{"ref":"DC-HSP-PR-03","title":"Advance Directives, Health-Care Decisions, Surrogates and MOST","category":"Client rights","summary":"Sets how the Agency gives written information on advance directives when hospice care begins, records whether each patient has one, honors durable powers of attorney for health care, Natural Death Act declarations and MOST Forms as District law provides, finds the right decision-maker when a patient cannot decide, and educates staff and the community.","inShort":["At the start of care, give every adult patient written information on advance directives under District law.","Ask about a health care power of attorney, a living will and a MOST Form, record the answer prominently, and keep copies.","Never make care depend on whether a patient has an advance directive. Staff do not act as witnesses.","Only a physician or advanced practice nurse treating the patient completes a MOST Form; it is reviewed at least once a year and after big changes.","If you are unsure whether a MOST Form was revoked, act as if there is no MOST Form and resuscitate."],"primaryCitation":"42 CFR §418.52(a)(2)","citations":["D.C. Code §21-2201 et seq.","D.C. Code §21-2204","D.C. Code §21-2205","D.C. Code §21-2210","D.C. Code §21-2221.01 et seq.","D.C. Code §7-621 et seq.","29 DCMR §939.11"],"federalCitations":["42 CFR §418.52(a)(2)","42 CFR §489.100","42 CFR §489.102","42 CFR Part 489, Subpart I"],"surveyorAsks":["Where in this record do you show whether the patient has an advance directive? Is it prominent?","What written information on District advance directive law do you give, and when?"],"forms":[{"ref":"DC-HSP-PR-03-A","title":"Advance Directive, Surrogate and MOST Record"}],"headings":["Terms of Reference","1. Purpose","2. Scope","3. Definitions","4. Policy Statement (42 CFR §418.52(a)(2))","5. Written Information at the Start of Care","6. Asking, Recording and Keeping Copies","7. District Advance Directives and Orders","8. When the Patient Cannot Decide","9. MOST Forms","10. The Agency’s Conscience Statement","11. Staff and Community Education","12. Responsibilities","13. Records and Compliance Monitoring","14. Staff Training","15. References","16. Related Policies and Forms","17. Approval","18. Revision History"],"version":"1.0","sample":false,"pack":"dc-hospice","state":"Washington, DC","service":"Hospice","guides":[{"path":"/guides/hospice-policies/","h1":"What policies are required for hospice?"},{"path":"/guides/hospice-conditions-of-participation/","h1":"Hospice Conditions of Participation: which policies each one needs"}],"agency":{"name":"Sample Agency","legalName":"Sample Agency, LLC","logo":null}}