Advance Directives: Nursing Guide
What should you know about advance directives? Nursing professionals need to be aware of each patient’s goals of care. An advance healthcare directive helps guide care providers and family members in situations where a patient can’t advocate for themselves. Learn about the types of advance directives and how to educate your patients about their options.
What Are Advance Directives in Nursing?
Advance directives are care instructions that a patient outlines in advance to direct their care in the event they can’t make decisions for themselves. These documents help nurses promote patient dignity by directing team members’ decisions. They are a legally binding method for patients to document refusal of treatment. For example, if a patient were to stop breathing, the healthcare team would refer to any advance directives to determine treatment options.
Without advance directives, it is assumed that a patient wants the full scope of medical interventions. While these documents vary, there are two main sections that nurses should be aware of:
- Durable power of attorney: This section identifies a person, sometimes called a healthcare power of attorney, who can make decisions for the patient if they cannot do so. This may be a family member, neighbor, friend, or guardian.
- Living will: Designates the treatments that a patient wants or doesn’t want. For example:
- Do Not Resuscitate (DNR): The patient does not want CPR in the event of a cardiovascular emergency.
- Do Not Intubate (DNI): The patient does not wish to be put on mechanical ventilation.
- Comfort Measures Only (CMO): The patient wants pain and symptom management without life-prolonging treatment.
- Artificial feedings: The patient does not want nutrition via a nasogastric tube.
Even though they’re essential for articulating a patient’s care goals, advance directives are not common — only about 37% of adults have completed them. And even for patients who have these measures in place, advance directives are often misinterpreted or not followed. Nurses play an important role in helping patients understand their options when it comes to advance care planning and advocating for their patients’ wishes.
Advance Directives: Nursing Considerations
The ANA Code of Ethics requires nurses to educate patients on their advance healthcare directive options, yet many nursing professionals are hesitant to do so. End-of-life and emergency care planning can be sensitive subjects for patients, their families, and nurses themselves. As the geriatric population increases, and patients often seek care without the support of family members, nurses need a firm grasp of care planning measures and how to navigate them.
1. Team Communication
When you learn a patient has an existing or new advance directive, communicate this with the healthcare team to ensure everyone is on the same page. Some units use door labels or additional arm bands to show when a patient has a DNR or DNI status, so that any staff entering the room will know about their wishes. Include advance directives on shift report sheets, and be sure that any required documentation moves with the patient upon transfer or discharge.
2. Timing
When should conversations about advance directives be brought up? Ideally, patients should receive education about advance directives through their primary care provider, upon hospital admission, and when any major medical changes occur. If you’re performing intake on a new patient, ask them if they have existing advance directives that the team should be aware of.
Ideally, these documents should be completed well before a change in status occurs. Avoid asking or advocating for advance directives during or immediately after a crisis, as patients may not be in the right state of mind to make major decisions.
3. Cultural Sensitivity
As with other medical decisions, a patient’s upbringing, values, and culture influence their perception of death and end-of-life care. Be respectful of potential sensitivities, and don’t push patients to make a decision they aren’t ready for. Rather than making recommendations, you might begin this conversation with questions about how a patient wishes to die and who they want involved.
Don’t sugar-coat the seriousness of these issues, especially in the case of very ill patients who need your honesty. Resources like The Conversation Project can help guide you in initiating talks about care planning decisions.
4. Moral Injury
Moral injury results from repeatedly witnessing or performing care that does not align with a nurse’s values or personal ethics. For example, a nurse might feel that administering CPR to a patient with dementia is unnecessary and traumatic, but if that patient is a full code, the nurse will need to administer CPR anyway. Advocating for appropriate care measures not only helps you advocate for patients’ wishes but can also help nursing staff.
Nurses are uniquely positioned to educate patients on the realities of end-of-life care and resuscitation, because they are witnesses to these measures and their drawbacks. For instance, few people know that only 15–25% of patients are successfully discharged after hospital CPR. Even when properly performed, resuscitation measures can lead to rib fractures, trauma, neurological effects, and other complications. With this in mind, nurses can play an important role in care planning conversations.
Advance Directives: Nursing FAQ
What populations should receive education about advance directive options?
While it’s especially important for older adults and those with chronic or life-limiting conditions, unexpected accidents or illnesses can happen at any age. All adult patients should be offered education about advance directives, regardless of their current health status.
What should I do if my patient is a DNR/DNI?
Verify that the order is properly documented in the medical record and ensure that all members of the care team are aware. Implement facility-specific interventions such as bracelets or bedside documentation, and document these in the electronic health record (EHR).
Do advance directives need to be notarized?
Each state has different requirements for these forms, and some require witnesses and notaries. While hiring a lawyer is generally not required to complete living wills and advance directives, some patients find it beneficial.
Can family members change advance directives against a patient’s wishes?
Advance directives are legally binding documents that can be changed by the patient, not by their family. However, many nursing professionals have witnessed instances where family members made different decisions after a patient became incapacitated. If you witness ethical violations against a patient’s wishes, go to your nurse manager or facility ethics board for guidance.
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Legal Disclaimer: This article contains general legal information, but it is not intended to constitute professional legal advice for any particular situation and should not be relied on as professional legal advice. Any references to the law may not be current as laws regularly change through updates in legislation, regulation, and case law at the federal and state level. Nothing in this article should be interpreted as creating an attorney-client relationship. If you have legal questions, you should seek the advice of an attorney licensed to practice in your jurisdiction.