Medical: Advance Health Care Planning, 71772-71774 [05-23505]
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Federal Register / Vol. 70, No. 229 / Wednesday, November 30, 2005 / Rules and Regulations
create a safe harbor for nonjurisdictional utilities that wish to
interconnect new generation without
jeopardizing their non-jurisdictional
status.
Request for Rehearing
107. NRECA repeats here the same
request it made in the Large Generator
Interconnection proceeding that the
Commission create a safe harbor to
allow non-jurisdictional utilities to
avoid the sometimes cumbersome
process of interconnecting new
generators under FPA sections 210, 211,
and 212. NRECA also points out that
many cooperatives are not ‘‘transmitting
utilities’’ as defined in the FPA and that
section 211 only applies to
interconnections with ‘‘transmitting
utilities.’’ Specifically, NRECA asks the
Commission to clarify that a cooperative
may settle a section 211 case and agree
to provide wheeling services without
that settlement being considered a
‘‘voluntary’’ service offering.
Commission Conclusion
108. As the Commission stated in
Order No. 2006, FPA section 211
already allows a non-public utility to
safeguard its non-jurisdictional status.
We see no need to create a second
method of doing the same thing. NRECA
also asks whether a cooperative may
settle a section 211 case and agree to
provide wheeling services without that
settlement being considered a
‘‘voluntary’’ service offering. That issue
is outside the scope of this rulemaking.
In this rulemaking proceeding, the
Commission is acting under its FPA
section 205 authority, and does not
address obligations under sections 210,
211, or 212.
IV. Information Collection Statement
109. Order No. 2006 contains
information collection requirements for
which the Commission obtained
approval from the Office of Management
and Budget (OMB). The OMB Control
Number for this collection of
information is 1902–0203. This order
denies most rehearing requests, clarifies
the provisions of Order No. 2006, and
grants rehearing on only three minor
issues. This order does not make
substantive modifications to the
Commission’s information collection
requirements and, accordingly, OMB
approval for this order is not necessary.
However, the Commission will send a
copy of this order to OMB for
informational purposes.
V. Document Availability
110. In addition to publishing the full
text of this document in the Federal
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19:03 Nov 29, 2005
Jkt 208001
Register, interested persons may obtain
this document from the Commission’s
Public Reference Room during normal
business hours (8:30 a.m. to 5 p.m.
Eastern Time) at 888 First Street, NE.,
Room 2A, Washington, DC. This
document is also available
electronically from the Commission’s
eLibrary system (https://www.ferc.gov/
docs-filing/elibrary.asp) in PDF and
Microsoft Word format. To access this
document in eLibrary, type ‘‘RM02–
12–’’ in the docket number field and
specify a date range that includes this
document’s issuance date. User
assistance is available for eLibrary and
the Commission’s website during
normal business hours from the
Commission’s Help Line at 202–502–
8222 or the Public Reference Room at
202–502–8371 Press 0, TTY 202–502–
8659. E-Mail the Public Reference Room
at public.referenceroom@ferc.gov.
VI. Effective Date
111. Changes to Order No. 2006 made
in this Order on Rehearing will become
effective on December 30, 2005.
List of Subjects in 18 CFR Part 35
Electric power rates, Electric utilities,
Reporting and recordkeeping
requirements.
By the Commission.
Magalie R. Salas,
Secretary.
The Appendices will not be published in
the Federal Register or the Code of Federal
Regulations.
[FR Doc. 05–23461 Filed 11–29–05; 8:45 am]
BILLING CODE 6717–01–P
DEPARTMENT OF VETERANS
AFFAIRS
38 CFR Part 17
RIN 2900–AJ28
Medical: Advance Health Care
Planning
Department of Veterans Affairs.
Final rule.
AGENCY:
ACTION:
SUMMARY: This document amends VA
medical regulations to codify VA policy
regarding advance health care planning.
The final rule sets forth a mechanism for
the use of written advance directives,
i.e., a VA living will, a VA durable
power of attorney for health care, and a
State-authorized advance directive. The
final rule also sets forth a mechanism
for honoring verbal or non-verbal
instructions from a patient when the
patient is admitted to care when
critically ill and loss of capacity may be
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imminent and the patient is not
physically able to sign an advance
directive form, or the appropriate form
is not readily available. This is intended
to help ensure that VA acts in
compliance with patients’ wishes
concerning future health care.
