Fundamentals - Principles, part 3: Advance Directives and HIPAA
by Meris Shuwarger July 12, 2021 Updated: December 29, 2021 10 min read
In this article, we'll explain two important nursing fundamentals topics: advanced directives and HIPAA regulations. You'll learn about the PSDA, advanced directive types including a DNR, a living will, a POLST, and durable power of attorney.
The Fundamentals of Nursing video series follows along with our Fundamentals of Nursing flashcards, which are intended to help RN and PN nursing students study for nursing school exams, including the ATI, HESI, and NCLEX.
Advanced directives are legal documents that communicate preferences regarding medical care if the patient becomes incapacitated or is unable to communicate their wishes.
Patient Self Determination Act
The Patient Self-Determination Act (PSDA) is a legal act that guarantees that a patient has the right to make their own decisions about their healthcare, which can include things like the right to refuse and advanced directives.
The PSDA is a legal act that supports the nursing ethical principle of autonomy. The rest of the nursing ethical principles you will need to know for your nursing exams are covered in our Fundamentals of Nursing Flashcards! Laws and ethics are different. Ethical principles do not always have laws that support them, but it is nice when they do, because it can make acting in accordance with these principles easier to navigate and understand.
The PSDA's relationship to advanced directives is that it mandates that patient advanced directives be followed, assuming they are valid and permissible by state law.
Types of Advance Directives
Advanced directives are directives (instructions) made a patient, in advance of the patient becoming incapacitated or unable to verbalize or communicate, regarding how they should be cared for. There are several types of advance directives, including a living will, a do not resuscitate order, physician's orders for life-sustaining treatment (POLST), and durable power of attorney.
For example, if a patient is incapacitated or brain-dead, they have already legally expressed their wishes using one of these methods, then their care team and family members know what to do. The patient has expressed specific wishes that they want the care team and family to follow.
The following types of advanced directives will likely be in your nursing exams, and you will encounter them in your nursing practice.
A living will is a document, drawn up by a patient* that indicates the types of medical interventions they do and don't want to have if they were incapacitated and unable to provide consent for themselves.
The type of will you have probably heard of, a Last Will (and Testament) is different from a living will. A last will directs the distribution of assets and burial/cremation after someone has died. A living will gives directions regarding medical interventions if they are no longer able to express informed consent.
The advance directives that can be included in a living will are directives that indicate a patient's desired or prohibited medical interventions including code status, level of intervention, or life-sustaining measures.
For example, a patient could include that they don't wish to be intubated, but they do wish to have tube feedings.
*In some states, patients require witnesses or a notary public to authorize their living will for it to be enforceable. In 26 states, a living will is not enforceable if a patient is pregnant.
Do Not Resuscitate Order
A Do Not Resuscitate Order is a specific type of advance directive stating that no CPR or resuscitative actions should be taken on a patient. This varies by state and you should make yourself familiar with the different DNR options available in your state. But in general, if your patient has a DNR order and goes into cardiac arrest, you would not begin CPR.
For a nurse to be able to act in accordance with a DNR, the order for a DNR must be put in the patient's chart by a physician, which is called a Physician's Orders for Life Sustaining Treatment (POLST), described below.
Physician's Orders for Life-Sustaining Treatment (POLST)
A Physician's orders for life-sustaining treatment (POLST) is a written medical order that summarizes a patient's wishes regarding medical care. A POLST form is often bright pink or another bright color.
POLST may contain a DNR, or may indicate "comfort care only."
POLST as a method/approach began in Oregon in 1991, and is active or in development in most states. Unlike a living will or durable power of attorney, which indicate a patient's preferences, a POLST is a medical order.
Durable Power of Attorney
Durable power of attorney is a legal document that identifies another person, or people, responsible for medical decision-making for a patient.
For example, a patient with a durable power of attorney in place may have designated their spouse or child as the legal decision-maker in giving consent for their medical treatments. This person does not have to be related to the patient.
Durable power of attorney is also called medical power of attorney, healthcare power of attorney, depending on the state.
The Health Insurance Portability and Accountability Act (HIPAA)
The Health Insurance Portability and Accountability Act (HIPAA) of 1996 is a federal law that required the creation of national standards that include protecting a patient's right to privacy and regulating how their health care information is used and disclosed.
HIPPAA also covers modernizations to the flow of healthcare information between institutions and insurance companies as well as limitations on health insurance coverage, but the main areas of HIPAA that you will need to know in a Fundamentals of Nursing course are all regarding a patient's right to privacy and how their healthcare information is used and disclosed.
As Meris notes in the video, this information is highly testable—likely to show up on your nursing exams!
The key provisions of HIPAA regarding a patient's right to privacy and how their information must be handled are:
- Patient information may NOT be disclosed to anyone that is not directly involved in the care of the patient without patient consent.
- Patients have a right to receive a copy of their health records
Directly involved in the care of the patient means providing direct patient care, such as a physician, respiratory therapist, yourself as the patient's nurse. But not, for example, another nurse on a different unit who is not providing care to that patient.
Furthermore, if your patient's spouse wants information on their lab work or their medicines, that is permissible only if the patient has signed a release of information indicating that you are allowed to share that information with that person. So you would not communicate the protected health information of your patients unless you have a signature saying it's ok to communicate that information to that person.
Best practices for protecting patient privacy
There are some best practices that have been established as a result of HIPAA on how to protect a patient's privacy. Practicing nurses and students in clinical should remember and follow these best practices (which you will likely be tested on).
Electronic health record security
- Log off the computer when stepping away from it. You must actually log off, not just turn the screen off.
