What concept is demonstrated by the patient self-determination act of 1991?

The Patient Self-Determination Act (PSDA) was passed by the United States Congress in 1990 as an amendment to the Omnibus Budget Reconciliation Act of 1990. Effective on December 1, 1991, this legislation required many hospitals, nursing homes, home health agencies, hospice providers, health maintenance organizations (HMOs), and other health care institutions to provide information about advance health care directives to adult patients upon their admission to the healthcare facility.[1][2] This law does not apply to individual physicians.

Because the 1991 PSDA does not apply to individual physicians, private clinics and practices, most of which are incorporated for-profit organizations, the problem of cruel over treatment for profit of the elderly on Medicare/Medicaid was not controlled to the extent that Congress hoped would be possible when the states would implement the goals of the 1991 PSDA in state laws. (In 2012, newspapers[which?] revealed that the United States Department of Health and Human Services and the Department of Justice have cooperated to prosecute over treatment of patients under the federal False Claims Act.) The goals of the 1991 PSDA are covered in the "Purpose" section, below.

Section 1233 of the proposed America's Affordable Health Choices Act of 2009 (H.R. 3200) would have authorized reimbursements for physician counseling regarding advance directives (once every five years)[3] but it was not included in the Patient Protection and Affordable Care Act of 2010 because of controversy over what were characterized as "death panels."[4][5]

Unfortunately, because the law of the 1991 PSDA does not require or mandate the treating physicians—after an educated "terminal" prognosis that is shared with the patient—to seek informed consent from elderly and terminal Medicare/Medicaid patients for either Curative Care under Medicare or palliative care, transition to Hospice in the last six months of life (also paid for out of the Medicare purse), the goals of the PSDA are not realized. Patient self rationing of expensive medical care at the end of life through the process of the advance directive under the provisions of the 1991 PSDA is discouraged because the patients have not had end-of-life conversations with the treating physicians.

Requirements[edit]

The requirements of the PSDA are as follows:

• Patients are given written notice upon admission to the health care facility of their decision-making rights, and policies regarding advance health care directives in their state and in the institution to which they have been admitted. Patient rights include:

1. The right to facilitate their own health care decisions
2. The right to accept or refuse medical treatment
3. The right to make an advance health care directive

• Facilities must inquire as to whether the patient already has an advance health care directive, and make note of this in their medical records.
• Facilities must provide education to their staff and affiliates about advance health care directives.
• Health care providers are not allowed to discriminately admit or treat patients based on whether or not they have an advance health care directive.

Purpose[edit]

The purpose of the Patient Self-Determination Act was/is to inform patients of their rights regarding decisions toward their own medical care, and ensure that these rights are communicated by the health care provider. Specifically, the rights ensured are those of the patient to dictate their future care (by means such as living will or power of attorney), should they become incapacitated.

The goals of the "purpose" of the Patient Self-Determination Act are/were (1) to prevent cruel over treatment of elderly/disabled Medicare/Medicaid patients for the profit motive and (2) to save money for Medicare and the private insurers in the form of the reduction of end-of-life costs for Medicare and the private insurers when elderly Medicare/Medicaid patients would ELECT/CHOOSE to refuse expensive ICU/CCU life-extending or life-saving treatments in the hospital in order to shorten their suffering unto a certain death. It was envisioned by the framers of the 1991 PSDA that the elderly/disabled on Medicare/Medicaid would die less expensively and more comfortably (out of pain) on the palliative care/Hospice Medicare Entitlement in their own personal residence or in the setting of a residential nursing home when the treating physicians consulted with them about their terminal diagnoses.

Patient Self Determination Act (PDSA) was an amendment proposed in 1990 and functions to amend titles XVIII and XIX of the Social Security Act (Medicare and Medicaid, respectively). The PSDA mandates that hospitals, skilled nursing facilities, hospice organizations, home health organizations, and HMO's perform a number of specific actions and ensure that other certain conditions are met. Among those mentioned above, it is required that patients be informed of their right to be involved in making decisions with regard to the medical care they receive. It is also required that the patient is asked about advanced directives, and to document any wishes the patient might have with regard to the care they want or do not want. It required that no discrimination take place by any healthcare organization against any patient putting forth advanced directives. It mandates that patient advanced directives be implemented if necessary, assuming those wishes are legally valid and permissible by State law. It requires education programs including advanced directives, bioethics, patient wishes, and the concept of patient self-determination. The PDSA went further to instruct the Secretary of the United States Department of Health and Human Services to coordinate an investigative study reviewing the implementation of advanced directive decisions. PDSA also asked to create and perform projects in specific locations across the country to build awareness of patient rights in the area of advanced directives and executing advanced directives. 

