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Wise Regional Health System The Federal Patient Self-Determination Act requires Medicare and Medicaid participating Facilities to maintain written policies and procedures regarding the provision of written information to adult patients concerning their rights under state law to make medical care decisions, including the right to accept or refuse treatment and to formulate advance directives. The adult patient must also be provided with information concerning the facility’s policies regarding the implementation of these rights under state law. This written information must be provided to inpatients at admission to a hospital or nursing home, enrollment with a medicare comprehensive medical plan or health maintenance organization or upon receiving initial care from a home health agency or hospice program. The advance Directives Act, Chapter 166 of the Health and Safety Code, consolidates three Texas Advance Directive Laws: The Directive to Physicians (formerly the Natural Death Act); the Out-of Hospital Do-Not Resuscitate order; and the Medical Power of Attorney (formerly the Durable Power of Attorney for Health Care). The act also includes subchapters on General Provisions, which are applicable to all three directives. The Directive to Physicians, formerly the Natural Death Act, establishes a mechanism whereby a person may provide in advance for the provision, withdrawal or withholding of medical care should that person be certified in writing by the attending physician as suffering from a terminal or irreversible condition. Through the execution of a Directive to Physicians and Family or Surrogates (copy attached) a person may instruct his or her physician to provide, withhold or withdraw life sustaining treatment if the person is suffering with a terminal or irreversible condition, even with available life sustaining treatment provided in accordance with prevailing standards of medical care. Under the provisions of the act any competent adult person may execute a Directive. To be effective the Directive must be signed by the declarant and witnessed by two competent adults. The requirement of a notarized specific form is prohibited. A competent qualified patient may issue a directive by verbal or by other non written means of communication if done in the presence of the attending physician and two qualified witnesses; the witnesses’ names must be entered into the medical record. A person may revoke the Directive at any time, even in the final stages of a terminal illness. An expressed desire to receive life sustaining treatment will at all times supercede the effect of a Directive. In situation where an adult qualified patient has not executed or issued Directive and is incompetent or incapable of communication, the attending physician and the patient’s guardian or agent under a Medical Power of Attorney may make a treatment decision concerning the withholding of withdrawal of life sustaining treatment. In cases where a guardian or agent has not been appointed, one family member may make treatment decisions in conjunction with the attending physician. The act specifies which family members are qualified to participate in decision making and designates a certain order of priority. A person who wishes to challenge a treatment decision made by a surrogate decision maker must apply for temporary guardianship under the Texas Probate Code. Also if the patient does not have a legal guardian and a designated person specified in the act is not available, a treatment decision that may include the withholding of life sustaining treatments must be concurred with by another physician who is not involved with the treatment of the patient, or who is a representative of the health care facility’s Ethics or Medical Committee. Advance Directives validly executed in other states will be honored in Texas. However provisions relating to the administration, withholding or withdrawal of health care otherwise prohibited by Texas Law will not be honored. The fact that a person has executed or issued an advance directive will not affect insurance policies or premiums. Also a physician, healthcare facility or provider, insurer or health plan may not require a person to execute an Advance Directive as a condition for receiving services or insurance. If a physician chooses not to follow a Directive or Treatment Decision a specific procedure must be followed if the physician, a health professional or a health care facility wishes to gain protections from being civilly and criminally liable or subject to review or action by the appropriate licensing board. The following procedures must be implemented if a physician refuses to honor a patient’s Advance Directive:
General Provisions Subchapter of the Advance Directives Act Several new definitions have been added to Texas Law: “Artificial Nutrition and Hydration” means the provision of nutrients or fluid by a tube inserted in a vein, under the skin in subcutaneous tissues or in the stomach. “Irreversible Condition” means a condition, injury or illness that may be treated but is never cured or eliminated, that leaves a person unable to care for or make decisions, and that without life sustaining treatment provided in accordance with prevailing standard medical care is fatal. “Life Sustaining Treatment” means treatment that, based on reasonable medical judgement, sustains the life of a patient and without which the patient will die. The term includes both life sustaining medications and artificial life support, such as mechanical breathing machine, kidney dialysis and artificial nutrition and hydration. “Terminal Condition” means an incurable condition caused by injury, disease or illness that according to reasonable medical judgement will produce death within six month even with available life sustaining treatment. DIRECTIVE TO PHYSICIANS AND FAMILY OR SURROGATES INSTRUCTIONS FOR COMPLETING THIS DOCUMENT: This is an important legal document known as an Advance Directive. It is designed to help you communicate your wishes about medical treatment at some time in the future when you are unable to make your wishes known because of