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In todays world, the older adultpopulation, 65 years and older, are living longer. In fact, the article titled Who will care for the elderly? The future ofhome care states it is estimated that 72 million people in the UnitedStates will be 65 years and older by 2030. According to the same article, inthe year 2010 alone, the population of adults aged 65 years and older accountedfor 13% of the overall United States population and the number of Baby Boomerswas about 40 million (Smith, 2013 p. 323). With the number of adults aged 65 andolder on the rise, there is no better time than now for hospitals, nursing andrehab centers, and home health care agencies to revisit health care proxy lawsand advanced directive compliance. When a sick, elderly patient gets dischargedfrom the hospital, but they still require care, they either go home with homecare services or become residents at a nursing and rehab center, so it isimperative that nursing centers and home health care agencies stay up to dateon laws regarding end of life care. Although health care proxy and advanced directiveinformation are a vital part of the medical record, information can get lostwhen transferring patients out of the hospital. It is extremely important fornursing centers and home health care agencies to make sure all paperwork is inorder when receiving a transfer patient from the hospital to ensure all wishesof the patient are carried out if they have advanced directives in place, andto educate the patients and their families on the importance of advanceddirective if they do not already have them in place.

The goal of this SMAC project is todetermine the level of advance directive completion and compliance in a nursingand home health care setting, as these care facilities and agencies play a crucialpart in caring for the growing elderly population. Advanced Directives and Health Care Proxy Laws            The textbook Legal Aspects of Healthcare Administration defines advanceddirectives for health care as, “instructions given by individuals specifyingwhat actions should be taken for their health in the event that they are nolonger able to make healthcare decisions as a result of illness or incapacity.”  Advanced directives include a living willand/or durable power of attorney. A living will is the “instrument or legaldocument that’s describes those treatments an individual wishes or does notwish to receive should he or she become incapacitated and unable to communicatetreatment decisions” and durable power of attorney is “a legal device thatpermits one individual, known as the principal, to give to another person,called the attorney-in-fact, the authority to act on his or her behalf”however, the power of attorney expires when the principal becomes comatose ormentally incompetent (Pozgar, 2016 p.

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435). Inrelation to the durable power of attorney is the health care proxy. A healthcare proxy is defined as “a legal document that allows a person to appoint a healthcareagent to make treatment decisions in the event he or she becomes incapacitatedand is unable to make medical decisions for him or herself.” The agent must beaware of the wishes of the patient with regards to nutrition and hydration inorder to be allowed to make decisions accordingly if necessary (Pozgar, 2016 p.

434). In relation to the living will, the health care proxy and living willwork together. The proxy grants authorization to the healthcare agent to maketreatment decisions and the living will provides guidance to the healthcare agentabout the patient’s health care wishes and provides specific instructions onwhat to do with regards to hydration and nutrition. (Advanced Planning and theHealth Care Proxy PowerPoint slide 21).

   There are laws in place to protect patient’s autonomy if therecomes a time where they are unable to make decisions for themselves. ThePatient Self-Determination Act (PSDA) is a federal law that requires every health care institution that expects to receiveMedicare or Medicaid funds must inform patients upon admission of state lawsgoverning self-determination issues. According to the article The Patient Self-Determination Act. A matterof life and death, “Its purpose is to ensure that a patient’s right to self-determinationin health care decisions be communicated and protected. Through advancedirectives–the living will and the durable power of attorney–the right toaccept or reject medical or surgical treatment is available to adults whilecompetent, so that in the event that such adults become incompetent to makedecisions, they would more easily continue to control decisions affecting theirhealth care.” Inresponse to the Patients Self-Determination Act, The New York State Health CareProxy law was created.

This law enables competent adults to protect theirhealth care wishes by appointing someone they trust to decide about treatmenton their behalf when they are unable to decide for themselves. Lyden, 2007 states “The two usual methods fordetermining capacity are a professional’s clinical assessment (psychiatrists,psychologists, and physicians are generally recognized) or a legal decision bya judge based on evidence and expert opinion.” The decision-making authority ofthe agent does not begin until the patient’s attending physician or a judge determinesthat the patient lacks capacity to decide about their health care.  In addition, this law protects healthcare providers from civil and criminal liability, and liability forunprofessional conduct, for honoring in good faith decisions by an agent, orfor other actions taken in good faith in accordance with the law. This law alsorequires that an “agent must consult with a physician, a registered nurse, alicensed clinical psychologist, or a certified social worker before makinghealth care decisions.” (Advanced Planning and the Health Care Proxy PowerPointslide 4,6,14,23).

