Patient Self-Determination Act Research Articles

Advance medical directives in U.S. hospitals and nursing homes: the implementation and impact of the Patient Self-Determination Act.

In 1990, the U.S. Supreme Court endorsed living wills and other written advance medical directives as the best way for people to indicate their desires regarding end-of-life medical treatment. Congress then enacted the Patient Self-Determination Act (PSDA), which requires most medical facilities to provide information about advance medical directives. However, results from a national survey of hospital and nursing home administrators reveal that the law is having little practical effect on patients and residents. Medical institutions need to institutionalize a more positive approach to advance directives, but other right-to-die policies are also needed.

Implementing the Patient Self-Determination Act (PSDA)

The Patient Self-Determination Act (PSDA) con- firmed one of our fundamental societal values. We are excited be- cause self-determination. has always been a prevalent principle in social work practice. But when it is incorporated into statutory law. it simply does not provide for, cultural diversity and sensibility. This paper intends to addrcss the problems of implementing h e PSDA with the Chinese-American population who have a unique but dif- ferent set of values and well-defined role relalionships. It also pro- poses h e use of group work as an effective mean to educate and engage this population in the decision of advance directives.

A quality improvement focus for patient rights

This article highlights the implementation and evaluation phases of specific mechanisms developed in a university hospital setting to comply with the Patient Self-Determination Act (PSDA) of 1991. The article describes the program within the context of a continuous quality improvement cycle beginning with a philosophy about patient involvement in health care decision making. The article takes the reader through each phase of the process, culminating in the development of a revised quality improvement plan.

PREVALENCE OF ADVANCE DIRECTIVES REMAINS LOW IN NURSING HOMES.

The Patient Self Determination Act (PSDA) of 1991 requires that health care facilities document advance directives and educate staff and communities

Prevalence of advance directives and do-not-resuscitate orders in community nursing facilities.

To determine the prevalence of advance directives and do-not-resuscitate (DNR) orders in nursing homes and to measure the effect of the Patient Self-Determination Act (PSDA) and patient characteristics on these prevalences. Cross-sectional study. Eight rural community nursing facilities. Six hundred forty-one records of nursing home residents (total census of eight facilities). The mean age of the residents was 82.6 years and 75% were women. Thirty-seven percent were judged to have decisional capacity. Less than one third of the records revealed an advance directive (standard living will, 11.5%; other written directive, 11.1%; durable power of attorney for health care, 12%). Thirty-six percent had DNR orders. Residents with advance directives were older than those without them. Those residents with advance directives were more likely to have been admitted to the nursing home after the enactment of the PSDA (25.1% before vs 37.9% after enactment; P < .0001). There was substantial variation among facilities in both prevalences. Written rationales for DNR orders were found in only 40% of records. Enactment of the PSDA reflects increased interest in documentation of advance directives. However, in many nursing facilities, the prevalence of advance directives and DNR orders is relatively low. A greater commitment will be required by providers, residents, and their proxies if we are to change this reality.

Health Care Providers' and Cancer Patients' Preferences Regarding Disclosure of Information About Advance Directives

The Patient Self-Determination Act (PSDA) of 1990 requires hospitals to tell patients when they are admitted to the hospital about their right to complete an advance directive. The purpose of the study was to learn how providers and patients believe information about advance directive should be presented. When focus groups of providers and patients from a regional cancer center were held, nurses expressed more comfort with the requirements of the PSDA than did physicians, who were particularly concerned about the effect of the Act on their ability to treat patients in critical situations. Although patients were in favor of advance directives, they felt that hospital admission was not the best time to learn about them. This exploratory study suggests that testing the effectiveness of distributing written information to patients before admission and using specially trained personnel to discuss advance directives with patients may be worthwhile.

The cost of ethics legislation: a look at the Patient Self-Determination Act.

The Patient Self-Determination Act (PSDA) requires hospitals to ask patients upon admission whether they have an advance directive. Although the PSDA has received extensive criticism, little attention has been paid to the cost of the law, either during its legislative course or following its implementation. Nonetheless, several tangible and intangible costs are associated with the PSDA. Such costs may be incurred by different parties. This paper examines the costs and benefits of the PSDA and illustrates the extent of some of its tangible costs. The incremental start-up cost for one institution's response to the PSDA is estimated to be $49,304 ($1.31 per admission) and the total implementation cost of the program to be $114,528. In addition, the national incremental start-up cost for hospitals to implement the PSDA is estimated to be between $43,625,114 and $101,569,922. Finally, the potential implications of the PSDA for future governmental health care ethics regulation are discussed.

