Advance directives are an essential part of patient-centered care in both home health and hospice settings. They provide legal documentation of a patient’s wishes regarding medical treatment in situations where they may no longer be able to communicate for themselves. For agencies, advance directives are not just an ethical consideration—they are also a regulatory requirement under the Medicare Conditions of Participation (CoPs).
This article explains what advance directives are, why they matter, how to obtain them, and best practices for ensuring compliance and compassionate care in home health and hospice.
What Is an Advance Directive?
An advance directive is a legal document that outlines a patient’s healthcare preferences in case they become unable to make decisions on their own. It typically includes:
Living Will: Specifies which treatments a patient wants—or does not want—such as resuscitation, ventilator use, or artificial nutrition.
Durable Power of Attorney for Healthcare (Healthcare Proxy): Designates a trusted person to make healthcare decisions on the patient’s behalf.
Do Not Resuscitate (DNR) / Physician Orders for Life-Sustaining Treatment (POLST): Depending on state laws, these documents clarify whether life-saving interventions should be performed.
Advance directives vary by state, but all serve the purpose of honoring patient autonomy and guiding healthcare providers.
Why Advance Directives Matter in Home Health and Hospice
Advance directives carry unique significance in home health and hospice care:
Respect for Patient Autonomy: They ensure that care decisions reflect the patient’s values, culture, and preferences.
Reduces Family Stress: Families are spared from making difficult decisions in crisis situations when wishes are unclear.
Supports Compliance: Agencies must ask patients about advance directives as part of the admission process, in line with the Patient Self-Determination Act (PSDA) of 1990.
Guides Care Planning: Advance directives inform care plans, especially in hospice, where the focus is comfort and dignity rather than curative treatment.
Regulatory Requirements for Advance Directives
Agencies participating in Medicare and Medicaid must follow strict requirements regarding advance directives:
Inquiry and Documentation: At the time of admission, agencies must ask if the patient has an advance directive and document the response.
Education: Agencies must provide written information about advance directives, including state-specific forms, to patients who do not have them.
Non-Discrimination: Care cannot be conditioned on whether or not a patient has an advance directive.
Staff Training: Agencies must educate staff on state laws and agency policies related to advance directives.
Compliance with State Laws: Each state has its own advance directive forms, witnessing requirements, and policies regarding recognition.
How to Obtain an Advance Directive in Home Health and Hospice
Obtaining an advance directive involves both education and support. Here are the key steps agencies should follow:
Step 1: Provide Education at Admission
Give patients written materials about advance directives, tailored to state-specific laws.
Explain the difference between a living will, healthcare proxy, and POLST/DNR orders.
Step 2: Facilitate Conversations
Encourage patients to discuss their wishes with family members, caregivers, and their physician.
Provide social workers or chaplains to help guide difficult discussions.
Step 3: Assist with Completion
Provide state-approved forms for advance directives.
Ensure patients understand the form and have the option to designate a healthcare proxy.
Clarify witnessing or notary requirements as mandated by state law.
Step 4: Integrate Into the Clinical Record
Place copies of advance directives in the patient’s electronic health record (EHR) and paper chart, if applicable.
Ensure all staff members involved in care are aware of the patient’s wishes.
Step 5: Communicate Across Settings
Share the advance directive with hospitals, physician offices, and long-term care facilities as needed.
Ensure continuity of care by confirming the document follows the patient across transitions.
Advance Directives in Home Health
In home health care, advance directives are part of the comprehensive assessment (§484.55 CoPs). The admitting nurse must:
Ask if the patient has an advance directive.
Document whether a copy is available.
Provide education if none exists.
Include the information in the care plan for the interdisciplinary team (IDT).
For patients with chronic or unstable conditions, discussing advance directives early in the home health episode can prevent unnecessary hospitalizations and ensure care aligns with patient wishes.
Advance Directives in Hospice
In hospice care, advance directives are central to care planning. Since hospice focuses on comfort rather than curative treatment, understanding patient choices about life-sustaining interventions is crucial.
Key hospice considerations include:
Aligning Goals of Care: Ensure the plan of care reflects patient wishes, such as avoiding hospital transfers or invasive procedures.
Emergency Scenarios: Clarify resuscitation status (DNR orders) to avoid confusion during crises.
Ongoing Review: As conditions change, revisit advance directive discussions with the patient and family.
Cultural Sensitivity: Many families approach end-of-life decision-making differently; staff should respect traditions while ensuring compliance.
Challenges in Advance Directive Implementation
Agencies often encounter barriers, such as:
Patient Reluctance: Some patients avoid discussions about end-of-life care.
Family Disagreements: Conflicts may arise if family members disagree on decisions.
State Law Variations: Agencies must remain up-to-date on differing state requirements.
Document Accessibility: Advance directives may not always follow the patient across care settings.
Best Practices for Agencies
To improve advance directive compliance and support patients effectively, agencies can:
Standardize Procedures: Use admission checklists that include advance directive questions.
Train Staff: Provide annual education on advance directives and state laws.
Use QAPI Integration: Track advance directive completion rates and include them in quality improvement initiatives.
Leverage Technology: EHR systems should flag patients without advance directives and store scanned copies for easy access.
Promote Early Conversations: Encourage discussions before crises occur, ideally at admission or shortly after.
Conclusion
Advance directives are essential tools for ensuring that patients in home health and hospice receive care that reflects their wishes and values. They provide clarity for families, guidance for providers, and compliance for agencies.
By understanding regulatory requirements, offering education, and supporting patients in completing advance directives, agencies can ensure both compliance and compassionate care. When integrated into assessments, care plans, and interdisciplinary teamwork, advance directives become more than just paperwork—they become the foundation for dignified, patient-centered care.
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