These steps help toensure the wishes of the patient are respected. CompletionRates and Compliance of Advanced DirectivesSince the enactment of the Patient Self-DeterminationAct, which made it mandatory for health careinstitution that expects to receive Medicare or Medicaid funds must informpatients upon admission of state laws governing self-determination issues,there has been an increase in awareness of advanced planning and majority ofthe focus has been on improving the completion rate of advance directives. Accordingto the article Use of Advance Directivesin Long-term Care Populations, “Among the three long-term care populations,having at least one AD in the medical record was highest among dischargedhospice care patients (88%) and lowest among home health care patients (28%),with 65% of nursing home residents having at least one AD” with the most commontypes of ADs among home health care patients, nursing home residents, anddischarged hospice care patients were living wills and do not resuscitateorders. Figure 1 below reflects the found data.  Figure1 Percentage ofhome health care patients, nursing home residents, and discharged hospicepatients with any advanced directive: United States, 2004 and 2007The article also found that “Care recipients under age 65 years wereless likely to have any AD than those aged 85 and over; black care recipientswere less likely than white care recipients to have any AD in all threepopulations. These age and racial differences were larger in the home healthcare and nursing home populations than in the hospice care population.” Figure 2 and Figure 3 below reflectthe data found.

Figure 2 Percentage ofhome health care patients, nursing home residents, and discharged hospicepatients with any advanced directive, by age: United States, 2004 and 2007Figure 3 Percentage ofhome health care patients, nursing home residents, and discharged hospicepatients with any advanced directive, by race: United States, 2004 and 2007            Accordingto a mail panel survey designed to be representative of the U.S. population ofadults 18 and over, only 26.3% had an advanced directive.

The article Completion of Advance Directives Among U.S.Consumers states, “Of the 7946 respondents, 26.3% had anadvance directive. The most frequently reported reason for not having one waslack of awareness. Advance directive completion was associated with older age,more education, and higher income and was less frequent among non-whiterespondents.”Although there has been an increase in advanced directive completion since theenactment of the PSDA many patients are still without them and there are significantracial and educational disparities amongst the population.

Steps must be takenby health care facilities and health care providers in order to increase completion rates amongst the despairedand the population as a whole.Discussionand Conclusion The Patient Self-DeterminationAct mandated health care institutions who receive Medicare or Medicaidfunds to inform patients upon admission of state laws governingself-determination issues was a large step in the right direction foradvanced planning and end of life care, however,the law only requires them to be notified in writing. The patient can decidenot to complete an advanced directive as the decision is completely up to thepatient. The use of advanced directives are not only beneficial to the patientsbut to their families as well. In a randomized control study conducted in 2009,researcher found advanced care planning improves end of life care, improvespatient and family satisfaction, and reduces stress, anxiety, and depression insurviving relatives (Detering, Hancock, Reade, Silvester, 2010).  As stated earlier, the mostfrequently reported reason for not having an advanced directive was lack ofawareness (Rao, Anderson, Lin, Laux, 2014). In order to increase advanceddirective completion healthcare facilities, especially nursing centers and homehealth agencies must increase awareness. Increasing awareness can be achievedthrough education and communication with patients and their families.

Healthcareproviders such as physicians, nurses, and social workers all play a crucialrole in educating and communicating with patients and their families. In thearticle Advance directive communicationpractices: Social workers’ contributions to the interdisciplinary health careteam, Black suggest social workers possess distinct skills that place themin a better position than doctors and nurses to communicate with patients andfamilies about advanced directives. Communication is key when itcomes to awareness on advanced directives. In the article Prevalence, views, and impact of advance directives among older adults,Kossman found that completion rates ofadvanced directives are related to how well the information about advanceddirectives is communicated to patients and their families. Kossman also foundthat “Advancedirective completion increases when health care providers ask culturallysensitive questions and educate patients about advance directives, but betterdocumentation and communication of advance directives are needed to ensureadherence to these measures.”Aspreviously stated, the number of adults aged 65 and older on the rise. There isno better time than now for hospitals, nursing and rehab centers, and homehealth care agencies to revisit health care proxy laws and advanced directivecompliance.

It is imperative that nursing centers and home health care agenciesstay up to date on laws regarding end of life care. Facilities must ensure allwishes of the patient are carried out if they already have advanced directivesin place, and must make every effort to educate the patients and their familieson the importance of advanced directive if they do not already have them inplace, as research has shown the lack of awareness is a main factor in the lowlevel of advanced directive completion