Advance Directives - The Patient Self-determination Act

In 1990 Congress enacted the Patient Self-Determination Act (PSDA) as part of the Omnibus Budget Reconciliation Act of 1990 (PL 101-508). This legislation was intended to "reinforce individuals' constitutional right to determine their final health care."

The PSDA took effect on December 1, 1991. It requires all health care providers participating in Medicare (a program of the federal government through which people age 65 and older receive health insurance) and Medicaid (a program run by the federal and state governments to provide health insurance to people younger than 65 years of age who cannot afford to pay for private health insurance) to provide all patients over age 18 with the following written information:

• The patient's rights under the law to participate in decisions about his or her medical care, including the right to accept or refuse treatments.
• The patient's right under state law to complete advance directives, which will be documented in his or her medical records.
• The health care provider's policies honoring these rights.

FIGURE 7.6
Artificial nutrition and hydration in statutes authorizing health care agents, 2004

Providers include hospitals, nursing homes, home health care providers, hospices, and health maintenance organizations (HMOs), but not outpatient-service providers or emergency medical personnel. The PSDA requires health care providers to educate their staff and the community about advance directives. It also prohibits hospital personnel from discriminating against patients based on whether they have an advance directive. (Patients are informed that having an advance directive is not a prerequisite to receiving medical care.)

PSDA: The Right Idea at the Wrong Time?

The Institute of Medicine's Committee on Care at the End of Life believes that admission to a hospital or long-term care facility is not the appropriate time to question or advise patients about their end-of-life preferences. In Approaching Death (Washington, DC: National Academy Press, 1997), the Committee noted that the advance directive information required by the PSDA would be just one of many pieces of information given to patients during stressful situations. Patients may not only be seriously ill but also frightened and confused. Family members who receive the information may be too distraught or traumatized to fully understand the information imparted. Others may not respond well to discussions about death when they are feeling vulnerable.

The Committee believes that advance directives are best discussed before a medical crisis—when individuals, their families, and physicians can have a series of in-depth discussions. Since health status changes and perspectives

TABLE 7.1
Health care power of attorney and combined advance directive legislation, January 2002

State	Type	Form	Limits on agent's powers	Prohibited agents	Formalities of execution	Prohibited witness	Authority over autopsy, organ donation or remains	Comity provision
1. Alabama Alabama Stat. § 22-8A-2 to -10 (West 1998)	Combined Advance Directive [Modeled on UHCDA]*	Yes Must be substantially followed	• Mental health facility admission and treatments • Psycho-surgery • Sterilization • Abortion • Pregnancy limitation	• Provider • Facility	• 2 or more witnesses	• Minor • Agent • Proxy • Relative • Heir • Person responsible for care costs	No	Yes
See also Durable Power of Attorney Act, §26-1-2
2. Alaska Alaska Stat. §13.26.332 to .356 (West 1998) Specifically §§13.26.344(1)	General DPA	Yes Must be substantially followed	• Life-sustaining procedures • Mental health facility admission • Electro-convulsive therapy • Psycho-surgery • Sterilization • Abortion	None specified	• Notarized	N/A	No	No
3. Arizona Ariz. Rev. Stat. Ann. §36-3201 to -3262 (West 1998)	Combined Advance Directive	Yes Optional	• None specified	None specified	• 1 witness or notarized	• Agent • Provider If only one witness, person may not be: • Relative • Heir	Autopsy & organ donation	Yes
4. Arkansas Ark. Code. Ann. § 20-13-104 (1999)	Special DPA	No (But proxy appointment in Living Will Declaration does have optional form)	• Life-sustaining treatment not included, unless the DPA incorporates a proxy authorization from the Living Will Declaration statute, §20-17-202 • Pregnancy limitation on life-sustaining treatment	None specified	• 2 witnesses	None specified	No	Yes, if it is a declaration relating to the use of life-sustaining treatment.
5. California Cal. Probate Code §§4600 to -4948 (West 1999)	Combined Advance Directive	Yes Optional	• Civil commitment • Electro-convulsive therapy • Psycho-surgery • Sterilization • Abortion	• Provider • Facility • Conservator-unless conditions are met.	• 2 witnesses or notarized • Special institutional requirements	• Agent • Provider • Facility One may not be: • Relative • Heir	Yes	Yes
6. Colorado Colo. Rev. Stat. §§15-14-503 to -509 (West 1998) See also §15-14-501	Special DPA	No	• None specified	None specified	None specified	N/A	No	Yes
7. Connecticut Conn. Gen. Stat. §1-43 (1993) and §19a-570 to -575 (West 1998)	Combined Advance Directive	Yes Optional	• None specified (but authority is described as authority to "convey" principal's wishes, rather than to make decisions for principal.)	• Provider • Administrator or employee of gov't agency financially responsible for care	• 2 witnesses • Special institutional requirements	• Agent	No	No

