, the patient's presence in
the hospital ward, ICU or clinic does not represent implied consent to all treatment and procedures. The patient's
wishes and values may be quite different than the values of the physician's. While the principle of respect for
person obligates you to do your best to include the patient in the health care decisions that affect his life and body,
the principle of beneficence may require you to act on the patient's behalf when his life is at stake.

What is the scope of consent? Generally, limited to specific procedure.

Extending. Caution advised when treatment exceeds the scope of consent

1. General Consent. When a patient consents to treatment of a CONDITION rather than a specific procedure,
the scope of treatment involves all measures reasonably necessary to treat the condition.
2. Unexpected Circumstances. When an unexpected condition arises while performing a consented
procedure and the patient is unable to grant consent, the doctor must use medical JUDGEMENT to decide
on the appropriate action. If time allows the doctor should consult the FAMILY or other LEGAL
representative

Limiting

1. Limited to a particular procedure or prohibit a particular procedure.
2. Except in emergency, the doctor is bound by these limits.
3. The doctor should try to convince the patient to forgo such limitations when in his medical judgment such procedure might
be necessary.


Who May consent?
The law presumes that patients 18 and over are competent to give consent to treatment.
For minors the doctor must look to the parents or legal guardian for consent.
Substituted consent must also be sought for incompetent adults and for those whose judgment is impaired
by their condition or medication.

Exceptions:

(a) Waiver
A patient waives his right to be informed or involved in decisions regarding either his standard
health care or his participating in research.
A patient may choose to delegate decision making to the physician.
In other cultures, delegation of such authority to a community leader may be the norm.
Patients request to waive disclosure on any or all of the items above must be treated with care and
accepted only in writing.
(b) Emergency

When life threatening demand immediate treatment and the patient is unable to consent and time is not
available to involve any other person to be contacted for substituted consent the doctor may proceed
without consent.
He should however carefully document the emergency and any attempts to obtain alternative consent.
The Act states that "there is an emergency if the person for whom the treatment is proposed is
apparently experiencing severe suffering or is at risk, if the treatment is not administered promptly, of
sustaining serious bodily harm."
(c) Therapeutic privilege

If disclosure would result in actual physical or emotional harm to the patient, jeopardize treatment or result in
an unreasonable choice of non treatment then the doctor may use reasonable medical judgment to restrict
disclosure.

Advance directives

The term "advance directives" refers to treatment preferences and the designation of a surrogate decision-maker in the
event that a person should become unable to make medical decisions on her or his own behalf.

An advance directive is a document by which a person makes provision for health care decisions in the event that,
in the future, he/she becomes unable to make those decisions.
There are two main types of advance directive the Living Will and the Durable Power of Attorney for Health
Care. There are also hybrid documents which combine elements of the Living Will with those of the Durable
Power of Attorney.
Living will: A Living Will is the oldest type of health care advance directive.
This is a written document that specifies what types of medical treatment are desired should the individual become
incapacitated. A living will can be general or very specific. The most common statement in a living will is to the effect that
if I suffer an incurable, irreversible illness, disease, or condition and my attending physician determines that my
condition is terminal, I direct that life-sustaining measures that would serve only to prolong my dying be withheld or
discontinued.
A Living Will is the oldest type of health care advance directive.
It is a signed, witnessed (or notarized) document called a declaration or directive. Most declarations instruct an
attending physician to withhold or withdraw medical interventions from its signer if he/she is in a terminal
condition and is unable to make decisions about medical treatment.
Since an attending physician who may be unfamiliar with the signers wishes and values has the power and
authority to carry out the signers directive, certain terms contained in the document may be interpreted by the
physician in a manner that was not intended by the signer.
Family members and others who are familiar with the signers values and wishes have no legal standing to
interpret the meaning of the directive.
More specific living wills may include information regarding an individual's desire for such services such as
analgesia (pain relief),
antibiotics,
artificial (intravenous or IV) hydration,
artificial feeding (feeding tube),
CPR (cardiopulmonary resuscitation),
life-support equipment including ventilators (breathing machines),
do not resuscitate (DNR).



