Jfk Medical Center

JFK MEDICAL CENTER DEPARTMENT/OWNER: POLICY DESCRIPTION: Risk Management Do Not Resuscitate Page 1 of 10 REPLACES POLICY DATED: 5/09 EFFECTIVE DATE: 4/11 REFERENCE NUMBER: COMMITTEE APPROVAL: APPROVAL DATE: ADMINISTRATIVE APPROVAL: APPROVAL DATE:

SCOPE: Organization Wide.

PURPOSE: To provide guidelines to assure that decisions regarding withholding of resuscitative services or life-prolonging treatments and procedures for patients are made in the framework of a medically responsible, ethical and sensitive process that protects the right of the patients and adheres to the Florida Statutes.

JFK Medical Center proposes the use of the "POLST" order set to serve as a guide for discussions regarding the use/nonuse of specific resuscitative measures.

POLICY: 1. In accordance with Florida Law, JFK Medical Center agrees, that every competent adult has the fundamental right to self-determination regarding decisions pertaining to his/her own health, including the right to choose to refuse medical treatment. The Hospital will respect and abide by a patient's wishes for end-of-life life decisions to the extent permitted by Florida State Statute and the federal law regarding "Self Determination".

2. JFK Medical Center recognizes that the purpose of cardiopulmonary resuscitation (CPR) is the prevention of sudden, unexpected death. In the event of cardiac or pulmonary arrest, it is standard practice in the hospital to perform CPR unless there is s specific "Do-Not-Resuscitate" order to the contrary.

3. It is also recognized that there are clinical situations in which life prolonging procedures (such as artificial nutrition and hydration, intravenous antibiotics, dialysis, etc) may be of uncertain medical value or medically futile. Also the hospital recognizes the right of the patient to participate in decisions affecting his or her life and to have his or her values and beliefs respected within the limits of the law. In any situation, a DNR Order (as prescribed in the POLST order set) requires the consent of the patient or surrogate or proxy.

4. Living Wills or oral declarations, other advance directives, and POLST order sets (including those completed by a physician not on staff at JFK Hospital) will be honored according to Florida Law and will be included as a part of the patient's medical record. This applies to both inpatients and outpatients.

5. The Right to Decline Life-Prolonging Procedures Law is applicable to all "Do Not Resuscitate Orders". To this end, all patients must have support of the physician and staff as well as have the proper documentation of such on the hospital record.

6. The attending physician will make every effort during the hospitalization to transform a patient's wishes outlined in their living will into an actionable POLST order set if one has not already been completed. The original POLST order set will placed on the front of the medical chart (or entered into meditech via the new CPOE system) for all to follow. Upon discharge from the facility, the original will be sent along with the patient while a copy of the POLST order set will remain in the medical record.

7. A patient will be presumed to be capable of making health care decisions for him/herself unless he/she is determined to be incapacitated. Every patient shall be presumed to consent to the administration of cardiopulmonary resuscitation in the event of cardiac or respiratory arrest, unless there is consent to the issuance of a Do-Not-Resuscitate order.

8. No person shall be required to make an advance directive as a condition for receiving health care services. JFK Medical Center may not require a patient to execute and advance directive or to execute a new advance directive using facility's forms. The patient's advance directive will be a part of his/her medical record. JFK MEDICAL CENTER DEPARTMENT/OWNER: POLICY DESCRIPTION: Risk Management Do Not Resuscitate Page 2 of 10 REPLACES POLICY DATED: 5/09 EFFECTIVE DATE: 4/11 REFERENCE NUMBER: COMMITTEE APPROVAL: APPROVAL DATE: ADMINISTRATIVE APPROVAL: APPROVAL DATE:

9. All staff members participating in the request of Advance Directives will be educated on patient rights during orientation and reorientation. Risk Management may be contacted for any questions.

DEFINITIONS (765.101)

"Physician Orders for Life Sustaining Treatment (POLST)" is an order set that aims to honor a patient's end of life care wishes as stated in their oral or written living will. It must be signed by the attending physician (or his/her surrogate who also holds an MD/DO degree) AND the patient (or his/her decision maker) in order to be valid.