As listed on the legislative portion of the 101st Congress, the bill reads as the following:

"To amend titles XVIII and XIX of the Social Security Act to require providers of services and health maintenance organizations under the Medicare and Medicaid programs to assure that individuals receiving services will be given an opportunity to participate in and direct health care decisions affecting themselves.

IN THE HOUSE OF REPRESENTATIVESApril 3, 1990Mr. LEVIN of Michigan (for himself, Mr. SWIFT, Mr. MOODY, Mr. MCDERMOTT, and Mr. FAUNTROY) introduced the following bill; which was referred jointly to the Committees on Ways and Means and Energy and Commerce A BILL To amend titles XVIII and XIX of the Social Security Act to require providers of services and health maintenance organizations under the Medicare and Medicaid programs to assure that individuals receiving services will be given an opportunity to participate in and direct health care decisions affecting themselves. Be it enacted by the Senate and House of Representatives of the United States of America in Congress assembled,

SECTION 1. SHORT TITLE.  This Act may be cited as the `Patient Self Determination Act of 1990'.

SEC. 2. MEDICARE PROVIDER AGREEMENTS ASSURING THE IMPLEMENTATION OF A PATIENT'S  RIGHT TO PARTICIPATE IN AND DIRECT HEALTH CARE DECISIONS AFFECTING THE PATIENT.

(a) IN GENERAL- Section 1866(a)(1) of the Social Security Act (42 U.S.C. 1395cc(a)(1)), as amended by section 6112 of the Omnibus Budget Reconciliation Act of 1989, is amended--(1) by striking `and' at the end of subparagraph (O), (2) by striking the period at the end of subparagraph (P) and inserting `, and', and (3) by inserting after subparagraph (P) the following new subparagraph: `(Q) in the case of hospitals, skilled nursing facilities, home health agencies, and hospice programs, to maintain written policies and procedures with respect to all individuals receiving medical care by or through the provider-- `(i) to inform such individuals of an individual's rights under State law (whether statutory or as recognized by the courts of the State) to make decisions concerning such medical care, including the right to accept or refuse medical or surgical treatment and the right to formulate advanced directives recognized under State law relating to the provision of care when such individuals are incapacitated (such a directive in this subparagraph referred to as an `advanced directive'), such as through-- `(I) the appointment of an agent or surrogate to make health care decisions on behalf of such an individual, and `(II) the provision of written instructions concerning the individual's health care (including instructions for the disposition of organs); `(ii) to inquire periodically (and to document in the individual's medical record) whether or not the individual has executed an advanced directive and to document in such record the individual's wishes (if any) with respect to such medical care; `(iii) not to deny the initial provision of care or otherwise discriminate against an individual based on whether or not the individual has executed an advanced directive; `(iv) to ensure that legally valid advanced directives and wishes otherwise documented under clause (ii) are implemented to the extent permissible under State law, including such provisions of State law as relate to the transfer of an individual in the case of a provider which, as a matter of conscience, cannot implement the wishes of the individual; and `(v) to provide (individually or with others) for educational programs for staff, individuals receiving medical care by or through the provider, and the community on ethical issues concerning patient self determination and concerning advance directives respecting such care.'.

(b) APPLICATION TO HEALTH MAINTENANCE ORGANIZATIONS- Section 1876(c) of such Act (42 U.S.C. 1395mm(c)) is amended by adding at the end the following new paragraph: `(8) A contract under this section shall provide that the eligible organization shall meet the requirements of section 1866(a)(1)(Q) in the same manner as they apply to hospitals.'. (c) Effective Dates- (1) The amendments made by subsection (a) shall apply with respect to services furnished on or after the first day of the first month beginning more than 180 days after the date of the enactment of this Act. (2) The amendment made by subsection (b) shall apply to contracts under section 1876 of the Social Security Act as of the first day of the first month beginning more than 180 days after the date of the enactment of this Act

