PATIENT RIGHTS

Joint Commission on Accreditation of Healthcare Organizations

1994

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Patient Rights is a section of the Joint Commission on Accreditation of Healthcare Organizations' (JCAHO) Accreditation Manual for Hospitals, 1994. Although many healthcare organizations demonstrate their recognition and support of patient/client rights by issuing lists of those rights, no list can assure that the rights are respected. The standards on patient rights included in JCAHO's Accreditation Manual are designed to reflect the implementation, as well as the existence, of institutional policies and procedures for the exercise and protection of a specified set of patient rights.

The scoring of the standards in this chapter will reflect evidence of the implementation of policies and procedures as well as the existence of such policies and procedures.

RI.1 The organization supports the rights of each patient.

RI.1.1 Organizational policies and procedures describe the mechanisms by which the following rights are protected and exercised:

Intent of RI.1 and RI.1.1

The policies and procedures that guide the organization's interaction with and care of the patient demonstrate its recognition and support of patient rights.

No listing of patient rights can assure the respect of those rights. It is the intent of these standards that the organization's interaction with and care of the patient reflect concern and respect for the rights of the patient.

The organization's policies and procedures describe the mechanisms or processes established to support the following patient rights:

• Reasonable access to care;
• Considerate (and respectful) care that respects the patient's personal value and belief systems;
• Informed participation in decisions regarding his/ her care;
• Participation in the consideration of ethical issues that arise in the provision of his or her care;
• Personal privacy and confidentiality of information;
• Designation of a representative decision maker in the event that the patient is incapable of understanding a proposed treatment or procedure or is unable to communicate his/her wishes regarding care.

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RI.1.1.1 [Organizational policies and procedures describe the mechanisms by which the following rights are protected and exercised:] The right of the patient to the hospital's reasonable response to his/her requests and needs for treatment or service, within the hospital's capacity, its stated mission, and applicable law and regulation;

Intent of RI.1.1.1

In response to the patient's request and need, the organization provides care that is within its capacity, its stated mission and philosophy, and applicable law and regulation. When the organization cannot meet the request or need for care because of a conflict with its mission or philosophy or incapacity to meet the patient's needs or requests, the patient may be transferred to another facility when medically permissible. Such a transfer is made only after the patient has received complete information and explanation concerning the need for and alternatives to such a transfer. The transfer must be acceptable to the receiving organization.

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RI.1.1.2 [Organizational policies and procedures describe the mechanisms by which the following rights are protected and exercised:] The right of the patient to considerate and respectful care;

RI1.1.2.1 The care of the patient includes consideration of the psychosocial, spiritual, and cultural variables that influence the perceptions of illness.

Intent of RI.1.1.2 and RI.1.1.2.1

The provision of patient care reflects consideration of the patient as an individual with personal values and a belief system that impact his/her attitude toward and response to the care provided by the organization. The organizational policies and procedures that guide patient care include recognition of the psychosocial, spiritual, and cultural values that affect the patient's response to the care given. Organizational policies and procedures allow the patient to express spiritual beliefs and cultural practices that do not harm others or interfere with the planned course of medical therapy for the patient.

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RI.1.1.2.2 The care of the dying patient optimizes the comfort and dignity of the patient through

RI.1.1.2.2.1 treating primary and secondary symptoms that respond to treatment as desired by the patient or surrogate decision maker;

RI.1.1.2.2.2 effectively managing pain; and

RI.1.1.2.2.3 acknowledging the psychosocial and spiritual concerns of the patient and the family regarding dying and the expression of grief by the patient and family.

NOTE: The term dying is used to refer to an incurable and irreversible condition such that death is imminent. Imminent is seen as impending or about to happen.

Intent of RI.1.1.2.2 Through RI.1.1.2.2.3

All hospital staff are sensitized to the needs of the dying patient in an acute care hospital. Support for the psychological, social, emotional, and spiritual needs of the patient and family demonstrates respect for the patient's values, religion, and philosophy. The goal of respectful, responsive care of the dying patient is to optimize the patient's comfort and dignity by providing appropriate treatment for primary and secondary symptoms as desired by the patient or surrogate decision maker, responding to the psychosocial, emotional, and spiritual concerns of the patient and family, and managing pain aggressively. (The management of pain is appropriate for all patients, not just dying patients. Guidelines such as those published by the Agency for Health Care Policy and Research for Acute Pain Management reflect the state of knowledge on effective and appropriate care for all patients experiencing acute pain.)

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RI.1.1.3 [Organizational policies and procedures describe the mechanisms by which the following rights are protected and exercised:]The right of the patient, in collaboration with his/her physician, to make decisions involving his/her health care, including

RI.1.1.3.1 the right of the patient to accept medical care or to refuse treatment to the extent permitted by law and to be informed of the medical consequences of such refusal, and

RI.1.1.3.2 the right of the patient to formulate advance directives and appoint a surrogate to make health care decisions on his/her behalf to the extent permitted by law.

