OBER|KALER Attorneys at Law Maryland Attorney General's Office
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VII.   INSTRUCTIONS ON CURRENT LIFE-SUSTAINING TREATMENT OPTIONS
  1. Instructions on Current Life-Sustaining Treatment Options Form10
    1. Within a reasonably prompt time from a Resident's admission, the Resident (or the Resident's Agent or surrogate) will be asked if he or she wishes to state preferences about relevant life-sustaining issues on a Instructions on Current Life-Sustaining Treatment Options Form. The Instructions on Current Life-Sustaining Treatment Options Form is provided as Attachment J.
    2. A completed Instructions on Current Life-Sustaining Treatment Options Form will be placed on the Resident's medical records. It will be maintained visibly at the front of the Resident's active chart.
    3. A completed Instructions on Current Life-Sustaining Treatment Options Form will be reviewed after any significant change in the Resident's condition, as determined by the Attending Physician.
    4. The purpose of the Instructions on Current Life-Sustaining Treatment Options Form is to provide a Resident with a standardized method of summarizing and communicating his or her preferences relating to life-sustaining procedures. It does not change or amend any of the other policies discussed in this manual, i.e., the requirements of an advance directive, or the authority of a surrogate decision maker, etc.
    5. The Instructions on Current Life-Sustaining Treatment Options Form is not a physician's order. Therefore, it cannot serve as a DNR Order or an Advance Directive. However, where appropriate, actions to obtain a DNR Order or Advance Directive should be taken promptly based on choices made on the Instructions on Current Life-Sustaining Treatment Options Form. This may include prompt actions to confirm an individual's status and authority as a surrogate or as an Agent, or to obtain necessary physician determinations to implement the instructions on the form.
    6. Only the form provided in Attachment J may be used as the Instructions on Current Life-Sustaining Treatment Options Form11. No alterations to the form may be made and the form should be reproduced as a two-sided, single sheet of paper.
  2. Voluntary Use of the Form
    1. The use of the Instructions on Current Life-Sustaining Treatment Options Form by the Resident, or the Resident's Agent or surrogate, is completely voluntary. The Resident, or the Resident’s Agent or Surrogate, may decline use of the form altogether. If the Resident, or the Resident’s Agent or Surrogate, decides to use the form as a means of stating preferences, the health care professional who is assisting the process should direct attention to those parts of the form for which a decision is currently appropriate and useful. The Resident, or the Resident’s Agent or Surrogate, should not be invited to complete parts of the form unrelated to the Resident’s current condition. If the Resident’s condition changes significantly, the form should be updated at that time.
    2. A decision by a competent Resident, or the Resident's Agent or surrogate, to decline the use of the Instructions on Current Life-Sustaining Treatment Options Form will be documented in the Resident's medical record. A form for this purpose is provided as Attachment K.
  3. Preparation of the Instructions on Current Life-Sustaining Treatment Options Form.
    1. A Resident, or a Resident's Agent or surrogate, who is considering use of the Instructions on Current Life-Sustaining Treatment Options Form will be offered assistance by the Resident's Attending Physician or another health care provider who:
      1. Has been determined by the Attending Physician to have the knowledge and skills to properly conduct a discussion about the form; and
      2. Acts under the general direction of the Attending Physician.
    2. If the Resident has an Advance Directive, it will be attached to the Instructions on Current Life-Sustaining Treatment Options Form.

      3. When a Resident's Agent or surrogate completes the Instructions on Current Life-Sustaining Treatment Options Form on behalf of a Resident, who has an Advance Directive in his or her medical records, the Attending Physician or other health care provider will take reasonable steps to ensure that entries made by the Resident's Agent or surrogate on the Instructions on Current Life-Sustaining Treatment Options Form are consistent with the Advance Directive. In the event that the instructions of an Agent or surrogate are inconsistent with those contained in a clear, unambiguous and applicable Advance Directive, the Attending Physician or other health care provider will inform the Agent or surrogate of the legal obligation to follow the instructions created by the Resident and memorialized in the Advance Directive. If there is a continuing dispute, the issue may need to be referred to the Facility’s Patient Care Advisory Committee or to court.

    3. A Resident, or the Resident's Agent or surrogate, who completes any part of the Instructions on Current Life-Sustaining Treatment Options Form will initial that part of the Form. In addition, the Form must be signed by:
      1. The Resident, or the Resident's Agent or surrogate;
      2. The Resident's Attending Physician; and
      3. If another health care provider prepared the form in accordance with Section VIII.C.1, the health care provider.
    4. A health care provider may initial a part of the Form or sign the Form on behalf of the Resident, Resident's Agent or surrogate, if all of the following conditions apply:
      1. The Resident, Resident's Agent or surrogate is unable to initial or sign personally;
      2. The Resident, Resident's Agent or surrogate expressly directs the health care provider to initial or sign the Form on his or her behalf; and
      3. The health care provider documents the circumstances in the Resident's medical record.
  4. Transfer of a Resident
    1. A completed and unaltered copy of the Instructions on Current Life-Sustaining Treatment Options Form will be included in the records that physically accompany a Resident who is transferred to another health care facility.
    2. In the event the Facility is unable to include the Instructions on Current Life-Sustaining Treatment Options Form in the records that physically accompany the Resident, the Facility (or the Attending Physician) will promptly transmit by facsimile or electronic means a complete and unaltered image of the form to the other health care facility.
    3. When the Facility receives an Instructions on Current Life-Sustaining Treatment Options Form for a Resident transferred from another facility, the Facility will make the Form available for review by the Resident's Attending Physician.

    The Maryland Attorney General's Office has issued three explanatory guides relating to the use of the Instructions on Current Life-Sustaining Treatment Options form, including guides for health care professionals, patients and proxies. See:

    The former Patient's Plan of Care Form and the Instructions on Current Life-Sustaining Treatment Options Form do not expand a surrogate's decision-making authority over life-sustaining treatments. Two advice letters issued by the Maryland Attorney General's Office regarding the former Patient's Plan of Care Form discuss this point: www.marylandadvancedirectives.com/pdf/advice-hubbard-102505.pdf and www.marylandadvancedirectives.com/pdf/advice-bob-110805.pdf

10 Effective April 1, 2008, the "Instructions on Current Life-Sustaining Treatment Options" Form replaced the former "Patient's Plan of Care" Form. 2007 Md. Laws, ch. 70.
11 The Maryland Attorney General regulations relating to the Instructions on Current Life-Sustaining Treatment Options Form, COMAR 02.06.03, require use of the form as provided in the regulations. The Facility is not permitted to alter the contents or format of the form, other than to include additional identifying information about the Resident and, for that purpose, to modify the spacing.

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