SEC. 3. MEDICAID STATE PLANS ASSURING THE IMPLEMENTATION OF A PATIENT'S RIGHT TO PARTICIPATE IN AND DIRECT HEALTH CARE DECISIONS AFFECTING THE PATIENT.(a) IN GENERAL- Section 1902(a) of the Social Security Act (42 U.S.C. 1396a(a)), as amended by section 6406(a) of the Omnibus Budget Reconciliation Act of 1989, is amended-- (1) by striking `and' at the end of paragraph (52), (2) by striking the period at the end of paragraph (53) and inserting `; and', and (3) by inserting after paragraph (53) the following new paragraph: `(54) provide that each hospital, nursing facility, home health agency, hospice program, or health maintenance organization receiving funds under the plan shall maintain written policies and procedures with respect to all individuals receiving medical care by or through the provider or organization-- `(A) to inform such individuals of an individual's rights under State law (whether statutory or as recognized by the courts of the State) to make decisions concerning such medical care, including the right to accept or refuse medical or surgical treatment and the right to formulate advanced directives recognized under State law relating to the provision of care when such individuals are incapacitated (such a directive in this paragraph referred to as an `advanced directive'), such as through-- `(i) the appointment of an agent or surrogate to make health care decisions on behalf of such an individual, and `(ii) the provision of written instructions concerning the individual's health care (including instructions for the disposition of  organs); `(B) to inquire periodically (and to document in the individual's medical record) whether or not the individual has executed an advanced directive and to document in such record the individual's wishes (if any) with respect to such medical care; `(C) not to deny the initial provision of care or otherwise discriminate against an individual based on whether or not the individual has executed an advanced directive; `(D) to ensure that legally valid advanced directives and wishes otherwise documented under subparagraph (B) are implemented to the extent permissible under State law, including such provisions of State law as relate to the transfer of an individual in the case of a provider or organization which, as a matter of conscience, cannot implement the wishes of the individual; and `(E) to provide (individually or with others) for educational programs for staff, individuals receiving medical care by or through the provider or organization, and the community on ethical issues concerning patient self determination and concerning advance directives respecting such care.'.

(b) EFFECTIVE DATE- The amendments made by subsection (a) shall apply with  respect to services furnished on or after the first day of the first month  beginning more than 180 days after the date of the enactment of this Act.

SEC. 4. STUDY TO ASSESS IMPLEMENTATION OF A PATIENT'S RIGHT TO PARTICIPATE  IN AND DIRECT HEALTH CARE DECISIONS AFFECTING THE PATIENT. (a) IN GENERAL- The Secretary of Health and Human Services shall (subject  to subsection (b)) enter into an agreement with the Institute of Medicine  of the National Academy of Sciences to conduct a study with respect to  the implementation of directed health care decisions. Such study shall--  (1) evaluate the experience of practitioners, providers, and government regulators experienced in complying with the requirement imposed by the  amendments made by sections 2(a) and 3(a); and (2) investigate methods of making decisions reached by a patient or nursing home resident transferrable, so that the wishes of the patient or resident can be known and respected in other health care settings to which the patient or resident may be transferred or discharged.

(b) ARRANGEMENTS FOR STUDY- The Secretary shall request the Institute of Medicine of the National Academy of Sciences to submit an application to  conduct the study described in subsection (a). If the Institute submits an acceptable application, the Secretary shall enter into an appropriate arrangement with the Academy for the conduct of the study within 28 days of the date the application is received. If the Institute does not submit an acceptable application to conduct the study, the Secretary may request one or more appropriate nonprofit private entities to submit an application to conduct the study and may enter into an appropriate arrangement for the conduct of the study by the entity which submits the best acceptable application.

(c) REPORT- The results of the study shall be reported to Congress and the Secretary by not later than 4 years after the date of the enactment of  this Act. Such report shall include such recommendations for legislation as may be appropriate to carry out further the purpose of this Act.

SEC. 5. PUBLIC EDUCATION DEMONSTRATION PROJECT. The Secretary of Health and Human Services, no later than 6 months after the date of the enactment of this Act, shall develop and implement a  demonstration project in selected States to inform the public of the option to execute advance directives and of a patient's right to participate in  and direct health care decisions. The Secretary shall report to Congress on the results of the project and on whether such project should be expanded  to cover all the States." [1][2][3][4][5]

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