Patient Self-Determination Act (PSDA)
The Patient Self-Determination Act (PSDA) is a federal law enacted in 1990 that aims to empower patients by ensuring they are informed about their rights to make decisions regarding their health care, particularly concerning advance directives and end-of-life care. Under this law, healthcare institutions, including hospitals, home health agencies, and long-term care facilities that receive Medicare and Medicaid funding, are required to provide patients with written information about their rights and institutional policies related to advance directives. These directives allow patients to express their treatment preferences and ensure that their wishes are respected, even when they cannot communicate them due to health conditions.
The PSDA also mandates that institutions document any existing advance directives and educate their staff about these important documents. Although it does not extend to all healthcare settings, such as private physicians' offices, it has significantly increased the number of patients with advance directives, especially among older adults and those with higher education. The act is part of a broader shift in medical ethics toward recognizing patient autonomy and the importance of informed consent, which has evolved over the past century. As states continue to address issues related to patients' rights, discussions surrounding advance directives and end-of-life options remain relevant and dynamic in the healthcare landscape.
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Patient Self-Determination Act (PSDA)
The Patient Self-Determination Act (PSDA) is a federal law. It requires that when admitting patients, most health care institutions must provide a written summary of patients' rights in making health care decisions and the institution's policies about advance directives, which include patients' decisions about end-of-life care. Institutions must also document patients' advance directives, if they have them; educate staff about advance directives; and not require advance directives or refuse patients who have them.
The PSDA applies to hospitals, home health agencies that are reimbursed by Medicaid and Medicare, and long-term care facilities. It does not apply to other types of health care settings, such as doctors' offices.
State laws vary. Under the PSDA, health care institutions must inform patients of state laws about their rights to make decisions about care. This may include the right to refuse treatment.
Background
People involved in medical ethics have long discussed consent and disclosure about health care and related issues. In early practice, doctors felt that it was acceptable, and often preferable, to lie to patients. Ancient Greek physicians felt it was most important for patients to feel confident that treatment was the correct course of action. In medieval Europe, physicians traditionally offered hope to their patients while withholding information about the treatment they provided and lied to patients to get them to cooperate. The doctor made decisions, and the patient was expected to agree and obey.
By the nineteenth century, physicians were divided on some topics. For example, many felt that they should tell patients when their conditions were poor and the outcome was likely to be fatal, but most said this information should not be shared with the patients. In the late nineteenth and twentieth centuries, as medical care advanced and more often involved surgery and other invasive procedures, questions about patients' rights to control their own bodies emerged.
Gradually, discussion of medical care began to include common law issues. English common law is not legislative law—it is customary or traditional—but has influenced the development of laws. Legal doctrine is a rule, idea, or principle of law. During the early twentieth century, courts began applying a common law doctrine of negligence to surgery. The courts saw negligence as breach of duty, or failure to live up to one's responsibility to provide care. Courts saw a physician's failure to explain treatment to the patient as a breach of duty. Another doctrine, the doctrine of assault and battery, is also based in English common law. Assault is a threat made by one person to physically harm another. Battery is one person touching another. Courts began applying this doctrine to cases about medical care. In 1914, Justice Benjamin Cardozo cited battery in the finding of Schloendorff v. Society of New York Hospital. This case determined that the patient has the right to make decisions about his or her care.
The term informed consent originated during the 1950s. The issue was not widely discussed until the 1970s, when multiple cases recognized patients' rights to informed consent. In Canterbury v. Spence (1972), for example, the court ruled that patients must be provided enough information about a procedure and possible outcomes to make a decision about surgery. In 1974, a surgeon was found liable for assault and battery in Relf v. Weinberger. The patient, who received public assistance benefits, was told her benefits would be reduced if she did not receive a tubal ligation. The court found that the patient gave her consent to sterilization under duress, so the consent was invalid.
Health care experts also came to recognize the importance of advance directives. These are documents in which the patient expresses his or her treatment preferences. Durable powers of attorney for health care and living wills are examples of advance directives. Such documents allow the patient's decisions to be respected and followed even if the patient is unable to express it due to illness or injury. A living will should contain responses to a variety of situations, such as resuscitation. A power of attorney gives the decision-making authority to an individual who understands the patient's desires and ensures medical staff to follow them.
The PSDA bill was introduced in early 1990 and was endorsed by the American Bar Association Commission on Law and Aging, the Society for the Right to Die, and other interest groups. The six legislative goals of the PSDA were to empower people, boost advance directives, honor advance directives, convince more states to enact advance directive statutes, encourage health care providers to provide less treatment to patients in the end stages of life if the patient and/or family wishes, and to control medical costs for terminal patients.
The PSDA was enacted by Congress as a budget amendment. It was signed into law on November 5, 1990.
Overview
In addition to informing and respecting patients' wishes about treatment options, the PSDA requires institutions to provide information to patients about advance directives and how to create one. Some facilities offer advance directive forms that people may choose to use. Health care providers suggest individuals should make these decisions in advance, however, because they should carefully consider their wishes. Individuals may be too unwell to make an advance directive when they are being admitted for medical care.
The PSDA has had an effect on the number of people who have advance directives. A 1998 study found that the percentage of residents of nursing homes with advance directives increased significantly after 1990. The six nursing homes in Connecticut included in the study had advance directive documents for 4.7 percent of their patients before the PSDA went into effect. The rate increased to 34.7 percent after the PSDA went into effect. Some patient populations were more likely to have advance directives, including residents with higher education and those who were admitted to the facilities from hospitals. Residents older than seventy-five years were more likely to have advance directives. Most of the patients who had advance directives had completed them more than six months before they were admitted to the nursing homes. Many of the patients who had advance directives said they had completed them because they had previous experiences with friends or relatives who had died after a long illness, and saw the importance of documenting their wishes.
Some states have modified their laws regarding patients' rights as issues arise. In the twenty-first century, advance directives continue to evolve. Laws and directions pertaining to advance directives vary by state.
Bibliography
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"Law for Older Americans: Health Care Advance Directives." American Bar Association, 18 Mar. 2013, www.americanbar.org/groups/public‗education/resources/law‗issues‗for‗consumers/patient‗self‗determination‗act.html. Accessed 23 Jan. 2025.
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