DATES: Effective Date: December 30,
2005.
FOR FURTHER INFORMATION CONTACT:
Ruth Cecire, Ph.D., Policy Analyst,
Ethics Policy Service, National Center
for Ethics in Health Care (10E), Veterans
Health Administration, Department of
Veterans Affairs, 810 Vermont Avenue,
NW., Washington, DC 20420; 202–501–
0364 (this is not a toll-free number).
SUPPLEMENTARY INFORMATION: In a
document published in the Federal
Register on November 2, 1998 (63 FR
58677), the Department of Veterans
Affairs (VA) proposed to amend its
medical regulations (38 CFR part 17) to
codify VA policy concerning advance
health care planning. Advance health
care planning provides an opportunity
for patients to give guidance to their
caregivers regarding their treatment
preferences for the future should they
become incapable of participating fully
in the decision-making process. We
requested comments for a 60-day period
that ended January 4, 1999. We received
three comments. Based on the rationale
set forth in the proposed rule and this
document, we are adopting the
proposed rule as a final rule with the
changes indicated below.
This final rule sets forth a mechanism
for the use of written advance
directives, i.e., a VA living will, a VA
durable power of attorney for health
care, and a State-authorized advance
directive. The rule also sets forth a
mechanism for honoring verbal or nonverbal instructions from a patient when
the patient is admitted to care when
critically ill and loss of capacity may be
imminent and the patient is not
physically able to sign an advance
directive form, or the appropriate form
is not readily available. The advance
health care planning discussion and
completion of a written advance
directive ideally would take place prior
to a patient being admitted to care in a
crisis situation. However, we recognize
that this is not always the case. The
mechanism for honoring the verbal and
non-verbal instructions of patients in
this circumstance enables such patients
to communicate their preferences
regarding their future health care and
ensures this information will be
carefully documented in the patient’s
health record and available to guide
caregivers should the patient lose
capacity. The final rule also states that
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Federal Register / Vol. 70, No. 229 / Wednesday, November 30, 2005 / Rules and Regulations
a patient who has decision-making
capacity may revoke an advance
directive or instructions in a critical
situation at any time by using any
means expressing the intent to revoke.
In addition, the final rule emphasizes
the obligation of any surrogate,
including a health care agent named in
the advance directive, making decisions
on behalf of a patient who lacks
decision-making capacity, to act in
compliance with the patient’s clearly
expressed wishes. The term surrogate is
defined in 38 CFR 17.32(a). Those
authorized to act as surrogates under VA
policy are identified in 38 CFR 17.32(e).
One commenter requested
clarification regarding proposed
§ 17.32(h)(2), which describes
‘‘Instructions in Critical Situations,’’
particularly with respect to the meaning
of ‘‘non-verbal instructions.’’ The
commenter suggests that ‘‘specific
guidelines must be established’’ to
define what would constitute acceptable
instructions. We agree with the
commenter’s point that this paragraph
could be more explicit, but do not
believe it would be possible, for
example, to specify all of the possible
variety and appearances in the way that
a patient who is unable to speak or write
might use to communicate. In the final
rule we are modifying this paragraph to
state more clearly the circumstances and
types of instructions to which this
paragraph would apply. Those changes
include adding that the patient must
have decision-making capacity and the
patient’s verbal or non-verbal
instructions must be unambiguous.
A second commenter suggested that
the language in proposed § 17.32(h)(1),
which describes ‘‘Witnesses,’’ was
overly restrictive, and could be
interpreted to prevent appropriate
individuals from serving as a witness.
The commenter stated: ‘‘Since a
witness’’ sole function is to attest to the
fact that the witness saw the patient sign
the VA Living Will or VA Durable
Power of Attorney for Health Care, the
general rule should be that a witness’
potential conflict of interest in making
that attestation may be raised by any
person seeking to challenge the validity
and enforceability of the VA Living Will
or VA Durable Power of Attorney for
Health Care, as part of an attempt to
discredit the truth of the witness’
attestation.’’ We agree and in the final
rule are modifying this paragraph to
make the requirements less restrictive.
