In and older accounted for 13% of

In todays world, the older adult
population, 65 years and older, are living longer. In fact, the article titled Who will care for the elderly? The future of
home care states it is estimated that 72 million people in the United
States will be 65 years and older by 2030. According to the same article, in
the year 2010 alone, the population of adults aged 65 years and older accounted
for 13% of the overall United States population and the number of Baby Boomers
was about 40 million (Smith, 2013 p. 323).

With the number of adults aged 65 and
older on the rise, there is no better time than now for hospitals, nursing and
rehab centers, and home health care agencies to revisit health care proxy laws
and advanced directive compliance. When a sick, elderly patient gets discharged
from the hospital, but they still require care, they either go home with home
care services or become residents at a nursing and rehab center, so it is
imperative that nursing centers and home health care agencies stay up to date
on laws regarding end of life care. Although health care proxy and advanced directive
information are a vital part of the medical record, information can get lost
when transferring patients out of the hospital. It is extremely important for
nursing centers and home health care agencies to make sure all paperwork is in
order when receiving a transfer patient from the hospital to ensure all wishes
of the patient are carried out if they have advanced directives in place, and
to educate the patients and their families on the importance of advanced
directive if they do not already have them in place.

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The goal of this SMAC project is to
determine the level of advance directive completion and compliance in a nursing
and home health care setting, as these care facilities and agencies play a crucial
part in caring for the growing elderly population.

Advanced Directives and Health Care Proxy Laws

            The textbook Legal Aspects of Healthcare Administration defines advanced
directives for health care as, “instructions given by individuals specifying
what actions should be taken for their health in the event that they are no
longer able to make healthcare decisions as a result of illness or incapacity.”  Advanced directives include a living will
and/or durable power of attorney. A living will is the “instrument or legal
document that’s describes those treatments an individual wishes or does not
wish to receive should he or she become incapacitated and unable to communicate
treatment decisions” and durable power of attorney is “a legal device that
permits one individual, known as the principal, to give to another person,
called the attorney-in-fact, the authority to act on his or her behalf”
however, the power of attorney expires when the principal becomes comatose or
mentally incompetent (Pozgar, 2016 p. 435).

In
relation to the durable power of attorney is the health care proxy. A health
care proxy is defined as “a legal document that allows a person to appoint a healthcare
agent to make treatment decisions in the event he or she becomes incapacitated
and is unable to make medical decisions for him or herself.” The agent must be
aware of the wishes of the patient with regards to nutrition and hydration in
order to be allowed to make decisions accordingly if necessary (Pozgar, 2016 p.
434). In relation to the living will, the health care proxy and living will
work together. The proxy grants authorization to the healthcare agent to make
treatment decisions and the living will provides guidance to the healthcare agent
about the patient’s health care wishes and provides specific instructions on
what to do with regards to hydration and nutrition. (Advanced Planning and the
Health Care Proxy PowerPoint slide 21).   

There are laws in place to protect patient’s autonomy if there
comes a time where they are unable to make decisions for themselves. The
Patient Self-Determination Act (PSDA) is a federal law that requires every health care institution that expects to receive
Medicare or Medicaid funds must inform patients upon admission of state laws
governing self-determination issues. According to the article The Patient Self-Determination Act. A matter
of life and death, “Its purpose is to ensure that a patient’s right to self-determination
in health care decisions be communicated and protected. Through advance
directives–the living will and the durable power of attorney–the right to
accept or reject medical or surgical treatment is available to adults while
competent, so that in the event that such adults become incompetent to make
decisions, they would more easily continue to control decisions affecting their
health care.”

In
response to the Patients Self-Determination Act, The New York State Health Care
Proxy law was created. This law enables competent adults to protect their
health care wishes by appointing someone they trust to decide about treatment
on their behalf when they are unable to decide for themselves. Lyden, 2007 states “The two usual methods for
determining capacity are a professional’s clinical assessment (psychiatrists,
psychologists, and physicians are generally recognized) or a legal decision by
a judge based on evidence and expert opinion.” The decision-making authority of
the agent does not begin until the patient’s attending physician or a judge determines
that the patient lacks capacity to decide about their health care.  In addition, this law protects health
care providers from civil and criminal liability, and liability for
unprofessional conduct, for honoring in good faith decisions by an agent, or
for other actions taken in good faith in accordance with the law. This law also
requires that an “agent must consult with a physician, a registered nurse, a
licensed clinical psychologist, or a certified social worker before making
health care decisions.” (Advanced Planning and the Health Care Proxy PowerPoint
slide 4,6,14,23). These steps help to
ensure the wishes of the patient are respected. 