TABLE 7.1
Health care power of attorney and combined advance directive legislation, January 2002

State	Type	Form	Limits on agent's powers	Prohibited agents	Formalities of execution	Prohibited witness	Authority over autopsy, organ donation or remains	Comity provision
8. Delaware Del. Code Ann. tit. 16, §§2501 to 2517 (2000)	Combined Advance Directive [Modeled on UHCDA]*	Yes Optional	• Pregnancy limitation	• Provider of residential LTC	• 2 witnesses • Special institutional requirements	• Facility • Relative • Heir • Creditor • Person responsible for care costs	No	No
9. District of Columbia D.C. Code Ann. §§21-2201 to -2213 (1992)	Special DPA	Yes Optional	• None specified	• Provider • Facility	• 2 witnesses	• Principal Provider • One may not be relative or heir	No	No
10. Florida Fla. Stat. Ann. §765.101 to -404 (West 2001)	Combined Advance Directive	Yes Optional	• Mental health facility admission* • Electro-convulsive therapy* • Psycho-surgery* • Sterilization* • Abortion* • Experimental treatments* • Life-sustaining procedures while pregnant* *Refusal permissible if expressly authorized	• Provider • Facility	• 2 witnesses	• Agent • One may not be spouse or relative	Only organ donation	Yes
11. Georgia Ga. Code Ann. §§31-36-1 to -13 (West 1997)	Special DPA	Yes Optional	• Mental health facility admission • Psycho-surgery • Sterilization • Treatments under Title 37 of Code	• Provider	• 2 witnesses • Special institutional requirements	None	Yes	No
12. Hawaii Hawaii Rev. Stat. §§327E-1 to -16 (West 1999) See also Hawaii Rev. Stat. §551D, special DPA statute.	Combined Advance Directive [Modeled on UHCDA]*	Yes Optional	• None specified	• Provider	• 2 witnesses or notarized	• Provider • Agent One may not be • Relative • Heir	No	Yes
13. Idaho Idaho Code §§39-4501 to -4509 (West 1998) Specifically §39-4505.	Special DPA	Yes Optional	• None specified	• Provider • Facility	• 2 witnesses or notarized	• Agent • Provider • Facility • One may not be relative or heir	No	No
14. Illionis 755 ILCS 45/4-1 through 4-12 (West 2001)	Special DPA	Yes Optional	• None specified	• Provider	None specified	None specified	Yes	Yes
15. Indiana Ind. Code Ann. §§30-5-1 to 30-5-10 (West 1998), specifically §30-5-5-17. (DPA) See also §16-36-1-1 to -14 (Health Care Consent Act)	General DPA and health care consent statute	Yes Optional, but mandatory language for authority re life-sustaining treatment in DPA	• None specified	None specified	• Notarized (for DPA) • 1 witness (for consent act)	• Agent	Yes	Yes

TABLE 7.1
Health care power of attorney and combined advance directive legislation, January 2002

