Patient Self-Determination Act

Patient Self-Determination Act
Name	Patient Self-Determination Act
Enacted by	United States Congress
Effective	December 1, 1991
Public law	Public Law 101–508
Citation	42 U.S.C. § 1395cc et seq.
Introduced in	101st United States Congress
Signed by	George H. W. Bush
Signed date	November 16, 1990

Patient Self-Determination Act

The Patient Self-Determination Act (PSDA) is a United States federal statute enacted as part of Omnibus Budget Reconciliation Act of 1990 that requires certain healthcare institutions to inform patients about advance directives and to document patients' preferences in medical records. The statute links Medicare (United States) and Medicaid participation to institutional policies on advance care planning, influencing practice in hospitals, nursing homes, home health agencies, and hospice providers.

Background and Legislative History

Congress debated advance directive legislation amid cases such as Karen Ann Quinlan and Nancy Cruzan that highlighted end-of-life decision-making and prompted judicial review by state courts and the Supreme Court of the United States. Legislative momentum drew on prior instruments including the Uniform Health-Care Decisions Act and state laws on durable power of attorney and living wills; proponents included advocacy groups such as AARP and bioethicists associated with Johns Hopkins Hospital and Harvard Medical School. The PSDA was adopted within the fiscal and regulatory packages negotiated in the 101st United States Congress and signed by George H. W. Bush as part of Public Law 101–508.

Key Provisions and Requirements

The Act requires Medicare- and Medicaid-participating providers to (1) inform patients of their rights under state law to make medical decisions, including the right to accept or refuse medical treatment and create advance directives; (2) provide written information about advance directives at the time of admission; (3) record the existence of any advance directive in the medical record; (4) not condition care on whether a patient has an advance directive; and (5) ensure staff and community education about advance directive policies. These mandates apply to entities regulated by Centers for Medicare & Medicaid Services, including acute care hospitals, skilled nursing facilities, home health agencies, and hospices.

Impact on Healthcare Delivery and Patient Rights

The PSDA reshaped institutional practice by embedding advance care planning into admission procedures used by Mayo Clinic, Cleveland Clinic, and regional health systems in states such as California, New York (state), and Texas. It galvanized growth in documents like living wills, durable powers of attorney for health care, and Physician Orders for Life-Sustaining Treatment as used at University of California, San Francisco and Mount Sinai Hospital (Manhattan). Research from Institute of Medicine-affiliated studies and analyses published in journals from American Medical Association and New England Journal of Medicine documented changes in documentation rates, though outcomes varied across Veterans Health Administration facilities and community hospitals.

Implementation and Compliance

Implementation required hospitals and nursing homes to adopt written policies, train staff, and audit records for compliance, overseen by Centers for Medicare & Medicaid Services surveyors and state health departments such as the California Department of Public Health and the New York State Department of Health. Compliance tools included model forms from organizations such as American Hospital Association and training curricula from The Joint Commission. Enforcement mechanisms combined survey citations, corrective action plans, and linkage to payment programs administered by Centers for Medicare & Medicaid Services and state Medicaid agencies.

Legal and Ethical Issues

The PSDA intersects with constitutional law decisions from the Supreme Court of the United States, statutes like the Patient Protection and Affordable Care Act, and state statutes governing surrogate decision-making and conservatorship. Ethical debates reference work by scholars at Georgetown University and University of Pennsylvania concerning autonomy, informed consent, and substituted judgment. Courts in jurisdictions including United States Court of Appeals for the Ninth Circuit and New Jersey Supreme Court have addressed disputes involving advance directives, religious objections posed by institutions such as Catholic Health Initiatives, and conflicts under state revocation rules.

Criticisms and Controversies

Critics argued the PSDA produced variable implementation, with disparities highlighted in studies from Centers for Disease Control and Prevention and Agency for Healthcare Research and Quality indicating inconsistent patient comprehension and documentation quality. Advocacy organizations like National Hospice and Palliative Care Organization and civil liberties groups such as American Civil Liberties Union raised concerns about institutional barriers, coercion, and the adequacy of patient education. Controversies also involved tensions between federal mandates and state law differences in places such as Florida and Massachusetts, and debates over the role of advance directives in contexts influenced by major events like the HIV/AIDS epidemic and the development of palliative care programs at centers such as Dana-Farber Cancer Institute.

Category:United States federal health legislation Category:Advance care planning