Durable power of attorney
is a signed, witnessed (or notarized) document in which the signer designates an agent to make health care decisions if the
signer is temporarily or permanently unable to make such decisions.
Through this type of advance directive, an individual executes legal documents that provide the power of attorney to others
in the case of an incapacitating medical condition. The durable power of attorney allows an individual to make bank
transactions, sign social security checks, apply for disability, or simply write checks to pay the utility bill while an individual is
medically incapacitated.
DPOA can also specifically designate different individuals to act on a person's behalf for specific affairs. For example, one
person can be designated the DPOA of health-care or medical power of attorney, similar to the health-care proxy, while
another individual can be made the legal DPOA.
This is a legal document in which an individual designates another person to make health-care decisions if he or she is
rendered incapable of making their wishes known. The health-care proxy has, in essence, the same rights to request or
refuse treatment that the individual would have if capable of making and communicating decisions.
Unlike most Living Wills, the Durable Power of Attorney for Health Care does not require that the signer have a
terminal condition.
An agent must be chosen with great care since the agent will have great power and authority to make decisions
about whether health care will be provided, withheld or withdrawn from the signer.
It is extremely important that the signer carefully discuss his/her values, wishes and instructions with the agent
before and at the time the document is signed. Such discussions may also continue after the document is signed.
It is also important that the agent be willing to exercise his/her power and authority to make certain that the
signers values, wishes and instructions are respected.
Common situations in which a person may be temporarily or permanently unable or incapable of making complex judgment
or end of life decisions are:
a. coma (from any cause);
b. stroke (if it results in coma or cognitive deterioration);
c. moderate or severe dementia (Alzheimer's or other types);
d. persistent vegetative state;
e. severe illness requiring placement on breathing machine and inability to communicate;
f. severe medical conditions such as advanced liver failure or kidney failure;
g. traumatic brain injury resulting in the inability to make complex decisions.