illness or injury. These wishes usually are based on personal values. In particular you may want to consider what burdens or hardships of treatment you would be willing to accept for a particular amount of benefit obtained if you were seriously ill. You are encouraged to discuss your values and wishes with your family or chosen spokesperson, as well as your physician. Your physician, other health care provider, or medical institution may provide you with various resources to assist you in completing your Advance Directive. Brief definitions are listed below and may aid you in your discussions and Advance Planning. Initial the treatment choices that best reflect your personal preferences. Provide a copy of your Directive to your physician, usual hospital and family or spokesperson. Consider a periodic review of this document. By periodic review you can best assure that the Directive reflects your preferences. In addition to this advance directive Texas Law provides for two other types of directives that can be important during a serious illness. These are the Medical Power of Attorney and the Out of Hospital Do Not Resuscitate Order. You may wish to discuss these with your physician, family, hospital representative or other advisors. You also may wish to complete a Directive related to the donations of organs and tissues. DIRECTIVE I,________________________________________(insert your name), recognize that the best health care is based upon a partnership of trust and communication with my physician. My physician and I will make health care decisions together as long as I am of sound mind and able to make my wishes known. If there comes a time that I am unable to make medical decisions about myself because of illness or injury, I direct that the following treatment preferences be honored: If in the judgement of my physician I am suffering with a terminal condition from which I am expected to die within six months, even with available life sustaining treatment provided in accordance with prevailing standards of medical care: _____ I request that all treatments other than those needed to keep
me comfortable be discontinued or withheld, and my physician allow me
to die as gently as possible; OR If in the judgement of my physician I am suffering with an irreversible condition so that I cannot care for myself or make decisions for myself and am expected to die without life sustaining treatment provided in accordance with prevailing standards of care: _____ I request that all treatments other than those needed to keep
me comfortable be discontinued or withheld, and my physician allow me
to die as gently as possible; OR Additional requests (After discussion with your physician you may wish to consider listing particular treatments in this space that you do or do NOT want in specific circumstances, such as artificial nutrition and fluids, intravenous antibiotics, etc. Be sure to state whether you DO or DO NOT want the particular treatment): ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ After signing this directive, if my representative or I elect hospice
care, I understand and agree that only those treatments needed to keep
me comfortable would be provided and I would not be given available
life sustaining treatments. If I do not have a Medical Power of Attorney and I am unable to make my wishes known I designate the following person(s) to make treatment decisions with my physician compatible with my personal values: 1.________________________________________________________________________________________ 2.________________________________________________________________________________________ If the above person(s) is/are not available, or if I have not designated a spokesperson, I understand that a spokesperson will be chosen for me following standards specified in the laws of Texas. If in the judgement of my physician my death is imminent within minutes to hours, even with the use of all available medical treatment provided within the prevailing standard of care, I acknowledge that all treatments may be withheld or removed except those needed to maintain my comfort. I understand that under Texas Law this Directive has no effect if I have been diagnosed as pregnant. This Directive will remain in effect until I revoke it. No other person may do so. Signed ______________________________________________ Date _______________________________ City, County, State of Residence ______________________________________________________________ Two competent adult witnesses must sign below, acknowledging the signature of the declarant. The witness designed as witness 1 may not be a person designated to make a treatment decision for the patient and may not be related to the patient by blood or marriage. This witness may not be entitled to any part of the estate and may not have a claim against the estate of the patient. This witness may not be the attending physician or an employee of the attending physician. If this witness is an employee of a health care facility in which the patient is being cared for, this witness may not be involved in providing direct patient care to the patient. This witness may not be an officer, director, partner or business office employee of a health care facility in which the patient is being cared for or of any parent organization of the health care facility. Witness 1 ___________________________________ Witness 2 _____________________________________ DEFINITIONS:
Explanation: Many serious illnesses such as cancer, failure of major organs (kidney, heart, liver or lung) and serious brain disease, such as Alzheimer’s Dementia, may be considered irreversible early on. There is no cure, but the patient may be kept alive for prolonged periods of time if the patient receives life sustaining treatments. Late in the course of the same illness the disease may be considered terminal when even with treatment the patient is expected to die. You may wish to consider which burdens of treatment you would be willing to accept in an effort to achieve a particular outcome. This is a very personal decision that you may wish to discuss with your physician, family, or other important people in your life.