However, we continue to think it best,
in order to avoid even the appearance of
a conflict of interest, that persons
named in the patient’s will, or as health
care agent in the advance directive, or
financially responsible for the patient’s
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19:03 Nov 29, 2005
Jkt 208001
care, should not sign as witnesses on the
advance directive form. In the final rule
we are removing the proposed rule’s
requirement that the witness not be
‘‘entitled to, or a claimant against, any
portion of the patient’s estate; or be
financially responsible for the patient’s
care’’ and replacing it with the
requirement that the witness not ‘‘to the
witnesses’’ knowledge be named in the
patient’s will, appointed as health care
agent in the advance directive, or
financially responsible for the patient’s
care.’’ The VA Advance Directive:
Living Will and Durable Power of
Attorney for Health Care form expressly
provides that by signing the form, the
witness attests to the fact that he or she
lacks such knowledge. In the final rule,
we are also removing, because we have
concluded that it is unnecessarily
restrictive, the proposed rule’s
requirement that VA employees of the
Chaplain Service, Psychology Service,
Social Work Service, or nonclinical
employees (e.g., Medical Administration
Service, Voluntary Service or
Environmental Management Service)
may serve as witnesses only ‘‘when
other witnesses are not reasonably
available.’’
The third commenter expressed
concern that the proposed rule ‘‘is
supposed to address VA employees’
responsibilities in following patient’s
expressed desires in end-of-life
decisions,’’ but did not go far enough to
clarify the weight carried by the
patient’s expressed desires, e.g., when
there is a dispute about the legitimacy
of a State-authorized advance directive.
Such a dispute might occur, for
example, if the veteran completed the
State-authorized advance directive
while living in one State and later
relocated to another jurisdiction. It is
our intention that the reference to
‘‘applicable State law’’ in the definition
of State-authorized advance directive be
broadly interpreted for the convenience
and benefit of VA patients. Indeed, the
chief purpose of the rule is to assure
that VA employees and surrogates
comply with patients’ clearly expressed
wishes to the greatest extent possible.
We are therefore in the final rule
specifying that, ‘‘[f]or the purposes of
this paragraph and paragraph (h) of this
section, ‘applicable State law’ means the
law of the State where the advance
directive was signed, the State where
the patient resided when the advance
directive was signed, the State where
the patient now resides, or the State
where the patient is receiving treatment.
VA will resolve any conflict between
those State laws regarding the validity
of the advance directive by following
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71773
the law of the State that gives effect to
the expressed wishes in the advance
directive.’’ We also are making changes
in the opening paragraph of § 17.32(h) to
clarify that ‘‘[a]n advance directive that
is valid in one or more States under
applicable State law, as defined in
paragraph (a) of this section, will be
recognized throughout the VA health
care system.’’
We are also adding in the final rule
nonsubstantive changes for purposes of
clarification. These include adding a
revision of the authority citation for
§ 17.32 to reflect that this rule is issued
under the authority of 38 U.S.C. 7331
through 7334.
Unfunded Mandates
The Unfunded Mandates Reform Act
of 1995 requires, at 2 U.S.C. 1532, that
agencies prepare an assessment of
anticipated costs and benefits before
issuing any rule that may result in an
expenditure by State, local, or tribal
governments, in the aggregate, or by the
private sector, of $100 million or more
(adjusted annually for inflation) in any
given year. This rule would have no
such effect on State, local, or tribal
governments, or the private sector.
Paperwork Reduction Act of 1995
Two collection of information
requirements that are related to 38 CFR
17.32 are currently approved by the
Office of Management and Budget
(OMB) under the provisions of the
Paperwork Reduction Act (44 U.S.C.
3501–3521). OMB has approved
collection of information requirements
for § 17.32 under OMB control number
2900–0583. In addition, OMB has
approved the information collection
requirements in VA Form 10–0137, VA
Advance Directive: Living Will and
Durable Power of Attorney for Health
Care, under OMB control number 2900–
0556. The references in the final rule to
a VA Living Will or to a VA Durable
Power of Attorney for Health Care are to
that form. No new collections of
information are associated with this
final rule.
