The Patient Self-Determination Act (PDSA) was proposed in 1990 and amended titles XVIII and XIX of the Social Security Act (Medicare and Medicaid, respectively). The PSDA requires hospitals, skilled nursing facilities, hospice organizations, home health organizations, and health maintenance organizations to perform several specific actions and to ensure that certain conditions are met. Among the requirements listed above is that patients be informed of their right to participate in decisions about the medical care they receive. It is also required that the patient be asked about advanced directives and any wishes they may have regarding the care they want or do not want be documented. It required that no healthcare organization discriminate against any patient submitting advanced directives. It requires the implementation of advanced patient directives if necessary, assuming those wishes are legally valid and permissible under state law. It necessitates education programs covering advanced directives, bioethics, patient preferences, and patient self-determination. The PDSA went on to direct the Secretary of the U.S. Department of Health and Human Services to coordinate an investigation into the implementation of advanced directive decisions. PDSA was also asked to develop and implement projects in specific locations nationwide to raise awareness of patient rights regarding advanced directives and execution.
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The bill is described in the legislative portion of the 101st Congress as follows:
“To amend Social Security Act titles XVIII and XIX to require providers of services and health maintenance organizations under the Medicare and Medicaid programs to ensure that individuals receiving services have the opportunity to participate in and direct health care decisions affecting themselves.
IN THE REPRESENTATIVE HOUSE
Mr. LEVIN of Michigan (for himself, Mr. SWIFT, Mr. MOODY, Mr. MCDERMOTT, and Mr. FAUNTROY) introduced the following bill on April 3, 1990, which was referred to the Ways and Means and Energy and Commerce Committees jointly. A BILL To amend Social Security Act titles XVIII and XIX to require providers of services and health maintenance organizations under the Medicare and Medicaid programs to ensure that individuals receiving services have the opportunity to participate in and direct health care decisions affecting themselves. Be it enacted by the United States Senate and House of Representatives in Congress assembled,
Section 1. SUMMARY. The ‘Patient Self-Determination Act of 1990’ may be cited.
SECTION 2: MEDICARE PROVIDER AGREEMENTS THAT ENSURE A PATIENT’S RIGHT TO PARTICIPATE IN AND DIRECT HEALTH CARE DECISIONS AFFECTING THE PATIENT.
(a) IN GENERAL- Section 1866(a)(1) of the Social Security Act (42 U.S.C. 1395cc(a)(1)), as amended by section 6112 of the Omnibus Budget Reconciliation Act of 1989, is amended as follows: (1) by striking ‘and’ at the end of subparagraph (O), (2) by striking the period at the end of subparagraph (P) and inserting ‘, and,’ and (3) by inserting after subparagraph (P) ‘(Q) in the case of hospitals, skilled nursing facilities, home health agencies, and hospice programs, to maintain written policies and procedures to all individuals receiving medical care by or through the provider— I to inform such individuals of their rights under State law (whether statutory or as recognized by the courts of the State) to make decisions concerning such medical care, including the right to accept or refuse medical or surgical treatment.
(b) APPLICATION TO HEALTH MAINTENANCE ORGANIZATIONS- Section 1876(c) of such Act (42 U.S.C. 1395mm(c)) is amended by adding at the end the following new paragraph: ‘(8) A contract under this section shall provide that the eligible organization shall meet the requirements of section 1866(a)(1)(Q) in the same manner as they apply to hospitals.’. (1) The amendments made by subsection (a) apply to services provided on or after the first day of the first month beginning more than 180 days after the date of the enactment of this Act. (2) The amendment made by subsection (b) applies to contracts made under section 1876 of the Social Security Act on the first day of the first month beginning more than 180 days after the date of this Act’s enactment.
SECTION 3: MEDICAID STATE PLANS THAT ENSURE A PATIENT’S RIGHT TO PARTICIPATE IN AND DIRECT HEALTH CARE DECISIONS AFFECTING THE PATIENT.
(a) IN GENERAL- Section 1902(a) of the Social Security Act (42 U.S.C. 1396a(a)), as amended by section 6406(a) of the Omnibus Budget Reconciliation Act of 1989, is amended by striking ‘and’ at the end of paragraph (52), (2) striking the period at the end of paragraph (53) and inserting ‘; and,’ and (3) inserting the following new paragraph after paragraph (53): ‘(54) require that each hospital, nursing facility, home health agency, hospice program, or health maintenance organization receiving plan funds maintain written policies and procedures governing all individuals receiving medical care from or through the provider or organization. — ‘(A) to inform such individuals of an individual’s rights under State law (whether statutory or as recognized by the State courts) to make decisions concerning such medical care, including the right to accept or refuse medical or surgical treatment and the right to formulate advanced directives recognized under State law relating to the provision of care when such individuals are incapacitated (such a directive is referred to in this paragraph as an ‘advanced dire
(b) EFFECTIVE DATE- The amendments made by subsection (a) shall apply to services provided on or after the first day of the first month beginning more than 180 days after the date of this Act’s enactment.