"Do Not Resuscitate Order" means a written medical order prepared by the attending physician that documents instruction by an adult patient, the patient's designated Surrogate, or an appointed Proxy, that in the event the patient suffers cardiac or respiratory arrest, cardio-pulmonary resuscitation is to be withheld.

"Life Prolonging Procedures" means any medical procedure, treatment or intervention, including artificially provided sustenance and hydration, which sustains, restores, or supplants a spontaneous vital function. The term does not include the administration of medication or performance of medical procedures, which such medication or procedure is deemed necessary to provide comfort care or to alleviate pain.

"Informed Consent" means consent voluntarily given by a person after a sufficient explanation and disclosure of subject matter involved to enable that person to have a general understanding of the treatment or procedure and the medically acceptable alternatives, including the substantial risks and hazards inherent in the proposed treatment or procedures, and to make a knowing health care decision without coercion or undue influence.

"Advance Directive" means a witnessed written document or an oral statement in which instructions are given by a principal or in which the principal's desires are expressed concerning any aspect of the principal's health care, and includes, but is not limited to, the designation of a health care surrogate, a living will or an anatomical gift made pursuant to Part X of Chapter 732.

"Living Will or Declaration" means: 1. A witnessed document in writing, voluntarily executed by the principal in accordance with s. 765.302; or 2. A witnessed oral statement made by the principal expressing the principal's instructions concerning life- prolonging procedure Health Care Surrogate" means any competent adult expressly designated by a principal to make health care decision on behalf of the principal upon the principal's incapacity.

"Durable Power of Attorney for Health Care” is an appointed agent, or a so called "attorney-in-fact", to act for individual in execution of legal, business, property affairs and making of health care decisions in place of establishing a legal guardian.

"Informed Consent" means consent voluntarily given by a person after a sufficient explanation and disclosure of subject matter involved to enable that person to have a general understanding of the treatment or procedure and the medically acceptable alternatives, including the substantial risks and hazards inherent in the proposed treatment or procedures, and to make a knowing health care decision without coercion or undue influence.

"Proxy" means a competent adult who has not been expressly designated to make health care decisions for a particular incapacitated individual, but who, nevertheless, is authorized pursuant to s. 765.401 to make health care decisions for such individual.

"Close Personal Friend" means any person 18 years of age or older who has exhibited special care and concern for the patient, and who presents an affidavit to the health care facility or to the attending or treating physician stating that he or she is a friend of the patient; is willing and able to become involved in the patient's health care; and has maintained such regular contact with the patient so as to be familiar with the patient's activities, health, and religious or moral beliefs. JFK MEDICAL CENTER DEPARTMENT/OWNER: POLICY DESCRIPTION: Risk Management Do Not Resuscitate Page 3 of 10 REPLACES POLICY DATED: 5/09 EFFECTIVE DATE: 4/11 REFERENCE NUMBER: COMMITTEE APPROVAL: APPROVAL DATE: ADMINISTRATIVE APPROVAL: APPROVAL DATE:

"Incapacity or Incompetent" means the patient is physically or mentally unable to communicate a willful and knowing health care decision. For the purpose of making an anatomical gift, the term also includes a patient who is deceased.

"End Stage Condition" means a condition that is caused by injury, disease, or illness which has resulted in severe and permanent deterioration, indicated by incapacity and complete physical dependency, and for which, to a reasonable degree of medical certainty, treatment of the irreversible condition would be medically ineffective.

"Terminal" means a condition caused by injury, disease, or illness from which there is no reasonable medical probability of recovery and which without treatment can be expected to cause death.

