Health, Health Systems Improvement, Licensing

Rule R432-31

Transferable Physician Order for Life-Sustaining Treatment

Notice of Proposed Rule

(Repeal and Reenact)

DAR File No.: 33282
Filed: 12/16/2009 01:37:24 PM

RULE ANALYSIS

Purpose of the rule or reason for the change:

In January 2008, the State Legislature passed the new Advance Directives Act (S.B. 161) affecting Section 75-2a-106. This law made changes to the Physician Orders for Life Sustaining Treatment (POLST). This rule amendment is to repeal the old POLST rule and reenact the new rule in order to reflect the requirements of Section 75-2a-106. The Health Facility Committee assigned a subcommittee to research and develop a draft rule for the Life With Dignity Order. The Health Facility Committee reviewed and approved this draft on 11/18/2009. (DAR NOTE: S.B. 161 (2008) is found at Chapter 107, Laws of Utah 2008, and was effective 05/05/2008.)

Summary of the rule or change:

This rule replaces the previous POLST rule. The rule adds elements to meet the new Advance Directives Act, including: changing the name of the order to "Life With Dignity Order", defining which types of health facilities are required to offer Life With Dignity Orders, what types of health professionals may sign an order, defining what policies and procedures health facilities may develop to meet the rule, training required for facility staff, transferability of orders between health facilities, EMS personnel responsibilities, Do Not Resuscitate orders with bracelets and necklaces, requirements to update old forms, where to place orders for in-home patients, and how health personnel must respond to prior orders. The items carried over from the old rule include: the circumstances in which a person may use a Life With Dignity Order in a health facility and details of how it should be offered to patients, how the order must be placed in a prominent part of the patient's chart, the requirement for facilities to review the order with patients, and the option for a legal representative to act in place of the resident.

State statutory or constitutional authorization for this rule:

• Section 75-2a-106
• Title 26, Chapter 21

Anticipated cost or savings to:

the state budget:

This rule amendment will have no fiscal impact on state budgets. No additional requirements are given for state agencies to initiate this rule. The rule has been in effect prior to this time and will not take additional work to continue.

local governments:

This rule amendment will not affect local government budgets. No new requirements are given that will require changes to local government.

small businesses:

This rule amendment may affect small business budgets. The requirement to assist resident/patients to update all old POLST forms may require enhanced staff time to complete. Some health facilities are considered small businesses. However, this requirement still rests upon the wishes of the patient/resident, so calculation of staff time is impossible. One year is given to make the updates, so this may be an issue that can be taken care of with existing assessment reviews already scheduled by the facilities.

persons other than small businesses, businesses, or local governmental entities:

This rule amendment may affect health care facility budgets. The requirement to assist resident/patients to update all old POLST forms may require enhanced staff time to complete. However, this requirement still rests upon the wishes of the patient/resident, so calculation of staff time is impossible. One year is given to make the updates, so this may be an issue that can be taken care of with existing assessment reviews already scheduled by the facilities.

Compliance costs for affected persons:

There may be some compliance costs for health facilities that are required to offer Life With Dignity Orders to patients/residents. These facilities must assist patients to update all old forms that existed before the new rule change and the new form were made available. Patients may decline the change, so calculation of staff time to update the new forms is impossible to calculate. Currently, facilities also review patient information yearly, so updates may be done on a scheduled basis with little or no additional staff time costs.

Comments by the department head on the fiscal impact the rule may have on businesses:

Respecting wishes regarding care at the end of life is critical to the dignity of that person. Any fiscal impact is expected to be minimal. Advising persons of this right is already a federal mandate. This rule will not add to that burden.

David N. Sundwall, MD, Executive Director

The full text of this rule may be inspected, during regular business hours, at the Division of Administrative Rules, or at:

Health
Health Systems Improvement, Licensing
288 N 1460 W
SALT LAKE CITY, UT 84116-3231

Direct questions regarding this rule to:

• Joel Hoffman at the above address, by phone at 801-538-6279, by FAX at 801-538-6024, or by Internet E-mail at jhoffman@utah.gov
• Carmen Richins at the above address, by phone at 801-538-9087, by FAX at 801-538-6024, or by Internet E-mail at carmenrichins@utah.gov

Interested persons may present their views on this rule by submitting written comments to the address above no later than 5:00 p.m. on:

02/15/2010

This rule may become effective on:

02/22/2010

Authorized by:

David Sundwall, Executive Director

R432. Health, Health Systems Improvement, Licensing.

[R432-31. Transferable Physician Order for Life-Sustaining Treatment.

R432-31-1. Legal Authority.

This rule is adopted pursuant to Title 26, Chapter 21.

 

R432-31-2. Purpose.

This rule provides for the orderly communication and transfer of physician orders that outline individual preferences for life-sustaining treatment when an individual transfers from one licensed health care facility to another.