Executive Order 12866
This document has been reviewed by
the Office of Management and Budget
under Executive Order 12866.
Regulatory Flexibility Act
The Secretary hereby certifies that
this final rule will not have a significant
economic impact on a substantial
number of small entities as they are
defined in the Regulatory Flexibility
Act, 5 U.S.C. 601–612. The rule will
affect only individuals and will not
directly affect any small entities.
E:\FR\FM\30NOR1.SGM
30NOR1
71774
Federal Register / Vol. 70, No. 229 / Wednesday, November 30, 2005 / Rules and Regulations
Therefore, pursuant to 5 U.S.C. 605(b),
this rule is exempt from the initial and
final regulatory flexibility analysis
requirements of sections 603 and 604.
Catalog of Federal Domestic Assistance
There are no applicable Catalog of
Federal Domestic Assistance program
numbers.
List of Subjects in 38 CFR Part 17
Administrative practice and
procedure, Alcohol abuse, Alcoholism,
Claims, Day care, Dental health, Drug
abuse, Foreign relations, Government
contracts, Grant programs-health, Grant
programs-veterans, Health care, Health
facilities, Health professions, Health
records, Homeless, Medical and dental
schools, Medical devices, Medical
research, Mental health programs,
Nursing homes, Philippines, Reporting
and recordkeeping requirements,
Scholarships and fellowships, Travel
and transportation expenses, Veterans.
Approved: July 15, 2005.
R. James Nicholson,
Secretary of Veterans Affairs.
For the reasons set out above, 38 CFR
part 17 is amended to read as follows:
I
PART 17—MEDICAL
1. The authority citation for part 17 is
revised to read as follows:
I
Authority: 38 U.S.C. 501, 1721, and as
stated in specific sections.
2. Section 17.32 is amended by:
a. Revising the section heading and
authority citation.
I b. In paragraph (a), adding a new
definition in alphabetical order.
I c. Adding paragraph (h) immediately
following paragraph (g)(4).
The revisions and additions read as
follows:
I
I
§ 17.32 Informed consent and advance
health care planning.
(a) * * *
Advance Directive. Specific written
statements made by a patient who has
decision-making capacity regarding
future health care decisions in any of
the following:
(i) VA Living Will. A written statement
made by a patient on an authorized VA
form which sets forth the patient’s
wishes regarding the patient’s health
care treatment preferences including the
withholding and withdrawal of lifesustaining treatment.
(ii) VA Durable Power of Attorney for
Health Care. A written instruction on a
VA form which designates the patient’s
choice of health care agent.
(iii) State-Authorized Advance
Directive. A non-VA living will, durable
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19:03 Nov 29, 2005
Jkt 208001
power of attorney for health care, or
other advance health care planning
document, the validity of which is
determined pursuant to applicable State
law. For the purposes of this paragraph
and paragraph (h) of this section,
‘‘applicable State law’’ means the law of
the State where the advance directive
was signed, the State where the patient
resided when the advance directive was
signed, the State where the patient now
resides, or the State where the patient is
receiving treatment. VA will resolve any
conflict between those State laws
regarding the validity of the advance
directive by following the law of the
State that gives effect to the expressed
wishes in the advance directive.
*
*
*
*
*
(h) Advance health care planning.
Subject to the provisions of paragraphs
(h)(1) through (h)(4) of this section, VA
will follow the wishes of a patient
expressed in an Advance Directive
when the attending physician
determines and documents in the
patient’s medical record that the patient
lacks decision-making capacity and is
not expected to regain it. An advance
directive that is valid in one or more
States under applicable State law, as
defined in paragraph (a) of this section,
will be recognized throughout the VA
health care system.
(1) Witnesses. A VA Advance
Directive: Living Will and Durable
Power of Attorney for Health Care must
be signed by the patient in the presence
of two witnesses. Neither witness may
to the witness’ knowledge be named in
the patient’s will, appointed as health
care agent in the advance directive, or
financially responsible for the patient’s
care. VA employees of the Chaplain
Service, Psychology Service, Social
Work Service, or nonclinical employees
(e.g., Medical Administration Service,
Voluntary Service, or Environmental
Management Service) may serve as
witnesses. Other individuals employed
by the VA facility in which the patient
is being treated may not sign as
witnesses to the advance directive.