RI.1.1.3.2.1 The organization has in place a mechanism to ascertain the existence of and assist in the development of advance directives at the time of the patient's admission.

RI.1.1.3.2.2 The provision of care is not conditioned on the existence of an advance directive.

RI.1.1.3.2.3 Any advance directive(s) is in the patient's medical record and is reviewed periodically with the patient or surrogate decision maker.

Intent of RI.1.1.3 Through RI.1.1.3.2.3

The quality of patient care is enhanced when the patient's preferences are incorporated into plans for care. The process by which care and treatment decisions are made elicit respect and incorporate the patient's preferences. Sound medical judgment is provided to the patient or the patient's surrogate decision maker for informed decision making.

In hospitals providing services to neonate, child, and adolescent patients, a mechanisms exists that is designed to coordinate and facilitate the family's and/or guardian's involvement in decision making throughout the course of treatment. The patient is responsible for providing, to the best of his/her knowledge, accurate and complete information about present complaints, past illnesses, hospitalizations, medications, advance directives, and other matters relevant to his/her health or care. The patient is also responsible for reporting whether he/she clearly comprehends a contemplated course of action and what is expected of him/her.

The hospital ascertains the existence of advance directives, and health care professionals and surrogate decision makers honor them within the limits of the law and the organization's mission and philosophy. An advance directive is a document a person uses to give directions about future medical care or to designate another person to give directions about medical care should he/she lose decision-making capacity. Advance directives may include living wills, durable powers of attorney, or similar documents and contain the patient's preferences.

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RI.1.1.4 [Organizational policies and procedures describe the mechanisms by which the following rights are protected and exercised:] The right of the patient to the information necessary to enable him/her to make treatment decisions that reflect his/ her wishes;

RI.1.1.4.1 A policy on informed decision making is developed by the medical staff and governing body and is consistent with any legal requirements.

Intent of RI.1.1.4 and RI.1.1.4.1

The patient is given clear, concise explanation of his/her condition and of any proposed treatment(s) or procedure(s), the potential benefit(s) and the potential drawback(s) of the proposed treatment(s) or procedure(s), problems related to recuperation, and the likelihood of success. Information is also provided regarding any significant alternative treatment(s) or procedure(s).

This information includes the identity of the physician or other practitioner who has primary responsibility for the patient's care and the identity and professional status of individuals responsible for authorizing and performing procedures or treatments. The information also includes the existence of any professional relationship among individuals treating the patient, as well as the relationship to any other health care or educational institutions involved in his/ her care.

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RI.1.1.5 [Organizational policies and procedures describe the mechanisms by which the following rights are protected and exercised:] The right of the patient to information, at the time of admission, about the hospital's

RI.1.1.5.1 patient rights policy(ies), and

RI.1.1.5.2 mechanism designed for the initiation, review, and, when possible, resolution of patient complaints concerning the quality of care;

Intent of RI.1.1.5 through RI.1.1.5.2

The organization assists the patient in exercising his/her rights by informing the patient of those rights during the admission process. The information is given to the patient or his/her representative in a form that is understandable to the patient (for example, in a language that is understood by the patient).

The patient has the right, without recrimination, to voice complaints regarding the care received, and to have those complaints reviewed and, when possible, resolved. This right, and the mechanism(s) established by the organization to assist the patient in exercising this right, are explained to the patient during the admission process.

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RI.1.1.6 [Organizational policies and procedures describe the mechanisms by which the following rights are protected and exercised:] The right of the patient or the patient's designated representative to participate in the consideration of ethical issues that arise in the care of the patient;

RI.1.1.6.1 The organization has in place a mechanism(s) for the consideration of ethical issues arising in the care of patients and to provide education to caregivers and patients on ethical issues in health care.

Intent of RI.1.1.6 and RI.1.1.6.1

Health care professionals provide patient care within an ethical framework established by their profession, the hospital, and the law. The health care professional has an obligation to respect the views of the patient or the patient's designated representative when ethical issues arise during the patient's care. Moreover, the hospital has an obligation to involve the patient or the patient's representative in the organizational mechanism for considering such issues. Such mechanisms may include community programs, education programs for patients or their representatives, and education programs for staff members. The hospital also has an obligation to provide education on important ethical issues in health care to caregivers, care recipients, and the community.

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RI.1.1.7 [Organizational policies and procedures describe the mechanisms by which the following rights are protected and exercised:] The right of the patient to be informed of any human experimentation or other research/educational projects affecting his/her care or treatment;

Intent of RI.1.1.7

The patient has the right to know of any experimental, research, or educational activities involved in his/her treatment: the patient also has the right to refuse to participate in any such activity.

