Page 63 - 2020 ARE eGuide for Clinical at Nonhospital Sites

The JOINT COMMISSION Standard RI 01.05.01 Elements of Performance (2018)

1. The hospital has written policies on advance directives, forgoing or withdrawing life-sustaining
treatment, and withholding resuscitative services, in accordance with law and regulation.
2. The hospital implements its advance directives policies.
3. Upon admission, the hospital provides the patient with information on the extent to which the
hospital is able, or unwilling to honor advance directives.
4. The hospital provides patients with written information about advance directives, foregoing or
withdrawing life-sustaining treatment, and withholding resuscitative services.
5. The hospital documents whether or not the patient has an advance directive.

6. Upon request, the hospital refers the patient to resources for assistance in formulating
advance directives.

7. Staff and licensed independent practitioners who are involved in the patient’s care, treatment,
and services are aware of whether or not the patient has an advance directive.

8. The hospital honors the patient’s right’s to formulate, or review and revise his or her advance
directive.

9. The hospital honors advance directives, in accordance with law and regulation and the
hospital’s capabilities.

11. The hospital honors the patient’s wishes concerning organ donation within the limits of the
hospital’s capability and in accordance with law and regulation.

12. The hospital documents the patient’s wishes concerning organ donation when he or she
makes such wishes known to the hospital or when required by the hospital’s policy, in
accordance with law and regulations.
13. The existence or lack of an advance directive does not determine the patient’s right to access
care, treatment, and services provided.