There are three types of Advance Directives:

• A Durable Power Of Attorney for health care (durable power) allows the member to name a patient advocate to act on behalf of the member
• A Living Will allows the member to state his or her wishes in writing but does not name a patient advocate
• A declaration for mental health treatment gives instructions about a member’s future mental health treatment if the member becomes unable to make those decisions. The instructions state whether the member agrees or refuses to have the treatments described in the declaration with or without conditions and limitations

IntegraNet advance directive policies include:

• Respecting the rights of the member to control decisions relating to his or her own medical care, including the decision to have provided, withheld or withdrawn the medical or surgical means or procedures calculated to prolong his or her life; this right is subject to certain interests of society, such as the protection of human life and the preservation of ethical standards in the medical profession
• Adhering to the Patient Self-Determination Act and maintaining written policies and procedures regarding advance directives; providers must adhere to this act and to all state and federal standards as specified in SSA 1902(a)(57), 1903(m)(1)(A), 42 CFR 438.6(i) and 42 CRF 489 subpart I
• Advising members of their right to self-determination regarding advance directives
• Encouraging members to request an advance directive form and education from their PCP at their first appointment
• Assisting members with questions about an advance directive; no IntegraNet employee may serve as witness to an advance directive or as a member’s authorized agent or representative
• While members have the right to formulate an advance directive, an IntegraNet associate, a facility or a provider may conscientiously object to an advance directive within certain limited circumstances if allowed by state law
• Having Member Services, Health Promotion, Provider Relations and/or Health Care Management Services staff review and update advance directive notices and education materials for members on a regular basis
• Member materials will contain information, as applicable, regarding provisions for conscience objection. Materials explain the differences between institution-wide objections based on conscience and those that may be raised by individual physicians
• IntegraNet or the practitioner must issue a clear and precise written statement of this limitation to CMS and request a conscience protection waiver. The conscientious objection will be stated clearly and describes the following:
• Describes the range of medical conditions or procedures affected by the conscience objection
• Identifies the state legal authority permitting such objection
• Noting the presence of advance directives in the medical records when conducting medical chart audits

Providers must:

• Comply with the Patient Self-Determination Act requirements.
• Make sure the first point of contact in the PCP’s office asks the member if he or she has executed an advance directive.
• Document in the member’s medical record his or her response to an offer to execute any advance directive in a prominent place, including a do-not-resuscitate directive or the provider and member’s discussion and action regarding the execution or nonexecution of an advance directive.
• Ask members who have executed an advance directive to bring a copy of the advance directive(s) to the PCP/provider at the first point of contact.
• Make an advance directive part of the member’s medical record and put in a prominent place.
• The physician discusses potential medical emergencies with the member and/or family/significant other and with the referring physician, if applicable.
• If an advance directive has not been executed, the first point of contact at the PCP/provider’s office will ask the member if he or she would like advance directive information. If the member desires further information, member advance directive education will be provided
• Not discriminate or retaliate against a member based on whether he or she has executed an advance directive.

The requirements for advance directives, to include psychiatric advance directives, vary from state to state. Specific forms that meet compliance with each state can be found on the state’s official website. Psychiatric advance directive information may be found at https://www.nrc-pad.org.