MDS Alert

Your facility’s policies and procedures should already include specifics on advanced directives, but are your protocols watertight? Your facility should prioritize honoring residents’ wishes, but you need to make sure you’re following various rules and regulations so you don’t face citations or even legal action.

Many terms and phrases surround medical emergencies toward the end of life, and some are used interchangeably, even though each term has a specific meaning.

Define These Terms

“There are multiple options for directives, including a living will, durable power of attorney, medical power of attorney, pre-existing medical orders for “Do Not Resuscitate” (DNR), Do Not Hospitalize (DNH) documents, as well as others,” says Linda Elizaitis, RN, RAC-CT, BS, president and founder of CMS Compliance Group in Melville, New York.

Advanced directives and do not resuscitate (DNR) orders are not interchangeable terms.

“The presence of a “Do Not Resuscitate” (DNR) order does not by itself indicate that the resident is declining other appropriate treatment and services. It only indicates that the resident has chosen not to be resuscitated if cardiopulmonary functions cease,” says the State Operations Manual (SOM) Appendix PP.

Offer Advanced Directives, but Don’t Require

Facilities need to juggle residents’ rights to choose whether to fill out an advanced directive, without pressuring them to do so or radically changing their care depending on the contents of the advanced directive.

“While there are many directives that a resident can execute, the resident is not required to do so. The facility is prohibited from discriminating against a resident based on whether he/she has executed an advance directive, and also is prohibited from conditioning the provision of medical care based on the presence of an advance directive or not,” Appendix PP instructs surveyors.

Of course, older, medically fragile people may be at greater odds of facing a situation in which an advanced directive will come into play. Employees need to be knowledgeable about each resident’s individual wishes and rights before and during any kind of situation where life-saving measures may be involved.

Appendix PP also warns surveyors that individual state laws may allow space for a provider to conscientiously object to a resident’s advanced directive: “… facility staff are not required to provide care that conflict[s] with an advance directive. In some circumstances, staff would not be required to implement an advance directive if State law allows the provider to conscientiously object to implementation and the provider is unable to implement the directive.”

Facilities need to have the means and protocols to assist residents in establishing and recording an advanced directive, as well as the wherewithal to record any conversations about advanced directives.

“The facility is also responsible for informing the resident/ representative of his/her right to establish an advance directive. Facility staff must provide the resident with assistance if he/she wishes to execute one or more advance directives. Any discussions that are had related to this topic must be documented in the resident record, along with any advance directives that the resident decides on,” Appendix PP says.

Keep Advanced Directives Current

Residents may wish to adjust their advanced directives depending on their health or any other number of reasons.

“This ongoing planning is incorporated into the comprehensive care planning process, and should be reevaluated routinely, as well as upon a change in a resident’s condition,” Elizaitis says. “A resident, along with family and/or the resident representative, can work with the interdisciplinary team to understand the resident’s goals and wishes should he/she become unable to make decisions or is actively dying. These goals and wishes may change over time, which is why it is important that they are continually reassessed.”

When you’re thinking about MDS assessments, make sure you consider advanced directives in conjunction with assessing and recording residents’ overall expectations.