In the PALTC space, we commonly care for patients with impaired decision making capacity either due to acute illness, delirium, depression, dementia, serious mental illness or medications. At those times, it’s wonderful to be able to identify someone who can represent them for important decisions that they currently don’t have capacity to make. When a willing representative is not available, we rely on the IDT process to discuss and decide about the use of antipsychotics, decisions to limit life sustaining care options (including DNR and POLST orders), or referral to hospice. This process has been well codified and is required for review of these interventions whether emergent or elective.

Since 1992, we have followed AB 3209 known as the Epple law (Health and Safety Code 1418.8), for patients who don’t have an identified representative. This code was amended in 1994 to include a patient representative where practical. In 2021, this code was further amended to require specific oral and written notices must be given for every convened IDT, to the patient, a patient representative unaffiliated with the facility, or the OLTCPR, which employs or contracts with a Public Patient Representative (PPR). Since then, the CDA (California Department of Aging) has developed the OLTCPR supported by funding from the General Fund. This office provides trained Public Patient Representatives (PPR) for residents who may need medical treatment, but lack capacity to provide informed consent and have no one identified and willing to represent them or serve as a member of the IDT. As of January 27, 2023, all IDTs in which decisions are being considered that require informed consent for an unrepresented incapacitated resident must include a non-facility-affiliated resident representative, which in most cases will be a PPR from the OLTCPR.

On January 19, 2023, leadership from the OLTCPR presented an excellent webinar on this new service which is now available on their website, see the trainings and resources tab at the bottom of this page.

To comply with HSC 1418.8, some facility IDT members should register with the OLTCPR CAPRIS reporting system, take the online training, and prepare to report the below information at the start of each quarter (beginning April 1, 2023):

1. Total # of IDT reviews conducted for patients without capacity.
2. The # of unique residents who have had an IDT review conducted.
3. The total # of emergency medical interventions authorized pursuant to HSC section 1418.8
4. The number of unique residents who have had an emergency medical intervention authorized.
5. A tabulation of medical interventions authorized by type
6. A tabulation of the outcomes of the IDT reviews
7. A tabulation of instances when judicial review was sought
8. A tabulation of emergency medical interventions where the IDT failed to meet within the time required by HSC section 1418.8 including the causes of the delay and the number of days after the intervention that the IDT finally met.

The above reports are required for all Epple IDTs, whether there’s a PPR involved or whether the facility has been able to locate another unaffiliated representative for the resident.

The resource page has templates for the required notices and flow charts.

This program is well designed and when implemented will benefit your unrepresented residents and insure you are in compliance with HSC section 1418.8

https://aging.ca.gov/Providers_and_Partners/Office_of_the_Long_Term_Care_Patient_Representative/