"Persistent Vegetative State" means a permanent and irreversible condition of unconsciousness in which there is: 1. The absence of voluntary action or cognitive behavior of any kind 2. An inability to communicate or interact purposefully with the environment

PROCEDURES FOR DNR AND WITHHOLDING/WITHDRAWING LIFE SUPPORT

A. PROCEDURE IN PRESENCE OF AN ADVANCE DIRECTIVE/LIVING WILL (Competent and Incompetent Patient) A "Living Will" is a written declaration that is used to direct the providing, withholding or withdrawing of life- prolonging procedures in the event that the person has a terminal illness, or has an end-stage condition or is in a persistent vegetative state.

In addition to making a living will, an individual may wish to name a Health Care Surrogate. If the patient wishes to designate a surrogate for the first time or to designate a new surrogate, the patient should complete the "Designation of a Health Care Surrogate" form.

This procedure is to be used if the patient has provided documented evidence of having made a living will and/or designated a Health Care Surrogate or Power of Attorney for Health Care Decisions.

1. The nurse shall obtain a copy of the Living Will Declaration and place it in the medical record. 2. If the patient is oriented and a surrogate has not been appointed request that the patient designate a health care surrogate 3. If the patient has made an Advance Directive/Living Will and is competent, the attending physician may proceed as directed by the patient in the living will. 4. If the patient is not competent (lacks decision making capacity) and has designated a Health Care Surrogate, the attending physician may proceed as directed by the Health Care Surrogate and in accordance with the Advance Directive. If a Health Care Surrogate has not been named, a proxy shall be determined according to the guidelines provided in this policy. 5. If the patient has made an Advance Directive/Living Will and lacks the ability to make an informed decision, the designated surrogate or proxy can make the decision regarding withholding/withdrawing of life support and making the patient a DNR according to patient's advance directive. If there is no designated surrogate or proxy, the physician can follow the patient's wishes according to the living will. 6. Before proceeding in accordance with the patient's living will, if the patient lacks decision making capacity, the designated surrogate, if there is one, or the appointed proxy, if there is no designated surrogate must be satisfied of the following: a. The patient does not have a reasonable probability of recovering decision making capacity so that the right to make decisions could be exercised directly by the patient, and JFK MEDICAL CENTER DEPARTMENT/OWNER: POLICY DESCRIPTION: Risk Management Do Not Resuscitate Page 4 of 10 REPLACES POLICY DATED: 5/09 EFFECTIVE DATE: 4/11 REFERENCE NUMBER: COMMITTEE APPROVAL: APPROVAL DATE: ADMINISTRATIVE APPROVAL: APPROVAL DATE:

b. The patient's physician and one other physician have determined that the patient has a terminal condition, or has an end-stage condition, or is in a persistent vegetative state and c. Any limitations or conditions expressed orally or in a written declaration has been carefully considered and satisfied. 7. The patient, health care surrogate and/or family members will have the opportunity to discuss the considerations of these decisions with the physician before making the decision. Pastoral counseling will be obtained if requested.

B. PROCEDURES IN THE ABSENCE OF ADVANCE DIRECTIVES (Appointment of a Proxy)

1. The Hospital recognizes that the absence of a Declaration does not create a presumption of the patient's intent to consent or to refuse life-prolonging treatment.

2. If the patient has not executed an advance directive or designated a surrogate to execute an Advance Directive, or the surrogate is no longer available to make health care decisions, a Proxy may be appointed to make health care decisions for the patient. Any of the following individuals may be appointed as a Proxy in the following order of priority, if no individual in the prior class is reasonably available, willing or competent to act.

a. A judicially appointed guardian with authority to make health care decisions for the patient, if one has been appointed b. The patient's spouse c. An adult child of the patient, or if the patient has more than one adult child, a majority of the adult children who are reasonably available for consultation d. The father or mother of the patient e. The adult sibling of the patient or the majority of the adult siblings who are reasonable available for consultation f. An adult relative of the patient, who has exhibited special care and concern and who has maintained regular contact with the patient and who is familiar with patient's activities, health, and religious or moral beliefs g. A close friend of the patient "Close personal friend' means any person 18 years of age or older who has exhibited special care and concern for the patient, and who presents an affidavit to the hospital or to the attending or treating physician stating that he/she is a friend of the patient; is willing and able to become involved in the patient's health care; and has maintained such regular contact with the patient so as to be familiar with the patient's activities, health and religious or moral beliefs. h. A clinical social worker licensed pursuant of Florida chapter 491, or who is a graduate of a court- approved guardianship program. Such a proxy must be selected by the hospital's Clinical Ethics Committee and must not be employed by the hospital. The proxy will be notified that, upon request, the hospital shall make available a second physician, not involved in the patient's care to assist the proxy in evaluating treatment. Decisions to withhold or withdraw life-prolonging procedures will be reviewed by the hospital bioethics committee. Documentation of efforts to locate proxies from prior classes must be recorded in the patient's record.

