11.1 Advance Care Planning and Life-Sustaining Therapies

Why advance care planning is a CHPN skill, not paperwork

Advance care planning (ACP) is a repeating conversation about values, likely outcomes, and specific life-sustaining therapies (LSTs). CHPN items treat it as a nursing facilitation skill. The exam trap is treating a signed form as finished work. A living will completed during an early cancer diagnosis does not automatically answer whether this week's hypotensive, delirious patient should receive vasopressors, intubation, or a feeding tube.

The Certified Hospice and Palliative Nurse (CHPN) exam, scored on a scaled 200–800 range with 500 required to pass, tests whether you can keep the patient (or the rightful surrogate) in charge of those decisions without coercing a do-not-resuscitate order to make the plan of care tidier.

Capacity before consent

Capacity is a clinical judgment. It is decision-specific and can fluctuate. A patient may have capacity to refuse a feeding tube and lack capacity to weigh a complex dialysis schedule. Assess four elements: understand the relevant information, appreciate how it applies to this body and this illness, reason about options, and communicate a choice. Delirium, severe depression, uremic or hepatic encephalopathy, hypoxia, and opioid toxicity can temporarily erase capacity. Treat reversible causes and reassess rather than rushing a surrogate into irreversible LST decisions.

Competence is different: it is a legal finding by a court. Answers that send every indecisive family to probate court are usually wrong. If the patient lacks capacity, use the appointed health-care agent. If there is no agent, use the state's default surrogate hierarchy (often spouse or domestic partner, then adult children, parents, siblings—the exact order is state law). Document who decided, why the patient lacked capacity for this decision, and which values guided the choice.

Advance directives versus portable medical orders

Families and covering clinicians mix these documents. Teach the difference every time a code-status conversation starts.

A living will is an advance directive. While capacitated, the patient writes future preferences about LSTs—typically cardiopulmonary resuscitation, mechanical ventilation, dialysis, and artificial nutrition and hydration. It speaks when the patient cannot. It is not a physician order. Emergency medical services and a covering hospitalist may not be able to treat a living will as an actionable DNR.

A durable power of attorney for health care (DPOA-HC)—also called a health-care proxy or health-care agent appointment—is also an advance directive. It names a person to decide if the patient loses capacity. The agent must use substituted judgment (what the patient would have wanted), not the agent's own appetite for treatment. If the patient's wishes are unknown, the agent uses a best-interest standard. Keep the agent inside that frame when guilt and family politics pull toward “do everything.”

POLST (Physician Orders for Life-Sustaining Treatment), MOLST (Medical Orders for Life-Sustaining Treatment), POST, and similar state programs are not advance directives. They are portable medical orders for people with serious illness or advanced frailty. A physician—and in many states a nurse practitioner or physician assistant—signs them with the patient or legal surrogate. Because they are orders, they travel across home, nursing facility, hospice, ambulance, and hospital better than a living will. Typical sections cover CPR, intensity of medical interventions (full treatment vs selective vs comfort-focused), antibiotics, and artificially administered nutrition. A healthy middle-aged adult should complete advance directives, not a POLST.

Do-not-resuscitate (DNR), do-not-attempt-resuscitation (DNAR), and allow natural death (AND) language all address cardiopulmonary resuscitation. DNAR acknowledges that CPR is an attempt that often fails in advanced illness. AND frames the same decision as permitting a natural dying process. None of these orders, by themselves, forbid intubation for a reversible airway problem, dialysis, vasopressors, antibiotics, or feeding tubes—unless the POLST or order set says so. CHPN items love that distinction.

Full code versus selective life-sustaining therapy

Full code means attempted resuscitation with the usual ACLS package: compressions, defibrillation, intubation, and emergency medications. Selective LST is common and valid. Do not collapse mixed preferences into “full versus none.” Examples the exam expects you to handle:

• No CPR, but continue hemodialysis that already matches goals
• No intubation, but a time-limited trial of vasopressors for a potentially reversible infection
• No percutaneous feeding tube in advanced dementia, with a plan for careful hand feeding and oral comfort
• Implantable cardioverter-defibrillator (ICD) shocks deactivated as withdrawal of an unwanted LST, while a pacemaker for symptomatic bradycardia may remain if it is contributing to comfort

ICD deactivation is not euthanasia and not assisted dying. It is stopping an electrical intervention the patient no longer wants. Arrange electrophysiology or manufacturer support; a magnet is a temporary field measure, not a substitute for a goals conversation and an order. Artificial nutrition is also an LST, not a required comfort measure. In advanced dementia, a feeding tube does not reliably prevent aspiration, reverse cachexia, or prolong meaningful survival; the CHPN teaches that evidence and documents the patient's or surrogate's choice.

The nurse's lane: facilitate, document, do not coerce

The CHPN facilitates, translates, and documents. The CHPN does not coerce a DNR to make the hospice census cleaner, hide prognosis to “protect” the family, or complete a POLST to match the nurse's personal values. Useful moves:

• Ask what a livable day looks like, then map each LST onto that picture
• Use teach-back: “If your heart stopped tonight, what should the ambulance crew do?”
• Invite social work, chaplaincy, and the attending into conflict rather than refereeing it alone
• Record who was present, the capacity assessment, each LST accepted or refused, and the resulting orders

Revisit ACP when the condition or setting changes: new hospitalization, loss of capacity, transfer to a facility, a sharp functional drop, family conflict, or a request to “do more” or “do less.” A POLST that was right at hospice admission may be wrong after a reversible pneumonia or after a new stroke.

If a loud relative demands full code while a valid POLST and appointed agent say comfort-focused care, follow the legal decision-maker and the medical orders. Do not let volume rewrite status. If documents conflict, pause non-emergency LST, get the attending and social work, and use ethics consultation rather than improvising in the driveway.

Exam scenario. A patient with end-stage heart failure has a MOLST marking “do not attempt resuscitation” and “no intubation,” but wants a time-limited trial of IV antibiotics and pressors for sepsis if he can still sit with his grandchildren. The covering hospitalist calls that combination “inconsistent.” The CHPN response is to confirm capacity or the agent's authority, document the selective LST list, and get matching orders—not to force a binary full-code or comfort-only package.