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Advanced directives in ASCs: 6 key points

Publish Date: 11/14/2012

There is no questioning the need for advanced directives when a patient receives care at an acute care hospital as many visits to hospitals are unplanned and urgent, and such situations may present unexpected outcomes.

But in an ASC, where procedures are elective and routine, and high-risk patients should be screened out, the need for advanced directives is a little less clear. Raymond Grundman, Accreditation Association for Ambulatory Health Care's (AAAHC) senior director of external relations and an AAAHC surveyor, identifies six key points to know about advanced directives in an ASC.

1. Advanced directives are not just DNR orders

It's important to understand that "do not resuscitate" (DNR) orders are just one component of advanced directives, Grundman says.

"People tend to make DNR the same as the advanced directives, but advanced directives are much broader. Within advanced directives are things like pain relief, hydration, as well as DNR. If we have patients who have trouble waking up after surgery because of their reaction to the anesthesia, which sometimes happens among healthy patients, who is authorized to make decisions on behalf of the patient? That's where the advanced directives come in. Even if it's not an end-of life-issue, that's where you want a health care surrogate who is in a position to discuss options."

2. Adult patients should have advanced directives

All adult patients who come into an ASC should have some form of advanced directives, Grundman says.

"That way, they've thought about who can make health care decisions on their behalf when they're incapacitated, even when it's after something like routine surgery where full recovery is expected, but maybe now a decision has to be made to transfer the patient to the hospital."

3. ASCs should discuss advanced directives with their patients

When the Medicare program came out with revised guidelines for ASCs in 2009, surgery centers were required to notify patients prior to the day of admission of their rights and responsibilities, including the organization's policy on advanced directives, as well as any financial interest physicians may have had in the facility. As of December 2011, Medicare revised the guidelines and permitted organizations to provide this information on the day of surgery.

Grundman says he has found most organizations still consider it a best practice to send such information to patients prior to the day of admission. "They'll do this just in case any issues come up that may require a lengthy discussion or potentially postponing the case," he says.

Regardless of when the information is provided, Grundman says ASCs should make sure to notify their patients about advanced directives.

"The Patient Self-Determination Act created some of the national legislation for advanced directives, and it was meant to give patients a voice in how their care is delivered," he says. "There should be some discussion or acknowledgement of the advanced directive, and that's part of keeping the patient's record up to date. It is a discussion that really should be held between health care practitioners and their patients to make sure everyone is on the same page and we understand what patients' expectations are. I think that's the strongest advocacy on behalf of our patients — to make sure we engage them in that discussion."

4. State guidelines may vary

Some states, such as Arizona, have very rigorous advanced directives statutes on their books, Grundman. "This varies state by state. If it's a non-Medicare patient, there may still be some requirements on a state level indicating you provide certain information with every healthcare encounter."

5. Work with legal counsel

Grundman says he always advises organizations to seek legal counsel when drafting a policy on advanced directives.

"Our best advice to organizations is to do your research and see what issues are out there. Then structure a policy that will make sense for your organization and have counsel review it to make sure it adheres to local, state and federal guidelines."

6. Check with insurance liability carriers

Insurance liability carriers may also have specific language concerning how they want ASCs to address advanced directives, Grundman says.

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