What is the importance of an advance directive?
Advance directives were developed as a result of widespread concerns over patients undergoing unwanted medical
treatments and procedures in effort to preserve life at any cost. As outlined in the following section (history of advance
directives), remarkable efforts were made to institute advance medical directives as a component of medical care in the
United States over the last few decades.
From a practical standpoint, medical directives and living wills facilitate a person's medical care and decision making in
situations when they are temporarily or permanently unable make decisions or verbalize their decisions. By having
previously documented personal wishes and preferences, the family's and physicians' immense decision-making burden is
lightened. At the same time, patient autonomy and dignity are preserved by tailoring medical care based on one's own
choices regardless of mental or physical capacity.
Instructive directives (advance directives, living wills, and health-care proxy designation) are completed by a person with
decision-making capacity. They only become effective when a person loses his/her decision-making capacity (mentally
incapacitated). While a person maintains ability to make decisions, he/she is the ultimate decision-maker rather than the
health-care proxy or surrogate decision-maker.
What is the history of advance directives?
Advance directives began to be developed in the United States in the late 1960s.
The first living wills: In 1967, an attorney named Luis Kutner suggested the first living will. Kutner's goal was to facilitate "the
rights of dying people to control decisions about their own medical care."
In 1968, the first living will legislation was presented to a state legislature. Walter F. Sackett, a doctor elected to the Florida
legislature, introduced a bill that would allow patients to make decisions regarding the future use of life-sustaining
equipment. The bill failed to pass in 1968. Sackett reintroduced the bill in 1973 and it was again defeated.
While Dr. Sackett was introducing living will legislation in Florida, Barry Keene was presenting similar bills in the California
legislature. Keene's interest in living wills was based on personal experience. In 1972, Keene's mother-in-law was unable to
limit medical treatment for a terminal illness even after having signed a power of attorney. Keene was elected to the
California State senate in 1974. The living will legislation he designed was defeated that same year. Keene reintroduced the
bill in 1976 and in September of that year California became the first state in the nation to legally sanction living wills.
The states: Within a year, 43 states had considered living will legislation and seven states had passed bills. Advance
directive legislation has subsequently progressed on a state-by-state basis. By 1992, all 50 states, as well as the District of
Columbia, had passed legislation to legalize some form of advance directive.
The first court decision to validate advance directives was at the state level. The decision was handed down by the New
Jersey Supreme Court in 1976. In Case 70 N.J. 10, 355 A 2nd 647, Chief Justice Robert Hughes upheld the following
judicial principles:
1. If patients are mentally unable to make treatment decisions, someone else may exercise their right for them.
2. Decisions that can lead to the death of a mentally incompetent patient are better made not by courts but by families,
with the input of their doctors.
3. Decisions about end-of-life care should take into consideration both the invasiveness of the treatment involved and the
patient's likelihood of recovery.
4. Patients have the right to refuse treatment even if this refusal might lead to death.
The case in which Judge Hughes ruled was the request by Joe Quinlan to make legally binding health-care decisions for his
daughter, Karen Ann Quinlan. As a result of the case, Karen Ann Quinlan was gradually weaned from mechanical
ventilation.
The federal government: The U.S. federal government has evidenced its interest in advance directives through two of its
bodies, the Congress and the Supreme Court.
The U.S. House of Representatives in 1991 enacted the Patient Self- Determination Act. The Act stipulates that all hospitals
receiving Medicaid or Medicare reimbursement must ascertain whether patients have or wish to have advance directives.
The Patient Self- Determination Act does not create or legalize advance directives; rather it validates their existence in each
of the states.
It was not until 1990 that the United States Supreme Court agreed to hear a case on the legality of advance directives. The
Supreme Court had been reticent to hear cases on advance directives, reflecting to some degree the belief that advance
directives are determined at the state rather than federal level. In 1990, the Court heard Cruzan vs. Director. The case,
similar to that of Karen Ann Quinlan, involved the desire to discontinue the percutaneous gastrostomy feedings of Nancy
Cruzan. The United States Supreme Court decided in favor of the individual right to refuse treatment, even life-sustaining
treatment. The Supreme Court refused to hand down a specific decision on medical treatment in the case. Following the
opinion of the Supreme Court, the case was referred back to the Missouri Supreme Court. The Missouri Supreme Court
heard testimony of a verbal advance directive that was deemed to be sufficient evidence to support the refusal of medical
treatment.
The landmark Quinlan and Cruzan cases emerged out of similar situations and similar needs. Both cases dealt with the
medical care of young, physically strong people in a persistent vegetative state. While similar in these regards, the two
judicial decisions dealt with different types of advance directives. The case of Karen Ann Quinlan dealt with the ability of the
individual to appoint a health-care proxy. The case of Nancy Cruzan addressed the right of a healthy individual to establish
a binding living will.
The current situation
In the United States, four out of every five adults has no advance directive, a situation that some have likened to taking your
car to the mechanic and saying, "I think it needs a tune-up, but if you find something really wrong with it, just go ahead and
fix it, even if it won't run afterward? And by the way, please charge me for the work and if I can't pay for it, I'm sure my
estate will!"
When asked what would provide a good death, the majority of Americans answer, in essence; "Quick, painless, at home,
and surrounded by family."
In 1950, about half of Americans who died did so at home. Now, about 85% of Americans die in a health-care setting: a
hospital, a nursing home, or a rehabilitation center. At least 12% die in an intensive-care unit.
Over the past three decades, the United States -- all 50 states and the District of Columbia -- have passed laws to legalize
the use of living wills, health-care proxies, and/or the durable power of attorney. The U.S. federal government has validated
state laws on advance directives through the 1991 Patient Self- Determination Act. And the U.S. Supreme Court has
handed down an opinion acknowledging the congruence of the Constitution of the United States with state laws on the right
to designate future medical treatment.
When do advance directives become helpful?
Advance directives become active when a patient is no longer able to make his/her own health-care decisions or becomes
mentally incapacitated. Until such point is reached, the patient is the ultimate decision maker regarding their health.
Some common scenarios where these directives can help with the decision making process are
coma,
persistent vegetative state,
severe brain injury,
strokes,
advanced Alzheimer's disease or other forms of dementia,
critical medical illness affecting mental capacity.
Advance directives not only help with decision-making in times of incapacity, but they can also clarify one's preferences
during times of uncertainties while still cognitively intact. At times, deciding whether to accept or decline a treatment may
overwhelm a person and cast uncertain on their judgment. By referring to previously delineated preferences based on
overall goals of care, such decisions may become simpler to make as smaller components of a bigger picture
How can one obtain and prepare living will and advance medical directive forms?
Comment on thisShare Your Story
Preparing documents for a living will and advance directive can be done at any time during an adult person's lifetime. As
one's preference can naturally change during one's life, these documents can also be amended and modified to reflect the
changes.
Obtaining medical advance directive documents is simple. Medical offices, hospitals, social workers, attorneys, and even
post offices may carry these documents. In fact, hospitals receiving medical and Medicaid payments are required to offer
their patients these documents.
A good place to begin this process is an open discussion with a primary-care doctor or other treating physicians. As stated
earlier, living wills and advance directives can be very broad or quite specific. Meanings, implications, risks, and benefits of
components of an advance directive deserve clear understanding before they are signed in a legally binding document that
may be relied upon for end-of-life decisions.
Selecting a person as a medical power of attorney is also an important decision. The surrogate decision maker does not
necessarily need to be a family member or a relative. In truth, any person in whom an individual trusts to carry out their
wishes on their behalf and in good faith, can be designated as a health-care proxy.
Additionally, because these are legal documents of various forms, appropriate and accurate drafting with the help of an
attorney is advised. Furthermore, as regulations may vary from state to state, your attorney can also guide you through how
to do a living will and an advance directive.
Although it is highly encouraged, it is often difficult to address issues pertaining to terminal illnesses, end-of-life care, and
death with loved ones and caregivers. Despite having proper documentation, it is important for family members and
caregivers to have some general knowledge about a patient's preferences. More importantly, family members or anyone
close to the individual must know where these documents are located and be able to provide them or refer to them in cases
of emergency. It is also extremely beneficial to have extra copies of these documents and to bring them with the patient to
the hospital, emergency room, or even doctors' offices.
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
Summary
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.