State	Type	Form	Limits on agent's powers	Prohibited agents	Formalities of execution	Prohibited witness	Authority over autopsy, organ donation or remains	Comity provision
16. Iowa Iowa Code Ann. §§144B.1 to .12 (West 1998)	Special DPA	Yes Optional	• None specified	• Provider	• 2 witnesses or notarized	• Agent • Provider • Person under 18 • One may not be relative	Yes	Yes
17. Kansas Kan. Stat. Ann. §§58-625 to -632 (West 1998)	Special DPA	Yes Must be substantially followed	• Cannot revoke previous living will	• Provider • Facility	• 2 witnesses or notarized	• Relative • Heir • Person responsible for care costs	Yes	Yes
18. Kentucky Ky. Rev. Stat. §§311.621 to .643 (West 2001)	Combined Advanced Directive	Yes Must be substantially followed	• Nutrition & hydration* • Pregnancy limitation *Refusal permissible if specified conditions are met	• Facility	• 2 witnesses or notarized	• Relative • Provider • Facility • Heir • Person responsible for care costs	No	No
19. Louisiana La. Rev. Stat. Ann 40:1299.58.1 to .10 (West 1997)	Proxy contained in Living Will statute	Yes Optional	• Powers implicitly limited to executing a living will declaration on behalf of principal	None specified	None specified* * Only requires that powers affecting real estate be signed before notary and 2 witnesses	• Relative • Heir	No	Yes
20. Maine Me. Rev. Stat. Ann. tit. 18A, §5-801 to §5-817 (West 1999)	Combined Advance Directive [Modeled on UHCDA]*	Yes	• Mental health facility admission, consent permissible if expressly authorized	• LTC Facility	• 2 witnesses	None specified	No	Yes
21. Maryland Md. Code Ann. [Health-Gen.] §§5-601 to -608 (West 2001)	Combined Advance Directive	Yes Optional	• None specified	• Facility	• 2 witnesses • Also recognizes oral directive to a physician with one witness	• Agent • One may not be person with no financial interest in person's death	Yes	Yes
22. Massachusetts Mass. Gen. Laws Ann. Ch. 201D (West 1997)	Special DPA	No	• None specified	• Facility	• 2 witnesses	• Agent	No	Yes

TABLE 7.1
Health care power of attorney and combined advance directive legislation, January 2002

State	Type	Form	Limits on agent's powers	Prohibited agents	Formalities of execution	Prohibited witness	Authority over autopsy, organ donation or remains	Comity provision
23. Michigan Mich. Comp. Laws Ann. 333.5651 to 333.5661 (1 West 2001)	Special DPA	Only for agent's acceptance	• Pregnancy limitation • Life-sustaining procedures* *Refusal permissible if expressly authorized	None specified	• 2 witnesses • Agent must accept in writing	• Agent • Relative • Heir • Provider • Facility • Employee of life/health insurance provider	No	No
Mich. Comp. Laws Ann. §700.5501 to 5513 (West 1999)	General DPA	Yes	• Pregnancy limitation • Life-sustaining procedures* *Refusal permissible if expressly authorized	None specified	• 2 witnesses • Agent must accept in writing	• Relative • Heir • Physician • Agent • Employee of life or health insurance provider	No	No
24. Minnesota Minn. Stat. §§145C.01 to .16 (West 2001)	Combined Advance Directive	Yes Optional	• None specified	• Provider	• 2 witnesses or notarized	• Agent • One may not be provider	Organ donation & Disposition of remains	Yes
25. Mississippi Miss. Code Ann. §§41-41-201 to -229 (West 2000)	Combined Advance Directive [Modeled on UHCDA]*	Yes Optional	• Mental health facility admission, consent permissible if expressly authorized *Refusal permissible if expressly authorized	• LTC Facility	• 2 witnesses or notarized	• Agent • Provider • Facility • One may not be relative or heir	No	Only if in compliance with this Act
26. Missouri Mo. Ann. Stat. §§404.700 to .735 And §§800 - 870 (West 1998)	Special DPA (within general DPA statute)	No	• Nutrition & hydration* *Refusal permissible if expressly authorized	• Physician • Facility	• Must be acknowledged as conveyance of real estate (§404.705)	None specified	No	Yes
27. Montana Mont. Code Ann. §§50-9-101 to -111, and -201 to -206 (1998)	Proxy contained in Living Will statute	Yes Optional	• Co-extensive with Living Will Declaration • Pregnancy limitation	None specified	• 2 witnesses	None specified	No	Yes
28. Nebraska Neb. Rev. Stat. §§30-3401 to-3434 (West 1998)	Special DPA	Yes Optional	• Life-sustaining procedures* • Nutrition & hydration* • Pregnancy *Refusal permissible if expressly authorized	• Provider • Facility • Any agent serving 10 or more principals	• 2 witnesses or notarized	• Agent • Spouse • Relative • Heir • Provider • Insurer One may not be administrator or employee of provider	No	Yes

