01.02 Advanced Directives

Overview

  1. Advanced Directives
    1. Living Will
    2. Medical Power of Attorney

Nursing Points

General

  1. Patient Wishes & Advocacy
    1. Patient Wishes
    2. Patient Advocacy
  2. Living Will
    1. Legal Document
    2. Written out for instances for which a patient cannot communicate their decisions
    3. Often DNR/Partial DNR/Full Code Wishes
      1. Full Code
        1. Chemicals/Drugs
        2. Compressions
        3. Shocks
        4. Intubation
      2. DNR – Do Not Resuscitate
        1. None of the Above
      3. Partial DNR
        1. One or more, but NOT all of the above
    4. State Dependent on executing them
  3. Medical Power of Attorney
    1. Legal Document
    2. Different than Durable Power of Attorney (DPOA)
    3. Designates a particular person or persons to make medical decisions for the patient
    4. In the absence of a MPOA, state laws dictate who makes medical decisions
      1. Example – TX – Spouse, Adult Children, Living Parents, Nearest Living Adult Relative, then providers
  4. Who needs a Living Will and who needs a Medical Power of Attorney
    1. Living Wills and Plans of Care
      1. Needed prior to injury, illness, hospitalization and/or treatment
      2. Example: Healthy individuals or those with chronic illness who may expect to receive treatment in the future
    2. Medical Power of Attorney
      1. Needed by those who may, at some point, be unable to voice their own decisions regarding medical care.
      2. Example: Patients with dementia or cancer.

Nursing Concepts

  1. Health Policy
  2. Ethical & Legal Practice
  3. End of Life

Patient Education

  1. Patients should be educated on advanced directives
  2. Patients should be educated on Power of Attorneys and Living Wills
  3. Chaplain can assist with obtaining an advanced directive in the hospital

Reference Links

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Video Transcript

In this lesson, we’ll be taking a look at advanced directives and ways we can follow our patient’s wishes regarding medical decisions.

This is a heavy subject and not everyone likes talking about things associated with end of life. But it’s really important, and more important for you as the nurse to realize.
There are lots of points that I’ll make throughout this lesson, but a big takeaway from this is that advanced directives are about the PATIENT and what they want regarding their care when they can’t tell you. Patients can often have conversations with family members about their wishes, but sometimes that information doesn’t get to the right people. Let’s say for example, you have a young married couple who knows exactly what each other want in terms of ICU care, but they get in a terrible accident. Because they didn’t tell OTHER family members, no one knows what medical decisions to make. This complicates the situation for everyone.
So how can you honor your patient’s wishes? First off, start by advocating for them. Talk to your patients and find out what they want, and if they’ve taken the steps to get their wishes written up in legal documentation. If so, then great, you’re now one step of the game. But if not, and hopefully by the end of this lesson, you can steer your patients in the right direction so that they can make sure that their family members know what they want.

What are living wills? Well living wills are legal documents put together by patients that discuss their wishes for care. They can be complex or simple, but the goal of the living will is to guide a medical team or family members in what care a patient would want if they couldn’t speak for themselves. It’s a way to give a voice to a patient, in their own words, before anything happens. For example, if a patient doesn’t wish to be on a ventilator, or to be intubated, then those things can be outlined in a living will. And sometimes they can outline what they want in respect to what is known as a “code status.” Code statuses are essentially a policy by a hospital which directs all healthcare workers in what life-saving measures to use in the event of an emergency like cardiac or respiratory arrest When we talk about Full Code statuses (or a “full code”), it simply means that the patient agrees to have all life saving measures done. This includes defibrillation, chest compressions, artificial breathing, administration of emergency drugs, and breathing tubes with machines like a ventilator.
A DNR code status is a Do-Not-Resuscitate order. It’s virtually the opposite of a full-code status. This means that the patient is refusing to be shocked, compressions, breathing tubes, drugs and any life-saving measures. One important thing to remember is that this requires an order by a doctor, AND discussion between the doctor and the patient or the family. Doctors can often refer to living wills for code statuses, and can use those to enact those orders.
Now one caveat to code statuses is that there is one more type of code status, known as a Partial DNR. This means a patient is refusing only PARTICULAR aspects of life saving measures, but not others. For instance, they could be a partial DNR with no chemicals or compressions, but will accept intubation. This means that the patient doesn’t want CPR, but will accept a breathing tube. There are multiple combinations of these partial DNR orders, so pay VERY close attention to them when you see them.