Section 4: STUDY TO EVALUATE THE IMPLEMENTATION OF A PATIENT’S RIGHT TO PARTICIPATE IN AND DIRECT HEALTH CARE DECISIONS THAT AFFECT THE PATIENT. (a) IN GENERAL- Subject to subsection (b), the Secretary of Health and Human Services shall agree with the Institute of Medicine of the National Academy of Sciences to conduct a study on implementing directed health care decisions. Such research shall: (1) evaluate the experience of practitioners, providers, and government regulators in complying with the requirements imposed by the amendments made by sections 2(a) and 3(a); and (2) investigate methods of making decisions reached by a patient or nursing home resident transferrable so that the patient’s or resident’s wishes can be known and respected in other health care settings to which the patient or resident may be transferred or relocated.
(b) STUDY ARRANGEMENTS- The Secretary shall request that the National Academy of Sciences’ Institute of Medicine apply to conduct the study described in subsection (a). If the Institute submits an acceptable application, the Secretary shall enter into an appropriate arrangement with the Academy for the conduct of the study within 28 days of the date the application is received. If the Institute does not submit an acceptable application to conduct the study, the Secretary may request one or more appropriate nonprofit private entities to apply to conduct the study and may enter into an appropriate arrangement for the conduct of the study by the entity which submits the best acceptable application.
(c) REPORT- The study results shall be reported to Congress and the Secretary no later than four years after the enactment of this Act. Such report shall include any legislative recommendations necessary to carry out the purposes of this Act.
Section 5. PUBLIC EDUCATION DEMONSTRATION PROJECT. No later than six months after the date of enactment of this Act, the Secretary of Health and Human Services shall develop and implement a demonstration project in selected States to inform the public of the option to execute advance directives and a patient’s right to participate in and direct health care decisions. The Secretary shall report to Congress on the project’s results and whether the project should be expanded to include all states.”  
Go to: Concerning Issues
The passage of this amendment raised several issues. Individual physicians were concerned at the time about accusations of assisting suicide if withdrawing IV fluids, feeding tubes, and so on because it was unclear how the law would treat any subsequent accusations against those attempting to implement the PSDA into their clinical practice. There was concern about malpractice liability if implementing patient wishes proved difficult. There was concern that physicians would have to adjust their moral compass, treating patients in ways they had not previously. There was concern that other people, from family and friends to insurance companies, would intervene and prevent a physician from carrying out a patient’s wishes or advanced directives. Many of these concerns have been addressed as the amendment approaches its 30th anniversary. Nonetheless, the dynamic State of healthcare delivery raises new concerns and complexities.   
Go to: Clinical Importance
The PSDA has multiple clinical implications. It took an official position on advanced directives and the requirement to inform patients of their legal rights. It allows patients to participate in the decision-making process regarding their healthcare delivery. It aimed to avoid over- and under-treatment by determining a patient’s specific wishes and having those wishes carried out if they could not dictate their wishes in real time due to incapacity. It also aimed to reduce costs by allowing patients to choose or decline costly critical care/I.C.U. interventions in the face of certain death from a terminal illness or catastrophic injury. The PSDA remains controversial in its implementation and successes nearly 30 years after its acceptance. Nonetheless, the innovative amendment transformed healthcare for millions of people, including patients, their families, and healthcare providers.  
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The interprofessional team, which includes clinicians and nurses, has an ethical obligation to ensure that patients know and understand their healthcare-related rights. It is possible that providing a holistic and integrated approach will result in better outcomes for the patient and their family in terms of comprehension. The PSDA has numerous applications in nursing, both in terms of actions and interventions. Understanding the PSDA legislation and how it applies to patients’ and nursing staff care will improve the quality of both care and communication.
The Patient Self-Determination Act (PSDA) was implemented to allow patients to state “Do Not Resuscitate” (DNS), or to assign a surrogate decision maker in the event that the individual is unable to make the decision. What relationship does an ethics committee have in enforcing the advance directives of the patients in their care? Support your analysis with a minimum of one peer-reviewed article.