POLICY STATEMENT.
The Division of Veterans Healthcare Services (DVHS) requires each of the New Jersey Veterans Memorial Homes (VMH) to discuss with each applicant or resident, upon admission and annually thereafter, their right to have or to execute, change, or revoke an Advance Directive disclosing their healthcare wishes. The homes will provide mandatory education for all staff concerning the “New Jersey Advance Directives for Health Care Act.”
PURPOSE.
An Advance Directive for Health Care will serve to disclose, in writing, the healthcare wishes of competent individuals. An Advance Directive for Health Care will also serve to collaborate with health care providers and significant others in the voluntary informed choice of accepting, rejecting or choosing alternate decisions regarding their health care that shall be exercisable notwithstanding the disability, incapacity, or later uncertainty as to the principal’s health care wishes.
DEFININTIONS.
PROXY - or (Health Care Representative) is the designated decision-making person.
COMPETENT - one who can act on their own behalf in an “informed manner.”
INCOMPETENT - an individual who lacks the capacity to make decisions or communicate decisions regarding their affairs, and has been adjudicated as such by a court of law.
ADVANCE DIRECTIVE - defines in writing the wishes of a competent adult to plan ahead for decisions regarding their health care. These directives permit the individual to make voluntary, informed choices, accept, reject, or choose alternate courses of medical and surgical treatment.
PROXY DIRECTIVE - or ("Durable Power of Attorney for Health Care") is a written document which designates a Health Care Representative to make health care decisions when the declarent lacks decision-making capacity.
INSTRUCTION DIRECTIVE - or ("Living Will") exists when a competent adult individual provides those responsible for their care a written statement of medical treatment preferences.
COMBINED DIRECTIVE - when the features of both the Proxy Directive and the Instruction Directive are combined; it gives written instructions and designates the health care representative responsible to ensure that the instructions are followed.
BIO-ETHICS COMMITTEE - has as its goal ongoing programs of staff education in the fundamentals of ethical decisions, policy development and implementation, and an awareness of attitudinal or administrative impediments to good decision-making. Other functions may include resident care consultation, retrospective care review, brochure development, article discussions, bulletin board information, resident and/or family conferences, and education. A Bio-Ethics Committee may be a sub-committee of the Human Rights Committee.
PROGNOSIS COMMITTEE - is concerned exclusively with the focal point of decision-making based on the prognosis as to the reasonable possibility of return to a cognitive and sapient life. This committee is composed specifically of physicians preferably, at least, one consulting doctor not on the staff of the facility in question. The function and responsibility of the Prognosis Committee is limited to the application of specialized medical knowledge to a particular case in order to arrive at a determination of concurrence or non-concurrence with the prognosis of the attending physician.
NURSE ETHICS COMMITTEE - is a committee whose role is educating and responding to areas of need within their departments in dialogue with their colleagues, and providing support to the family and sharing communications with the Bio-Ethics Committee.
LIFE-SUSTAINING TREATMENT - means medical care, procedures, or interventions which, when applied to a resident with a terminal illness, would have little or no effect on the under-lying disease, injury, or condition, and which would serve only to delay the time of death. This may include, but is not limited to resuscitation, artificial nutrition and hydration, mechanical ventilation, and dialysis. Life-sustaining treatment does not include medical procedures deemed necessary to provide comfort care, such as oxygen for dyspnea, morphine for pain, etc.
SURROGATE DECISION MAKER - is an individual whose role is to make health care decisions for another person who is unable to act on their own behalf. A surrogate decision maker may be either the person set forth in an Advance Healthcare Directive ("Advance Directive") or in the event that no document exists, other more distant relatives, grandchildren, aunts, uncles, cousins, and close friends may serve in this capacity. The attending health care professionals may determine that the relative or friend can and should be treated as a close and caring family member or associate. The surrogate decision maker must be an adult at least 21 years of age or older.
An employee of the facility in which the individual is a resident may not serve as a health care representative (i.e., surrogate decision maker) pursuant to an Advance Directive, unless the employee is related to the individual by blood, marriage, or adoption.
DECISION MAKING CAPACITY - refers to the ability of a resident to reach informed decisions concerning healthcare by being able to understand and appreciate the nature and consequences of the decisions, including the intended benefits and foreseeable risks of, and alternatives to, proposed treatment options.
TERMINAL ILLNESS - refers to a debilitating condition which is medically incurable, or not treatable with current technology, and which can be expected to cause death.
ATTENDING PHYSICIAN - means the physician primarily in charge of the resident’s care, or a staff physician who has the primary responsibility for the treatment of the resident.
PROCEDURE.
A. New Jersey Veterans Memorial Homes
1. The New Jersey Veterans Memorial Homes (VMH) will recommend and/or encourage all applicants or residents, at the time of admission and annually thereafter, of their right to have or to execute, change, or revoke an Advance Directive disclosing their health care wishes.
