JCAHO Requirements for Advance Directives

The Joint Commission (TJC, formerly known as JCAHO) is a nationwide organization that issues accreditations to various types of health care facilities. For an organization to achieve Joint Commission accreditation, it must adhere to hundreds of points of performance that fall under larger standards (or requirements). Each chapter of the Joint Commission’s manual contains detailed instructions on how to comply with these standards, including requirements for advance directives.

Advance Directives

• Advanced directives are defined by the Joint Commission as “A document or documentation allowing a person to give directions about future health care or to designate another person(s) to make health care decisions if the individual loses decision-making capacity. Advance directives may include living wills, durable powers of attorney, do-not-resuscitate (DNR), right-to-die documents, or similar documents listed in the Patient Self-Determination Act that express the person's preferences.”

  Health care providers are required to make themselves familiar with a patient's advance directives.

Policies

• The Joint Commission requires that the hospital has detailed policies on advance directives that fall in line with state and federal laws and regulations. Included in this policy is the hospital’s declaration that it will comply with advanced directives and if it will also honor them in the outpatient setting.

Patient Education

• The Joint Commission mandates that patients be offered educational materials on advanced directives when they are admitted. If patients choose to formulate their advanced directives at that time, the hospital will provide them with assistant to do so. Patients are allowed to revise them at any time, and the hospital must comply with those changes.

Documentation

• The Joint Commission requires documentation of a patient's advance directives, all the steps taken to ensure the patient is aware of her rights and any decisions made by the patient. They also require documentation regarding the patient's requests regarding organ donations.