And now, I would like to introduce our speaker to get us started today. Ms. Laura Dixon most recently served as the Director of Risk Management and Patient Safety for the Colorado region of Kaiser Permanente. Prior to joining Kaiser, she served as the Director of Facility Patient Safety and Risk Management and Operations for COPEC from 2014 to 2020. In her role, Ms. Dixon provided patient safety and risk management consultation and training to facilities, practitioners, and staff in multiple states. Ms. Dixon has more than 20 years of clinical experience in acute care facilities, including critical care, coronary care, perioperative services, and pain management. Prior to joining COPEC, she served as the Director of Western Region Patient Safety and Risk Management for the Doctors' Company in Napa, California. In this capacity, she provided patient safety and risk management consultation to the physicians and staff for the Western United States. As a registered nurse and attorney, Laura holds a Bachelor of Science from Regis University, a Doctor of Jewish Prudence from Drake University College of Law, and a registered nurse diploma from St. Luke's School of Professional Nursing. She is licensed to practice law in Colorado and in California. Thank you for being here with us today, Laura. We invite you to go ahead and get us started. Okay. Thank you very much and welcome, everyone. Our program today is talking about a subject that can raise a lot of emotions, not only with ourselves, but with our patients and their families, and that's advanced directives. What do we do with them? How do we make sure that if the patient has one, that we have access to it? And who do we share information with, with advanced directives? And so CMS does have some regulations for us, but also Joint Commission has guidance in that respect. And so that's what we want to cover today. I always include my disclaimer in these programs in that this information, the webinar is informational only. I don't want it to serve as legal advice. And I've certainly not established an attorney-client relationship. So please consult with your own attorney or in-house counsel, and especially if there's any specific state law that might come up, because we're going to talk on one or two items such as medical futility that might have a certain state law that would impact it. So I want to do a brief introduction and just some background history on this whole topic of advanced directives. Well, we know that at least two out of three adults don't complete one. They've talked to family, they've talked to their friends over the time, and just made some comments now and then, but they don't go to that next step of actually putting it into writing so that folks like you, the hospital, the care providers know what can I do, what don't you want done. And of course, it's impacted by many things, whether it's state law, federal law, huge federal law on it. But we also have the conditions of participation and the Joint Commission standards. Now these are what those two entities want you to meet in order to get reimbursement, but it also flows back into what the patient actually wants. There are multiple types of advanced directives, and whatever they call it, well, we didn't know some of these probably were considered advanced directives, like an organ donor card. That would be considered a form of advanced directive because it's telling who's ever taken care of them, this is what's to happen. Of course, we're very familiar with do not resuscitate, living wills. We have all of these advanced directives on even visitation, who do they want? There's also such things as behavioral health advanced directives. So again, there's many, many more things that encompass what is an advanced directive. I want to show you a picture. This is actually a picture that was taken in an emergency department. A friend of mine did happen to see this and sent it over to me, says, you're not going to believe this one. And so this was actually tattooed onto the chest of a patient that was found out. And so that brings me to my first question that Lindsay happened to mention. So I'll have her put that up and let's talk about it. Let's go ahead and get that one up here on your screen. OK, so this says a 48 year old patient is brought to your hospital and via EMS after collapsing at home. The patient's 80 year old parent called 911 after finding the patient on the bathroom floor. CPR was in progress by EMS. Once in the ER, the staff finds the do not resuscitate on the patient's chest. What would you do here? And your options continue with resuscitative efforts started by EMS, discontinue and provide comfort care or stop efforts and evaluate if patient cardiovascular status resumes and then provide further support. Give you just a couple of seconds here, I see your responses coming in. Great. And, you know, some of you who work and especially in risk management may have had these type of issues brought to you. Or if you're on the ethics committee, you know, what do we do in this situation? Because we've started, we can't do we just stop. What do we do? Because, again, this is a fairly young individual, 48 years old, and they have no idea what was going on with his past medical history. Why did this individual collapse at home? OK, I've got some good good. Yeah, continue and start. OK, so let's go ahead and talk about what do we do? And I'm going to start with some case law. I'm going to do a little backtracking here and do some case law. Some of you probably have seen these situations where you have a patient who is on complete 100 percent life support, where they're intubated, they can't talk, of course, they may be getting two feedings. Probably some of you saw this quite a bit during the COVID pandemic. So let's start with the overview very quickly. Those patients who are mentally competent and maybe just not patients, but individuals who are mentally competent, they can refuse treatment. Treatment. We don't have to take a treatment if we don't want it. Joint Commission CMS, they require us to honor those rights to refuse treatment. Of course, that means the patient has to be educated on what those rights are, with an awareness of what those risks and benefits happen to be. They may not, you know, may not be able to recite them. But if we can inform them, this is what will happen if you refuse to have this particular type of treatment. Quinlan Cruzon, those were the first two cases that really established the right to refuse life sustaining treatment. And that really also spread to a new focus of patients, and that is those noncompetent patients. Earlier cases, what usually happened is the hospital, someone went in and appointed a guardian to act on that person's behalf. But here, these cases extended those rights to that person who couldn't speak for themselves. So Karen Quinlan, those of us who have probably been around for a while, we know this one very well. 1976 is when this one just really finally came to an end. It was the first case, the very first case that talked about permanent vegetative state. She took an overdose at the age of 21 and arrested. She was found for a while. So, of course, they started resuscitative efforts. And by that time, she had already had pretty much some significant cerebral damage. They took her off the ventilator back in 1976. She lasted, and I mean lasted, she continued to live until 1985, almost nine years later, before she finally succumbed to pneumonia. So that's how long that took. And I've got the site there for her case. Nancy Beth Cruzon was a little bit different, still a young lady, 25 years old. She was in, they found her, I believe it was a rollover accident, single car. She was found 35 feet from the car. She was in a ditch. She was not breathing. So needless to say, she was not wearing her seatbelt. They believe, they believe she had been without oxygen for at least 20 minutes. They put a feeding tube in her. And after five years, finally, the family said, OK, we need to take out this feeding tube because she would not have wanted to live like that. And the same with Karen Ann Quinlan. Karen Ann had expressed to some friends, not family, but friends, hey, I never want to live like that if that happens. I don't want to live like that. So here we have two cases where it's not written down, it's verbal, but yet they've expressed their beliefs on how they do and do not want to survive. One of the more recent one was back in 1990, Teresa Chavio. She had potassium imbalance. This young lady did have an eating disorder and she arrested at age 27. And by the way, they believe that's what also took the life of Karen Carpenter was because of the eating disorder. Back in 96, again, 96, her husband petitioned to have this feeding tube removed and allow nature to take its course. She wasn't on a ventilator, neither was Nancy Cruz on. They were not on ventilators. These were feeding tubes. Her parents, Teresa's parents said, no, don't do that. We want her to survive. And this went through several court sections in order to have this. Yes, no, yes, no. After nine years, the court finally agreed with the husband and said, it's time. We need to take out this feeding tube. We are going to follow on his request. It was taken out in March 18th, and she died roughly 15, 16 days later as a result of the feeding tube. So what they did here, and they wanted us to learn, hopefully, from this. So they did do an autopsy, even though it had been multiple years since that original injury. They found the left side of her brain was fine, no problem. The right side showed huge loss of brain tissue. The black area you see here is what they found there. That was the left. It's called Hydrocephalus Exvaco, where there was nothing there. And it was actually half the normal weight of what a normal brain would be. And so they