Witnesses are attesting only to the fact
that they saw the patient sign the form.
(2) Instructions in critical situations.
VA will follow the unambiguous verbal
or non-verbal instructions regarding
future health care decisions of a patient
who has decision-making capacity when
the patient is admitted to care when
critically ill and loss of capacity may be
imminent and the patient is not
physically able to sign an advance
directive form, or the appropriate form
is not readily available. The patient’s
instructions must have been expressed
to at least two members of the health
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care team. The substance of the patient’s
instructions must be recorded in a
progress note in the patient’s medical
record and must be co-signed by at least
two members of the health care team
who were present and can attest to the
wishes expressed by the patient. These
instructions will be given effect only if
the patient loses decision-making
capacity during the presenting situation.
(3) Revocation. A patient who has
decision-making capacity may revoke an
advance directive or instructions in a
critical situation at any time by using
any means expressing the intent to
revoke.
(4) VA policy and disputes. Neither
the treatment team nor surrogate may
override a patient’s clear instructions in
an Advance Directive or in instructions
in critical situations, except that those
portions of an Advance Directive or
instructions given in a critical situation
that are not consistent with VA policy
will not be given effect.
*
*
*
*
*
(Authority: 38 U.S.C. 7331 through 7334)
[FR Doc. 05–23505 Filed 11–29–05; 8:45 am]
BILLING CODE 8320–01–P
ENVIRONMENTAL PROTECTION
AGENCY
40 CFR Part 52
[Region 2 Docket No. R02–OAR–2005–NJ–
0002, FRL–7999–8]
Approval and Promulgation of
Implementation Plans; New Jersey
Architectural Coatings Rule
Environmental Protection
Agency (EPA).
ACTION: Final rule.
AGENCY:
SUMMARY: The Environmental Protection
Agency (EPA) is approving a revision to
the New Jersey State Implementation
Plan (SIP) for ozone concerning the
control of volatile organic compounds.
The SIP revision consists of
amendments to Subchapter 23
‘‘Prevention of Air Pollution From
Architectural Coatings’’ of 7:27 of the
New Jersey Administrative Code, which
are needed to meet the shortfall in
emissions reduction identified by EPA
in New Jersey’s 1-hour ozone attainment
demonstration SIP. The intended effect
of this action is to approve a control
strategy required by the Clean Air Act,
which will result in emission reductions
that will help achieve attainment of the
national ambient air quality standard for
ozone.
DATES: Effective Date: This rule will be
effective December 30, 2005.
E:\FR\FM\30NOR1.SGM
30NOR1
]]>Agencies
[Federal Register Volume 70, Number 229 (Wednesday, November 30, 2005)]
[Rules and Regulations]
[Pages 71772-71774]
From the Federal Register Online via the Government Printing Office [www.gpo.gov]
[FR Doc No: 05-23505]
=======================================================================
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DEPARTMENT OF VETERANS AFFAIRS
38 CFR Part 17
RIN 2900-AJ28
Medical: Advance Health Care Planning
AGENCY: Department of Veterans Affairs.
ACTION: Final rule.
-----------------------------------------------------------------------
SUMMARY: This document amends VA medical regulations to codify VA
policy regarding advance health care planning. The final rule sets
forth a mechanism for the use of written advance directives, i.e., a VA
living will, a VA durable power of attorney for health care, and a
State-authorized advance directive. The final rule also sets forth a
mechanism for honoring verbal or non-verbal instructions from a patient
when the patient is admitted to care when critically ill and loss of
capacity may be imminent and the patient is not physically able to sign
an advance directive form, or the appropriate form is not readily
available. This is intended to help ensure that VA acts in compliance
with patients' wishes concerning future health care.
DATES: Effective Date: December 30, 2005.
FOR FURTHER INFORMATION CONTACT: Ruth Cecire, Ph.D., Policy Analyst,
Ethics Policy Service, National Center for Ethics in Health Care (10E),
Veterans Health Administration, Department of Veterans Affairs, 810
Vermont Avenue, NW., Washington, DC 20420; 202-501-0364 (this is not a
toll-free number).