2. The New Jersey Veterans Memorial Homes (VMH) will assist the applicant or resident with the execution or documentation of an Advance Directive, as desired, and provide a forum to discuss or resolve disputes concerning the resident’s decision making.
3. The presence or absence of an Advance Directive shall be noted on the resident’s Medical Record and prompt notification will be provided to all concerned health care professionals to assure implementation of the resident’s wishes.
4. In instances of acute care transfer to address the medical needs of the individual, a copy of the Advance Directive shall be transferred with the resident for the purpose of assuring its implementation.
5. Acts of failure to follow the requirements of the “New Jersey Advance Directives for Health Care Act” (P. L. 1991, c.201) will be subject to administrative action for professional misconduct, and the institution will be subject to monetary fines for each offense.
B. Department of Social Services
1. The Department of Social Services will enclose a sample copy of an Advance Directive in the Admissions Application Packet, advising as to the availability of these documents for execution.
2. The Department of Social Services will review each application for completeness and ascertain whether the applicant has executed an Advance Directive, and will assist as needed.
3. Applicants who do not execute an Advance Directive during the application process will be encouraged and/or provided an opportunity to do so upon admission, and annually thereafter.
a. Each resident and/or representative will be given the opportunity to execute, change, or revoke an Advance Directive disclosing the individual’s health care wishes at the time of admission and annually thereafter.
4. At the time of admission, and annually thereafter, applicants/residents will be given a copy of the handout, New Jersey Department of Health and Senior Services - “Your Right to Make Health Care Decisions in New Jersey” (see Addendum A).
a. Documentation regarding the Advance Directive must:
1. be recorded in the Medical Record,
2. be identified in the Medical Record,
3. be implemented upon a physician’s order, and
4. be noted in the Progress Notes that the physician had discussed implementation of the Advance Directive in regards to diagnosis and prognosis
b. A “Do Not Resuscitate “(DNR) directive must:
1. be written as the Attending Physician’s Order when clearly stated in the Advance Directive,
2. be identified in the Medical Record,
3. remain in effect unless revoked by the resident, and
4. be reviewed at least annually with the resident, and this review must be documented.
5. If a resident wishes to have an Advance Directive written or revised, the facility will assist in providing “Advance Directive” samples.
6. The facility will assist the resident in obtaining a representative from the Legal Aid Society when requested.
7. The Advance Directive will be maintained in the Medical Record. A copy will be retained in the Social Services Case File or Medical Records Department.
8. Provisions will be made to assist non-English speaking individuals.
C. Advance Directive Implementation
1. The Advance Directive will NOT go into effect or be implemented until it has been determined that the resident lacks the capacity to make health care decisions.
a. The attending physician, in conjunction with another physician, will determine that the resident’s decision-making capabilities are lacking.
b. Family disputes concerning Advance Directives will be referred to the Bio-Ethics Committee for discussion regarding diagnosis, prognosis, and advantages/disadvantages of prolonging treatment. Further assistance can be obtained through the New Jersey:
1. Office of the Ombudsman
2. Public Guardian
3. Judicial System
4. Department of Health and Senior Services
c. A second medical opinion is NOT necessary if both the attending physician and the healthcare representative (if designated) agree, or the competent resident has clearly indicated his/her desires.
d. When there is no Advance Directive and the following exists:
1. the resident is incapable of making a decision,
2. a surrogate decision maker was not appointed,
3. the resident meets the definition of “terminal illness”,
4. there is no court appointed medical guardian,
…then the consent to life-sustaining treatment will be implied.
2. In the event of a medical crisis when a transfer to an acute care hospital is necessary, the facility will inform and provide the hospital a copy of the Advance Directive.
3. A resident may reaffirm, modify, suspend, or reinstate an Advance Directive at any time by oral or written notification. This change must be documented with a witness’ signature. The physician, family, representative and other necessary staff must be notified.
4. In situations where the resident is determined to be lacking the decision making capacity, the physicians must note their findings as to the nature, course, extent, and probable duration of the incapacity, and inform the resident and/or healthcare representative. If either party contests this decision, the matter will be forwarded to the Bio-Ethics Committee for discussion.
5. When an Advance Directive is placed into effect, if designated, an updated address and phone number for the healthcare representative must be documented and communicated.
6. The Department of Social Services, in conjunction with Staff Development, will provide education and training for designated staff with regard to:
a. Rights and responsibilities of staff under the New Jersey Advance Directives for Health Care Act (P.L. 1991, c.201)
b. Federal Patient Self-Determination Act (P.L. 101-508)
c. Facility policies and procedures guiding these laws
D. Treatment will be withdrawn or withheld under the following circumstances:
1. When life-sustaining treatment is experimental.
2. When treatment is not proven therapy.
3. When treatment is considered ineffective and/or futile in prolonging life.
4. When treatment is considered to be likely to prolong an imminent death.
5. When the resident is determined to be in a permanent vegetative state (P.V.S.) by the attending physician and confirmed by a second physician.