realized this was a learning lesson that perhaps with this individual, there was no coming back. She was not going to wake up. It was not going to improve with that much of a brain damage. Well, then there's other areas where, OK, the person has it. Another case came out, but we didn't respect it. So this happens to be Glenwood Gardens. It's an independent living facility in California. Here, they refused to do CPR on an 87-year-old. Well, the reason they didn't, the nurse said that the policy, the facility policy, prevented me from doing CPR if that patient collapses in the dining room. Rather, you call 9-1-1 and wait. Well, here the patient did not actually have an order for the DNR process, but the family was still OK with, OK, that's that's fine with that. She's 87. She's had a good life. If she collapses, fine. Well, CMS said, yeah, no, not necessarily. Unless there is an order for DNR, you must still do CPR and resuscitate them on theirs. Again, we didn't have that order, even though everybody was fine with it, wasn't written. Other cases, Linda Schleibel. Here we had where a nursing home didn't honor her advance directive. This was back in 07. This patient took every step possible. She completed a living will and it was specific. No CPR. No, no feeding tubes. Don't keep me alive, OK? I don't want surgery. I don't want a ventilator. And the physician still wrote an order in the chart. For do not resuscitate. Well, sure enough, she collapsed and they did all of it with the exception of surgery. So the family came back and said, really, that's not what she wanted. You completely ignored her wishes. So to the effect of one hundred and fifty thousand. Here we have a patient who was she was pregnant and the husband said, turn off life support because, you know, this is not what she wanted. Well, the hospital said, wait a minute, she's got a 23 week fetus. Therefore, we're going to ignore that and wait until the child delivers and then we'll take it from there. Well, they said, no, we're going to go ahead and find on the side of the husband because she was declared legally dead. She was found unconscious in her home. They think she threw a clot at that time. And of course, 23 week fetus probably had a lot of abnormalities as a result of the oxygen deprivation. But not again. The hospital ignored those wishes and ended up having to pay for that extended stay. And this one went a little bit further. This was sixteen point five million. Here we had a mother and daughter. The daughter was the patient. She had a extreme seizure disorder that wasn't going to get better. In fact, her physician, her care physician said it's only going to get worse. And so she had an advanced directive that gave her mother durable power of attorney who said you can stop treatment if I become incapacitated. Well, sure enough, she collapses. She arrest and the hospital intubated her against their wishes. Patient remained in a coma for at least two months. She is now total care. And those of you who are very familiar with extended care of this nature, that is extremely expensive and it's very wearing not only the patient, but also the family. Here again, completely ignored it and went against her wishes. This was the first kind of those substantial damages. Normally you could see the other damages, 100,000, 150,000. So this one was really it meant to send a message. It really did. So now we'll probably have somewhat of a new wave that if you don't honor those advanced directives, then that's what you may face. If there is one in place, you have immunity. You do have immunity from the American Hospital Association. Their president said, you know, it's going to take a while for us to deal with this because we're in the business of helping people. We're there to help them get better. Hopefully go home, go back to where they were. And that's a tough call. And it's tough for us to kind of step back and say, OK, but this is a new area of law and legal theories. And we still have some that are developing. I want to talk about end of life planning, because now we have a little bit of a help on our side. But first, of course, it's that physician's responsibility. They must give them information, decisions on, you know, this is what is going to involve with your medical decisions. Not everyone is fortunate to have someone who works in health care. You know, they're not fortunate like your family members are to know. Translate what's going on. What does this mean to me? We should have a code status on all admitted patients. Palliative care, that's very different than hospice palliative. They have found having palliative care really slows those ICU admissions, maybe fewer use of ventilators because we're aware of what they want, what's valuable to them. And then talking to the patients, what do you want? How do you wish to lead this life? And that's why they have advanced care planning decisions and they to provide the education. You'll see an asterisk on this slide. There is a resource in the appendix. Whenever you see that there is a resource in the appendix for having these conversations. Some physicians are phenomenal at it. They're very good. Others would rather have a root canal without anesthesia in order to have that conversation. But most of them are starting to get better at it. How how do you want this to go? What do you expect or what do you hope to have as your days may be coming to an end? But now the thing is, now you get paid for this planning. The physicians can. January CMS added to that to their physician payment rules. You can have that discussion. What do you want? When do you want this treatment and have it before it's too late, before they get that diagnosis where they kind of shut out all information, all other conversations that are coming to them? These are tough conversations. I'm not going to hit you on that. They are very tough. But if you can go into it early on. And yes, they have a right to change their mind. But just, you know, make sure that you start that conversation and it gets comfortable. The benefits improve some of our outcomes because there were fewer hospitalizations. You know, when you have maybe some of the older population or those who have several disabilities, where perhaps they have to keep coming back to the hospital because these things are happening. Maybe they live. It's an elderly couple. They live alone and in their house. They have a lot of cables or cords around for those wonderful space heaters. I admit I have one, too. Or they have these trip rugs. It's such a pretty rug. And and I don't want to give it up, but it slips or trips. Having that palliative care come in or having those discussions on, hey, how are things at home? What can we do to help you be more comfortable at home? It does result in fewer hospitalizations. We're not calling 9-1-1 all the time. Maybe it's less intensive treatments where we can start and then work up if we need to. And maybe there's more hospice utilization because we know. Yeah, it's out there. It is a benefit. And it also brings up that conversation. Where do you want to have your life stopped? Where do you want to die? Do you want to die at home? Do you want to are you OK here? And these were all consistent. This regulation really went along with what the AMA recommendations also were. So in talking to your Medicare patients about their end of life planning, this includes living wills. And we all know the purpose behind those is that I have the right. I have the control over the decisions with myself, with my body on what I do and do not want done. Code is for about 30 minutes of face to face. I do it during their welcome, their initial Medicare visit. And of course, when it's appropriate, maybe something's happened during their own annual wellness that during that time frame, they've come up with a new cancer diagnosis or perhaps they've had an M.I. in that interim. That was a pretty significant M.I. that could reoccur. OK, have you thought anything further or had any change of heart on what you do want? CMS did include nine quality measures, 19, excuse me, quality measures that you do, of course, have to fill a report. And these all really focus on that patient centered care. So documented, if they do have one of those advanced directive type documents, whether it's called a DPOA, a DNR, even an organ donor card or post. And we'll talk about post as we get near the end of the program, because you have to have in that record at least for, you know, for advanced care planning. What are the patient preferences? Yes, you've had this discussion. What are the questions relative to their goals and those advanced directives, durable power of attorney for health care if they have one? So it's very important to have that record. These could be just a couple of sentences. You could have those things listed out in a checklist and check them off as you go by. But at least we have to have those. And here's just that article from 2017. This was Kaiser that it's more than just a chat on Medicare's time. In fact, ninety three million twenty three thousand providers did bill for this discussion much higher than expected. But at least the discussions were started. Five hundred and seventy five thousand Medicare patients alone. And it really helped with their informed decision making what they do or do not want. Do they want CPR if they're in a permanent vegetative state and their coronary status crumbs on them? Do they want to be intubated? Now, these are not I'm going to repeat. This is not easy discussions to have. But once you open that door, it does help. Starts getting more comfort level. You may have some family members that I don't want to talk about it. We're not talking about it with mom. Mom's not able to handle it. Respect mom, because she probably she can assimilate. More than perhaps what the family knows or wants