3. The Proxy may then act only when: a. The patient's terminal condition, end-stage condition or persistent vegetative state must be certified in writing, by the attending physician and one other consulting physician who has examined the patient. b. The patient has been certified as incapacitated by the physician. JFK MEDICAL CENTER DEPARTMENT/OWNER: POLICY DESCRIPTION: Risk Management Do Not Resuscitate Page 5 of 10 REPLACES POLICY DATED: 5/09 EFFECTIVE DATE: 4/11 REFERENCE NUMBER: COMMITTEE APPROVAL: APPROVAL DATE: ADMINISTRATIVE APPROVAL: APPROVAL DATE:

c. The proxy's decision must be supported by clear and convincing evidence that the decision would have been the one the patient would have chosen had the patient been competent.

C. PROCEDURES FOR DETERMINING CAPACITY AND PATIENT CONDITION

1. Determination of Capacity

The patient is presumed to be capable of making health-care decisions for him/herself unless he/she is determined to be incapacitated. Incapacity may not be inferred from the person's voluntary or involuntary hospitalization for mental illness or from his or her mental retardation.

If the patient's capacity to make health care decisions for him/herself or provide informed consent is in question, the following procedure will be followed:

- the attending physician shall evaluate the patient's capacity - If the attending physician concludes that the patient lacks capacity, that evaluation shall be documented in the medical record. - If the attending physician has a question as to whether the patient lacks capacity, another physician shall also be called to evaluate the patient - If the second physician agrees that the patient lacks the capacity to make health care decision or provide informed consent, as described in the definition section, the second physician will document this evaluation in the physician's progress notes. - If the patient has a designated health Care Surrogate, the physician or staff shall notify the surrogate, in writing, that his/her authority has begun. - In the event that the attending physician determines that the patient has regained capacity, the authority of the surrogate shall cease. The physician's determination must be documented in the Physician's Progress Notes.

2. Implementing Advance Directives in a patient without capacity to consent Prior to implementing a patient's desire to have life-prolonging procedures withheld or withdrawn, the patient's attending physician and at least one other consulting physician must separately examine the patient and document that a medical condition or limitation referred to in the advance directive (end-stage condition, terminal condition, and/or persistent vegetative state) exists and that there is no reasonable medical probability of recovery from such condition. The findings of such examination must be documented in the patient's medical record and signed by each examining physician before life-prolonging procedures may be withheld or withdrawn.

* See Definitions at beginning of policy for statutory definitions.

D. PROCEDURE FOR "DO NOT RESUSCITATE ORDERS"

1. DNR Decision Making: a. A DNR order may be written at any time by a physician after confirming this order with the patient who has decision making capacity. If the patient is competent to participate in the decision and requests or agrees to be made a DNR, the physician must document this process in the patient’s medical record. b. The attending physician will make every effort during the hospitalization to transform a patient's wishes outlined in their living will into an actionable POLST order set if one has not already been completed. (See policy on "Physician Orders for Life Sustaining Treatment (POLST)" c. If a patient does not have decision making capacity and has a living will a DNR Order may be written when the patient is determined by two physicians to have a terminal condition, or an end- JFK MEDICAL CENTER DEPARTMENT/OWNER: POLICY DESCRIPTION: Risk Management Do Not Resuscitate Page 6 of 10 REPLACES POLICY DATED: 5/09 EFFECTIVE DATE: 4/11 REFERENCE NUMBER: COMMITTEE APPROVAL: APPROVAL DATE: ADMINISTRATIVE APPROVAL: APPROVAL DATE:

stage condition, or is in a persistent vegetative state. The evaluation of the patients’ condition must be documented in the medical record by the attending physician and one other physician who has independently examined the patient. d. If the patient lacks the capacity to participate in the decision, the physician must evaluate patient for capacity and document his findings in the medical record. If the physician is not sure of the patient's competency/capacity, he must consult with the one other physician to agree that the patient lacks capacity to make the decision. e. Once the patient is determined not to have capacity to make the decision, the physician must discuss the situation with a designated surrogate or appointed proxy and document their agreement with the decision to withhold resuscitative measure. f. Documentation of the patient's capacity and condition should be recorded on the "Certification of Patient Capacity and Condition" at the end of this procedure. it is also acceptable to document the decision and determination of patient's capacity and condition in a dated and signed progress note on the patient's medical record.

2. DNR Order a. Orders written in accordance with this policy are to be respected and carried out by all Hospital Personnel b. Any order other than a DNR Order (e.g. Partial resuscitation, Chemical Code) is not allowed. Orders regarding specific resuscitative measures must be precisely stated in terms of specific modalities of therapy to be included or excluded and under what circumstances. Such an order should be fully reviewed with all involved health care workers. c. Once the DNR decision has been made, there must be a written order by the attending physician on the Physicians Order Sheet in the patient's medical record. d. A Telephone order for DNR may be accepted, provided all other requirements have been met. Telephone order for "Do Not Resuscitate" must be signed within 24 hours by the ordering physician. e. A DNR order may be accepted from the physician's designee who is taking calls for the attending physician. f. DNR orders will remain at all times with the working chart. If the chart is thinned, this order will not be put in the thinned portion. g. Communication of the DNR will be provided to all caregivers including other departments that may receive the patient for tests and procedures. Designation of DNR Status will be placed on the patient's medical record and Kardex.

3. Care of DNR Patient a. All patients, including those for whom a DNR Order has been written shall continue to receive appropriate medical care that has not been refused, as well as routine comfort care, support, privacy, counseling and comfort. b. DNR orders do not preclude other medical and/or nursing care such as providing comfort measures, providing pain relieving medications and care, maintaining adequate airway, providing medications as ordered and feedings. Withholding of any other medical orders must be specifically requested by patient or surrogate or proxy and written by the physician.

4. Temporary Suspension or Revocation of DNR Order a. Instances may arise when it is appropriate to temporarily suspend the DNR order. The physician should carefully explain the situation to the patient and/or designee in order to help them make a decision regarding temporarily suspending the order. Examples that may be cause for temporary suspension of a DNR order include: b. A temporary medical problem which is easily correctable JFK MEDICAL CENTER DEPARTMENT/OWNER: POLICY DESCRIPTION: Risk Management Do Not Resuscitate Page 7 of 10 REPLACES POLICY DATED: 5/09 EFFECTIVE DATE: 4/11 REFERENCE NUMBER: COMMITTEE APPROVAL: APPROVAL DATE: ADMINISTRATIVE APPROVAL: APPROVAL DATE:

c. Palliative surgery for a pathological fracture; or d. Surgery for an unrelated condition e. Since anesthesia itself or special procedures can induce significant cardiopulmonary compromise, suspension of DNR orders may be desirable for certain Surgical Procedures. The anesthesiologist and/or surgeon should discuss the specific anesthesia and surgical risk with the patient/patient's surrogate or proxy pre-operatively to ascertain whether the procedure can reasonably be undertaken despite maintenance of a DNR order, or whether a modification of the order is necessary. f. A DNR Order may be revoked at any time by the patient and/or designee by a signed dated writing or an oral expression of intent to revoke to the attending physician in the presence of another witness.

