Implementation of the Patient Self-Determination Act (PSDA) in nursing homes in New York City

OBJECTIVE: To examine implementation of the Patient Self Determination Act (PSDA), verbal directives, procedures for determination of resident' decision-making capacity, and role of ethics committees in nursing homes in New York City. DESIGN: Telephone survey. PARTICIPANTS: Social workers in 109 (69%) nursing homes in New York City. MEASUREMENT: An 80-item instrument addressing: (1) social worker knowledge of the PSDA; (2) informing residents about advance directives (living wills and durable power of attorney for health care [health care proxies]); (3) determination of decision-making capacity to be informed about advance directives; (4) estimates of advance directives executed; (5) perceptions of PSDA effect; (6) ethics committees; (7) follow-up and documentation; and (8) staff and community education. MAIN RESULTS: Virtually all social workers in nursing homes stated that they made what they perceived to be a 'serious effort' to inform residents about advance directives and to have residents execute directives (preferentially a health care proxy). More residents were thought to have executed a directive pursuant to the PSDA law than before the Act went into effect. Social workers in most homes informed residents about directives through face-to-face discussions. Most homes, however, did not inform residents who were thought to lack decision-making capacity about their right to execute a directive. Only 37% of homes had written procedures to determine a resident's decision- making capacity to be informed about directives; most homes relied on physician and social work assessments. Voluntary homes differed significantly from proprietary homes in that they were larger, more likely to have an ethics committee, and more aggressive in their implementation of the PSDA. Forty-five percent of homes with an ethics committee had written procedures for determination of resident decision-making capacity compared with 26% of homes without a committee. Overall, 24% of residents were thought to have executed an advance directive. The number of directives per bed did not vary significantly by facility size, ownership, religious affiliation, or whether they did or did not have an ethics committee. CONCLUSIONS: The fact that social workers in nursing homes speak with most residents about advance directives has the potential to improve resident understanding around end of life decisions. The practice of not informing residents about advance directives when they are perceived to lack decision-making capacity is problematic given that most homes have no clear procedures for determining residents' cognitive capacity to execute a directive. There is a need to replicate the benefits achieved by homes with ethics committees in implementing the PSDA in other homes.