to accept. But we still have that duty to the patient. And so again, this is frequently asked questions about billing and that fee. I listed the address there for you. Medicare has a learning network you can tap into. They have a fact sheet. This is from 23. This is the last one I could find. And it talks about this advanced care planning. It's a good tool. If you do education for your providers on anything and including meds, it's advanced directive. You might wanna look into that because it could be a good start for you and have some good questions or talking points for you. Federal law. So again, we have state law and we have CMS. Federal law is the Patient Self-Determination Act. Again, it's a federal law, so we have to abide by it. So here's the definition that they have. Advanced directive, any written instrument, doesn't matter what you wanna call it, living will, durable power of attorney that is recognized under your state, either statutorily, in other words, it's in your constitution by your state, or the state courts have made a ruling on it. And it talks about the provision of healthcare when that person can't make those decisions. So again, there's multiple names for this document. The federal law, I have it here. And the idea was behind it, really inform patients of what are their rights regarding care. And using this, it helps us ensure they're communicated to their providers. In other words, it's a written summary of their decision-making rights on admission. And it ensures that the patient dictates what their future care will be should they become incapacitated. Generally, it applies to Medicare certified hospitals, but it's also to a whole host of other areas. HMOs, hospice, home health, skilled nursing facilities, all of these fall under that Patient's Health Determination Act. Passed in 1990, and it requires all of these organizations to give information to our patients on advanced directives. Do you have an advanced directive? You probably, it's just part of your routine admission questions. Yes, do you have a copy you can provide to us at some time? Or would you please provide a copy of us, especially if it's gonna be an anticipated long one? If not, would you like information on it? But again, we're trying to give them information so they know what their rights are based upon that just basic principle of informed consent. So it really is a very basic principle. So what do you have to do? You have to provide written information to patients on their decision-making rights that you will implement those rights should it become necessary. Document if they have one, if they have an advanced directive. Of course, you wanna make sure anything they do complies with state law. I had one for years in Colorado, and it was pretty extensive. Had it down to how many IV sticks that I would allow them to do. Well, my Colorado law went and revamped all of it now. And so now we had to go back and redo my advanced directive to be in compliance with that state law. I can still have those items as information for my providers, but the advanced directive itself is different. And of course we need to educate our staff, not only on what our policies and procedures are, but what are the basic points behind advanced directives? And they also require community education on advanced directives on what we will do. How do we do that? If you have a website, that's a good place to start. And I have seen that on many hospitals now on their website about additional information for patients and down the list is advanced directive. So those of you who are doing it, good job, kudos. You have to have a written policy and procedure. How are you going to implement each patient rights? And that includes advanced directives. There is in the PSDA, the Patient Self-Determination Act, a conscious objection. And where, and you want to include that in your policy and procedure, where if you have someone on your staff who objects on a religious basis to completing or following that advanced directive, that you, they have that right to say no, but we have to then get someone in there who will then take over the care of that patient. Include in there clear, precise limitation. What is the difference between what an institution-wide objection is as opposed to those to an individual provider? And then put in there your state authority permitting those objections. You know, what are the wide range of conditions that could impact that conscientious objection? It's going to be very helpful when the physicians or someone has to go look that up. And of course we can't discriminate against a person if they do or do not have one of those directives. It's been well over, I mean, even 25 years plus since this act went into effect. There was an article that came out and it found patients rarely do talk about it with their physicians. 88% of physicians would opt for a DNR status for their patient if that patient was terminal. Only 50% of terminal patients actually have advanced directives. And that's why there's now a national teaching program respecting choices. They want to try and change that for those patients. All right, now we're going to switch over to CMS. Again, Centers for Medicare and Medicaid, it's a division of Health and Human Services. And those of you who've listened know that it's very, that's who pays us as far as the hospital for taking care of these patients. We want to talk deficiencies briefly because it still comes up. Now you can access the data on these deficiencies and it has the tag numbers. It's updated quarterly. And so here on slide number 41, for those of you listening on slide 41, there is the actual link there. What you want to do is when you get to that site, scroll to the bottom where it says full text statement and you will get a huge Excel document, but you can pull it up. For advanced directives, these are in the patient rights section. This is overall the most problematic section for hospitals within the manual. As of April of 19, there were almost 1500 deficiencies. Advanced directive deficiencies alone. In December of 21, it went up by 402. January of 23, it went up another almost 2000. So this is a pretty significant one. What are some of the reasons the hospitals were cited? What were the, for the deficiencies? Well, no, it's staff education on advanced directive. How do they know that? They go back and look at their personnel folders and they ask what's your training for advanced directives. They tell the family or representative that in this situation, because the patient was incapacitated, you have the right to make advanced directives and have them followed. The directives weren't included in the record, even though they were provided to the staff. Facility didn't follow the advanced directive. This was a very common one. We knew it was there and we did not follow. It's not that we didn't know it wasn't there and we just forgot about it. We simply didn't follow them. They didn't let the patient make an advanced directive and they didn't allow the patient to have visitors without sufficient justification. And this again, is one of those part of advanced directives when they're near the end of life or perhaps they're very, very ill. They didn't have enough justification. And this was not COVID related. So I did want to point that out. So for the conditions of participation, I'm gonna talk about the regulations. Now, just real briefly, we know that the regulation starts in the Federal Register. CMS puts it out there in a transmittal and then they develop interpretive guidelines and survey procedures for their surveyors. And the three types are certification when you're starting, validation when you're going back and seeing how things are doing, or just want to check up on one of the accrediting organizations. And then of course, a complaint. There are a couple of ways to keep up with those changes that have come out. I would subscribe to the Federal Register, especially if you're in compliance because then you'll get notice of what's new. Make sure you have the most recent manual. For Appendix A, where a lot of the patient rights sections are for acutes. Your last was updated in this year, April of this year. For critical access hospitals, your last update was back in 2020. And patient rights sections for you are actually in the swing bed section. You don't have a similar one in the rest of your manual. Always check the transmittal page if there is a new one and then the survey certification site. That's where you'll get notice of the memos. So for what we're talking about today is Hospital A. Now, I believe I briefly touched on critical. So again, you don't have a comparable section in your manual on these patient rights other than the swing bed section. By the way, for transmittals, that's what it would look like when you pop it up on your computer. And for Appendix W, same thing. This is just what it looks like. Push on to where it says that first line and it will take you to what that transmittal says. All right, so for advanced directives, again, Appendix A, it's in the A standards and critical, your C standards, but you're in the swing bed section. It includes what's in the federal register, the interpretive guidelines, and the majority have survey procedures. The majority do. Some of these are pretty common sense and you would expect a person just to know it. So what is a surveyor going to do? First off, they're gonna talk to a patient or family. Did you get information about advanced directives? Were you told you had a right to make one? What were you told about those rights? Then they're going to look at documents, your medical records. They wanna see some evidence of that advanced directive. Like when they're coming into ER, do you have an advanced directive, yes or no? And do you want one, yes or no? They're in standards and I've listed them out