H.R.4449 -- Patient Self Determination Act of 1990 (Introduced in House - IH)


HR 4449 IH
101st CONGRESS
2d Session
H. R. 4449
To amend titles XVIII and XIX of the Social Security Act to require providers of services and health maintenance
organizations under the medicare and medicaid programs to assure that individuals receiving services will be given
an opportunity to participate in and direct health care decisions affecting themselves.
IN THE HOUSE OF REPRESENTATIVES
April 3, 1990
Mr. LEVIN of Michigan (for himself, Mr. SWIFT, Mr. MOODY, Mr. MCDERMOTT, and Mr. FAUNTROY) introduced
the following bill; which was referred jointly to the Committees on Ways and Means and Energy and Commerce

A BILL
To amend titles XVIII and XIX of the Social Security Act to require providers of services and health maintenance
organizations under the medicare and medicaid programs to assure that individuals receiving services will be given
an opportunity to participate in and direct health care decisions affecting themselves.
Be it enacted by the Senate and House of Representatives of the United States of America in Congress assembled,
SECTION 1. SHORT TITLE.
This Act may be cited as the `Patient Self Determination Act of 1990'.
SEC. 2. MEDICARE PROVIDER AGREEMENTS ASSURING THE IMPLEMENTATION OF A PATIENT'S RIGHT
TO PARTICIPATE IN AND DIRECT HEALTH CARE DECISIONS AFFECTING THE PATIENT.
The intent of the Patient Self Determination Act (PSDA) of 1990 is to:

1. enhance personal control over legal care decisions.
2. encourage medical treatment decision making prior to need.
3. give one federal standard for living wills and durable powers of attorney.
4. emphasize patient education.




1.