 

R432-31-3. Definitions.

"Advance directive" means a written instruction, such as a living will or durable power of attorney for health care, recognized under State law relating to the provision of health care when an individual is incapacitated.

 

R432-31-4. Transferable Physician Order.

(1) A physician may enter a individual's preferences and the physician's orders for life- sustaining treatment on a transferable physician order form. The Department shall, in consultation with the Health Facility Committee, design a uniform transferable physician order for life-sustaining treatment form that may be used by physicians and health care facilities.

(2) Upon admission to a health care facility or acceptance to a home health agency, the facility or agency shall make a good faith effort to determine whether the individual's physician has completed a transferable physician order for life-sustaining treatment.

(a) Health care facilities shall inform each individual, or if the individual does not have the capacity to act, the individual's family or legal representative, about transferable physician orders for life-sustaining treatment in the same manner as required for providing information about advance directives.

(b) The facility shall offer each individual an opportunity to complete a transferable physician order for life-sustaining treatment upon admission to the facility.

(c) The facility shall place the transferable physician order for life-sustaining treatment in a prominent part of the individual's current medical record.

(3) A physician or licensed practitioner, as defined in R432-1-3(69), must sign the transferable physician order for life sustaining treatment.

(4) A health care facility or its employee that makes a good faith effort to follow the instructions in a transferable physician order for life-sustaining treatment is not subject to any Department sanction as a result of those good faith efforts.

(5) The facility shall review the transferable physician order for life-sustaining treatment with the individual, or if the individual does not have the capacity to act, the individual's family or legal representative, when any of the following occur:

(a) there is a substantial, permanent change in the individual's health status;

(b) the individual is transferred from one care setting to another; and

(c) the individual's treatment preferences change.

(6) The transferable physician order for life-sustaining treatment is fully transferable between all licensed health care facilities.

(7) A transferring licensed health care facility shall send the physician order for life-sustaining treatment, if it exists, with the individual to the receiving facility. The receiving facility and health care providers at the receiving facility shall honor the physician order for life-sustaining treatment until it has been properly changed or voided.]

R432-31. Life with Dignity Order.

R432-31-1. Authority and Purpose.

(1) This rule is adopted pursuant to Utah Code Title 26, Chapter 21, and Section 75-2a-106.

(2) This rule establishes the forms and systems for Life with Dignity Orders.

 

R432-31-2. Definitions.

The definitions found in Sections UCA 26-21-2 and 75-2a apply to this rule. In addition, "licensed health care facility" means a facility or entity licensed pursuant to Title 26, Chapter 21, Health Care Facility Licensing and Inspection Act.

 

R432-31-3. Life with Dignity Order Forms.

(1) An individual who desires to execute a Life with Dignity Order must use a form created by the Department. The form may not be altered in layout or style, including font style and size, without the express written permission of the Department.

(2) Any person, health care provider or health care facility may obtain a form from the Department and, if made available by the Department, from a website established for that purpose.

(3) A health care provider, licensed health care facility, or EMS provider may act upon a copy of a Life with Dignity Order as if it were the original.

 

R432-31-4. Facilities That Must Offer Life with Dignity Orders-Policies and Procedures.

(1) The following health care facilities must comply with Subsection (2):

(a) a general acute hospital licensed under R432-100;

(b) a long-term acute care hospital licensed under R432-104;

(c) a nursing care facility licensed under R432-150;

(d) a mental disease facility licensed under R432-151;

(e) a mental retardation facility licensed under R432-152;

(f) a small health care facility (four to sixteen beds) licensed under R432-200;

(g) an assisted living facility licensed under R432-270;

(h) a small health care facility - type N licensed under R432-300;

(i) a hospice agency licensed under R432-700-750, whether inpatient or home-based;

(j) a critical access hospital licensed under R432-106; and

(k) a home health agency licensed under R432-700.

(2) Each facility described in Subsection (1) shall establish and follow policies and procedures that conform to Section 75-2a-106 and that assure that:

(a) the facility determines upon admission whether each individual has a Life with Dignity Order;

(b) the facility determines which of those individuals who do not have a Life With Dignity Order should be offered the opportunity to complete a Life with Dignity Order;

(c) the facility identifies circumstances under which the facility shall review for changes or amendments the Life with Dignity Order for each individual who has one;

(d) the facility maintains the Life with Dignity Order in a prominent location in the individual's medical record for each individual who has a Life with Dignity Order; and

(e) the facility identifies circumstances under which it would not follow a Life With Dignity Order.

 

R432-31-5. Facilities Not Required to Offer Life with Dignity Orders-Policies and Procedures.