here. They're also in the introduction. So CMS is trying to get the point across that, hey, this is important and we need to follow these on advanced directives. So I'm coming up to my next question. Lindsay, would you put that up? I sure will. I think I'm gonna read this first part to you and then I'll put up the options here. So this says state surveyors arrived at Hospital Z for an unannounced complaint-driven survey, patient rights violations. During the interview phase, questions are asked about advanced directives. The admissions coordinator was unable to provide a hospital policy regarding advanced directive information to be given to patients. Will Hospital Z be cited? Okay, and your options should now be on the screen that says yes, no, or not sure. And Laura, we had a question that came in that asked, what would the appropriate response to that DNR tattoo be? Oh. Mm-hmm. This is because, okay, technically, overall, they should have stopped. They should have stopped CPR, because they did have that. Now, this hospital chose to go ahead and continue until they could figure out, okay, what's going on? Because he did come by EMS. Resuscitation had already been started. And so they felt that they had a legal obligation to continue that resuscitation. So once they found it and once they got mom in there, mom, again, 87-year-old lady, brought in her son's advanced directive with her. And so then he was stable. He did eventually code again, and they did not resuscitate him. Under that circumstance, I think they chose right. They continued to do CPR until they could figure out what's going on for sure. That was a tattoo. We don't know how long that tattoo had been there. Daddy changed his mind, et cetera, et cetera. And so that's why they waited until they could get more documentation to support it. They erred on the side of, I guess, caution would be a good word for it. And I was okay with that. I agreed with what they did and decided to do, because they asked me, what would you have done in that situation? I said, exactly what you did. I would have continued until I had more information. Now, if mom had come in with the patient and say, no, he doesn't want any of this. He never wanted it. Then they could have stopped. I think they would have been fine either way. But he did eventually pass away. He had a massive MI is what happened to him. Okay. And that was, well, I said that and I think another question came in here. Okay. That happens every time. It said, is it required for a hospital to make patients aware of advanced directives in the emergency department versus on admission? No, on admission. On admission, that doesn't have to be in the, usually they do ask them in the ED when you come in or it's on your intake form, do you have advanced directives? And if so, in the case of admission, could you get us a copy or if we need it, can we get a copy of it? But they do say we have to make them aware. And I would do it also if they're coming in through ED, just ask them, do you have advanced directives? Do you want information on one? If no, but definitely on admission. Okay. I'm gonna go ahead and end this poll and share those results here. Yes. Oh, yes. No. And if it had been, if the surveyors had just gone up and asked the admission clerk, where's your policy and procedure on this? She said, and she kind of said, I'm gonna have to think about that for admission for a minute. I would have understood it. But when the admissions coordinator didn't even know about it, that was a little different because you're supposed to know what's in your policy, you know, what policy and procedures are out there. At least they should be aware of it. That as it specifically affects their job. So what do we have to do? We have to inform patients of their rights in advance of providing care in a way they can understand it. You know, simple language, low health literacy, limited English proficiency. That's what we have to do. CMS can also refer if you're not compliant over to the Office of Civil Rights because again, they have a right for an informed care. And that's one of those basic rights. OCR can find a hospital, CMS cannot find a hospital. Of course, that extends to their representatives. Patient rights given to the patient and their representative. We should take reasonable steps to determine what are their risks as to a representative. They don't have to have one, but do you have a representative who, you know, you want us to communicate with and keep apprised of everything and discuss those rights with them? You know, these basic rights. We all know that as a minor, parents tend to be their representative or their legal guardian. Could be a legal guardian for someone who is declared or determined to be incompetent. Or DPOA, if they are incapacitated. That support person, they do visitation. By the way, Joint Commission calls them advocates as opposed to a support person. And if they don't have anything on file and someone happens to walk in with them or come in with them, they can be, and they say, hey, I'm their representative. We have to take them at their word. Said I'm their spouse, I'm their partner, I'm their best friend, I'm their neighbor. And they come in with them saying, I'll be their, I'm their representative. We have to take them at that word. Otherwise that competent patient, they can designate who that is. And it can be verbal or in writing. So what do we have to do? We then need to give this person and the patient the required notice of their rights. Of course we want it in writing, that's the best. And make sure if there is an explicit designation of that representative, that's awesome because that will take precedent over someone who is non-designated. In other words, if you have it in writing or the patient writes, hey, so-and-so is my representative and then so-and-so third cousin twice removed you want the one that is written. And this continues throughout the care, throughout their admission, or if they're coming in for outpatient treatment. If someone comes with an advanced directive or DPOA for an incompetent or incapacitated patient, follow your policy and procedures. Again, that written document takes precedent over anything that is non-designated. Now, of course, this is until the patient stops being incapacitated or actually withdraws that designation. Say, I don't want them to be my representative anymore. Don't talk to them because it can be done orally. And of course, written writing is always best. If there is no advanced directive and the person who comes in with them asserts that relationship, you have to accept it but you cannot demand supporting documentation unless one or more show, more than one show up. And then you can. I need something to support your claim as the one and only representative, whether it's proof of marriage, co-legal finances, whatever it happens to be. Now, if you have common law marriages where you don't necessarily have a documentation, how can you do that to say, hey, yes, indeed, this is their representative? State law may have something also that can guide you in that respect. That's why you wanna make sure that's in your policy and procedures. But if you're going to refuse to recognize someone as that representative, well, make sure it's documented in the record and the rationale for that refusal. Why is it that you're not going to recognize them? Perhaps you have familiarity with this patient. They have been back or been a patient before and you had someone else who was a representative forever. And all of a sudden they show up and here's somebody new, okay? What's going on? Why is this someone new? That could be a very valid reason. Perhaps the other person died, moved out of state, whatever. But if your gut tells you, no, this doesn't seem right, act on it. Just make sure that you give them also a chance to show or to prove, yes, indeed, they are the valid representative. So then again, continue with patient rights. The basic, make decisions on their care and be informed of that status. That goes along with refusing or requesting care. They can delegate it, even though they're competent. A competent patient can still delegate medical decision to another individual if they want. But it is not a mechanism to demand any unnecessary or flat out inappropriate care. Now, if they come in and say, you know, I don't like the way that left foot looks, I want you to take it off. And it's a fully functional left foot, it's okay to say no. Just because they don't like the way it looks, that's probably not a good reason to have it whacked off. Take reasonable steps to determine what are their wishes, especially in the designation of that representative. Consent. You have a patient who's not competent. Those who present hopefully with a document, whether it's an advanced directive, whatever it is, you can get informed consent from that person. If they're not competent and no advanced directive, again, whoever comes in and claims to be the representative, you can take their word for it. And you can't demand documentation unless two or more claim to be that person. We already talked about the right to make an informed decision. Now that presumes we've given them their information on what it is about. What is their status? What's their diagnosis? What's their prognosis? What are the risks and benefits of that care? So we have to make sure not only the patient, but perhaps in their place, their representative gets that information. And gone with that, the right to formulate advance directives. And you have to comply with them. Consult with them when they do become unconscious or incapacitated. Hopefully their care provider, if they do have that PCP, is aware of them and knows them. And again, I've gone over my advance directives with my providers, so they're very clear on what I do and do not want. And the same with my