Medical Directives

Service: Risk Management
Subject: Care
Type: Risk Notes

Overview of Issue

Medical directives are written orders from healthcare providers for the performance of treatments, interventions or procedures on particular patients when specific conditions and circumstances are met. Medical directives rely on the collaboration between regulated health professionals and administrators. They are intended to optimize patient care (timely, effective, efficient, and of the highest quality). Medical directives order the performance of the treatments, interventions or procedures that are specified in them. The delegating physicians (MDs) and nurse practitioners (NPs) remain the most responsible practitioners (MRPs) for the patient care provided pursuant to medical directives. As such, they must be fully aware of, and approve, the medical directives’ content in order to ensure their safe and effective implementation. HIROC’s claims reveal, that medical directives pose risks to patient safety and may result in civil liability when they are: drafted too vaguely or without sufficient precision; used as substitutes for direct (and timely) assessment by MDs and NPs; used for economic considerations or convenience or administrative expediency. Poorly drafted and implemented medical directives have resulted in multi-million dollar settlements being paid on behalf of HIROC subscribers.

Key Points

  • Implementers of medical directives are not ordering a treatment - they are implementing an authorizer’s order for a treatment.

Things to Consider

Medical Directives

  • Defined as the delegation of controlled acts from regulated health professionals with the authority to perform them to regulated/unregulated health professionals who are not independently authorized to perform them.
  • Require healthcare providers who enact medical directives to acquire and maintain specified levels of knowledge, skill and judgment.
  • Require each MD and NP whose patients will receive care pursuant to the medical directive to agree with its contents and sign-off on it.
  • Are utilized only in the best interests of the patient.
  • Are always written, using simple, clear, concise and precise language.
  • Clearly define what will be implemented.
  • Reflect the best available evidence and the best medical practice.
  • Require an institutionally standardized development and approval process.
  • Require all staff (including float pool/agency nurses) to be made aware of the existing medical directives and the need to implement them when they are indicated/ triggered.
  • While regulatory accountability rests with the ordering MDs and NPs, civil liability almost certainly will rest with the institution.

Essential Medical Directive Components

  • The name and a description of the procedure, treatment or intervention being ordered.
  • An outline of what will be performed, by whom, under what conditions and circumstances.
  • A list of the contraindications to its implementation.
  • The specifics of the patients to whom it will apply.
  • The assessment processes and resources necessary to safely enact it.
  • The individuals and entities that approved its content, authorized/approved its use, and who are assuming responsibility for it.

The Physician / Nurse Practitioner Authorizing a Medical Directive

  • Thoroughly reviews and analyzes the medical directive and ensures that it does not increase the risk to his/ her patients.
  • Must be satisfied that each individual implementing the medical directive has the knowledge, skill and judgment to perform the act.
  • Fully appreciates the circumstances and conditions under which it will be implemented.
  • Is ultimately responsible for the care of the patients who have procedures, treatments or interventions performed pursuant to it.
  • Must sign the medical directive.

The Healthcare Provider Implementing a Medical Directive

  • Has acquired and maintained the knowledge, skill and judgment to carry out medical directives.
  • Obtains and documents (in the medical record) the patient’s informed consent to perform the procedure/ treatment/intervention.
  • Is implementing an authorizer’s order.
  • Performs a relevant assessment, ensuring that specified criteria have been met prior to its implementation.
  • Knows the risks associated with its implementation and is capable of handling any complications.
  • Documents each time a medical directive is enacted, including: date; time; name and number of the medical directive; name of the authorizing MD/NP; name, and signature of the implementer.
  • Notifies the MRP in a timely way if she/he believes that an applicable medical directive should not, or will not, be initiated.
  • Knows how and when to contact the MDs, NPs and any other authorizers as required for timely and quality patient care.

Corporate Policies

  • Ensure all medical directives are developed under the auspices of a single responsible individual or entity.
  • Address the development and approval processes for all medical directives.
  • Require a standardized template for the structure/ format of all medical directives.
  • Retain and archive all superseded medical directives indefinitely.
  • Set out the institution’s expectations for the use, development, contents, approval processes, ongoing evaluation, and periodic review of medical directives.
  • Ensure that implementers acquire and maintain specified levels of knowledge, skill and judgment so that they can safely enact medical directives without increasing the risk to the institution’s patients.

References

Date last reviewed:
This is a resource for quality assurance and risk management purposes only, and is not intended to provide or replace legal or medical advice or reflect standards of care and/or standards of practice of a regulatory body. The information contained in this resource was deemed accurate at the time of publication, however, practices may change without notice.