Want to know more

ADVANCE DIRECTIVES
Geriatric Nursing Standard of Practice: Advance Directives Protocol

Ethel L. Mitty, EdD, RN, Gloria C. Ramsey, JD, RN

Evidence-Based Content - Updated March 2008

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

 

Guiding Principals

A. All people have the right to decide what will be done with their bodies.

B. All individuals are presumed to have decision-making capacity until deemed otherwise.

C. All patients who can participate in a conversation, either verbally or through an alternate means of communication, should be approached to discuss and record their treatment preferences and wishes.

D. Health care professionals can improve end-of-life care for elderly patients by encouraging the use of ADs.

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Background

A. Education about advance directives: 1, 2

1. Patients uniformly state that they want more information about ADs.

2. Patients want nurses (and doctors) to approach them about ADs.

3. Fewer than 20% of Americans have completed an AD.

B. Advance Directives

1. 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. 3

2. Provide guidance for health care professionals, families, and substitute decision makers about health care decision making that reflect the person’s wishes.

3. Provide immunity for health care professionals, families, and appointed proxies from civil and criminal liability when health care professionals follow the AD in good faith.

C. Two types of Advance Directives: Durable Power of Attorney for Health Care (DPAHC) (also called a Health Care Proxy) and Living Will (LW)

1. A Durable Power of Attorney allows individuals to appoint someone, called a health care proxy, agent, or surrogate, to make health care decisions for them should they lose the ability to make decisions or communicate their wishes.

2. A Living Will provides specific instructions to health care 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.

D. Instructional or Medical Directive: Intended to compensate for the weaknesses of LWs, this kind of directive identifies specific interventions that are acceptable to a patient in specific clinical situations.

E. 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 ADs vary by state.

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Assessment Parameters

A. All adult patients regardless of age (with the exception of patients with persistent vegetative state, severe dementia, or coma) should be asked if they have a LW or if they have designated a proxy.

B. All patients, regardless of age, gender, religion, socioeconomic status, diagnosis, or prognosis, should be approached to discuss ADs and advance care planning.

C. Discussions about ADs should be conducted in the patient’s preferred language to enable information transfer and questions and answers.

D. Patients who have been determined to lack capacity to make other decisions may still have the capacity to designate a proxy or make some 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. 4

E. If a LW has been completed or proxy has been designated:

1. The document should be readily available on the patient’s current chart.
2. The attending physician should know that the directive exists and has a copy.
3. The designated health care proxy should have a copy of the document.
4. The AD should be reviewed periodically by the patient, attending physician/nurse, and the proxy to determine if it reflects the patient's current wishes and preferences.

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Care Strategies

A. Nurses should assist patients and families trying to deal with end-of-life care issues. 5, 6

B. Patients may be willing to discuss their health situation and mortality with a nurse or clergyman rather than with a family member and should be supported in doing so.

C. Patients should be assisted in talking with their family/proxy about their treatment and care wishes.

D. Patients should be assessed for their ability to cope with the information provided.

E. Nurses must be mindful of and sensitive to the fact that race, culture, ethnicity, and religion can influence the health care decision-making process. The fact that patients from non-Western cultures may not subscribe to Western notions of autonomy does not mean that these patients do not want to talk about their treatment wishes or that they would not have conversations with their families about their treatment preferences. 7

F. Patients must be respected for their decision to not complete an AD and reassured that they will not be abandoned or receive substandard care if they do not elect to formulate an AD.

G. Nurses should be aware of the institution’s mechanism for resolving conflicts between family members and the patient or proxy or between the patient/family and care providers and assist the parties in using this resource.

H. Nurses should be aware of which professional in their agency/institution is responsible for checking with the patient that copies of the AD have been given to their primary-care provider(s), to their proxy, and that the patient is carrying a wallet-size card with AD and contact information.

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Evaluation of Expected Outcomes

To determine whether implementation of this protocol influenced the type as well as the number of ADs created, changes should be measurable and contribute to the facility's ongoing quality improvement program. Look at:

A. As documented in the record:

1. whether patients are asked about advance care planning and directives
2. whether patients do or do not have an AD

B. Of those patients with an AD, the percentage of ADs included in patient charts

C. The use of interpreters to assist staff discussion of ADs with patients for whom English is not their primary language

D. The number of ADs completed in association with admission to or receipt of services from the agency/institution

E. The number of nurse referrals to the Ethics Committee of patient or staff situations regarding ADs 

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For Definition of Levels of Quantitative Evidence Click Here

Reprinted with permission from Springer Publishing Company. Kresevic, D. M. (2008). Advance directives protocol. In E. Capezuti, D. Zwicker, M. Mezey, & T. Fulmer (Eds.) Evidence-Based Geriatric Nursing Protocols for Best Practice. (3rd ed.) (pp. 23-40). New York: Springer Publishing Company, Inc.

 

References

1.  Morrison, R.S., Chichin, E., Carter, J., Burack, O., Lantz, M., & Meier, D.E. (2005). The effect of a social work intervention to enhance advance care planning documentation in the nursing home. Journal of the American Geriatrics Society, 53(2), 290-294. Level of Evidence IV: Non-experimental study.

2.  Gutheil, I.A. & Heyman, J.C. (2005). Communication between older people and their healthcare agents: Results of an intervention. Health & Social Work, 30(2), 107-116. Level of Evidence II: Single experimental study.

3.  Rodriquez, K.L. & Young, A.J. (2006). Patients’ and healthcare providers’ understandings of life-sustaining treatment: Are perceptions of goals shared or divergent? Social Science Medicine, 62(1), 125-133. Level of Evidence: IV: Non-experimental study.

4.  Mezey, M., Teresi, J., Ramsey, G., Mitty, E., & Bobrowitz, T. (2002). Determining a resident’s capacity to execute a Health Care Proxy. Voices of Decision in Nursing Homes: Respecting residents’ preferences for end-of-life care. New York: United
Hospital Fund of New York. Level of Evidence: IV: Non-experimental study.

5.  Schwartz, C.E., Wheeler, H.B., Hammes, B., Basque, N., Edmunds, J., Reed, G., et al. (2002). Early intervention in planning end-of-life care with ambulatory geriatric patients: Results of a pilot trial. Archives of Internal Medicine, 162(14), 1611-1618.

6. Engel, S.E., Kiely, D.K., & Mitchell, S.L. (2006). Satisfaction with end-of-life care for Nursing Home residents with advanced dementia. Journal of the American Geriatrics Society, 54(10), 1567-1572.

7.  Cox, C.L., Cole, E., Reynolds, T., Wandrag, M., Breckenridge, S., & Dingle, M. (2006). Implications of cultural diversity in do not attempt resuscitation (DNAR) decision-making. Journal of Multicultural Nursing & Health, 12(1), 20-28. Level of  I: Systematic review 

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Last updated - March 2008