JCAHO TX3.1



POLICY

It shall be the policy of Downriver Community Services to provide for the patient’s right to receive assistance in the formulation or development of an advance directive. It is the patient’s right under state law to make decisions concerning medical care, including the right to accept or refuse medical treatment and the right to formulate advance directives.

|Board Approved Date: July 27, 2000 |Board Reviewed Date: October 28, 2003 |

PROCEDURE

When the patient expresses need for support in formulating advance directives, staff (whether registration staff or clinical staff) will make such information available to assist the patient in developing the advance directives. To reorder forms go to mbs/practiceservice/dpa.html or call 517-336-5772.

A signed form is to be placed on the medical record indicating whether or not an Advance Directive was made and that the patient has been informed of his/her rights under the Patient Self-Determination Act.

An Advance Directive presented by the patient will be reviewed with the patient by appropriate clinical staff and lodged in the patient health record.

Upon transfer for care at another site or facility, a copy of the advance directive will accompany the patient and the receiving facility will be informed of the advance directive.

Providers of care in Downriver Community Services will honor advance directives when patients supply legal documents proving their wishes.

Addresses JCAHO standard RI.1.2.6

Advance Directives

An advance directive is a legal document that gives direction to health care providers about the treatment you wish to be carried out during certain circumstances.

You may become too sick to make your own decisions about your medical care, and if you have not given any instructions, no one will know what you would decide if you still could. If that happens, then decisions will be made for you.

If you would like information on advance directives, please ask your physician. The front office will provide you with the forms should you request them:

“Durable Power of Attorney for Health Care”

“Designation of Patient Advocate Form”

Your physician will answer questions about advance directive treatment decisions.

Treatment decisions are difficult and we encourage you to think about them in advance and discuss them with your loved ones, legal and religious advisors, and health professionals.

Part I.

DURABLE POWER OF ATTORNEY FOR HEALTH CARE (DPAHC)

I appoint this person to make decisions about my health care if there ever comes a time when I cannot make those decisions myself.

|Name: | |

|Street Address: | |

| | | | | | |

|City: | |State: | |Zip: | |

If the person above cannot or will not make decisions for me, I appoint this person:

I have notified the individuals listed above of my decision.

I have not appointed anyone to make health care decisions for me in this or any other documents.

PART II. LIVING WILL

These are my, (print your name on the blank line)________________________, wishes for my future health care if there ever comes a time when I can’t make these decisions for myself. I want the person I have appointed as my Health Care Agent (HCA), my doctors, my family and others to be guided by the decisions I have made below.

Life-Sustaining Treatments

If I should have an incurable or irreversible condition that will cause my death, or am in a state of permanent unconsciousness from which, to a reasonable degree of medical certainty there can be no recovery, it is my desire that my life not be artificially prolonged by administration of “life-sustaining” procedures. If, at that time, I am unable to participate in decisions regarding my medical treatment, I direct my physician to withhold or withdraw procedures that merely prolong the dying process and are not necessary to my comfort or freedom from pain.

OR

Treatment Preferences/Other Directions

You have the right to be involved in all decisions about your health care. If you have wishes not covered in other parts of this document, please indicate them here. Treatments or situations you may wish to consider include:

Yes No Cardiopulmonary Resuscitation (CPR) should be administered

Yes No Insert Nasogastric Feeding Tube (tube from nose to stomach) for nutrition

Yes No Insert Percutaneous Enterogastric Feeding Tube (tube surgically

Yes No inserted to stomach) for nutrition

Yes No Insert Hyperalimentation (chest wall catheter feeding directly to the circulatory system)

Yes No Allow Intravenous (IV) for the purpose of medication/hydration/nourishment

Yes No Allow use of Respirator (artificial breathing machine)

Yes No Allow use of Chemicals to treat arrhythmias (cardiac drugs to treat the heart)

Yes No Allow pain reducing drugs to be administered

Yes No Allow oxygen

Yes No Allow suctioning of the lungs

Yes No Allow blood transfusions

Yes No Allow transfer to another ward

Yes No Allow oral antibiotics to be given

Yes No Allow extensive blood testing or x-rays

PART III. SIGNATURES

A. Your Signature – By my signature below, I show that I understand the purpose and the effect of this document.

B. Your Witnesses’ Signatures – I am not, to the best of my knowledge, named in the person’s will. I am not the person appointed as Health Care Agent (HCA) in this advance directive. I am not a health care provider (or an employee of the health care provider), or financially responsible, now or in the past, for the care of the person making this advance directive. (Exception: where other witnesses are not reasonably available, employees of the Chaplain Service or Environmental Management Service may serve as witnesses.)

Witness #1: I personally witnessed the signing of this advance directive.

|Name: | |

|Street Address: | |

| | | | | | |

|City: | |State: | |Zip: | |

| | | | | |

|Signature: | | |Date: | |

Witness #2: I personally witnessed the signing of this advance directive.

|Name: | |

|Street Address: | |

| | | | | | |

|City: | |State: | |Zip: | |

| | | | | |

|Signature: | | |Date: | |

Patient Rights Brochures will be available to all patients in the patient waiting areas of all facilities of Downriver Community Services. They will be presented to patients upon initial enrollment for care. Upon request, every effort will be made to translate the Patient Rights Brochure into the dominant language of the patient.

(Need to Complete)

Joe will professionally print the following

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This health center was created to serve the needs of your community. You own it! So we want you to be an active part of your treatment here.

That means you have to know what you can expect from us. You need to see what your rights are! We want you to be informed about our policies regarding confidentiality, treatment of minors, and other ethical issues. There are some situations, however, when the law itself determines what we must do.

We want you to know your rights as a patient of this center, and to exercise them! Patients who participate in their own care help to create a successful outcome!

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You have a right to a reasonable response to your requests for treatment, within the scope of the health center’s mission, capacity, and regulations.

You have a right to considerate

and respectful care.

You have a right to confidential treatment. You also have the right to approve or prohibit the release of any disclosures or records, except when release is required by law.

You have a right to information about your diagnoses, treatments and prognosis. This information will help you to make informed decisions regarding your care.

You have the right to access any information contained in your medical record.

You have the right, and are encouraged, to participate in decisions about the intensity and scope of your treatment, within the limits of the health center’s mission, and applicable laws.

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You have a right to care that takes into consideration your psychosocial, spiritual, and cultural values.

You have the right to accept medical care, or to refuse treatment, to the extent permitted by law. You also have the right to be informed of the medical consequences of refusing treatment.

You have the right to participate in the consideration of ethical issues that arise in your care.

Your guardian, next of kin, or legally authorized responsible person can exercise your rights for you if you have been medically or legally determined to be unable to participate yourself.

You have the right to be informed of any research or experimentation that could affect your care. You may then decide whether or not you want to participate in it.

You have the right to be made aware of advanced directives, and to know how this organization will respond to such advance directives.

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This information about patient rights can be found in:

The Joint Commission’s

Comprehensive Accreditation Manual

for Ambulatory Care,

1998

DOWNRIVER COMMUNITY SERVICES

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CHECK

OUT

YOUR

RIGHTS!

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