How well is the patient self-determination act working?: An early assessment

objectives: To assess the association between implementation of the Patient Self-Determination Act (PSDA) and (1) the use of formal, written advance directives, (2) the use of informal advance care arrangements, and (3) discussions between patients and their physicians and proxies on advance care planning and end-of-life treatment preferences. design: A time-sequence study in which patients discharged from acute care hospitals 1 month before the implementation of the PSDA and 5 months after implementation of the PSDA were interviewed. setting: Two medical school-affiliated, major teaching hospitals with more than 500 beds and 3 nonteaching community hospitals with fewer than 400 beds in eastern Massachusetts. patients: A total of 579 adult patients were interviewed: 258 patients discharged before the implementation of the PSDA (pre-PSDA) and 321 patients discharged 5 months after implementation of the PSDA (post-PSDA). measurements: Patients were asked about their formal, written or informal advance care planning arrangements, about the frequency of inquiries and information provided on advance care planning by the hospitals, and about their discussions of advance care planning and end-of-life treatment preferences with physicians and their proxies. results: In the pre-PSDA cohort, 60.9% of the patients had some kind of advance care planning, whereas in the post-PSDA cohort, 72.6% did (p = 0.01). However, there was not a significant increase in the proportion of patients who had advance care planning “in a written document” (19.8% of the pre-PSDA cohort compared with 25.5% of the post-PSDA cohort, p = 0.11). The increase in written advance care planning was concentrated in the community, nonteaching hospitals (10.7% pre-PSDA versus 23.7% post-PSDA). Overall, 41.4% of patients recalled inquiries or information about advance care planning during their hospitalization. Implementation of the PSDA was not associated with a significant change in the proportion of patients who discussed advance care planning or end-of-life issues with their physicians (13.6% pre-PSDA versus 17.1 % post-PSDA, p = 0.25). However, there was an increase in the proportion of patients with poorer health who spoke with their physicians (15.4% pre-PSDA versus 24.8% post-PSDA). Implementation of the PSDA was associated with an increase in the proportion of patients who had general discussions with proxies about end-of-life issues (61.8% pre-PSDA versus 73.0% post-PSDA, p = 0.024). However, 33.6% of pre-PSDA and 33.2% of post-PSDA patients had detailed discussions with their proxy about specific interventions such as mechanical ventilation or artificial nutrition. Patients with formal proxies had detailed discussions significantly more frequently than other patients (50.0% versus 26.8%, p <0.0001). conclusions: The PSDA was associated with significant effects on general advance care planning issues, increasing the proportion of patients who had (1) some kind of advance care arrangements and (2) general discussions of end-of-life issues with their proxies. However, the PSDA did not appear associated with significant increases (1) in the use of formal, written advance care documents, (2) in the frequency of discussions between patients and their physicians on advance care documents or end-of-life issues, or (3) in the frequency of discussions about specific treatment preferences between patients and their proxies.

Prevalence of advance directives and guardianship in nursing home patients.

The Patient Self-Determination Act (PSDA) now requires federally funded nursing homes to inform newly admitted patients of their right to determine their future medical care. Many nursing home patients may not be able to understand these rights, given the high prevalence of mental disorders, particularly dementia, in this population, and well need family members for assistance. Prior to the onset of the PSDA we surveyed the families of all residents of a large, proprietary nursing home to determine whether family members understood the concept of advance directives and guardianship. We also ascertained the rate of use of these instruments in the population studied. We found that the majority of family member respondents understood these concepts, but that substantial proportions of both competent and incompetent patients lacked surrogate decision-making authority, either in the form of a court-appointed guardian or a written advance-directive instrument. Informing newly admitted patients and their families about advance directives is warranted because many lack these plans. However, the high proportion of incompetent patients among nursing home patients indicates the need to encourage currently competent patients to formulate advance directives prior to nursing home placement.

WHEN THE LIMITS ARE NOT THEIR OWN: WHY THE ELDERLY MUST PARTICIPATE IN HEALTH CARE REFORM

WHEN THE LIMITS ARE NOT THEIR OWN: WHY THE ELDERLY MUST PARTICIPATE IN HEALTH CARE REFORM

The impact of the Patient Self-Determination Act's requirement that states describe law concerning patients' rights.

As of December 1991, the Patient Self-Determination Act (PSDA) mandated that health care institutions which receive funding from Medicare or Medicaid provide written information about persons' rights to participate in medical decision-making and formulate advance directives. The PSDA required each state "...acting through a State agency, association, or other private nonprofit entity develop a written description of the law of the State (whether statutory or as recognized by the courts of the State) concerning advance directives that would be distributed by providers or organizations under the requirements of [the Act]." This mandate allowed each state considerable flexibility in its approach to the process of writing the state description and to its content. In 1990, the American Bar Association's Commission on Legal Problems of the Elderly prepared and distributed the Patient Self Determination Act: State Law Guide to assist each state in preparing its written description of state law. In follow-up to the distribution of this guide, we conducted a telephone survey with a representative from each state (including the District of Columbia) about each state's process for writing the state law description. This paper presents an evaluation of the process used by the states and of the documents they produced.

