What Is the Patient Self-Determination Act (PSDA)?

The Patient Self-Determination Act is a 1990 federal law that requires hospitals, nursing facilities, hospices, home health agencies, and HMOs participating in Medicare or Medicaid to inform every adult patient about their right to accept or refuse medical treatment and to create an advance directive.¹ Congress passed it as part of the Omnibus Budget Reconciliation Act of 1990, and it took effect on December 1, 1991. The law does not create new medical rights. It guarantees that you’ll actually be told about the ones you already have under your state’s laws, at a moment when you can still act on them.

Why the Law Exists

The Act was a direct response to the Supreme Court’s 1990 decision in Cruzan v. Director, Missouri Department of Health. Nancy Cruzan had been in a persistent vegetative state since a 1983 car accident, kept alive by a feeding tube. Her family asked to have the tube removed based on statements she’d made during her life. Missouri refused, and the Supreme Court upheld the state’s right to demand “clear and convincing evidence” of an incapacitated person’s wishes before life-sustaining treatment could be withdrawn.²

The message from that ruling was blunt: if you haven’t written your medical wishes down, your family may not be able to speak for you. Congress passed the PSDA later that same year so that patients would learn about advance directives before a crisis made the conversation impossible.

Which Facilities Are Covered

The law applies to any facility that accepts Medicare or Medicaid dollars. On the Medicare side, that includes hospitals, skilled nursing facilities, home health agencies, hospice programs, and managed care organizations.¹ The Medicaid side mirrors those requirements and adds nursing facilities and Medicaid managed care organizations.³ The implementing regulations extend coverage further to critical access hospitals and rural emergency hospitals.⁴

One gap worth knowing about. The Act does not apply to your regular doctor’s office, an outpatient clinic, or an urgent care center unless it falls within one of the covered facility types. Most people interact with the healthcare system primarily through outpatient visits, and those providers have no federal obligation under this law to bring up advance directives. You’ll typically encounter the PSDA’s requirements when you’re admitted to a hospital, enter a nursing facility, start home health or hospice services, or enroll in a managed care plan.

What Providers Must Do for You

Covered facilities carry six specific duties, each written to make sure advance directives actually come up during care rather than getting buried in the intake packet.

Written Information About Your Rights

The facility must give adult patients written information about two things: your rights under state law to make medical decisions (including refusing treatment and creating advance directives), and the facility’s own policies for carrying out those rights.¹ If the facility has a conscience-based objection to implementing certain directives, its written policy must clearly explain which conditions or procedures are affected and identify the state law that permits the objection.⁴

Delivered at the Right Time

The statute pins the timing to the type of facility:

Hospitals: at the time of inpatient admission.
Skilled nursing facilities: at the time of admission as a resident.
Home health agencies: before care begins (the first home visit is acceptable if information is given before any care is provided).
Hospice programs: when the patient first begins receiving hospice care.
Managed care organizations: at the time of enrollment.
Rural emergency hospitals: at the time the patient registers.

A hospital that waits until discharge to raise advance directives has already missed its window.⁴

Documentation, Staff Training, and Community Education

Beyond the initial notice, the facility must record in a prominent part of your medical chart whether you have an advance directive. It must also train staff on the facility’s advance directive policies and provide community education on the topic.¹

Your Rights Under the Law

The rights the Act protects come from your state’s law, not from the federal statute. The federal role is to make sure you hear about them at a useful moment. In practical terms, you can:

Accept or refuse any medical or surgical treatment, including treatment that might prolong your life.
Put your wishes in writing through a living will, healthcare power of attorney, or another document recognized by your state.
Receive care regardless of whether you have an advance directive. No covered facility can refuse to treat you or treat you differently because you do or do not have one.

The non-discrimination protection runs in both directions. A facility cannot pressure you into signing an advance directive as a condition of admission, and it cannot penalize you for having one it disagrees with.¹ The statute does clarify that non-discrimination doesn’t force a provider to deliver care that conflicts with your directive. If your directive says no ventilator, the hospital isn’t obligated to put you on one for the sake of equal treatment.

Filing a Complaint

If a facility fails to inform you of your rights or ignores its own advance directive policies, you can file a complaint with your state’s survey and certification agency. The regulations specifically require facilities to tell patients that this option exists.⁴

Advance Directives Themselves

An advance directive is a written document, recognized under state law, that spells out what medical care you want or don’t want if you lose the ability to speak for yourself.¹ The federal definition is broad, but two forms do most of the work.

Living Wills

A living will describes what treatments you do or don’t want if you’re at the end of life or permanently unconscious. It typically addresses whether to use a ventilator, feeding tube, or dialysis. It takes effect only after a physician confirms you can no longer make your own decisions and that you meet the medical criteria your state requires, such as a terminal condition or permanent unconsciousness. It doesn’t apply to routine decisions while you’re still competent.

