Key Takeaways
- Advance directives express healthcare wishes when a person cannot speak for themselves
- DNR means no CPR—it does NOT mean no other treatment or comfort care
- Healthcare Power of Attorney designates someone to make medical decisions
- CNAs provide comfort care, support families, and respect patient wishes at end of life
- Hearing is often the last sense to remain—continue speaking to dying patients
Advance Directives and End-of-Life Care
Advance directives are legal documents that allow people to express their wishes for healthcare decisions in advance, in case they become unable to speak for themselves. CNAs must understand and respect these documents.
Types of Advance Directives
| Document | Purpose |
|---|---|
| Living Will | States preferences for medical treatment if terminally ill or permanently unconscious |
| Healthcare Power of Attorney (HCPOA) | Designates a person to make healthcare decisions if patient cannot |
| DNR (Do Not Resuscitate) | Instructs not to perform CPR if heart stops |
| POLST/MOLST | Physician orders for life-sustaining treatment (more detailed than DNR) |
Living Will
A living will specifies what medical treatments a person does or does not want if they become terminally ill or permanently unconscious.
May address:
- Mechanical ventilation (breathing machine)
- Tube feeding
- IV fluids
- Antibiotics for infections
- Dialysis
- Pain management
- Organ donation
Healthcare Power of Attorney
Also called healthcare proxy or durable power of attorney for healthcare.
The designated person (agent) can:
- Make healthcare decisions when patient cannot
- Access medical records
- Consent to or refuse treatment
- Choose healthcare providers
The agent CANNOT:
- Make decisions contrary to the patient's known wishes
- Override a valid advance directive
- Make financial decisions (unless also given financial POA)
DNR Orders
DNR (Do Not Resuscitate) means:
- No CPR (chest compressions)
- No defibrillation
- No intubation (breathing tube)
- No resuscitation medications
DNR does NOT mean:
- No other treatment
- No comfort care
- "Give up"
- Poor quality of care
DNR Requirements:
- Must be ordered by a physician
- Must be documented in the medical record
- All staff must be aware
- Often posted at bedside or in specific location
CNA Role with Advance Directives
What CNAs SHOULD Do:
- Know if resident has advance directives
- Know the resident's code status (DNR vs. full code)
- Provide care as directed by the care plan
- Respect resident's wishes
- Report any questions or concerns to nurse
What CNAs should NOT Do:
- Interpret advance directives
- Make decisions about applying directives
- Discuss your personal opinions about patient's choices
- Assume what patient would want
End-of-Life Care
Comfort care (palliative care) focuses on comfort rather than cure.
Goals:
- Relieve pain and symptoms
- Maintain dignity
- Provide emotional support
- Support family members
- Honor patient's wishes
CNA Role in End-of-Life Care:
| Area | CNA Responsibilities |
|---|---|
| Physical Comfort | Positioning, mouth care, skin care, keeping clean and dry |
| Pain Management | Report signs of pain, assist with comfort measures |
| Emotional Support | Listen, provide presence, allow family time |
| Environment | Quiet, comfortable, respect privacy |
| Observations | Report changes in condition to nurse |
Signs of Approaching Death
Physical changes that may occur:
| System | Changes |
|---|---|
| Circulation | Mottling, cool extremities, weak pulse |
| Breathing | Cheyne-Stokes, irregular, "death rattle" |
| Level of Consciousness | Decreased alertness, unresponsive |
| Intake | Decreased eating and drinking |
| Output | Decreased urine, incontinence |
| Skin | Pale, gray, waxy appearance |
| Senses | Hearing often last sense to go |
Supporting Families
CNAs can help families by:
- Being available and present
- Listening without judgment
- Providing updates (within scope)
- Allowing private time
- Offering practical assistance (getting water, tissues)
- Respecting grief reactions
Remember:
- Grief reactions vary widely
- Some families are calm, others emotional
- Cultural practices differ
- Don't take behaviors personally
- Refer questions about prognosis to nurse
After Death (Postmortem Care)
When death occurs:
- Call the nurse immediately
- Stay with the body (per facility policy)
- Note time
- Provide emotional support to family
- Assist with postmortem care when directed
Postmortem Care:
- Prepare body according to facility policy
- Respect family and cultural wishes
- Maintain dignity
- Keep body flat with one pillow
- Close eyes, place dentures
- Remove tubes (per policy)
- Apply clean gown and linens
What does a DNR order mean?
Who can make healthcare decisions for a patient who cannot make decisions for themselves?
Which sense is often the last to remain as a person is dying?