Purpose
To establish standardized procedures for handling advanced directives in accordance with state laws and surgical best practices.
Policy Statement
This practice recognizes and respects patients' rights to make informed decisions about their medical care through advanced directives.
Procedures
1. Documentation Requirements
- Verify existence of advanced directives during pre-surgical assessment
- Obtain current copies for patient's medical record
- Document advanced directive status in prominent location in chart
- Update EMR advanced directive field
2. Staff Responsibilities
Surgical Coordinator
- Request advanced directive documentation during initial scheduling
- Forward documents to medical records
- Note status in pre-surgical checklist
Pre-operative Nursing Staff
- Verify advanced directive status during pre-op assessment
- Confirm documentation matches patient's current wishes
- Place appropriate identifiers on chart/EMR
Surgeons
- Review advanced directives prior to surgery
- Document discussion in surgical consent notes
- Address any conflicts between directives and surgical plan
3. Special Considerations
Temporary Suspension
- Document if patient requests temporary suspension during perioperative period
- Obtain written acknowledgment of suspension
- Specify exact timeframe for suspension
Emergency Situations
- Follow emergency protocols when advanced directives are unknown
- Document all attempts to determine directive status
Compliance
- Annual staff training required
- Quarterly audits of documentation compliance
- Immediate reporting of any policy violations
References
- State Medical Board Guidelines
- American College of Surgeons Position Statement
- Hospital Accreditation Requirements