Want to know more


The information in this "Want to know more" section is organized according to the following major components of the NURSING PROCESS:


Guiding Principals

  • All people have the right to decide what will be done with their bodies.
  • All individuals are presumed to have decision-making capacity until deemed otherwise.
  • All patients who can participate in a conversation, either verbally or through alternate means of communication should be approached to discuss advance directives.
  • Health care professionals can improve the end-of-life decision making for older patients by encouraging the use of advance directives.
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Durable power of attorney for health care (DPAHC), also called a Health Care Proxy, allows an individual to appoint someone, called a healthcare proxy, agent, or surrogate, to make health care decisions for him or her should he or she lose the ability to make decisions or communicate his or her wishes.

Living will provides specific instructions to healthcare providers about particular kinds of health care treatment an individual would or would not want to prolong life. Living wills are often used to declare a wish to refuse, limit, or withhold life-sustaining treatment.

Oral advance directives (verbal directives) are allowed in some states if there is clear and convincing evidence of the patient's wishes. Clear and convincing evidence can include evidence that the patient made the statement consistently and seriously over time, specifically addressed the actual condition of the patient, and was consistent with the values seen in other areas of the patient's life. Legal rules surrounding oral advance directives vary by state.

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Advance Directives (AD):

  • Patients uniformly state that they want more information about advance directives.
  • Patients want nurses (and doctors) to approach them about advance directives.
  • Fewer than 20% of Americans have completed an advance directive.

Use of Advance Directives:

  • Allow individuals to provide directions about the kind of medical care they do or do not want if they become unable to make decisions or communicate their wishes.
  • Provide guidance for health care professionals and families about health care decision making that reflects the person's wishes.
  • Provide immunity for health care professionals and families from civil and criminal liability when health care professionals follow the advance directive in good faith.
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  • All patients (with the exception of patients with persistent vegetative state, severe dementia, or coma) should be asked if they have a living will or if they have designated a healthcare proxy.
  • All patients, regardless of age, gender, religion, socioeconomic status, diagnosis, or prognosis, should be approached to discuss advance directives and advance care planning.
  • Discussions about advance directives should be conducted in the patient's preferred language to enable information transfer and questions and answers.
  • Patients who have been determined to lack capacity to make other decisions may still have the capacity to designate a healthcare proxy or make health care decisions. Decision-making capacity should be determined for each individual based on whether the patient has the ability to make the specific decision in question.
  • If a living will has been completed or healthcare proxy has been designated:
    • Is the document readily available on the patient's current chart?
    • Does the attending physician know the directive exists and have a copy?
    • Does the designated healthcare proxy have a copy of the document?
    • Has the document been recently reviewed by the patient, attending physician/nurse, and healthcare proxy to determine if it reflects the patient's current wishes and preferences?
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Nursing Care Strategies/Treatment/Management

  • Nurses can assist patients and families trying to deal with end-of-life care issues.
  • Patients who may be reluctant to discuss their own mortality or begin coping with their current health situation may be willing to discuss these issues with a nurse or clergyman.
  • Race, culture, ethnicity, and religion can influence the health care decision-making process. Nurses should be mindful of these factors but should always treat the patient as an individual, not as a class of persons.
  • Assess each patient's need for and ability to cope with the information provided. Patients from other cultures may not subscribe to Western notions of autonomy, but that does not mean that these patients do not want to talk about advance care planning or advance directives or that they would not have conversations with their families.
  • Respect each person's right not to complete an advance directive.
  • Inform patients that you will not abandon them or provide substandard care if they elect to formulate an advance directive.
  • Know the institution's mechanism for resolving conflicts between family members and the patient or between the patient/family and care providers. This may include consultation with a social worker or the patient advocate or bringing the issue to the hospital ethics committee.
  • Notify the appropriate person if you are unable to provide care should the patient's wishes conflict with your personal beliefs.
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To determine whether implementation of this protocol influenced the nature as well as the number of advance directives created, some changes can be measured and can contribute to the facility's ongoing quality improvement program.

  • As documented in the record:
    • the percent of patients asked about advance directives
    • whether a patient does or does not have an advance directive
  • Of those patients with an advance directive, the percentage of advance directives included in patient charts
  • The use of interpreters to assist staff discussion of advance directives with patients for whom English is not their primary language
  • Advance directives completed in association with admission to, or receipt of services from, the facility
  • Nurses referral of patient or staff situations regarding advance directives to the Ethics Committee or appropriate liaison

Reprinted with permission from Springer Publishing Company. Ramsey, G. & Mitty, E. (2003). Advance Directives: Protecting Patient's Rights. In Geriatric Nursing Protocols for Best Practice, (2nd ed.). Mezey, M., Fulmer, T., Abraham, I. (Eds.); Zwicker, D., (Managing editor). Spinger Publishing Company, Inc.

Last updated - February 2005

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