(1) The following health care facilities must comply with Subsection (2):

(a) a specialty hospital - psychiatric licensed under R432-101;

(b) a specialty hospital - chemical dependency/substance abuse licensed under R432-102

a freestanding ambulatory surgical center licensed under R432-500;

(c) a specialty hospital - rehabilitation licensed under R432-103;

(d) an orthopedic hospital licensed under R432-105;

(e) a birthing center licensed under R432-550;

(f) an abortion clinic licensed under R432-600; and

(g) an end stage renal disease facility licensed under R432-650.

(2) Each facility described in Subsection (1) shall establish and follow policies and procedures that conform to Section 75-2a-106 and that assure that:

(a) the facility determines upon admission whether each individual has a Life with Dignity Order;

(b) the facility maintains the Life with Dignity Order in a prominent location in the individual's medical record for each individual who has a Life with Dignity Order; and

 

R432-31-6. Training.

Each licensed health care facility shall appropriately train relevant health care, quality improvement, and record keeping staff on the requirements of Title 75, Chapter 2a, the Advance Health Care Directive Act; this rule; and the facility's policies and procedures established pursuant to this rule.

 

R432-31-7. Transferability of Life with Dignity Orders.

(1)(a) A Life with Dignity Order is fully transferable between all health care facilities.

(b) The health care providers assuming the individual's care at the receiving licensed health care facility shall read the Life with Dignity Order.

(c) The receiving provider must have policies and procedures to address the circumstances under which the provider will not follow the instructions contained in the Life With Dignity Order.

(2)(a) A licensed health care facility that discharges, but does not transfer to another licensed health care facility, an individual who has a Life with Dignity Order, shall provide a copy of the individual's Life with Dignity Order to the individual or, if the individual lacks the capacity to make a health care decision, as defined in section 75-2a-104, to the individual’s surrogate.

(b) A licensed health care facility that transfers an individual with a Life with Dignity Order to another licensed health care facility shall provide a copy of the Life with Dignity Order to the receiving licensed health care facility.

(3) A licensed health care facility shall allow an individual to complete, amend, or revoke a Life with Dignity Order at any time upon request.

 

R432-31-8. Presentation of Life with Dignity Orders to EMS Personnel.

(1) Except for home health agencies and home-based hospice, a licensed health care facility in possession of a Life with Dignity Order must present the individual's Life with Dignity Order to EMS personnel upon the arrival of EMS personnel who are present to treat or transport the individual; and

(2) For an individual who resides at home, if home health agency or home-based hospice personnel are present when EMS personnel arrive at the home, the personnel must present the individual's Life with Dignity Order, upon the arrival of the EMS personnel who are present to treat or transport the individual.

 

R432-31-9. Home Placement of Life with Dignity Orders

(1) If an individual under the care of a home health agency or a hospice agency possesses a Life with Dignity Order, the agency must ensure that a copy of the Life with Dignity Order is left at the individual's place of residence.

(2) For an individual adult who resides at home, including an emancipated minor, it is recommended that a copy of the Life with Dignity Order be posted on the front of the refrigerator or over the individual's bed.

(3) For a minor who resides at home, it is recommended that a copy of the Life with Dignity Order be placed in a tube and placed on the top shelf of the door of the refrigerator.

 

R432-31-10. Life with Dignity Bracelets and Necklaces.

(1) The Department may contract with a vendor or vendors to provide an approved Life with Dignity bracelet or necklace.

(2) An individual with a Life with Dignity Order may obtain an approved Life with Dignity bracelet or necklace from a vendor approved by the Department. The approved Life with Dignity bracelet or necklace identifies the individual to EMS or other health care providers as possessing a Life with Dignity Order.

 

R432-31-11. Prior Orders and Out of State Orders.

(1) EMS and other health care providers may recognize as valid all POLST, Life With Dignity and EMS/DNR orders, including bracelets and necklaces, unless superseded by a subsequent Life with Dignity Order or POLST.

(2) Licensed health care facilities must ensure that all individuals receiving services who have current POLST/Life With Dignity Orders, receive assistance to complete new orders to comply with current rule requirements by January 31, 2011.

(3) Physicians may complete and sign new Life With Dignity Orders for individuals with prior forms who no longer have capacity to complete new orders, and who do not have a surrogate/guardian to authorize the new order. The physician must indicate on the new order that the individual's preferences from the prior order are still applicable.

(4) A form that an individual executed while in another state may be honored as if it were executed in compliance with this rule and Section 75-2a-106 if it:

(a) is substantially similar to a Life with Dignity Order or a Physician's Order for Life Sustaining Treatment; and

(b) was executed according to the laws of that state.

 

KEY: [health facilities]POLST, do not resuscitate, Life with Dignity Order

Date of Enactment or Last Substantive Amendment: [April 13, 2006]2010

Notice of Continuation: November 21, 2007

Authorizing, and Implemented or Interpreted Law: 26-21, 75-2a-106