Healthcare Power of Attorney

A healthcare power of attorney (sometimes called a healthcare proxy or medical power of attorney) names someone you trust to make medical decisions for you if you can’t. Where a living will covers specific scenarios, a proxy can address any medical question that comes up. Your proxy can talk with your doctors, review options, and choose based on what they know about your values. The proxy’s authority begins only after a physician confirms you’re unable to decide for yourself.

POLST Forms

A POLST form (Provider Orders for Life-Sustaining Treatment, called MOLST in some states) is a medical order signed by both you and your healthcare provider. Because it’s an order rather than a directive, emergency responders and other medical personnel can act on it immediately without needing to interpret it or confirm your capacity first. POLST forms complement advance directives rather than replace them, and they’re most commonly used by people with serious or chronic illnesses.

Changing or Revoking a Directive

You can cancel or update an advance directive at any time. The process depends on your state, but generally you can revoke a healthcare proxy by telling your agent, your doctor, or anyone with a copy, verbally or in writing. For a living will, destroying the document is usually sufficient. In most states, executing a new directive automatically supersedes the old one. If your state grants your spouse the proxy role by default, that designation is typically revoked automatically on divorce.

Whatever method you use, make sure the people who matter know: your doctor, your proxy, your family, and any facility where you receive care. An outdated directive sitting in a chart can cause real harm if no one knows it’s been replaced.

Traveling Between States

Most states recognize advance directives from other states, either because the directive was valid where it was signed or because it meets local requirements. But “most” is not “all,” and even where portability exists, a provider unfamiliar with your home state’s form may hesitate to follow it. If you split time between states or travel often, consider completing a directive that satisfies each state where you’re likely to receive care.

What the Law Cannot Do

Emergencies

The notice requirements don’t override the obligation to stabilize patients in an emergency. Under federal emergency treatment rules, hospitals must screen and stabilize anyone with an emergency medical condition regardless of paperwork, insurance status, or advance directive status. A hospital cannot delay emergency screening or stabilization to hunt for a directive or to discuss end-of-life planning.

In practice, if you arrive in cardiac arrest, the team will begin resuscitation. A valid advance directive or POLST form refusing resuscitation can guide care once the team becomes aware of it, but the default when your wishes are unknown is to treat. POLST forms and medical alert identifiers exist partly to close that communication gap in time-sensitive situations.

Conscience Objections

Both the statute and the regulations allow a provider to decline to carry out a directive on grounds of conscience.³ A religiously affiliated hospital, for example, might refuse to withdraw life-sustaining treatment even if your directive requests it. When a facility takes that position, the regulations require it to disclose the limitation in its written materials, explain which conditions or procedures are affected, identify the state law that permits the objection, and distinguish between objections that apply institution-wide and those raised by individual physicians.⁴

A conscience objection doesn’t erase your rights. It means you may need to transfer to a facility willing to honor your directive, which is why knowing a facility’s policies before you need them matters.

What Happens When a Facility Doesn’t Comply

Enforcement runs through Medicare and Medicaid participation. CMS can terminate a provider’s agreement if the provider is not complying with the requirements of the Medicare or Medicaid program, and those requirements include the PSDA’s advance directive obligations.⁵ Losing a Medicare provider agreement is an existential threat for most healthcare facilities, so the incentive to comply is significant even without dedicated PSDA fines.

Separately, if a provider ignores a valid advance directive and delivers unwanted treatment, state courts have increasingly recognized this as grounds for a medical malpractice or battery claim. The details vary by state, but the direction has been toward holding providers accountable when they disregard clearly documented patient wishes.

Creating Your Own Advance Directive

You don’t need a lawyer, a hospital admission, or a life-threatening diagnosis. In most states, you need a written document that meets your state’s formal requirements (typically a signature and one or two witnesses, sometimes notarization), and you need to get copies to the people who will need them.

Get your state’s form. Organizations like CaringInfo (a program of the National Hospice and Palliative Care Organization) offer free, state-specific advance directive forms with instructions. Many state health departments also provide downloadable forms at no cost.
Choose a healthcare proxy carefully. Pick someone who will advocate for your actual wishes, not someone who will substitute their own judgment. Have a frank conversation with them about what you’d want in different scenarios.
Be specific where it counts. A living will that says “no extraordinary measures” can mean different things to different doctors. Naming your preferences about ventilators, feeding tubes, dialysis, and resuscitation removes ambiguity.
Distribute copies. Give your directive to your proxy, your primary care doctor, any specialist you see regularly, and close family members. If you’re admitted to a facility, bring a copy so it can be added to your chart.
Review it periodically. Marriage, divorce, a serious diagnosis, or the death of your chosen proxy should each trigger a review. Even without a specific event, revisiting your directive every few years keeps it aligned with your values.

1
Office of the Law Revision Counsel. 42 USC 1395cc – Agreements with Providers of Services
2
Justia Law. Cruzan v Director, Missouri Department of Health, 497 US 261 (1990)
3
Office of the Law Revision Counsel. 42 USC 1396a – State Plans for Medical Assistance
4
eCFR. 42 CFR 489.102 – Requirements for Providers
5
eCFR. 42 CFR 489.53 – Termination by CMS