Advance Directives and Quality of Care
Advance directives are legal documents that allow patients to express their healthcare preferences in advance of situations where they may be unable to make decisions. Quality programs should address advance directive processes because they are essential for delivering patient-centered care. CPHQ candidates should understand the types of advance directives and their role in quality.
Types of Advance Directives
The two primary types are living wills and durable powers of attorney for healthcare. A living will documents the patient's wishes regarding specific treatments, such as mechanical ventilation, artificial nutrition, and resuscitation. A durable power of attorney for healthcare designates a person to make medical decisions on the patient's behalf. POLST (Physician Orders for Life-Sustaining Treatment) forms translate patient preferences into actionable medical orders.
Regulatory Requirements
The Patient Self-Determination Act (1990) requires healthcare facilities receiving Medicare and Medicaid funds to inform patients of their right to create advance directives. Organizations must document whether the patient has an advance directive, provide written information about advance directive policies, and ensure that care is not conditioned on whether a directive exists.
Quality Implications
Advance directive documentation rates are a quality indicator. When advance directives are absent or inaccessible, patients may receive care that does not align with their values and preferences. This can result in unwanted aggressive treatment, unnecessary suffering, and family distress. Quality programs should monitor advance directive completion rates and accessibility.
Barriers to Completion
Common barriers include patient discomfort discussing end-of-life issues, provider reluctance to initiate conversations, cultural considerations, health literacy challenges, and system issues such as directives not being accessible across care settings. Quality professionals can address these barriers through education programs, workflow redesign, and technology solutions.
Integration into Care
Effective advance directive programs ensure that documents are completed, easily accessible in the medical record, reviewed and updated regularly, communicated across care transitions, and honored when applicable. Quality metrics should track not only completion rates but also the accessibility and application of directives in clinical decision-making.