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Advance Directives for Health Care: A Guide for Nurses

Instructor: Zona Taylor

Zona has taught Nursing and has a master's degree in Nursing Education and Maternal-Infant Nursing from University of Maryland Baltimore.

This lesson covers what the nurse needs to know about a patient's Advance Directive. Learn what it is, where it comes from, what it includes, who can witness the patient signing it, and more.

What Is an Advance Directive?

If you're a nurse, you may already have an Advance Directive, because you've probably seen firsthand how helpful it can be for medical professionals and family to have a patient's wishes for end-of-life care documented. An Advance Directive (AD) is a legal document that allows you to determine what medical decisions you want made in the event you are unable to make your wishes known. Generally, an AD comes into play when there is a terminal illness or condition that is likely to leave you dependent on machines for the rest of your life. All Advance Directives can be modified or cancelled anytime you want.

You should be aware that not every state honors POLSTs or ADs from other states. Nurses should find out which laws apply to the locality where they practice.

Following are the four types of Advance Directives.

Living Will

This is a legal written document that spells out what the patient does or does not want by way of life-extending medical treatments. A Living Will applies to the patient in a hospital or nursing facility. It holds no power with emergency responder (ambulance) staff or Emergency Department staff.

Medical Power of Attorney or Health Care Proxy

The Medical Power of Attorney is the legal document used to name the person who will make decisions regarding health care matters on behalf of the patient when the patient is unable to speak for himself. A general Power of Attorney (POA) does not usually extend to health care decisions. A general Power of Attorney usually concerns financial issues. These two patient representatives would best be two different individuals.

DNR/DNI

It is not necessary to have an Advance Directive to request a Do Not Resuscitate (DNR) or Do Not Intubate (DNI) order. These are simply doctor's orders that would be placed in the medical record for a patient currently in the hospital or other nursing facility.

Physician Orders for Life-Sustaining Treatment (POLST)

Unlike the other types of ADs mentioned, the Physician Orders for Life-Sustaining Treatment (POLST) are for individuals who have already been diagnosed with a serious illness. What makes it different from the other types of AD is that the POLST serves as doctor's orders in settings other than in the hospital as well as in the hospital or nursing facility. Ambulance staff and other medical team members use it to guide which measures to start (or not) based on the patient's desires as recorded on the POLST.

A POLST provides a way for the doctor to list what treatment to use, under what conditions, how long the treatments should be continued, and at what point specific treatments should be stopped. The most common topics included in a POLST (the same as those addressed in other types of ADs) are as follows:

  • Cardiopulmonary Resuscitation (CPR) - attempt to restart heart
  • Mechanical respirator/ventilator - machine that breathes for patient
  • Tube feeding - tube placed in stomach for liquid food
  • Use of antibiotics
  • Requests to stay at home and not to transfer to an emergency room
  • Requests not to be admitted to the hospital
  • Pain management
  • Avoiding needle sticks and other painful procedures

A POLST also includes what other ADs the patient has created and who has been appointed Medical Power of Attorney.

Development of AD Laws

After attempts in Florida and California to pass Advance Directive legislation were defeated in the late 1960s and early 1970s, California became the first state in 1976 to succeed in passing AD legislation. By 1992, all fifty states plus Washington DC had enacted laws regarding AD. Because every state has its own law, if you're a nurse moving from one state to another, you must find out what is different from your previous understanding of AD.

A legal challenge to AD came to the New Jersey Supreme Court in 1976. The findings supporting AD upheld previous court rulings as follows:

  1. If patients are mentally unable to make treatment decisions, someone else may exercise their right for them.
  2. Decisions that can lead to the death of a mentally incompetent patient are better made not by courts but by families, with the input of their doctors.
  3. Decisions about end-of-life care should take into consideration both the invasiveness of the treatment involved and the patient's likelihood of recovery.
  4. Patients have the right to refuse treatment even if this refusal might lead to death.

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