E. PROCEDURE FOR "REMOVING LIFE SUPPORT" - CALL DONOR REFERRAL HOTLINE AT 1-800-255-4483

1. Removal of a patient from the ventilator is one of the most difficult forms of withdrawing life-support and often requires more time for consideration than that of withholding CPR or other treatments that might prolong the dying process. Once the decision process has been made that the patient's condition is such that resuscitative measures should be withheld and documentation supports that decision, other life-prolonging procedures may be removed or withheld as deemed appropriate by the physician in consultation with the patient, patient's surrogate or designated proxy. Documentation of these decisions should be included in the progress notes of the patient's medical record and an order written to implement these measures.

2. The documentation of consent for the removal of life support may be found on the form "Physician Certification of Patient's Condition."

SPECIAL CIRCUMSTANCES

A. PATIENT'S WITHOUT ADVANCE DIRECTIVES AND IN PERSISTENT VEGETATIVE STATE

1. For persons in a persistent vegetative state, as determined by the attending physician, in accordance with currently accepted medical standards, who have no advance directive and for whom there is no evidence indicating what the person would have wanted under such conditions, and for whom, after a reasonably diligent inquiry, no family or friends are available or willing to serve as a proxy to make health care decisions for them, life-prolonging procedures may be withheld or withdrawn under the following conditions:

a. The person has a judicially appointed a guardian representing his or her best interest with authority to consent to medical treatment; and b. The guardian and the person's attending physician, in consultation with the clinical ethics committee of the facility where the patient is located, conclude that the condition is permanent and that there is no reasonable medical probability for recovery and that withholding or withdrawing life prolonging procedures is in the best interest of the patient.

2. The Clinical Ethics Committee shall review the case with the guardian, in consultation with the person's attending physician, to determine whether the condition is permanent and there is no reasonable medical probability for recovery. The individual committee members and the facility associated with the Clinical Ethics Committee shall not be held liable in any civil action related to the performance of any duties required in this subsection.

B. CONFLICT RESOLUTION JFK MEDICAL CENTER DEPARTMENT/OWNER: POLICY DESCRIPTION: Risk Management Do Not Resuscitate Page 8 of 10 REPLACES POLICY DATED: 5/09 EFFECTIVE DATE: 4/11 REFERENCE NUMBER: COMMITTEE APPROVAL: APPROVAL DATE: ADMINISTRATIVE APPROVAL: APPROVAL DATE:

1. Decisions concerning removing or withholding life support and/or resuscitative services (including CPR) from an individual are made by the patient in consultation with the Physician, Designated Surrogate or Appointed Proxy and Family Members. Nursing and Risk Management assistance may be requested when needed.

2. If conflicts in this decision-making process occur, the patient's wishes, if known, take precedent.

3. If the patient is not competent to state their decision regarding health care, conflicts will be settled with the designated surrogate or appointed proxy in the patient's absence. 4. If the conflict cannot be resolved, or if any involved member desires, a referral may be made to the Ethics Committee in accordance with the Ethics Committee Policy. 5. The patient's family, the Hospital, the Attending Physician or any other interested person who may reasonably be expected to be directly affected by the decision may seek expedited judicial intervention, if that person believes: a. The Surrogate's or Proxy's decision is not in accord with the patient's knowledge, desires or the provisions of the law. b. The advance directive is ambiguous, or the patient has changed his/her mind after execution of the Advance Directive. c. The Surrogate or Proxy was improperly designated or appointed or the designation of the Surrogate is no longer effective. d. the surrogate or proxy has failed to discharge duties, or incapacity or illness renders the surrogate or proxy incapable of discharging duties. e. The surrogate or proxy has abused powers f. The patient has sufficient capacity to make his or her own health care decisions.

C. TRANSFER OF A PATIENT

1. An attending physician who because of moral or ethical standards refuses to comply with the living will of a patient or the treatment decision of a surrogate or proxy lawfully authorized to make such decisions, shall make a reasonable effort to transfer the patient to another physician or health care facility.

2. If the patient has not been transferred within seven days following the decision to withdraw or withhold life- prolonging procedures, the attending physician or the Hospital shall carry out the wishes of the patient.