Pediatrics and the Patient Self-Determination Act

On December 1, 1991, the requirements of a new federal law, the Patient Self-determination Act (PSDA), went into effect.1 The PSDA requires hospitals, nursing home facilities, hospices, home health care programs, and health maintenance organizations to give adults (in most states, individuals 18 years of age or older) information about their rights under the laws of their state to accept or refuse medical treatment; to prepare an advance directive such as a living will which states the individual's preferences for medical treatment under certain circumstances that might occur in the future, at a time when the patient is no longer able to make decisions; and to appoint a health care agent or proxy, someone to make health care decisions on behalf of the individual if he or she is no longer able to make decisions.

Advance Directives and Surrogate Laws

The Patient Self-Determination Act has spawned a great deal of activity by states as well as by hospitals. Advance directives have become firmly established by law, and statutes establishing hierarchies of surrogates have proliferated. Such activities are intended to foster informed patient choice when it comes to end-of-life matters. Whether, ultimately, they will do this or whether they will, in fact, reduce ethical medical decision making will depend on the way these instruments and laws are used. In this article, I caution against the almost unbridled enthusiasm with which these steps have been greeted. Whether health care professionals will use these instruments to enhance dialogue and to see choice as being made not only by and for individuals but by and for individuals who are enmeshed in community remains to be seen. The federal Patient Self-Determination Act (PSDA), which became effective in December 1991, has spawned a rash of legislation

The Patient Self Determination Act: opportunity knocks again.

The recent Patient Self Determination Act (PSDA) gives patients the right to exercise greater control over the care they receive from health care facilities and programs during the final phases of their lives. Social work can make important contributions to health care facilities as they develop policies and programs for implementing the Act's provisions about advance directives and refusal and withdrawal of treatment.

Implementation of Advance Directives

When the Patient Self-Determination Act (PSDA) went into effect on December 1, 1991, a new right was bestowed uniformly on all Americans, the right to determine the kinds of care that they will accept and the kinds of care that they will not accept should they become incompetent. The right of the competent patient to refuse care is rooted in the common law and has been recognized for generations in the United States.¹The courts in the United States have struggled for 15 years, since the<i>Quinlan</i>case brought the question dramatically into public view, to find a way by which the right of the competent individual to refuse care could be made available equally to the incompetent patient.^2,3Physicians struggled over those years to make decisions regarding life-prolonging care for incompetent patients but, despite even the most conscientious efforts, decisions were sometimes driven as much by fear

The Patient Self-Determination Act: potential ethical quandaries and benefits.

As Part of the Omnibus Budget Reconciliation Act of 1990, the Patient Self Determination Act (PSDA) legislates new responsibilites for healthcare facilities. The authors served as members of the California Consortium on Patient Self-Determination, and the materials produced by this group offer healthcare facilities a valuable guide for implementing the PSDA. The ACt follows a historical trend led by doctrines of informed consent and increasing patient autonomy regarding rights to accept or refuse medical treatment and to execute advance directives. The requirements of the Act will influence healthcare facilities and how they communicate with patients about advance directives. Although the Act seeks to increase awareness of advance directices among all participants in healthcare interactions, it could pose major stumbling blocks to providing sensitive and humane care if certain concerns are nor addressed adequatley. The benefits of the Act could be far reaching and substantial for patients and healthcare facilities alike.

Unanswered Questions Surrounding the Patient Self–Determination Act

The Patient Self-Determination Act (PSDA) imposes new requirements on health care providers for informing patients of their rights to make decisions concerning their medical care. The Act is intended to, and is likely to, encourage patients and residents of certain healhtcare facilities to consider their treatment preferences in advance of incapacity and, in particular, to determine the circumstances in which life-sustaining treatment will be provided to them. However, many questions concerning how healthcare providers will implement the Act remain unanswered.

The Patient Self-Determination Act: a cooperative model for implementation.

In 1990, I voiced strong doubts about a bill entitled the Patient Self-Determination Act (PSDA), which had been introduced in the U.S. Senate by John Danforth (R-MO) and Daniel Patrick Moynihan (D-NY). I hoped to see it defeated. In 1991, after the bill had become a small part of a massive status (the Omnibys Budget Reconciliation Act of 1990) adopted in the waning hours of the 101st Congress, I devoted countless hours to its implementation. I wanted to see it succeed. Why the change?