- Use secure, unique passwords and change them frequently. You have made enough online passwords by now to know what a secure password is!
- Never share passwords, including with your manager.
- You can only access charts for the patients you are directly caring for. So you can't look up charts for a friend of yours, or a celebrity in the hospital—this would not be an appropriate use of a patient's health record
- Only discuss patient information in a secure environment, like a nurses' station or break room.
- Do not discuss patient information in a public place, like an elevator or hospital cafeteria.
Report any breaches of confidentiality of a patient's protected information.
Accidents do happen. You may break confidentiality accidentally (or witness someone else break it accidentally or intentionally). If that happens, hold yourself and others accountable and report that breach to your direct supervisor. It's uncomfortable, but very important.
Hi. I'm Meris, and in this video we're going to be talking about advance directives and HIPAA. I will be following along with our Fundamentals of Nursing flashcards which are available on LevelUpRN.com.
If you are following along with me, I am starting on card number seven, so let's get started.
Alright. Let's talk about advance directives. One of the things that you're going to notice on this card is that we talk first about the Patient Self Determination Act, and this is the legal act that is actually the thing that guarantees that a patient has the right to make their own decisions about their healthcare. Very important to understand that that's what this document sets up.
This is how we are able to have the ethical principle of autonomy.
Now let's talk about some different types of advance directives. And they are what they sound like. It is a patient being allowed to direct their care in advance. So this means that if I am incapacitated or brain-dead or something similar, I have already legally expressed my wishes somehow, and we're going to talk about the different ways. This is very important for patients who have specific wishes they wish to be followed.
So the first one we're going to talk about is a living will. And a living will is the document a patient draws up which indicates the types of interventions they do and do not want to have if they were incapacitated and unable to provide consent for themselves. So this is very specific. The patient can say, I don't wish to be intubated. I do wish to have tube feedings. I don't want this kind of intervention. That is the document, a living will.
Now a Do Not Resuscitate order is a specific type of advance directives that says, "in the event of cardiac death, I do not want for you to perform CPR." No resuscitative actions, and depending on your state, there may be variations of this, so definitely make yourself familiar with all of the different DNR options available in your state.
But if your patient is a DNR and they have a cardiac arrest, we would not begin CPR. So the thing that's important to understand though is that we do require physician's orders for life-sustaining treatment [(POLST)] to be in place. And this means that the physician needs to actually put orders into the system saying something like, "do not resuscitate," or "comfort care only," or whatever the patient's advance directives are. The physician does need to put orders in so that we can as nurses carry out those orders.
Now durable power of attorney is something you're going to hear a lot about in nursing school, and this is a legal document that designates another person as being able to make medical decisions for the patient. So for instance, if I had a durable power of attorney, I could say in the event I'm unable to give consent myself, my husband, my mother, whoever I wish to designate, they have the legal ability to give consent for medical treatment only, medical treatment in my stead.
There are other forms of power of attorney that allow you to give consent for other things, but not this. Medical care only. The other thing is they don't have to be related to the person.
So for instance, I could say "Cathy Parkes, you are my durable power of attorney. We are not related, but will you be the one to make healthcare decisions if I could not?"
So those are very important advance directives to understand, because you will certainly see these come up on your nursing exams.
Okay, next we're going to be talking about HIPAA, which is the Health Insurance Portability and Accountability Act. This is very important for you to understand. It's highly testable because it's so important, because this is the law that sets forth the principles protecting a patient's privacy when it comes to their medical records. So very important to understand. So we have a lot of things to go over here. I would recommend reviewing this card in depth, because this is very testable information.
So some things that you need to keep in mind about HIPAA.
You are absolutely allowed to discuss a patient's care with other members of the healthcare team who are providing direct patient care, such as their physician or the respiratory therapist. That's okay.
What isn't allowable by HIPAA though would be something like speaking to a nurse on a different unit about the patient who isn't providing care to that patient.
Furthermore, if your patient's spouse wanted information on their lab work or their medicines, that's okay only if the patient has signed a release of information indicating that you are allowed to share that information with that person. So don't give away any of the protected health information of your patients unless you have that written signature saying it's okay to talk to this person.
Now when you do have conversations with other members of the healthcare team, make sure that these are in secure locations such as the break room or the nurses' station. That's all okay, but don't have these conversations in public areas such as the cafeteria or in the elevator. That would not be appropriate.
Now when it comes to the electronic health record, EHR, there's some things to keep in mind there too as to how to protect their information when you're working on the computer.
One of the most important things is going to be your password. You need to use a strong and unique password, change it frequently, and never share that password with anyone, including your own manager. That's very important.
When you step away from the computer, you need to log off entirely. It's not enough to just turn off your screen or turn the screen away. That's not allowable by HIPAA.
Some other things to keep in mind, you can only access patient charts for the patients that you are directly caring for, so you can't look up charts for a friend of yours or a celebrity that's in the hospital. That's not an okay use of a patient's health record.
So that is essentially the best practices around HIPAA. Keep in mind that accidents happen and people do break confidentiality intentionally or otherwise. When that happens though, you need to hold yourself accountable and hold others accountable and report that breach to your direct supervisor. It's uncomfortable but it's very important.
Okay, so that's it for advance directives and HIPAA. I hope you found that review helpful. If you did, please be sure to give us a like. You can drop a comment below to let me know what you liked about that video, and it's awesome if you want to subscribe so that you don't miss any of the videos that we put out on lots of different nursing content.
Next, I hope you join me. We're going to talk about something that is really important but very tricky. We're going to talk about intentional and unintentional torts. Really important concepts. And we're also going to go over mandatory reporting. Thanks so much and happy studying!
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