PURPOSE:
To provide the health care team members information to assist them in working with patients
who have Advance Directives such as a living will, healthcare surrogate or proxy appointment,
or durable power of attorney.

POLICY:
In an ambulatory care setting, where we expect to provide less invasive care to patients who are
not acutely ill, admission to the center indicates the patient will tolerate the procedure in the
ambulatory setting without difficulty. Per regulation, the physician must determine that the ASC
setting is appropriate for the patient based upon the type of surgery planned, the type of
anesthesia, and the patient’s medical condition. Resuscitation due to a deterioration of the
patient’s medical condition is not expected. Therefore, if a patient should suffer cardiac or
respiratory arrest or any life-threatening condition, there will always be an attempt to resuscitate
and the patient will be transferred to a more acute level of care, that is, a hospital.
Advance directives include written or verbal directions a patient gives in advance to state choices
for health care or name someone to make those choices for the patient if the patient is unable to
make decisions for himself/herself. A living will states what kinds of medical treatments would
be acceptable at the end of life.

If a patient, who is to receive a procedure at the facility, presents the staff with a living will, the
patient must be advised that the policy is to always attempt to resuscitate and to transfer any
patient requiring resuscitation or emergency care to the hospital. The hospital can then
determine when to implement the living will.

A patient or designated agent or surrogate must be informed of the right to make informed
decisions regarding the patient’s care. A patient may have a person designated as an agent,
proxy, or health care surrogate or may have granted a person a durable power of attorney for
health care. This enables the person to perform as a decision maker in the event the patient
cannot speak for himself/herself. The scope of the decisions this other person may make for the
patient may be defined in a document. The Center will record whether such a document has been
presented to the Center. The document will be placed in the medical record along with a living
will, if one was also presented to the Center for inclusion in the Center’s records. When a patient
has designated someone to speak in his/her behalf when the patient cannot speak for himself/herself, that person should be contacted to advise of any pending transfer to a higher level of care. That person may express a choice of the hospital to contact for a transfer. If possible, considering the physician’s privileges and close proximity of the facilities, the health care surrogate’s choice should be honored. The designated person may also receive information from the physician and be asked to make decisions should the patient be unable to participate in the decision. This means that some advance directives, such as the appointment of an agent, proxy, or health care surrogate by the patient and the center’s discussion with that agent, proxy, or health care surrogate, are honored by the surgery center.

It is required by regulation that the provider or facility notifies a patient in writing of its policy
about honoring advance directives. The patient has a right to select another provider or facility.
Patients who disagree with this policy must address the issue with the attending physician prior
to signing the form acknowledging an understanding of the policy regarding advance directives
and living wills.

Patients must be informed of the policy prior to the procedure and prior to anesthesia of any kind
so that the patient will have the opportunity to discuss any concerns with the attending physician
and/or make arrangements for a change in location for the procedure. The facility may decide to
discuss during the pre-admission phone call whether the patient has a living will or other type of
advance directive and to advise of the center’s policy.

The patient must also receive information about where he/she can learn information about a
advance directives if the patient desires to consider preparing or revising one. The Center must
provide information about advance directives should the patient request this information.
Information must include a description of applicable state laws. The information may include a
state provided resource directory for advance directives such as a state agency, library, or state
web site or sample forms provided by state agencies.

It is not required that a patient have a living will or advance directives. It is required that the
Center inform the patient of the right to have an advance directive, the right to have the advance
directive placed in the patient’s medical record, the policy of the Center to resuscitate and
transfer when indicated, and the right to discuss these policies with the provider of services.
A copy of the state regulation permitting the discussion with the physician and decisions about
the place for services will be reviewed by the governing body and attached to the minutes for
that meeting.

There must be documentation in a prominent part of the patient’s current medical record whether
or not the individual has an advance directive. The staff shall have annual education on Advance Directive policies and of any changes as they may occur.