representative, my husband. He knows what I do and do not want should I become incapacitated. So here's the definition under CMS, a written document recognized under state law that relates to the provision of care when that individual cannot make that decision, when they are incapacitated. This applies to both inpatient and outpatients, because they do recognize, CMS recognizes, patients have a right to refuse medical care, but it should be an educated right. In other words, these are the risks and benefits, if you do not want to have that surgery. As far as the content, just what does the patient want and not want? They can delegate it to another person, they step into the shoes, and they get consent from that surrogate decision maker. They can delegate a support person also. And here, this person would exercise their visitation rights. And again, any designation in that written document takes precedent over something that is oral. So that's why your hospital policy has to include that written notice that you are giving patients, inpatients, when admitted at the time of registration, that they have a right to make an advance directive. Have a summary, don't give them a copy of your policy and procedure, but make sure it's documented in the medical record. CMS mentions that you should provide to outpatients and their representatives. You don't have to, but you should, especially in the ED, because we don't know where they're going to end up. Are they going to be admitted? Are they going to be transferred? What's going to happen to them? But maybe you have someone in observation, same-day surgery, perhaps you have outpatient procedures such as IV therapy, chemotherapy. And here we have reference that, yes, indeed, they have advance directives, and here's our copy of them. So again, should, but they must be at the time of admission and registration. I always say, ask them in ED, because you don't know if they're going to be admitted. Rights, these are also same rights in the Joint Commission, and that's why we want to make sure that staff, practitioners, what they do is consistent with those directives. And have a clear statement of any limitations on those conscious objections. So I want to go just a little bit more into here. Have that provision to allow it, but make sure it's narrowly focused. What is the condition or procedure where that conscious objection can be exerted? And make sure that it does not allow refusal to honor part that designates the person. Such does not concern a medical condition. In other words, I have a conscious objection to allowing that person to be their representative. That's not it. What we're talking about is treatment and care. But again, we also have to give notice to the patient on the clear, make it clear what is the basis of that conscious objection. Now, Dr. So-and-so is going to step in for Dr. Heer, if they ask why, it says he has exerted, he or she has exerted his right to not participate in this treatment. If you want to go that far. Otherwise, just say he's going to step in for this physician to continue with this procedure. The Office of Civil Rights does enforce it and they respect and will protect those conscious objections. So that could be a host of items. But that's what your policy has to spell out. Abortion, assisting in sterilization, assisted suicide. There is a section on the website that talks, on the OCR website, not CMS, on OCR, that talks about conscious objection. Otherwise, if there is no basis, we know patients can file a complaint if they believe they've been discriminated against based upon that person not performing that procedure. There are resources on enforcement of the provider's conscious objection protection laws. So, again, they are out there also. We just have to make an accommodation. The requirements, again, clarifying your policy, the difference between the facility-wide and those of the individual providers. Is there any state law that you can also add into your policy that permits such objection? What are the conditions of procedures that are going to be affected by that objection? And again, just a quick information to the patient on their rights under state law. As far as advanced directives, of course, we document if they have one. We can't condition treatment on if they do actually have one. We want to make sure it complies with any state laws and inform the patient that they can file a complaint with the state. That could be depending on where you are, Department of Health. If it's a Medicare patient, they would file with the BFCC. That's a beneficiary of the family, the QI Quality Improvement Organization. Those are the ones who oversee any issues regarding care provided to Medicare patients. Education to staff is crucial. You saw that was one of the deficiencies. Staff weren't aware. I don't know what my policy is. I don't know what I'm supposed to do. And again, community education website, great way to do it. Also, there are certain laws on psychiatric advanced directives that your state law may permit. If they have them and they permit them, then they're given the same respect and consideration as any other type of advanced directive. And this may apply if they are subject to involuntary commitment. This is where I'm going to have to have you work with your in-health counsel on it. If you have a lot of these patients and they happen to have that PAD, that psychiatric advanced directive, okay, what do we need to know and do in that situation? On the survey procedure, they want to see your notice that you're giving to these patients, whether, of course, all inpatients and those outpatients that you find are necessary. And included that you have a right to make an advanced directive and the staff has a requirement that they will comply according to state law. They'll look at records, medical records. Is there evidence of compliance with that advanced directive? They'll look for documentation that you gave them notice when they registered for admission. Again, do you have an advanced directive, yes or no? And sometimes that's what the patient can complete and they sign off on it. That's the best way to do it. The surveyor is going to go around and talk to people now. They're going to start with the patient. Do you have an advanced directive? Yes. Did they ask for a copy for your medical record? Why, no, they didn't. Did you offer to provide them with a copy? Yes, I did. What process do you have in place to help a patient make one if they don't want one? Hey, yeah, I've always been thinking about doing that. What do you have for me? And then how would they update that current advanced directive? Oh, yeah, it's several years old. I've been thinking about updating it. Can you help me with that? They'll look at what education you have provided, not only to providers, but to your staff. Are they aware of it? And then they'll talk to staff. What do you know about advanced directives? Do you know any limitations on them? Do you know a situation where perhaps it could have been done better? And if so, tell me about that situation. Then we move over to visitation and notice. Again, this was an area I was very surprised to see how many times the advanced directive on visitation had been cited, just something as simple as visitation. Patient, their support person, determines visitation. And of course, patient can withdraw consent at any time. They don't want to see somebody, they don't have to. If they're incapacitated, then it goes to the support person. And it can be a separate visitation advanced directive. Now, that's different from a durable power of attorney. This is just simply a visitation advanced directive. Again, if there is no designated representative, it's the person that shows up and said, I'm it, I'm that person. And you accept it without requiring proof. Unless there's more than one, then yes, you can ask for that documentation. You have to use non-discriminatory process for resolution of any complaint, any dispute. And if you refuse to honor it, document it. And why? Now, I want to point this out, especially if you have pediatric patients, those patients at risk, maybe you have an at-risk adult. Because you may have someone who comes to visit, perhaps you have a non-custodial parent who's making a ruckus in your hospital, and you don't want to allow visitation. And the custodial parent saying the same thing. Or you have at that at-risk adult, who you're really concerned about where that visitor could happen to be their caregiver. And you're concerned about perhaps mistreatment of that adult. You can actually use that for a basis that, hey, this is why I'm concerned about it. And then work with your in-house resources, if that's risk management, if that's your legal department, to try and determine, what do we need to do? Because this person has bruises that don't make sense for what they're going through, and I'm concerned for their safety. Do you need to call Adult Protective, Child Protective Services, et cetera? Now, here's an interesting one, advanced directives and surgery. It's actually not in the patient rights section, this is in the surgical section. Here at the standard requires a policy on a do not resuscitate status. So the staff need to be aware of that policy, especially when they're going to surgery. You can look at position statements, there are professional organizations, I have a couple of them, I think at the end, like American College of Surgeons, AMA has one, AORN, they also have position statements, Society for PACU Nurses, and surgical nurses, they have statements, American Society of Anesthesiology, those statements are out there, those positions are on there. But of course, we have to also look at our state regulations. The rules contain the substantive information on how you should proceed. So if you have a patient going to surgery who has a