SUPPLEMENTARY INFORMATION: In a document published in the Federal
Register on November 2, 1998 (63 FR 58677), the Department of Veterans
Affairs (VA) proposed to amend its medical regulations (38 CFR part 17)
to codify VA policy concerning advance health care planning. Advance
health care planning provides an opportunity for patients to give
guidance to their caregivers regarding their treatment preferences for
the future should they become incapable of participating fully in the
decision-making process. We requested comments for a 60-day period that
ended January 4, 1999. We received three comments. Based on the
rationale set forth in the proposed rule and this document, we are
adopting the proposed rule as a final rule with the changes indicated
below.
This final rule sets forth a mechanism for the use of written
advance directives, i.e., a VA living will, a VA durable power of
attorney for health care, and a State-authorized advance directive. The
rule also sets forth a mechanism for honoring verbal or non-verbal
instructions from a patient when the patient is admitted to care when
critically ill and loss of capacity may be imminent and the patient is
not physically able to sign an advance directive form, or the
appropriate form is not readily available. The advance health care
planning discussion and completion of a written advance directive
ideally would take place prior to a patient being admitted to care in a
crisis situation. However, we recognize that this is not always the
case. The mechanism for honoring the verbal and non-verbal instructions
of patients in this circumstance enables such patients to communicate
their preferences regarding their future health care and ensures this
information will be carefully documented in the patient's health record
and available to guide caregivers should the patient lose capacity. The
final rule also states that
[[Page 71773]]
a patient who has decision-making capacity may revoke an advance
directive or instructions in a critical situation at any time by using
any means expressing the intent to revoke. In addition, the final rule
emphasizes the obligation of any surrogate, including a health care
agent named in the advance directive, making decisions on behalf of a
patient who lacks decision-making capacity, to act in compliance with
the patient's clearly expressed wishes. The term surrogate is defined
in 38 CFR 17.32(a). Those authorized to act as surrogates under VA
policy are identified in 38 CFR 17.32(e).
One commenter requested clarification regarding proposed Sec.
17.32(h)(2), which describes ``Instructions in Critical Situations,''
particularly with respect to the meaning of ``non-verbal
instructions.'' The commenter suggests that ``specific guidelines must
be established'' to define what would constitute acceptable
instructions. We agree with the commenter's point that this paragraph
could be more explicit, but do not believe it would be possible, for
example, to specify all of the possible variety and appearances in the
way that a patient who is unable to speak or write might use to
communicate. In the final rule we are modifying this paragraph to state
more clearly the circumstances and types of instructions to which this
paragraph would apply. Those changes include adding that the patient
must have decision-making capacity and the patient's verbal or non-
verbal instructions must be unambiguous.
A second commenter suggested that the language in proposed Sec.
17.32(h)(1), which describes ``Witnesses,'' was overly restrictive, and
could be interpreted to prevent appropriate individuals from serving as
a witness. The commenter stated: ``Since a witness'' sole function is
to attest to the fact that the witness saw the patient sign the VA
Living Will or VA Durable Power of Attorney for Health Care, the
general rule should be that a witness' potential conflict of interest
in making that attestation may be raised by any person seeking to
challenge the validity and enforceability of the VA Living Will or VA
Durable Power of Attorney for Health Care, as part of an attempt to
discredit the truth of the witness' attestation.'' We agree and in the
final rule are modifying this paragraph to make the requirements less
restrictive. However, we continue to think it best, in order to avoid
even the appearance of a conflict of interest, that persons named in
the patient's will, or as health care agent in the advance directive,
or financially responsible for the patient's care, should not sign as
witnesses on the advance directive form. In the final rule we are
removing the proposed rule's requirement that the witness not be
``entitled to, or a claimant against, any portion of the patient's
estate; or be financially responsible for the patient's care'' and
replacing it with the requirement that the witness not ``to the
witnesses'' knowledge be named in the patient's will, appointed as
health care agent in the advance directive, or financially responsible
for the patient's care.'' The VA Advance Directive: Living Will and
Durable Power of Attorney for Health Care form expressly provides that
by signing the form, the witness attests to the fact that he or she
lacks such knowledge. In the final rule, we are also removing, because
we have concluded that it is unnecessarily restrictive, the proposed
rule's requirement that VA employees of the Chaplain Service,
Psychology Service, Social Work Service, or nonclinical employees
(e.g., Medical Administration Service, Voluntary Service or
Environmental Management Service) may serve as witnesses only ``when
other witnesses are not reasonably available.''