Explanation: Many serious illnesses may be considered irreversible early in the course of the illness, but they may not be considered terminal until the disease is fairly advanced. In thinking about terminal illness and its treatment you again may wish to consider the relative benefits and burdens of treatment and discuss your wishes with your physician, family or other important people in your life.
______________________ INFORMATION CONCERNING THE MEDICAL POWER OF ATTORNEY THIS IS AN IMPORTANT LEGAL DOCUMENT. BEFORE SIGNING THIS DOCUMENT YOU SHOULD KNOW THESE IMPORTANT FACTS: Except to the extent you state otherwise, this document gives the person you name as your agent the authority to make any and all health care decisions for you in accordance with your wishes, including your religious and moral beliefs, when you are no longer capable of making them yourself. Because “health care” means any treatment, service or procedure to maintain, diagnose or treat your physical or mental condition, your agent has the power to make a broad range of health care decisions for you. Your agent may consent, refuse to consent or withdraw consent to medical treatment and may make decisions about withdrawing or withholding life sustaining treatment. Your agent may not consent to voluntary inpatient mental health services, convulsive treatment, psycho surgery or abortion. A physician must comply with your agent’s instructions or allow you to be transferred to another physician. Your agent’s authority begins when your doctor certifies that you
lack the competence to make health care decisions. You should inform the person you appoint that you want the person
to be your health care agent. You should discuss this document with
your agent and your physician and give each a signed copy. You should
indicate on the document itself the people and institutions who have
signed copies. Your agent is not liable for health care decisions made
in good faith on your behalf. THIS POWER OF ATTORNEY IS NOT VALID UNLESS IT IS SIGNED IN THE PRESENCE OF TWO COMPETENT ADULT WITNESSES. THE FOLLOWING MAY NOT ACT AS ONE OF THE WITNESSES:
---------------------------------Medical Power of Attorney to follow on next page------------------------------------------- MEDICAL POWER OF ATTORNEY DESIGNATION OF HEALTH CARE AGENT I, ______________________________________________________(insert your name) appoint: Name: _______________________________________________________________________ Address: _____________________________________________________________________ _______________________________________________Phone: ________________________ as my agent to make any and all health care decisions for me, except to the extent I state otherwise in this document. This Medical Power of Attorney takes effect if I become unable to make my own health care decisions and this fact is certified in writing by my physician. LIMITATIONS OF THE DECISION MAKING AUTHORITY OF MY AGENT ARE AS FOLLOWS: __________________________________________________________________________________ ___________________________________________________________________________________ DESIGNATION OF ALTERNATE AGENT (You are not required to designate an alternate agent, but you may
do so. An alternate agent may make the same health care decisions as
the designated agent if the designated agent is unable or unwilling
to act as your agent. If the agent designated is your spouse, the designation
automatically is revoked by law if your marriage is dissolved). Name __________________________________________________________________________ Address:________________________________________________________________________ __________________________________________Phone: _______________________________ B. Second Alternate Agent Name ___________________________________________________________________________ Address: ________________________________________________________________________ ___________________________________________Phone: _______________________________ The following individuals or institutions have signed copies: Name: ___________________________________________________________________________ Address: _________________________________________________________________________ Name: ____________________________________________________________________________ Address: __________________________________________________________________________ DURATION (If applicable) This Power of Attorney ends on the following date: ________________________________ PRIOR DESIGNATIONS REVOKED - I revoke any prior Medical Power of Attorney. ACKNOWLEDGMENT OF DISCLOSURE STATEMENT I sign my name to this Medical Power of Attorney on the ______________day of _________________(Month) ____________(year) at ___________________________________(City and State) ________________________________ _________________________________
STATEMENT OF FIRST WITNESS I am not the person appointed as agent by this document. I am not related to the principal by blood or marriage. I would not be entitled to any portion of the principal’s estate on the principal’s death. I am not the attending physician of the principal or an employee of the attending physician. I have no claim against any portion of the principal’s estate on the principal’s death. Furthermore if I am an employee of a health care facility in which the principal is a patient I am not involved in providing direct patient care to the principal ad am not an officer, director, partner or business office employee of the health care facility or of any parent organization of the health care facility. Signature: ____________________________________ Print Name: ________________________________ Date: ________________ Address: ___________________________________________________________ SIGNATURE OF SECOND WITNESS Signature: _______________________________________ Print Name: ______________________________ Date: _________________ Address: ____________________________________________________________ |