6. When the resident is in a terminal condition, as determined by the attending physician and confirmed by a second physician.
7. When the wishes and burdens associated with the medical intervention outweigh the likely benefit of medical intervention and considered inhumane.
Reference: Addendum A (Attached) – “Your Right to Make Health Care Decisions in New Jersey”
Revised: July 1993
Revised: November 1996
Revised: March 2004
Revised: July 2007
This document explains your rights to make decisions about your own healthcare under New Jersey law. It also tells you how to plan ahead for your health care if you become unable to decide for yourself because of an illness or accident. It contains a general statement of your rights and some common questions and answers.
YOUR BASIC RIGHTS.
You have the right to receive an understandable explanation from your doctor of your complete medical condition, expected results, benefits and risks of the treatment recommended by your doctor, and reasonable medical alternatives. You have the right to accept or refuse any procedure or treatment used to diagnose or treat your physical or metal condition, including life-sustaining treatment.
You also have the right to control decisions about your health care in the event you become unable to make your own decisions in the future by completing an Advance Directive.
WHAT HAPPENS IF I’M UNABLE TO DECIDE ABOUT MY HEALTH CARE?
If you become unable to make treatment decisions due to your illness or an accident, those caring for you will need to know about your values and wishes in making decisions on your behalf. That is why it is important to write an Advance Directive.
WHAT IS AN ADVANCE DIRECTIVE?
An Advance Directive is a document that allows you to direct who will make health care decisions for you and to state your wishes for medical treatment if you become unable to decide for yourself in the future. Your Advance Directive may be used to accept or refuse any procedure or treatment, including life-sustaining treatment.
WHAT TYPES OF ADVANCE DIRECTIVES CAN I USE?
There are three kinds of Advance Directives that you can use to say what you want and who you want your doctors to listen to:
A PROXY DIRECTIVE (also called a “Durable Power of Attorney for Healthcare”) lets you name a “healthcare representative,” such as a family member or friend, to make health care decisions on your behalf.
An INSTRUCTIONAL DIRECTIVE (also called a “Living Will”) lets you state what kinds of medical treatments you would accept or reject in certain situations.
A COMBINED DIRECTIVE lets you do both. It lets you name a healthcare representative and tells that person your treatment wishes.
WHO SHOULD FILL OUT THESE FORMS?
You can fill out an Advance Directive in New Jersey if you are 18 years or older, and you are able to make your own choices. You do not need a lawyer to fill it out.
WHO SHOULD I TALK TO ABOUT ADVANCE DIRECTIVES?
You should talk to your doctor, family members, close friends, or others you trust to help you. Your doctor or a member of our staff can give you more information about how to fill out an Advance Directive.
WHAT SHOULD I DO WITH MY ADVANCE DIRECTIVE?
You should talk to your doctor about it and give a copy to him or her. You should also give a copy to your health care representative, family member(s), or others close to you. Bring a copy with you when you must receive care from a hospital, nursing home, or other health care agency. Your Advance Directive becomes part of your medical records.
WHAT IF I DON’T HAVE AN ADVANCE DIRECTIVE?
If you become unable to make treatment decisions and you do not have an Advance Directive, your close family members will talk to your doctor and, in most cases, may then make decisions on your behalf. However, if your family members, doctor, or other caregivers disagree about your medical care, it may be necessary for a court to appoint someone as your legal guardian. (This may also be needed if you do not have a family member to make decisions on your behalf.) If you are age 60 or older, and you become unable to decide for yourself, it may be necessary that the New Jersey Ombudsman for the Institutionalized Elderly review a decision to forego life-sustaining treatment. That is why it is important to put your wishes in writing to make it clear who should decide for you, and to help your family and doctor know what you want.
WILL MY ADVANCE DIRECTIVE BE FOLLOWED?
Yes. Everyone responsible for your care must respect your wishes that you have stated in your Advance Directive. However, if your doctor, nurse, or other professional has a sincere objection to respecting your wishes to refuse life-sustaining treatment, he/she may have your care transferred to another professional who will carry them out.
WHAT IF I CHANGE MY MIND?
You can change or revoke any of these documents at a later time.
WILL I STILL BE TREATED IF I DO NOT FILL OUT AN ADVANCE DIRECTIVE?
Yes. You don’t have to fill out any forms if you do not want to, and you will still get medical treatment. Your insurance company also cannot deny converge based on whether or not you have an Advance Directive.
WHAT OTHER INFORMATION AND RESOURCES ARE AVAILABLE TO ME?
Your doctor or a member of our staff can provide you with more information about our policies on Advance Directives. You also may ask for written information, materials, and help. If there is a question or disagreement about your health care wishes, we have an Ethics Committee or other individuals who can help.
Revised: March 2004
Revised: July 2007