TABLE 7.1
Health care power of attorney and combined advance directive legislation, January 2002

State	Type	Form	Limits on agent's powers	Prohibited agents	Formalities of execution	Prohibited witness	Authority over autopsy, organ donation or remains	Comity provision
29. Nevada Nev. Rev. Stat. §§449.800 to .860 (West 1998)	Special DPA	Yes Must be substantially followed	• Mental health facility admission • Electro-convulsive therapy • Psycho-surgery • Sterilization • Abortion	• Provider • Facility	• 2 witnesses or notarized	• Agent • Provider • Facility • One may not be relative or heir	No	No
30. New Hampshire N.H. Rev. Stat. Ann. §§137-J:1 to -J:16 (West 1998)	Special DPA	Form and disclosure statement. Must be substantially followed.	• Mental health facility admission • Sterilization • Pregnancy limitation • Nutrition & hydration* *Refusal permissible if expressly authorized	• Provider • Facility	• 2 witnesses • Principal must acknowledge receipt of mandatory notice	• Agent • Spouse • Heir • One may not be provider or facility	No	Yes
31. New Jersey N.J. Stat. Ann. §26:2H-53 to -78 (West 1998)	Combined Advance Directive	No	• None specified	• Physician • Facility	• 2 witnesses or notarized	• Agent	No	Yes
32. New Mexico N.M. Stat. Ann. §§24-7A-1 to -16 (West 1997)	Combined Advance Directive [Modeled on UHCDA]*	Yes Optional	• None specified	• LTC Facility	• 2 witnesses recommended, but not required	None specified	No	Only if in compliance with this Act
33. New York N.Y. Pub. Health Law §§2980 to 2994 (West 1998)	Special DPA	Yes Optional	• Nutrition & hydration* *Principal must make his/her wishes "reasonably known"	• Provider • Facility	• 2 witnesses • Special institutional requirements	• Agent	No	Yes
34. North Carolina N.C. Gen. Stat. §§32A-15 to -26 (West 2001)	Special DPA	Yes Optional	• None specified	• Provider	• 2 witnesses and notarized	• Relative • Heir • Provider • Facility • Creditor	Yes	No
35. North Dakota N.D. Cent. Code §§23-06.5-01 to -18 (West 1998)	Special DPA	Yes Optional	• Mental health facility admission 45 days • Psycho-surgery • Abortion • Sterilization	• Provider • Facility	• 2 witnesses or notarized • Agent must accept in writing	• Agent • Provider • Facility • Spouse • Heir • Relative • Creditor	No	Yes
36. Ohio Ohio Rev. Code §§1337.11 to .17 (West 2001)	Special DPA	Only for mandatory disclosure statement	• Life-sustaining procedures* • Nutrition & hydration* • Pregnancy limitation *Refusal permissible if specified conditions are met	• Physician • Facility	• 2 witnesses or notarized	• Agent • Relative • Physician • Nursing home administrator	No	Yes

TABLE 7.1
Health care power of attorney and combined advance directive legislation, January 2002