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RI.1.1.8 [Organizational policies and procedures describe the mechanisms by which the following rights are protected and exercised:] The right of the patient, within the limits of law, to personal privacy and confidentiality of information; and

RI.1.1.8.1 The patient and/or the patient's legally designated representative has access to the information contained in the patient's medical record, within the limits of the law.

Intent of RI.1.1.8 and RI.1.1.8.1

The patient has the following rights:

• To be interviewed, examined, and treated in surroundings designed to give reasonable visual and auditory privacy;
• To have access to his/her medical record and to have his/her medical record read only by individuals directly involved in his/her care, or by individuals monitoring the quality of the patient's care, or by individuals authorized by law or regulation (other individuals may read the medical record only with the patient's written consent or that of a legally authorized or designated representative); and
• To request a transfer to a different room if another patient or a visitor in the room is unreasonably disturbing him/her and if another room equally suitable for his/her care needs is available.

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RI.1.1.9 [Organizational policies and procedures describe the mechanisms by which the following rights are protected and exercised:] The right of the patient's guardian, next of kin, or a legally authorized responsible person to exercise, to the extent permitted by law, the rights delineated on behalf of the patient if the patient has been adjudicated incompetent in accordance with the law, is found by his/her physician to be medically incapable of understanding the proposed treatment or procedure, is unable to communicate his/her wishes regarding treatment, or is a minor.

Intent of RI.1.1.9

Although the patient is recognized as having the right to participate in his/her care and treatment to the fullest extent possible, there are circumstances under which the patient may be unable to do so. In these situations, the patient's rights are to be exercised by the patient's designated representative or other legally authorized person.

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RI.2 There are hospital-wide policies on the withholding of resuscitative services from patients and the forgoing or withdrawing of life-sustaining treatment.

Intent of RI.2

No single set of policies can anticipate the varied situations in which the difficult decisions about withholding resuscitative services or forgoing or withdrawing life-sustaining treatment will need to be made. However, organizations can develop the framework for a decision-making process. Such a framework would include policies designed to assist the organization in identifying its position on the initiation of resuscitative services and the use and removal of life-sustaining treatment. Policies of this nature need to conform to the legal requirements of the organization's jurisdiction.

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RI.2.1 The policies are developed in consultation with the medical staff, nursing staff, and other appropriate bodies and are adopted by the medical staff and approved by the governing body.

Intent of RI.2.1

Organizational policies that provide a framework for the decision-making process for withholding resuscitative services or forgoing or withdrawing life-sustaining treatment offer guidance to health professionals on the ethical and legal issues involved in such decisions and decrease the uncertainty about the practices permitted by the organization. It is vital that the policies guiding such decisions be formally adopted by the organization's medical staff and approved by the governing body in order to assure that the process is consistent and that there is accountability for the decisions made.

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RI.2.2 The policies describe

RI.2.2.1 the mechanism(s) for reaching decisions about the withholding of resuscitative services from individual patients or forgoing or withdrawing of life-sustaining treatment;

RI.2.2.2 the mechanism(s) for resolving conflicts in decision making, should they arise; and

RI.2.2.3 the roles of physicians and, when applicable, of nursing personnel, other appropriate staff, and family members in decisions to withhold resuscitative services or forgo or withdraw life-sustaining treatment.

Intent of RI.2.2 through RI.2.2.3

Organizational policies regarding the withholding of resuscitative services or the forgoing or withdrawing of lifesustaining treatment outline a process for reaching such decisions. This process protects the decision-making rights of the patient or his/her designated representative; decreases staff uncertainty about practices permitted by the organization; clarifies the roles and duties, and therefore the accountability, of health professionals; and reduces arbitrary decision-making procedures.

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RI.2.3 The policies include provisions designed to assure that the rights of patients are respected.

Intent of RI.2.3

Organizational policies regarding the withholding of resuscitative services or the forgoing or withdrawing of lifesustaining treatment empower the patient or designated representative to make such decisions and assure that such decisions made by a patient or designated representative explicitly affirm the patient's responsibility for such decision making.

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RI.2.4 The policies include the requirement that appropriate orders be written by the physician primarily responsible for the patient and that documentation be made in the patient's medical record if life-sustaining treatment is to be withdrawn or resuscitative services are to be withheld.

Intent of RI.2.4

Decisions regarding the withholding of resuscitative services or the withdrawal of life-sustaining treatment are communicated to all health professionals involved in the patient's treatment to assure that the decision is implemented.

NOTE: This does not mean that for all deaths in which resuscitative services were not utilized there must be an order to withhold resuscitative services.

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RI.2.5 The policies address the use of advance directives in patient care to the extent permitted by law.

Intent of RI.2.5

The organization is expected to use any advance directives prepared by the patient and known to the organization in the decision-making process surrounding the consideration of the withholding of resuscitative services or the initiation or withdrawal of life-sustaining treatment, to the extent permitted by law and supported by the organization's mission and philosophy.

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