Effective today, ASCs are required by the revised CMS
Conditions of Coverage
(42 CFR § 416.50) to inquire with all patients about advance directives and to
provide patients with information about their policies on advance directives and
information on applicable state law. Furthermore, ASCs must provide patients
with official state advance directives forms, if requested.
Although state laws vary, advance directives typically come in two forms:
- Designation of an agent (or “proxy” or
“surrogate” or “durable power of attorney for healthcare”) to specific a
decision-maker at any time a patient cannot speak for himself/herself.
- “Living will” to specify the patient’s healthcare
wishes in the event of a terminal condition.
In addition to the above advance directives, many patients have “Do Not
Resuscitate” (or “Allow Natural Death”) orders that set forth the type of care
wanted in the event of cardiac and/or respiratory arrest. In some states, DNR
orders are considered to be advance directives.
Although the procedures performed in ASC typically do not create situations
in which advance directives or DNRs will be an issue, CMS has recognized that
discussions about advance directives are becoming a standard practice and are
important in those rare circumstances in which complications arise. Furthermore,
honoring advance directives is required by the AAAHC accreditation standards
(Rights of Patients Standard F.8), and both the
American College of Surgeons and
American Society for Anesthesiologists have professional standards
indicating that automatic suspension or revocation of DNRs for surgery is
In light of the new rules, ASCs should reexamine any existing advance
directives policies and/or create new ones; document, in a prominent part of the
patient’s record, whether the patient has an advance directive; ensure that
their professional and support staff are educated on the topic; and ensure that
they have up to date information and forms available for their patients that are
consistent with applicable state law.
For more information on advance directives, including free forms for every
state, please consider the materials available on the
Decisions Day website. Note: this nation-wide advance directives educational
event was founded and is chaired by Nathan Kottkamp.
For assistance with advance directives issues, including development of
policies and staff education, or any other questions about the revised ASC
Conditions of Coverage, please contact the authors.