The Patient Self-Determination Act (PSDA) is a federal law passed in 1990 that requires healthcare facilities to inform you of your right to make decisions about your own medical care, including the right to accept or refuse treatment and to create advance directives. It applies to every hospital, skilled nursing facility, home health agency, and hospice program that receives Medicare or Medicaid funding.
What the Law Requires
The PSDA places a set of specific obligations on healthcare facilities. When you are admitted as an adult patient, the facility must provide you with written information explaining your rights under your state’s law to make decisions about your medical care. This includes your right to accept or refuse medical or surgical treatment and your right to create advance directives that would guide your care if you become unable to speak for yourself.
Beyond handing you paperwork, the facility is also required to ask whether you already have an advance directive in place and to document your answer in your medical record. If you do have one, the facility must note that. If you don’t, they cannot deny you care or treat you differently because of it. The law also requires facilities to maintain written policies and procedures around these rights and to educate their staff on them.
Which Facilities Must Comply
The law covers a broad range of healthcare settings. Hospitals, skilled nursing facilities (commonly called nursing homes), home health agencies, and hospice programs all fall under the PSDA if they participate in Medicare or Medicaid. Because the vast majority of these facilities do participate, the law has an extremely wide reach. Private physician offices and outpatient clinics that don’t receive this federal funding are generally not covered.
Advance Directives Explained
The core documents the PSDA is designed to promote are advance directives. These are legal documents that provide instructions for your medical care and only take effect if you cannot communicate your own wishes. The two most common types are the living will and the durable power of attorney for health care.
A living will spells out the specific medical treatments you would or would not want in emergency situations. You can state, for example, whether you want life-sustaining measures like mechanical ventilation or tube feeding, and under what conditions those preferences apply. A durable power of attorney for health care is different: instead of listing specific treatments, it names a person (your health care proxy) who is authorized to make medical decisions on your behalf if you’re unable to do so. Many people complete both documents, covering both specific treatment wishes and designating a trusted decision-maker.
The PSDA also recognizes written instructions concerning organ disposition, meaning you can include your wishes about organ donation within your advance directive paperwork.
Federal Law, State Rules
One important detail about the PSDA is that it does not itself create the right to refuse treatment or establish the rules for advance directives. Those rights come from state law, and they vary from state to state. What the federal law does is require facilities to inform you of whatever rights your particular state recognizes, whether those rights come from state statutes or from court decisions. This means the specific forms you fill out, the requirements for witnesses or notarization, and the scope of decisions your health care proxy can make all depend on where you live.
Because of this structure, an advance directive created in one state may not automatically be honored in another. If you split time between states or travel frequently, it’s worth checking whether your documents meet the requirements of each state where you might receive care.
How It Works at Admission
In practice, the PSDA is the reason you’re handed paperwork about advance directives when you check into a hospital or enter a nursing home. The facility must give every adult patient this information at the time of admission. Staff will typically ask if you have an existing advance directive, explain your rights in writing, and give you the opportunity to create one if you haven’t already. The facility cannot make having an advance directive a condition of receiving care.
This process is meant to happen before a medical crisis, when you’re still able to think clearly about your preferences. The goal is to ensure that if you later become incapacitated, your care team and your family already know what you want.
Completion Rates Remain Low
Despite the law being in effect for over three decades, advance directive completion rates in the United States remain modest. A systematic review of 150 studies covering nearly 800,000 people found that only about 36.7 percent of U.S. adults had completed any type of advance directive, with 29.3 percent having a living will specifically. Perhaps surprisingly, people with chronic illnesses were only slightly more likely to have completed one (38.2 percent) compared to healthy adults (32.7 percent). These proportions stayed relatively flat across the years studied, from 2011 to 2016, suggesting that simply being informed about advance directives at admission isn’t always enough to prompt people to complete them.
Enforcement and Consequences
The PSDA is enforced through the Medicare and Medicaid participation requirements. Facilities that fail to comply risk penalties from the Centers for Medicare and Medicaid Services (CMS), which can include civil money penalties, suspension of enrollment, or even termination from the Medicare or Medicaid program. Losing participation in these programs would cut off a major revenue stream for most healthcare facilities, making the financial incentive to comply significant.