The third commenter expressed concern that the proposed rule ``is
supposed to address VA employees' responsibilities in following
patient's expressed desires in end-of-life decisions,'' but did not go
far enough to clarify the weight carried by the patient's expressed
desires, e.g., when there is a dispute about the legitimacy of a State-
authorized advance directive. Such a dispute might occur, for example,
if the veteran completed the State-authorized advance directive while
living in one State and later relocated to another jurisdiction. It is
our intention that the reference to ``applicable State law'' in the
definition of State-authorized advance directive be broadly interpreted
for the convenience and benefit of VA patients. Indeed, the chief
purpose of the rule is to assure that VA employees and surrogates
comply with patients' clearly expressed wishes to the greatest extent
possible. We are therefore in the final rule specifying that, ``[f]or
the purposes of this paragraph and paragraph (h) of this section,
`applicable State law' means the law of the State where the advance
directive was signed, the State where the patient resided when the
advance directive was signed, the State where the patient now resides,
or the State where the patient is receiving treatment. VA will resolve
any conflict between those State laws regarding the validity of the
advance directive by following the law of the State that gives effect
to the expressed wishes in the advance directive.'' We also are making
changes in the opening paragraph of Sec. 17.32(h) to clarify that
``[a]n advance directive that is valid in one or more States under
applicable State law, as defined in paragraph (a) of this section, will
be recognized throughout the VA health care system.''
We are also adding in the final rule nonsubstantive changes for
purposes of clarification. These include adding a revision of the
authority citation for Sec. 17.32 to reflect that this rule is issued
under the authority of 38 U.S.C. 7331 through 7334.
Unfunded Mandates
The Unfunded Mandates Reform Act of 1995 requires, at 2 U.S.C.
1532, that agencies prepare an assessment of anticipated costs and
benefits before issuing any rule that may result in an expenditure by
State, local, or tribal governments, in the aggregate, or by the
private sector, of $100 million or more (adjusted annually for
inflation) in any given year. This rule would have no such effect on
State, local, or tribal governments, or the private sector.
Paperwork Reduction Act of 1995
Two collection of information requirements that are related to 38
CFR 17.32 are currently approved by the Office of Management and Budget
(OMB) under the provisions of the Paperwork Reduction Act (44 U.S.C.
3501-3521). OMB has approved collection of information requirements for
Sec. 17.32 under OMB control number 2900-0583. In addition, OMB has
approved the information collection requirements in VA Form 10-0137, VA
Advance Directive: Living Will and Durable Power of Attorney for Health
Care, under OMB control number 2900-0556. The references in the final
rule to a VA Living Will or to a VA Durable Power of Attorney for
Health Care are to that form. No new collections of information are
associated with this final rule.
Executive Order 12866
This document has been reviewed by the Office of Management and
Budget under Executive Order 12866.
Regulatory Flexibility Act
The Secretary hereby certifies that this final rule will not have a
significant economic impact on a substantial number of small entities
as they are defined in the Regulatory Flexibility Act, 5 U.S.C. 601-
612. The rule will affect only individuals and will not directly affect
any small entities.
[[Page 71774]]
Therefore, pursuant to 5 U.S.C. 605(b), this rule is exempt from the
initial and final regulatory flexibility analysis requirements of
sections 603 and 604.
Catalog of Federal Domestic Assistance
There are no applicable Catalog of Federal Domestic Assistance
program numbers.
List of Subjects in 38 CFR Part 17
Administrative practice and procedure, Alcohol abuse, Alcoholism,
Claims, Day care, Dental health, Drug abuse, Foreign relations,
Government contracts, Grant programs-health, Grant programs-veterans,
Health care, Health facilities, Health professions, Health records,
Homeless, Medical and dental schools, Medical devices, Medical
research, Mental health programs, Nursing homes, Philippines, Reporting
and recordkeeping requirements, Scholarships and fellowships, Travel
and transportation expenses, Veterans.