ROLES OF HEALTH CARE WORKERS IN CARE OF THE PATIENT AT THE END OF LIFE

All care providers will assist patient and/or designated decision makers with decisions and needs of the patient at the end of life. Concern for the patient's comfort and dignity will be the primary concern through all aspects of end of life care. Considerations of the patient and/or family's psychological, social, emotional, spiritual and cultural preferences will be used in any decisions for appropriate care.

A. PHYSICIAN

The attending physician is responsible for consultation and discussion with the patient and family and/or family regarding end-of-life decisions. The decision to withhold or withdraw life support including the decision to withhold CPR is ultimately between the physician and the patient and/or designated representatives. It is the responsibility of the Attending Physician to determine the appropriateness of withholding or withdrawing life-prolonging procedures including resuscitative measures. JFK MEDICAL CENTER DEPARTMENT/OWNER: POLICY DESCRIPTION: Risk Management Do Not Resuscitate Page 9 of 10 REPLACES POLICY DATED: 5/09 EFFECTIVE DATE: 4/11 REFERENCE NUMBER: COMMITTEE APPROVAL: APPROVAL DATE: ADMINISTRATIVE APPROVAL: APPROVAL DATE:

The physician is responsible for completing required documentation in the medical record, using the appropriate forms and written orders.

B. NURSING

1. Nursing is the patient advocate and responsible for coordinating efforts to comply with the patient's wishes regarding end of life care. The nurse will assist the patient, family, surrogate, proxy and any other significant other person in the implementation of decisions regarding end of life care decision. 2. Nursing will facilitate communication with the physician, Case Management/Social Workers, Pastoral Services, Hospice and any other supporting agencies to assist patient, family and designated decision makers in implementing the wishes of the patient. 3. Nursing will assess pain levels with the patient and/or designated decision makers and institute comfort measures during the end of life hospitalization. The patient's right to pain management will be respected and supported. 4. Nursing will discuss with patient and/or designated decision-makers any end-of-life decisions regarding treatments, procedures, organ donation, and autopsy to determine patient and family wishes and methods to ease the implementation of these decisions. 5. Communicate to the Physician any revocation or changes of attitude regarding health care decisions.

C. OTHER CLINICAL AND SUPPORT PERSONNEL 1. Case Management may be consulted as needed to assist with the following care: a. Offering pastoral services by contacting appropriate community religious affiliations b. Contacting appropriate resources for family when needed (i.e. Hospice, Home Health Organizations) c. Discussing and/or assisting in making final arrangements with supportive counseling 2. Case Management should maintain contact with Nursing Personnel to review patient, family, surrogate or proxy needs.

D. CLERGY The patient and his/her family will be offered the opportunity to receive pastoral support. At the patient's or family request, the Clergy will be notified in order to provide spiritual counseling. The extent of spiritual counseling provided will be determined by the patient and/or family. The Clergy may visit the patient and families as needed as there are open visiting hours.

E. RISK MANAGEMENT JFK MEDICAL CENTER DEPARTMENT/OWNER: POLICY DESCRIPTION: Risk Management Do Not Resuscitate Page 10 of 10 REPLACES POLICY DATED: 5/09 EFFECTIVE DATE: 4/11 REFERENCE NUMBER: COMMITTEE APPROVAL: APPROVAL DATE: ADMINISTRATIVE APPROVAL: APPROVAL DATE:

Risk Management Department will provide consultation with the physician, hospital staff, and patient/patient representatives regarding the “Advance Directive Statute, Hospital Policy and avenues for resolving conflicts regarding end-of-life decisions.

F. CLINICAL ETHICS COMMITTEE Any conflicts that can be resolved by hospital personnel, physicians and family may be referred to the Clinical Ethics Committee using the Ethics Policy and Consultation Procedure.

Developed: 7/97 Reviewed: 10/07, 5/09 Revised: 3/00, 4/03, 5/05, 4/11 Owner: Director of Risk Management