State	Type	Form	Limits on agent's powers	Prohibited agents	Formalities of execution	Prohibited witness	Authority over autopsy, organ donation or remains	Comity provision
37. Oklahoma Okla. Stat. Ann. tit. 63, §3101.1 to -.16 (West 2001)	Combined Advance Directive	Yes Must be substantially followed	• Nutrition & hydration* • Pregnancy limitation *Refusal permissible if expressly authorized	None specified	• 2 witnesses	• Heir	No	Yes
38. Oregon Or. Rev. Stat. §§127.505 to .640 (West 1998)	Combined Advance Directive	Yes Must be followed	• Mental health facility admission • Electro-convulsive therapy • Psycho-surgery • Sterilization • Abortion • Life-sustaining procedures* • Nutrition & hydration* * Refusal permissible if expressly authorized or if specified conditions are met	• Attending physician • Facility	• 2 witnesses • Agent must accept in writing • Special institutional requirements	• Agent • Attending physician • One may not be relative, heir, or facility	No	Yes
39. Pennsylvania Pa. Stat. Ann. tit. 20, §§5401 to 5416 (West 2001).	Living Will Statute	Yes Optional	Authorizes agent to act only if principal is in a • terminal condition, or • state of permanent unconsciousness • Nutrition & hydration* • Pregnancy limitation *Refusal permissible if expressly authorized *Refusal permissible if expressly authorized	None specified	• 2 witnesses	• Person who signs declaration on declarant's behalf	Organ Donation	No
See also 20 Pa. Cons. Stat. Ann. §§5601 to 5607	(Also in General DPA See Note 2)
40. Rhode Island R.I. Gen. Laws §23-4.10-1 to -12 (1996)	Special DPA	Yes Optional	• None specified	• Provider • Facility	• 2 witnesses • Principal must be Rhode Island resident	• Agent • Provider • Facility • One may not be relative or heir	No	Yes
41. South Carolina S.C. Code §62-5-504 (West 1998) See also §62-5-501 re durable power.	Special DPA	Yes Must be substantially followed	• Nutrition & hydration "necessary for comfort care or alleviation of pain"* • Pregnancy limitation *Refusal permissible if expressly authorized	• Provider • Nursing care facility	• 2 witnesses	• Agent • Spouse • Relative • Heir • Attending physician • Creditor • Life insurance beneficiary • Person responsible for care costs • One may not be facility	No	Yes

TABLE 7.1
Health care power of attorney and combined advance directive legislation, January 2002

State	Type	Form	Limits on agent's powers	Prohibited agents	Formalities of execution	Prohibited witness	Authority over autopsy, organ donation or remains	Comity provision
42. South Dakota S.D. Codified Laws Ann. §§34-12C-1 to -8, and §§59-7-2.1 to -2.8 (West 1998)	Special DPA	No	• Pregnancy limitation • Nutrition & hydration* *Refusal permissible if specified conditions are met	None specified	None specified	None specified	No	Yes
43. Tennessee Tenn. Code Ann. §§34-6-201 to -214 (West 1998)	Special DPA	Only for disclosure statement (which is not mandatory)	• Nutrition & hydration* *Refusal permissible if expressly authorized. However, cannot withhold "simple nourishment or fluids"	• Provider • Facility • Conservator* * Unless certain conditions are met	• 2 witnesses and notarized	• Agent • Provider • Facility • One may not be relative or heir	Yes	Yes
44. Texas Tex. [Health & Safety] Code 166.001 to -.166 (West 2000)	Special DPA	Yes Must be substantially followed	• Mental health facility admission • Electro-convulsive therapy • Psycho-surgery • Abortion • Comfort care	• Provider • Facility	• Warning disclosure • 2 witnesses	• Agent • Provider • Spouse • Heir • Creditor	No	Yes
45. Utah Utah Code Ann. §75-2-1101 to -1119 (West 1998)	Special DPA	Yes Must be substantially followed	• Life-sustaining procedures* • Pregnancy limitation *Agent makes health care decisions by executing a medical directive. Decisions may include the withholding of life-sustaining procedures unless principal is pregnant	None specified	• Notarized	None specified	No	Yes
46. Vermont Vt. Stat. Ann. tit. 14, §3451 to 3467 (1989)	Special DPA	Yes Must be substantially followed	• Mental health facility admission • Sterilization	• Provider • Facility	• Warning disclosure • 2 witnesses • Special institutional requirements	• Agent • Provider • Facility • Relative • Heir • Creditor	No	Yes
Combined Advance Directive	Yes Optional	• Mental health facility admission • Psycho-surgery • Sterilization • Abortion • Decisions about "visitation" unless expressly authorized	None specified	• 2 witnesses	• Spouse	• Relative	Yes	Yes
48. Washington Wash. Rev. Code Ann. §§11.94.010 to .900 (West 1998)	General DPA	No	• Electro-convulsive therapy • Psycho-surgery • Other psychiatric • Amputation	• Provider • Facility	None specified	N/A	No	Yes