DNR, your policy needs to spell out, what do we do now? Is it suspended? Is it going to be continued? And we hope for the best during surgery. The big thing is we have that discussion with the patient and or representative on what can be. And if it is, yeah, we understand, no, go ahead and suspend them, but then resume them once I'm out and back on the floor. If you're going to transfer a patient, then send that information with them. Copy is best if you can get a copy of it. Of course, we use that interpreter. And don't forget that low health literacy for when you ever use it. So that's for the acute hospitals. Now I'm going to talk critical access hospitals. This is a little bit different. Again, you don't have the similar section set aside in your manual than the swing bed statements, the patient rights, that part. So here's my, I believe my next question, Lindsay. Okay, let's go ahead and get that one up here on your screen. And actually let me read this first part to you. So this says critical access hospital Benton community often receives elderly patients from a nearby nursing home without a family member or a power of attorney. Documentation from the nursing home mentions the patient is a DNR, but there is no signed document on file. What would you do? First option here, discuss with the patient what their wishes are and document their statements and hope for the best or continue to reach a family member friend for any information on the patient's possible wishes or not sure what to do in this scenario. And we did have one question come in here, Laura. And it's kind of a scenario question here that said, I had a patient in the ER one day that I was not familiar with. The patient started to go into cardiac arrest. And at that point, I did not have a written record of her wishes. I quickly asked her if she did want anything done. She shook her head, no. And verbally said no. That patient did die within 15 minutes. My question is, legally, should we have done resuscitation since we did not officially have it in writing? Again, you can take an oral advance directive. You can. I hope you had someone witness that with you so that you have backup if nothing else. And that's my attorney talking on that one there. But as long as, you know, you didn't have any information, you're acting in good faith. You also might want to do kind of a follow-up on this one, as far as, okay, what do we do if this comes again? You know, as a nurse, or a very trained, very well-trained health provider, if what I believe is in the patient's best interest, and I'm not violating any laws, you know, very badly, and oh, yeah, I knew they were fine. I knew I could have resuscitated. I knew they would have been okay after, and I ignored it and walked away, that's different. But here you did take an appropriate step to determine what does that person want? And if they verbally said no and shook their head no, I think you're going to be okay. I really do, because you acted in good faith, and you took reasonable steps to determine what do they want, and they verbalized it to you. I really hope that was all documented, and it could very well. I think you acted appropriately. I really do. Perfect. Okay. Okay. And then just a comment here saying that it can be problematic when state law does not require patient capacity for that patient to dismiss their representative. Right. Yeah. It can be very challenging when they don't have that capacity, and that's hard to determine capacity. You know, they, the physician can make the determination, you know, is this person making sound, rational decisions, but as far as being incompetent, sometimes that requires a court order to make that call. And that can be very challenging when that happens. Okay. I don't see any other questions. I'll go ahead and end this and share those results there. So, yeah. Absolutely. What do you want? And that's exactly right. Okay. What do you want? Tell me what's going on with you. What do you, you know, what are your wishes here? So we can treat you according to what you want. Okay. Next question. Again, this is a critical access. All patients have a right to make advanced directives. We have to comply with federal and state laws, and that, again, they can refuse treatment, have a durable power, somebody else make them in there. They can designate that support person, like for visitation, and again, if incapacitated, have that durable power. And we just have to give them information to that person because they're stepping into the patient's shoes. You have to seek consent of their representative when it is required for any care decision. So what do you have to do as a hospital? One, provide information to the competent patient when they're admitted. Should give, again, to ED. I always say give it to ED because you don't know where they're going to go. Document in the record that you've given it to them, or if they have one, or if they don't have one information on it. If incapacitated, it goes to that next person, family, their surrogate. As with the acutes, you have that conscious objector clause that we can, we still must allow them to make it, but there is that conscious objector. Overall, as with the acutes, you cannot require it. Educate your staff on it, and that includes a psychiatric advanced directive. This is very important if you happen to have that designated behavioral health unit. Just as an aside, if you have such a unit, the 10-bed unit, you're surveyed under Appendix A, not Appendix W. And again, with an acute hospital, a critical must also provide community education. I always say your website's a good place to start. I want to go to joint commission. For those of you who have deemed status, they really follow quite a bit with CMS. They have the definition pretty much the same. It's a document that allows a person to give a direction for their future care, or say someone else can make these decisions if I cannot do it. And the same list of what it's called, DPOA, do not resuscitate, right to die, living wills, whatever it is, something that expresses their wishes. And this doesn't have to be a real formal document. That is, most states, you don't have to have it certified, and I have to have that little certification stamp. It can be handwritten out and say, here, here's my advanced directives. So they're in the page RI, that's the right section, that you address these decisions about care that they receive for their end-of-life care. It doesn't have a rationale, which I found a little surprising, but maybe they figured this is pretty straightforward. There were originally 16 elements of performance, but with a huge overhaul that joint commission did, they only left four of those remaining original ones. As with CMS, you have to have written policy and procedures on advanced directives that covers foregoing or withdrawing life-sustaining treatment and withholding resuscitative efforts. You provide patient-written information, and you provide it on admission if also you're unwilling or unable to honor, in other words, the objection. You communicate the policy in outpatient settings. Include in there if you're going to honor those advanced directives in that outpatient setting. Now, outpatient, the idea is you're going to come in and go home, and we're hopefully not going to have anything happen while you're here. If that's the case, maybe we should admit you, but that's the idea, that you don't have to do it in outpatient, but maybe we should. Again, honor that we're going to write, honor them to formulate, review, and we're going to tell our staff that those who are involved in advanced care, excuse me, in the patient care, this is the treatment, the services the patient wants under those advanced determinations. You document if they do or do not have one, that you refer a patient to help in drafting upon request, and we don't determine care based upon the fact if they do or do not have an advanced directive. The record of care, now we're in a different one. There's two references to advanced directives. Medical record contains any advanced directives, and that the record contains discharge information and any advanced directives. Then as far as provision of care chapter, when a patient is discharged or transferred, note two, that's what it's called, note, for deemed status, that we send that information along with them if they're being transferred on advanced directives. These are just some suggestions. You don't have to do these. Here's some things I've seen over the years. Sometimes there's a sticker on the front of the chart. It will list the type of advanced directive, and we mark one. Maybe there's a tab in the electronic record that would indicate advanced directive. Make sure staff know if they do have one. There's nothing more, I don't want to say frustrating or concerning when it's all over the place, or maybe the patient was just admitted, it's been 12 hours since they've been there, all of a sudden they code on you, and you're doing CPR and says, wait a minute, he had a note, it was a DNR, what are you doing? Make sure staff know that as soon as possible. We always ask the patient, do you want any changes to advanced directives? Because they could change depending on why they're coming in. If I'm coming in for, oh, I don't know, say maybe a knee replacement as opposed to bypass surgery, I might wanna change up my advanced directives a little bit and see what's gonna change. Make sure there's something on every patient and try to get a copy in the record. It can be challenging to know, okay, yes, I have advanced directives. I have my wife bring them in and they don't, as far as, okay, what do you want and what do you not want? Document to make sure the patient has not changed their minds. Again, check box on the advanced directive form if that's what you have. And then a policy. What happens when