Approved: July 15, 2005.
R. James Nicholson,
Secretary of Veterans Affairs.
0
For the reasons set out above, 38 CFR part 17 is amended to read as
follows:
PART 17--MEDICAL
0
1. The authority citation for part 17 is revised to read as follows:
Authority: 38 U.S.C. 501, 1721, and as stated in specific
sections.
0
2. Section 17.32 is amended by:
0
a. Revising the section heading and authority citation.
0
b. In paragraph (a), adding a new definition in alphabetical order.
0
c. Adding paragraph (h) immediately following paragraph (g)(4).
The revisions and additions read as follows:
Sec. 17.32 Informed consent and advance health care planning.
(a) * * *
Advance Directive. Specific written statements made by a patient
who has decision-making capacity regarding future health care decisions
in any of the following:
(i) VA Living Will. A written statement made by a patient on an
authorized VA form which sets forth the patient's wishes regarding the
patient's health care treatment preferences including the withholding
and withdrawal of life-sustaining treatment.
(ii) VA Durable Power of Attorney for Health Care. A written
instruction on a VA form which designates the patient's choice of
health care agent.
(iii) State-Authorized Advance Directive. A non-VA living will,
durable power of attorney for health care, or other advance health care
planning document, the validity of which is determined pursuant to
applicable State law. For the purposes of this paragraph and paragraph
(h) of this section, ``applicable State law'' means the law of the
State where the advance directive was signed, the State where the
patient resided when the advance directive was signed, the State where
the patient now resides, or the State where the patient is receiving
treatment. VA will resolve any conflict between those State laws
regarding the validity of the advance directive by following the law of
the State that gives effect to the expressed wishes in the advance
directive.
* * * * *
(h) Advance health care planning. Subject to the provisions of
paragraphs (h)(1) through (h)(4) of this section, VA will follow the
wishes of a patient expressed in an Advance Directive when the
attending physician determines and documents in the patient's medical
record that the patient lacks decision-making capacity and is not
expected to regain it. An advance directive that is valid in one or
more States under applicable State law, as defined in paragraph (a) of
this section, will be recognized throughout the VA health care system.
(1) Witnesses. A VA Advance Directive: Living Will and Durable
Power of Attorney for Health Care must be signed by the patient in the
presence of two witnesses. Neither witness may to the witness'
knowledge be named in the patient's will, appointed as health care
agent in the advance directive, or financially responsible for the
patient's care. VA employees of the Chaplain Service, Psychology
Service, Social Work Service, or nonclinical employees (e.g., Medical
Administration Service, Voluntary Service, or Environmental Management
Service) may serve as witnesses. Other individuals employed by the VA
facility in which the patient is being treated may not sign as
witnesses to the advance directive. Witnesses are attesting only to the
fact that they saw the patient sign the form.
(2) Instructions in critical situations. VA will follow the
unambiguous verbal or non-verbal instructions regarding future health
care decisions of a patient who has decision-making capacity when the
patient is admitted to care when critically ill and loss of capacity
may be imminent and the patient is not physically able to sign an
advance directive form, or the appropriate form is not readily
available. The patient's instructions must have been expressed to at
least two members of the health care team. The substance of the
patient's instructions must be recorded in a progress note in the
patient's medical record and must be co-signed by at least two members
of the health care team who were present and can attest to the wishes
expressed by the patient. These instructions will be given effect only
if the patient loses decision-making capacity during the presenting
situation.
(3) Revocation. A patient who has decision-making capacity may
revoke an advance directive or instructions in a critical situation at
any time by using any means expressing the intent to revoke.
(4) VA policy and disputes. Neither the treatment team nor
surrogate may override a patient's clear instructions in an Advance
Directive or in instructions in critical situations, except that those
portions of an Advance Directive or instructions given in a critical
situation that are not consistent with VA policy will not be given
effect.
* * * * *
(Authority: 38 U.S.C. 7331 through 7334)
[FR Doc. 05-23505 Filed 11-29-05; 8:45 am]
BILLING CODE 8320-01-P