TABLE 7.1
Health care power of attorney and combined advance directive legislation, January 2002

State	Type	Form	Limits on agent's powers	Prohibited agents	Formalities of execution	Prohibited witness	Authority over autopsy, organ donation or remains	Comity provision
49. West Virginia W. VA. Code §16-30-1 to -24 (Lexis 2000)	Combined Advanced Directive Law but maintains separate Living Will and Medical Power of Attorney documents	Yes	• None specified	• Provider • Facility	• 2 witnesses and notarized	• Agent • Attending physician • Principal's signatory • Relative • Heir • Person responsible for care costs	Yes	Yes
50. Wisconsin Wis. Stat. Ann. §§155.01 to .80 and 11.243.07(6m) (West 2001)	Special DPA	Yes Optional, but disclosure statement is mandatory	• Mental health facility admission • Electro-convulsive therapy • Mental health research • Drastic mental health treatment • Nutrition & hydration* • Admission to nursing home or residential facility-very limited unless expressly authorized in the document • Pregnancy limitation, unless expressly authorized *Refusal permissible only if specified conditions are met	• Provider • Facility	• 2 witnesses	• Agent • Provider • Relative • Heir • Person responsible for care costs	No	No
51. Wyoming Wyo. Stat. Ann. §§3-5-201 to -214 (West 1998)	Special DPA	No	• Mental health facility admission • Electro-convulsive therapy • Psycho-surgery	• Provider • Facility	• 2 witnesses or notarized	• Agent • Provider • Facility • One may not be relative or heir	Organ donation & Disposition of remains	Yes
UNIFORM HEALTH-CARE DECISIONS ACT	Comprehensive Health Care Decisions Act	Yes Optional	• None specified	• LTC Facility	• 2 witnesses recommended, but not required	None	No	Only if in compliance with this Act
Abbreviations:
DPA Durable Power of Attorney
UHCDA Uniform Health Care Decisions Act
Caution: The descriptions and limitations listed in this chart should be viewed as broad characterizations for comparison purposes and not as precise quotations from legislative language.
SOURCE: "Appendix 1. Health Care Power of Attorney and Combined Advance Directive Legislation January 1, 2002," American Bar Association, Commission on Legal Problems of the Elderly, Washington, DC, 2002. © 2002 by the American Bar Association. Reprinted with Permission.

often change, the topics of discussion should be revisited. Health care providers must fulfill their responsibility to educate the community as required by the PSDA.

PSDA Has No Impact on Terminal Care

Despite the promise of greater patient participation in health care decisions through advance directives, the PSDA has not changed the way seriously ill patients die. Joan M. Teno, et al., in "Advance Directives for Seriously Ill Hospitalized Patients: Effectiveness with the Patient Self-Determination Act and the SUPPORT Intervention" (Journal of the American Geriatrics Society, vol. 45, no. 4, April 1997), found that having an advance directive did not always result in physician action honoring patients' treatment requests.

Although documentation in patients' charts of the existence of an advance directive increased from 6 to 35 percent, physicians did not seem to pay much attention to patients' written instructions. Almost half the patients who indicated refusal of CPR did not have a Do Not Resuscitate (DNR) notation in their medical charts. Moreover, despite increased efforts to foster communication among patients, families, and doctors, there was no improvement in following through with patients' directives.