the patient goes to surgery? Maybe you wanna include that. If you're giving out packets of information, I don't know if they're still doing some of the hard copy. We're trying to save trees, et cetera. Is there anything, sometimes they will now just put those on their website. Hopefully the patients all have access to a computer and can tap into it, know how to use it. But this is what will happen when you go to surgery. So I mentioned before organizational position statements, and I have some of them here. So let's start with Marin College of Surgery. They talk about advanced directives in the OR room. AORN, Association of Operating Room Nurses, a good policy on perioperative care for those who do have DNR. Because what they have said, automatically suspending them undermines that patient's right for self-determination. Automatic suspension. In other words, I don't care what the patient wants, we're suspending them. So they say, we need to talk about this. We need to talk to the patient, discuss it and document it. Are we going to continue this NOR? Is it going to be suspended? Is it going to be partially suspended? And then you get down to, okay, what can we do? And what can we not do? Are we going to do chest compressions? Are we going to cardiovert? Are we going to simply treat them chemically? What are we going to do? ASA, American Society of Anesthesiologists, they talk about their ethical guidelines for anesthesia care for those patients who have those DNR or other directives that do limit treatment. Again, they reiterate, just as AORN does, that those automatically suspending orders address patient's rights to self-determination. Because we know anesthesia can involve some practice that could be seen as resuscitation. For example, you're going to undergo general anesthesia. You're going to have a tube in your throat. That's intubation. Is that considered resuscitation? So their position, full attempt at resuscitation includes the immediate post-op period. And I agree with that. In other words, I've just come out of anesthesia and I'm going to recovery. That should be included as far as what's included in a full code. Limited attempts with defined procedures. Maybe it's DFAB, maybe put the trach tube back in or tracheal, whatever it happens to be. Tell the patient, this is essential for your anesthesia to be successful and the proposed procedure to be successful. And then maybe it's not essential. And they can refuse it. So they go to a little bit further and limited attempt with regard to what the patient wants. Well, again, the physicians can use their clinical judgment. What ones do they consider will meet those patients' goals and values? What's very important to that patient. Then there's the Council on Surgical and Perioperative Safety. They have an X website. They talk about DNR positions for many organizations. I have it down here for you, that site. It's a really good, quick, down and quick way to get that information. ASPAN for PACU, American College of Surgeons for the OR, AORN for your perioperative nurses, also for surgical techs, they even have it. So that's a really nice website where you can get all of these position statements available. You might want to use them for some of your policy and procedures. Just quickly, ASPAN nurses follow your standards for post-anesthesia practice and their position. There is one on that perioperative patient who has a DNR advanced directive. What are the standards of PACU nursing? There are four recommendations that they have. One patient who has that DNR, will you re-clarify your wishes at the time of surgery? What is the nature of anesthesia? What measure do we have to take to protect your cardiovascular respiratory systems during anesthesia? Number two, the consent will include a thorough review of your advanced directive and those that specify DNR. Documentation of that discussion. Three, every hospital should have a policy. What are the resources and the procedures for staff to follow? How do you manage that patient who has that DNR order? And especially during that perioperative. And then finally, personal conviction. If there is someone in PACU that their personal conviction, religious, usually it's a religious base, that prohibits them in participating in not doing something, then that nurse may remove themselves from that care situation. As long as it doesn't harm the patient, is not seen as a breach of duty. So we still have to make sure their needs are met. Swap out patients if you have that luxury. So again, that is the position statement on what it looks like and the four items. There are other position statements. American College of Emergency Physicians, they talk about do not attempt resuscitation. American College of Surgeon on advanced directives, DNR orders. I have the links there for you. They talk about, American College of Surgeons, they talk about policies that either have automatic enforcement of it or disregard it, automatic cancellation of such orders. But again, they recognize that may not sufficiently address what the patient wants. Also that an institutional policy of cancellation, automatic cancellation, where surgical procedures to be done, takes that patient out of it, takes them out of that appropriate participation in the decision-making. So we just need to talk to them about it. Automatic enforcement may lead to inappropriate perioperative and anesthetic management. I talked earlier about, it's called a MOLST or a POST. This one is Medical Orders for Life-Sustaining Treatment. Usually you can find them on your state website. My state has them. And so it's very helpful because it's right there. All the information you need. This is a state approved form. And it has the information you would need to communicate to that patient or what the patient needs to know. Now that doesn't mean it's all inclusive or the nitty gritty, like I said, how many IV sticks can you do? Or are you permitted to do before you have to stop? But again, it talks about, if you have a patient who has that lack of capacity, this is the medical order. The POST is the patient one. And I'll show you an example in the appendix here. But brings me down to our last 15 minutes or so with our last item. Or no, this is another question. Excuse me, my apologies. Lindsay, would you put this up? My bad, sorry. Absolutely, no problem. I'm gonna read this first part to you and I'll post the options up here for you. This says, Gladys, who is an alert 91-year-old patient is admitted for a right below the knee amputation due to diabetic ulcers. She has an AD on file with the hospital, which provides for no CPR or cardioversion. Hospital policy states DNRs are suspended during surgery. What would you advise the hospital do? And then I'll put the options up here for you. So this first one says, proceed with the hospital and suspend the advance directive. Discuss options with Gladys, including options to the DNR and transfer Gladys to a hospital that will accept the DNR. It looks like I think we have one question that came in to the chat here, Laura, that says if a patient states on admission that they have an advance directive, but they did not bring it with them, are there requirements for follow-up and attempts to obtain that advance directive? No, there are no requirements that yes, you go out and you get it. It's just now you know they have it. And hopefully we can convince someone to go get it and bring it in, in that case. Like a family member, can you go get it? Hopefully it's not in their safety deposit box. That's not a good place to put your advance directives because no one can get to it. Have someone who knows where it is, how they can access it, give them a copy if you need to. Because again, locked up in your safety deposit box doesn't do you any good. At that point in time, it's too late. So no, you do not have to make sure you get a copy of it. Just that we tell them you have a right to make one. If you have one, could we get a copy? That's it. That's the extent of your responsibility. Of course, in following it when you do get it. Okay, I don't see any other questions. I'll go ahead and end this and share that result. Okay, yes, thank you. And Gladys is very alert and oriented. She's very with it. Okay, and back to the AORN. They have a policy automatic suspension, takes the patient out of it, undermines them. So we need to discuss and document it. What do you want done? Continued, not continued, partially suspended. We have to recognize and respect their autonomy. The physician, anesthesia provider, document those issues that you have with the patient. Decide if you're going to continue with that DNR, allow natural death orders. Are you going to maintain them, partially suspend them? What are we going to do? And communicate it with the entire OR team. And likewise, as Aspen said, if that nurse has the objection, then make a reasonable effort to find someone else. Now here, AORN takes another step. They say, if you don't have another body that can step in, that nurse must assist. Discuss with the patient, include what is the goals of their treatment and how likely is it that they're going to need to be resuscitated? What happens with or without resuscitation? And does it really compromise? Why did you consent to surgery then? And use abbreviations, acronyms, please don't do that. We need to make sure that we're not miscommunicating with them. Otherwise, a few more other position statements. Emergency nurses, they have resuscitative decisions. AMA, theirs are based on out of hospital DNR systems. There's the opinion of the council, their ethical and judicial affairs. AMA, they have model legislation on uniform DNR laws. And again, I mentioned some states have the POLST or MOLST. POLST is the physician orders, the other is the medical orders. So it depends on which one you want to use. That's a very