Although the Patient Self-Determination Act was passed 25 years ago, it is still extremely relevant to your practice as a critical care nurse. Your knowledge of the PDSA and your pivotal role in ensuring that a patient’s wishes concerning treatment or nontreatment are carried out is an invaluable contribution you can give to your patients.
Informed consent or informed refusal of consent for treatment is a basic right of all adult patients. Many individuals were, and still may be, unaware of this basic right. To provide a mechanism whereby an individual can make personal treatment decisions known to healthcare professionals, Congress passed PSDA, according to The Patient Self-Determination Act, Public Law 101-508 (1990).
The PSDA requires all healthcare entities that receive federal funding to, among other responsibilities:
• Inform patients about their rights under state law, including advance directives, to make decisions governing treatment or nontreatment;
• Ask if a patient has an advance directive when admitted to a facility and to document the patient’s response in the medical record;
• To not condition the provision of care, or undertake any other discriminatory action, against an individual who does not have an advance directive;\
• Provide educational opportunities to facility staff and the community on advance directives. This is according to the chapter “Informed Consent and Refusal of Treatment,” in my book, “Nurses and the Law: A Guide to Principles and Applications, 2nd Edition, 220-221.”
An advance directive under the PSDA is a written document, such as a living will and/or a durable power of attorney for healthcare recognized under state law that allows the patient to designate a surrogate decision-maker for treatment issues when the patient cannot personally do so.
The AACN Advanced Critical Care article, “Ethics in Critical Care: Twenty Years Since Cruzan and the PSDA: Opportunities for Improving Care at the End of Life in Critical Care Settings,” identified how critical care nurses can assist the PSDA’s continued usefulness to those critical care patients. The article, written in 2012 by authors Cynda Rushton, PhD, RN; Brett Kaylor, MS, BA; and Myra Christopher, BS, includes the following guidelines, abbreviated below in part:
Uphold ethical obligations
Advocating for patients who cannot speak for themselves is essential, according to the article authors. The critical care nurse can enhance this guideline through the establishment of good interpersonal communications with the patient’s family and other members of the healthcare team.
The authors point out that although written advance directives are important, so too are verbal directives and conversations that the patient and the family may initiate. Such conversations can help all team members understand the patient’s goals and preferences concerning care and need to be part of the patient’s medical record.
Shift from advance directives to advance care planning
Although conformity with the PSDA and ensuring that written advance directives are filled out and a part of the patient’s medical record, critical care nurses also are in a unique position to “cultivate relationships and dialogue” that results in a plan that reflects the patient’s wishes. Clearly, ACP is a process that involves “discernment, decision-making, and mindful documentation.”
Identify and empower healthcare agents to make decisions
The authors point out that critical care nurses should not defer to the admitting clerk or other health team members to determine who the patient’s healthcare agent is. Rather, they emphasize, the critical care nurse should be asking their patients: “Who will speak for you if you can’t speak for yourself?” to determine if the patient has considered this issue, has discussed it with the person they have identified as someone whom they would want to make such decisions, and have documented their choice in an advance directive. •