Now a medical power of attorney is another legal document that helps medical providers to make decisions about medical care.
A power of attorney is a legal document that assigns a particular person the right to make legal decisions about another person. There are two different types of power of attorney, a medical power of attorney and a durable power of attorney.
For the medical power of attorney, what happens is that a patient picks someone and grants them the ability to make medical decisions about their care and their care only.
This is different than a durable power of attorney. A durable power of attorney gives someone the authority to make decisions for someone else, and it excludes medical decisions. So an example of this would be like paying bills, withdrawing money from a bank account, and other court or legal issues.
The important point here though is that a medical power of attorney helps to give a patient a voice by using someone they trust. And that person then makes decisions regarding their medical care for them. So who makes medical decisions when there’s no advanced directive? There’s usually a list of people, and an order in which they’re picked, to be that patient’s decision maker. It varies by state and country, so be sure to check your state jurisdiction for those.

So who needs what? Who needs a living will and who needs a medical power of attorney?In short, a patient needs a living will PRIOR to any injury or illness. They can be healthy individuals or patients with chronic conditions. The patients that need a medical power of attorney are those who know that, maybe inevitably, in the future they may not be able to make their own medical decisions. So it’s important for them to assign someone to make those decisions for them. Examples of this are patients with dementia or even cancer. Let’s take a look at some nursing concepts for advanced directives. Advanced directives are a direct reflection of ethical and legal practice. They’re also a product of health policy, seeing as these situations can be complicated. That being said, follow up with your government to find out what laws apply where you live. And lastly, end of life, while not always an easy subject to talk about goes hand in hand with advanced directives. It’s always best to know your patient’s wishes

Now let’s recap.

When we look at our patient’s we need to know what they want in terms of their care. Advanced directives are a way to give them that opportunity.

Living wills are outlines PRIOR to treatment.

And a medical power of attorney picks someone to make decisions for a patient, so usually someone they trust. And who needs what?

A Living will plans for future events and a medical power of attorney picks someone to help with making decisions when the patient can’t.
And finally, know your patient’s code status regarding emergencies. Know the difference between a full code and a DNR status, and what you need to do to make sure you follow your patient’s wishes.

Read more

  • Question 1 of 8

In the case of a client becoming incompetent to make his or her own decisions, the person who is durable power of attorney for healthcare can authorize which of the following? Select all that apply.

  • Question 2 of 8

A client is admitted to the cardiac ICU after suffering a myocardial infarction. The nurse discovers that the client does not have advance directives in place. Which of the following has been shown to be a reason for noncompletion of advance directives? Select all that apply.

  • Question 3 of 8

A client with advanced kidney disease and diabetes wants to sign an advance directive stating that he or she does not want dialysis if it is eventually needed. Which response from the nurse is accurate in this situation?

  • Question 4 of 8

An older adult client who has been diagnosed with lymphoma does not have a living will in place, but has filled out a values history. Which of the following is associated with this type of directive? Select all that apply.

  • Question 5 of 8

A client is having a yearly well visit and asks the nurse, “If I appoint a power of attorney do I lose my right to make medical decisions?” Which of the following responses is best?

  • Question 6 of 8

A client is admitted to the hospital for surgery and the nurse discovers that the client has a living will. In addition to placing a copy of the document on the client’s chart, what would be a priority action for the nurse?

  • Question 7 of 8

You are caring for a patient who has just arrived on your unit from the PACU after a craniotomy for tumor debulking. After completing your initial assessment you gave him a dose of morphine for pain. He is groggy, but oriented and compliant. His daughter has approached you outside of the patient’s room and asked, “Can you just knock him out? He is really agitated, and getting on my nerves. He’s probably in pain and just needs to sleep off the rest of the day. It’s okay. I’m his health care power of attorney, just check the chart.” What’s the most appropriate response?

  • Question 8 of 8

The nurse is caring for a 70-year-old client diagnosed with pneumonia. The treatment plan includes antibiotics, breathing treatments and incentive spirometer use. The client is alert and oriented to person, place, time, and situation. They are on 2L nasal cannula without any signs or symptoms of distress. The client states, “I do not want to have any antibiotics, I just want this to run its course.” The nurse knows this client has a durable power of attorney. Which of the following should the nurse do?

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