Completion
Rates and Compliance of Advanced Directives

Since the enactment of the Patient Self-Determination
Act, which made it mandatory for health care
institution that expects to receive Medicare or Medicaid funds must inform
patients upon admission of state laws governing self-determination issues,
there has been an increase in awareness of advanced planning and majority of
the focus has been on improving the completion rate of advance directives. According
to the article Use of Advance Directives
in Long-term Care Populations, “Among the three long-term care populations,
having at least one AD in the medical record was highest among discharged
hospice care patients (88%) and lowest among home health care patients (28%),
with 65% of nursing home residents having at least one AD” with the most common
types of ADs among home health care patients, nursing home residents, and
discharged hospice care patients were living wills and do not resuscitate
orders. Figure 1 below reflects the found data.

 Figure
1 Percentage of
home health care patients, nursing home residents, and discharged hospice
patients with any advanced directive: United States, 2004 and 2007

The article also found that “Care recipients under age 65 years were
less likely to have any AD than those aged 85 and over; black care recipients
were less likely than white care recipients to have any AD in all three
populations. These age and racial differences were larger in the home health
care and nursing home populations than in the hospice care population.” Figure 2 and Figure 3 below reflect
the data found.

Figure 2 Percentage of
home health care patients, nursing home residents, and discharged hospice
patients with any advanced directive, by age: United States, 2004 and 2007

Figure 3 Percentage of
home health care patients, nursing home residents, and discharged hospice
patients with any advanced directive, by race: United States, 2004 and 2007

            According
to a mail panel survey designed to be representative of the U.S. population of
adults 18 and over, only 26.3% had an advanced directive. The article Completion of Advance Directives Among U.S.
Consumers states, “Of the 7946 respondents, 26.3% had an
advance directive. The most frequently reported reason for not having one was
lack of awareness. Advance directive completion was associated with older age,
more education, and higher income and was less frequent among non-white
respondents.”
Although there has been an increase in advanced directive completion since the
enactment of the PSDA many patients are still without them and there are significant
racial and educational disparities amongst the population. Steps must be taken
by health care facilities and health care providers in order to increase completion rates amongst the despaired
and the population as a whole.

Discussion
and Conclusion

The Patient Self-Determination
Act mandated health care institutions who receive Medicare or Medicaid
funds to inform patients upon admission of state laws governing
self-determination issues was a large step in the right direction for
advanced planning and end of life care, however,
the law only requires them to be notified in writing. The patient can decide
not to complete an advanced directive as the decision is completely up to the
patient. The use of advanced directives are not only beneficial to the patients
but to their families as well. In a randomized control study conducted in 2009,
researcher found advanced care planning improves end of life care, improves
patient and family satisfaction, and reduces stress, anxiety, and depression in
surviving relatives (Detering, Hancock, Reade, Silvester, 2010). 

As stated earlier, the most
frequently reported reason for not having an advanced directive was lack of
awareness (Rao, Anderson, Lin, Laux, 2014). In order to increase advanced
directive completion healthcare facilities, especially nursing centers and home
health agencies must increase awareness. Increasing awareness can be achieved
through education and communication with patients and their families. Healthcare
providers such as physicians, nurses, and social workers all play a crucial
role in educating and communicating with patients and their families. In the
article Advance directive communication
practices: Social workers’ contributions to the interdisciplinary health care
team, Black suggest social workers possess distinct skills that place them
in a better position than doctors and nurses to communicate with patients and
families about advanced directives.

Communication is key when it
comes to awareness on advanced directives. In the article Prevalence, views, and impact of advance directives among older adults,
Kossman found that completion rates of
advanced directives are related to how well the information about advanced
directives is communicated to patients and their families. Kossman also found
that “Advance
directive completion increases when health care providers ask culturally
sensitive questions and educate patients about advance directives, but better
documentation and communication of advance directives are needed to ensure
adherence to these measures.”

As
previously stated, the number of adults aged 65 and older on the rise. There is
no better time than now for hospitals, nursing and rehab centers, and home
health care agencies to revisit health care proxy laws and advanced directive
compliance. It is imperative that nursing centers and home health care agencies
stay up to date on laws regarding end of life care. Facilities must ensure all
wishes of the patient are carried out if they already have advanced directives
in place, and must make every effort to educate the patients and their families
on the importance of advanced directive if they do not already have them in
place, as research has shown the lack of awareness is a main factor in the low
level of advanced directive completion