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June 2020
From the Executive Director

As we begin a cautious reemergence from the constraints imposed by COVID-19 and resultant changes to our way of life, we are simultaneously confronted with the harsh realities of a society that has remained very much unchanged when it comes to issues of race and racial injustice. In the wake of the unnecessary and avoidable deaths of George Floyd, Breonna Taylor, Rayshard Brooks and so many others, the fundamentally racist underpinnings of many American systems are being revealed. The violence perpetrated against BIPOC communities and individuals is part of a contiguous history of injustices that has been ignored and hidden from public view for too long.

At the Vermont Ethics Network, our mission is to advance ethics in health care. One of the cornerstones of health care ethics is the principal of justice. As an organization, we cannot be silent about systems that fundamentally deny human rights or health care practices that do not respect the rights and autonomy of black, brown and indigenous bodies. We are committed to the pursuit of change that not only condemns racism and violence, but also seeks to remove prejudice and discrimination embedded in policy and social systems. While this fight is gaining momentum in 2020, VEN is dedicated to continuing to name injustice where it exists and to advocate for systemic change that results in a just and fair health care system for all.
 
In our newsletter and on our website, we will be sharing and amplifying the voices of those with knowledge and lived experience that must be heard. As a starting point, we recommend the following articles:

Law Passes for Remote Witnessing & Explaining of Advance Directives Due to COVID-19

When the COVID social distancing recommendations and requirements began, VEN received many inquiries about how to safely engage in advance care planning and complete advance directive documents without being in the physical presence of witnesses and/or explainers. At that time, we recommended (and provided information on our website) that people utilize telephone and virtual forms of communication to have conversations and document “virtual” witnessing and explaining. Keeping in mind that while this did not meet existing legal requirements for properly executed advance directives, such documents carried moral weight and would still be considered when making medical decisions for a patient who lacked capacity. We also recommended that people be prepared to complete a replacement document with in-person witnessing as soon as it was safe to do so. 
 
Since providing this initial guidance, we shared that a bill ( H.950 ) addressing remote witnessing and explaining of advance directives was making its way through the legislative process. We are happy to report that H.950 passed and was signed by Governor Scott on June 15, 2020 as Act Number 107 . This Act addresses the legal status of advance directives completed using remote witnesses and/or explainers during two time-frames:

  • Documents completed between February 15, 2020 and June 15, 2020 (the period 30 days prior to the declared COVID state of emergency until the effective date of H.950) 
  • Documents completed between June 15, 2020 and June 30, 2021 (the period after the effective date of H.950)
 
In the case of documents completed using remote witnesses between February 15 and June 15 of 2020—these documents are considered valid if: the remote witnesses were known to the principal (a principal is the person completing their advance directive), the remote witnesses were informed about their role in witnessing the advance directive, and the principal included the name and contact information of the remote witnesses. Documents completed during this time frame will be considered valid ONLY UNTIL June 30, 2021 unless amended, revoked or suspended by the principal prior to that date. 
 
In the case of documents completed using remote witnesses between June 15, 2020 and June 30, 2021—these documents are considered valid if: the remote witnesses were known to the principal, the witnesses attested that the principal seemed to understand the nature of the document and was free from duress or undue influence at the time the advance directive was signed, and the principal included the name, contact information and relationship of the witnesses to the principal. Documents completed during this time shall remain valid unless amended, revoked or suspended by the principal. 
 
For detailed instructions about how to complete an advance directive using remote witnessing, please visit the link below.
Clarification of CMS Waiver and Patient Self-Determination

In early May, concerns were raised about a policy change embedded in a list of waivers from the Centers for Medicare and Medicaid Services (CMS) that potentially would undermine patient self-determination. There was fear that one of the waivers invalidated key provisions of the 1990 Patient Self Determination Act which requires hospitals and other healthcare facilities to inform patients of their legal right to fill out an advance directive and to accept or refuse medical treatment. VEN worked with both the Vermont Association of Hospitals and Health Systems and the Vermont Department of Health to affirm that the CMS waiver does NOT negate Vermont’s advance directive statute and the obligations and requirements contained therein. To further clarify, just because CMS passed this broad language as part of a series of necessary regulatory changes per the COVID-19 emergency, authority and obligations of Vermont health care providers, health care facilities and residential care providers relative to advance directives and DNR/COLST orders are still very much in effect.
TalkVermont Courses Offered

COVID-19 has reminded us about the importance of goals of care conversations and finding out what matters most to patients and their loved ones. TalkVermont is a collaboration between VitalTalk (the premier serious illness communication skills coaching program), Ariadne Labs from Harvard University, and the University of Vermont Health Network. Their courses help strengthen clinician communication skills with immediate results that promote lasting improvement in providing honest, compassionate conversations with seriously ill patients and their families. They use an immersive small-group experience with simulated patients to help bolster skills. TalkVermont offers two types of courses: Early Goals of Care (for outpatient providers) and Late Goals of Care (for inpatient providers). Learn more.

Upcoming workshops:
DNR/COLST Update: Documentation of a Clinician's Verbal Order

The Vermont EMS protocol has been updated to indicate that documentation of a clinician signature as a “verbal order” on the Vermont DNR/COLST form is considered acceptable and will be  honored by EMS. In order for a clinician’s verbal order signature on the  DNR/COLST form to be valid, the following is required:

  • The patient’s nurse or social worker must print the clinician’s name in Section A6 for DNR and/or Section H for COLST and write “Verbal Order” on the clinician signature line.
  • The nurse or social worker documenting the verbal order must also sign and date the form.
  • A duplicate DNR/COLST must be completed and sent to the clinician for an original signature.
  • At the earliest convenience, the order with the original signature must be returned to the patient to replace the previously documented verbal order.
Save the Date for Fall Palliative Care Conference

In light of COVID-19 concerns, our Spring Palliative Care Conference was postponed. It has now been rescheduled for Monday, November 9 at Lake Morey Resort in Fairlee, VT. Our goal is to host an in-person conference with appropriate social distancing. If that is not advisable or permitted, we are making contingency plans to convert this offering to a virtual event. Additional details and registration will be available soon.
Regional Advance Care Planning Support

In an effort to best support the higher volume of individuals seeking to complete an advance directive during the COVID-19 pandemic, VEN reached out to our network of partners across the state to identify contacts by region who are available to provide one-on-one advance care planning support remotely by phone or video conference. To access this list, please click here or visit the link below.

If you are an individual seeking advance care planning support, we encourage you to connect with the contact(s) listed for your region.

If you represent an organization that has staff or volunteers available to provide remote advance care planning support and are not yet listed, please contact us to be added.
HEALTH DECISIONS is a publication of the Vermont Ethics Network.

The mission of the Vermont Ethics Network is to advance ethics in health care.
Board of Directors
Geraldine Amori, PhD
E. Tobias Balivet, Esq.
Linda Cohen, JD, MHCDS
Linda Hurley, RN, MS
Alden Launer, MDiv
Peg Maffitt
Tim McAdoo, LNHA, FACHCA
Kier Olsen DeVries, MA
Martha Richardson
Hilary Ryder, MD, MS, FACP, FHM
Michelle Tavares
Staff
Cindy Bruzzese, MPA, MSB, HEC-C
Executive Director and Clinical Ethicist

Honorary Board Members
James L. Bernat, MD
Michelle Champoux, LICSW
Jean Mallary, RN
Robert Macauley, MD