national approach. And this is really helpful on those communications and conversations between the patient, the family, and their physician. If the patient wants treatments, they want when they're seriously ills. Again, it's really nice to have those already completed. There are also forms on that website from New York, Oregon, Washington, West Virginia, Wisconsin. Mine happens to be on my state statute with Colorado. But we also have pediatrics. What do we do for pediatric patients when you have those do not resuscitate? Now, there has been some legislation coming out recently that talked about medical futility. At what point do we stop medical care or not provide medical care based upon the futility? If a parent brings a child or an infant in and wants care given, we must provide it. We can't use, well, it's gonna be futile, it won't be worth it. We can't use that anymore. We have to do that. But on the flip side, if they say DNR, how do we handle that? Again, the American Academy of Pediatrics, for those of you who take care of them, I would pull this up and make sure your pediatricians are familiar with it. So now I have my last discussion. So I'll go ahead and read this because it's a few slides long. We have this 28-year-old, a C3 fracture. He's a quadriplegic, he had a diving accident. Extensive, and he was inpatient for a long time, lots of PT. He had reached his maximum abilities. Where he was was where he was. He's in a wheelchair. He has to have a lot of help with his ADLs. Now, before the accident, he drew up an advanced directive that said no life-saving or supportive care in the event I can no longer take care of my own needs. I can't do that. So now he's at this level where, okay, we're not gonna do anything. He's not gonna get any more, he's done. He wants to go home, but he's refused home care. Hospital therapists is very concerned about how he's going to continue taking care of himself. He will be living with a sister, but I don't want anybody coming in and taking care of me. We can handle it. He's had two psychological examinations that have already cleared him. He is not depressed, he is not suicidal. He's just a very determined young man, and he knows what he wants and what he doesn't want. So you're the nurse on this floor, or the risk manager who's been tapped into to ask, hey, what do we do now? What do you suggest? Do you discharge him, follow up with the sister by phone? Do you get a third exam, confirm, no, he's not suicidal. Or what do you do? Set him up at home and hope for the best and discharge him. And this was an actual situation, so I'll tell you what happened. I had worked with the hospital on this. This is a long-term care hospital. So while we're doing that, do you want me to go through some of the slides or wait a little bit, Lindsay? Sure, while we have a few responses coming in, then that would be great. Okay, I just didn't know if it would take away the polling question. Good, it did not. Okay, toolkit crystal. This is one that talks about, that's a criteria for screening triaging for appropriate alternative care. You know, when you have that patient who is dying within your hospital. CMS actually has a form, end of life form for hospice. There's that conversation starting kit. IHI has this one, it's very nice. It kind of helps get the ball rolling on how do you start your conversation with family, with friends, with whoever it happens to be. I wanted to include the OCR, Office of Civil Rights Conscious Objection segment so that you can tap into it if you wanted to. ASA stands on the DNR orders. The Council on Surgical and Perioperative Safety, also their standards on the DNR. And also in the outpatient settings, that would be like ER, your outpatient surgical. POLST, what is that? What does that encompass? And then the physician orders. Now HIPAA, they talk about this. What do we need to do? And some of your attorneys, they may be aware of this one. A lot of the, excuse me, the attorneys who are doing life planning, like Wills and Trust, they may offer this to you if they have it. And then there's the American Bar Association that put out some myths and facts about advanced directives. And I did want to include psychiatric advanced directives for those. I know I mentioned it briefly. There is a state-by-state information for you. There is the link if you wish to have it. ASA website, their standards and guidelines. I love ASA because they put a lot of these things out to us and we don't have to be members. So they're really very proactive. A few others, about five or six more. So let's go back and see what was the final discussion. And then I'll tell you how the case ended out. Perfect. Go ahead and share those results there. Great. Okay, yeah, work with Bill, discharge him and follow up with the sister. You both got it. Absolutely. We did discharge him. We did. And it was hard because a lot of the staff really felt like Bill had given up. And that he said, you know, he was done. He said, I'm tired. I don't want to do this anymore. I'm 27. My life is over, essentially. That's what they were concerned about. Bill never said that. That's just how they perceived it. Yes, he was very determined. This man was a diver. So he wasn't a couch potato by any means. He was out there and he was active. So they did work with him. They said, look, just let us help you set up something at home, like a ramp. We can get that going. We can have someone come in and make sure that if you're sitting at the desk and you want to like watch TV or work on the computer to the extent you can, he had very minimal gross motor movements of his upper hands where he could kind of move his upper arms, of course his upper arms, his arms and, you know, hit buttons. So he did have some gross motor. And said, look, that's all we will do for you. And then they did follow up with the sister. He did do pretty well. He did eventually get some kidney infections and Bill lasted several years, as a matter of fact, before he did finally succumb to a pneumonia. That's what ended up taking his life, but it was years after the fact. I think that first came to me about 2003 and he passed away in about 2015. So he was, it was quite a significant amount of time that he did survive. And, you know, most of the physicians said that would have been normal, even if he had had home health, anything else going on, it would have probably been the same outcome. So they did work very closely with him and respecting his wishes. And he really, he had that appreciation for him. You know, hey, I understand you're concerned about me, but this is what I want. So Lindsey, thank you for your help. I will send it back to you to go ahead and close us out and see if we have any other questions. Perfect, thank you so much. I did just post some information there for you all in the chat as a reminder that you're gonna receive an email tomorrow morning, but just note that it will come from education, noreplyatzoom.us. So if you have not joined a webinar with us before and have seen how that process works, just note that you will receive that email tomorrow, but because it does come from that Zoom email address, it very well may get called on your spam, quarantine, possibly your junk folder. So if you don't see it in your inbox in the morning, I would first encourage you to check those additional folders and then maybe mark that email address as a safe sender so that you do get those emails in the future. Included in that email will be a link to the full recording of today's session, as well as the slides that Laura presented. I did go ahead and include the link to the slides there in that chat there as well. So you have that as a resource now. And of course included will be the full slides and including the resources that Laura just went over a few moments ago with you as well. Just note that when you do click on the link, if you wanna go back and access the recording, that we do have an additional security measure in place. So when you click on that Zoom link, it'll ask you to put in your information. That will prompt an email to come to us for approval. We do approve those recording access requests very quickly, but we ask that you give us one business day to do so. And then again, you'll have full access to the recording for 60 days from today's date. And then if you're joining us as a member of the Georgia Hospital Association, please do pay special attention to that last link that will be included in that email tomorrow. And that will be a link to the survey that you'll need to complete to obtain information regarding continuing education credits and to receive your certificate of attendance. If you're joining us as a member of a partner state hospital association, please reach out to your contact within your hospital association to obtain any information that they may be able to provide to you regarding continuing education credits. Okay, I don't see any other pending questions at this time. You do see Laura's contact information here on the screen, and she is wonderful about being very thorough and timely and to any follow-up questions that you may have. But I also do encourage you just to reach out to us directly to education at gha.org. And we're happy to get those questions over to Laura and then follow up with you with her response. We appreciate you all joining us today and thank you for your questions, your participation. Thank you so much, Laura, as always, for your time and information that you shared with us. I hope you all have a wonderful afternoon. We look forward to having you with us for future sessions. Thank you, Laura. Thank you, everyone. Thank you, Lindsay. Bye-bye.

advance directives

Laura Dixon

clinical care

risk management

living wills

patient wishes

healthcare providers

CMS guidelines

DNR orders

end-of-life preferences

legal compliance

patient education