Section 4: Establishing Policies and Procedures on Advance Directives

TOC | Intro | 1 | 2 | 3 | 4 | 5 | 6 | 7 | Resources

As introduced in Section One of this manual, the Patient Self-Determination Act (PSDA) requires hospitals and other facilities to establish written policies and procedures on advance directives and act upon them. Failure to comply could result in non-renewal or termination of a Medicare Provider Agreement.

These policies and procedures must be developed by the hospital to suit the needs of the institution. Involve an attorney in the development and/or review of the entire plan. Here are suggestions to start the process:

  1. Promulgate a general POLICY on advance directives setting forth the hospital’s intention to comply with the PSDA and to assist patients, staff, and the community in understanding advance directives – specifically, what they are and their purpose.The policy must explicitly state that the hospital will not discriminate against patients based on whether or not they have advance directives.
  2. Establish SYSTEMS and PROCEDURES based on this policy which:
    • designate when, where, and who in the hospital will ask patients whether they have advance directives;
    • provide for documentation of patient responses in their medical records;
    • indicate whether or not the hospital will require copies of the health care directive, durable power of attorney for health care, or mental health advance directive documents, and if so, how the hospital will ask for them and where they will be kept when received; and
    • explain the hospital’s policies for honoring advance directives. If they conflict with the patient’s wishes, the hospital should make a statement which at a minimum:
      1. clarifies any differences between institution-made moral or ethical objections and those that may be raised by individual providers;
      2. identifies the state legal authority permitting such objections; and
      3. describes the range of medical conditions or procedures affected by any moral or ethical objections.
        If the patient chooses to stay under the hospital or physician’s care, the hospital must agree upon a written plan of action and enter it into the medical record;
    • assure that each patient is given clear, concise, written information about applicable state law (both by statute and by the courts) and the hospital policy on advance directives;
    • explain how the hospital will carry out the community and staff education requirements;
    • provide for accurate record keeping of the action the hospital takes to meet the requirements of the law;
    • provide for periodic evaluation of the effectiveness of these policies, procedures, and programs in meeting the PSDA’s requirements; and
    • indicate whether or not the hospital will provide patients with health care directive, durable power of attorney for health care, and mental health advance directive forms. This decision should be made in consultation with an attorney. This manual includes sample forms for all three types of directives. They are to assist each hospital, in consultation with its attorney, in developing its own suggested forms for its patients’ use, if it will be the hospital’s policy to provide patients with forms in addition to the obligation to inform its patients of their rights to formulate advance directives. Another good source for an advance directive document is the “5 Wishes” program (see:
  3. As facilities develop policies and procedures to meet the PSDA requirements, existing instructions may need to be reviewed and/or revised. Relevant instructions include:
    • how the hospital identifies patients with a terminal condition;
    • how the hospital manages terminal patients while they are in the hospital;
    • how the hospital manages patients in a coma or persistent vegetative state (PVS);
    • the hospital’s position on use of artificial nutrition and hydration for terminal, PVS, and coma patients;
    • how the hospital communicates with and involves the families or other patient representatives in medical care decisions;
    • how patients (or their representatives) are told that, under Washington law, they have the right to control decisions about their own medical care, including whether life-sustaining procedures are to be withheld or withdrawn in case of terminal illness;
    • whether or not a health care directive, durable power of attorney for health care, or mental health care advance directive makes a difference in the handling of the patient and, if so, under what conditions; and
    • how the hospital’s policies and procedures on advance directives relate to the hospital’s policies and procedures on the POLST form (see Section Six of this manual).

Suggestions On How To Meet Community Education Requirements

The Patient Self-Determination Act requires hospitals to educate the community about advance directives. The educational materials must inform members of the public of their rights under state law to make decisions about their medical care, the right to formulate an advance directive, and the hospital’s implementation policies concerning an individual’s advance directive.

The community efforts may be carried out in a variety of methods or formats – such as health fairs, seminars, or workshops. The statute allows facilities to join with others to fulfill the education requirements. A provider must be able to document its community education efforts. Documentation may include simply maintaining copies of any materials used, such as a brochure. A sample brochure on advance directives is included in this section. (See Section Two for a sample brochure on mental health advance directives.)

The same materials used to inform patients of their rights regarding advance directives may also be used to meet the community education requirement.

Here are some possible ways to accomplish the community education required by law:

  1. Distribute written materials at every opportunity, not just when patients are admitted. Here are some ways this might be done:
    • Medical staff can provide information to patients in their offices.
    • Senior citizens centers or senior citizen groups may distribute the information in a variety of ways.
    • The local library might put materials in its collection.
    • If community groups ask for information about the hospital, include materials on advance directives.
    • Employers and labor unions may be interested in providing the information to their staff and members.
    • Give this material to adults who tour or visit the hospital.
    • Use public service announcements on radio and/or television, and newspaper stories or advertisements to offer the brochures to the public.
    • Keep track of how materials are distributed, periodically reviewing the program to decide if there are other opportunities to reach people.
  2. Sponsor periodic community forums.Though forums are time consuming because they require careful planning, they are often worth the effort. A hospital may hold them as frequently or infrequently as needed in the community. They can be as simple as one knowledgeable person explaining the law or more complicated, such as convening a panel to present information and answer questions.
  3. Seek opportunities to meet with community groups.Some groups may want to join with the hospital to develop and present community education programs. Good liaisons can enhance the quality of the program and increase the number of people reached. Another idea is to seek out community organizations and ask if they are receptive to a presentation during a meeting.Keep records of contacts. Review the list periodically to decide which groups have been missed and what opportunities are available for reaching new groups.
  4. Work with news media.News media can be helpful in any community education program. Here are some ways to incorporate them:
    • Use news releases to tell the media about the law and education programs undertaken.
    • Offer an expert spokesperson to the media for interviews. This could result in a routine news story, feature story, television or radio interview, or an appearance on a talk show. The media will find real stories about the ethical dilemmas and struggles of medical providers compelling, but remember the duty to guard the privacy of individual patients.
    • Offer patient information materials or announce events through radio and television public service announcements.
    • Talk to the local media owners, editors, and/or managers about the project and ask for editorial support. Submit opinion pieces stating views on the need for advance directives.

Any combination of these suggestions may be utilized to undertake community education. The most important part of doing this correctly is knowing the community and assessing how best to reach it. Think about the community and the people who might be interested in advance directives. Elderly and retired people come immediately to mind – but what about younger people just starting families? They may be ready to make orderly life plans. An obstetrics unit may provide a link to these younger individuals.

A second important step is to develop at least one expert on the subject of advance directives. Chances are that there is someone in the community with an interest in this issue. If no one on the hospital staff is available, there might be an attorney, clergy member, or physician with particular expertise. Finding a person or persons truly interested in this topic, who have the sensitivity and enthusiasm to talk about it, can make or break a project.

Sample Advance Directive Forms

Back to Top


Contact Us

Washington State Hospital Association
999 Third Avenue
Suite 1400
Seattle, WA 98104

Map / Directions

206.281.7211 phone
206.283.6122 fax

Staff List