9.3 Advance Directives and End-of-Life Care

Advance Directives and End-of-Life Care

Advance directives are legal documents in which a competent adult records healthcare wishes to take effect if they later cannot speak for themselves. The federal Patient Self-Determination Act requires facilities to ask about and honor them. CNAs do not write or interpret these documents, but they must know each resident's wishes and code status.

The Four Documents to Distinguish

The exam loves the living-will-versus-HCPOA contrast: a living will states the wishes; a healthcare power of attorney names the person who will voice them.

What a DNR Really Means

This is the most-missed item in the chapter. A DNR prevents resuscitation only:

• No chest compressions (CPR)
• No defibrillation (shock)
• No intubation or breathing tube
• No code/resuscitation medications

A DNR does NOT mean: no food, no fluids, no antibiotics, no pain medicine, no repositioning, or lower-quality care. A DNR resident still receives full comfort care and all routine care. Telling a worried family that DNR means "giving up" is wrong and outside your scope.

Key DNR facts: it must be ordered by a physician, documented in the record, and known to all staff. If a resident with a valid DNR stops breathing, the CNA does not start CPR and instead notifies the nurse immediately.

CNA Role with Directives

Do: know if a resident has directives, know the code status, follow the care plan, and report questions to the nurse.

Do NOT: interpret the document, decide when it applies, voice personal opinions about the resident's choices, or assume what the resident would want.

Comfort (Palliative) Care

End-of-life care shifts the goal from cure to comfort and dignity. The CNA's contribution:

Signs Death Is Approaching

After Death: Postmortem Care

When a resident dies, the CNA's sequence is: notify the nurse, note the time, and support the family. Postmortem care, done per facility policy and family/cultural wishes, maintains dignity:

1. Position the body flat on the back with one pillow under the head to prevent pooling and discoloration.
2. Close the eyes and replace dentures to preserve a natural appearance.
3. Bathe as needed, apply a clean gown and fresh linens.
4. Remove tubes only if facility policy and the nurse direct it (not if the death is a coroner's case).
5. Allow the family private time and honor religious or cultural practices.

Supporting Families

Grief looks different in everyone, from calm to weeping to anger. Be present, listen without judging, allow private time, offer practical help (tissues, water), and refer prognosis questions to the nurse. Never take a grieving family's emotions personally.

The Five Stages of Grief

Many exams reference the Kubler-Ross model, which describes five common emotional stages: denial, anger, bargaining, depression, and acceptance. People do not move through them in a fixed order, may skip stages, and may revisit them. A CNA should recognize that a resident's anger or denial is part of grieving rather than a personal attack, and should respond with patience and presence rather than argument or false reassurance. Telling a frightened resident "everything will be fine" is dishonest and dismissive; simply staying, listening, and reporting emotional distress to the nurse is more appropriate and within scope.

Hospice vs. Curative Care

Hospice care is a form of comfort care for residents whose physician certifies a life expectancy of roughly six months or less and who have chosen to stop curative treatment. The focus shifts entirely to comfort, dignity, and family support. CNAs working with hospice residents prioritize pain relief reporting, frequent mouth and skin care, gentle repositioning, and a calm environment. Understanding that hospice is a choice the resident or proxy made helps the CNA respect, rather than question, the decision to forgo aggressive treatment.

Cultural and Spiritual Sensitivity

End-of-life customs vary widely: some families want continuous bedside presence, specific prayers, particular handling of the body, or that only certain people touch the deceased. The CNA should ask, follow the care plan, and never impose personal beliefs. Honoring these wishes is both an ethical duty (respect and dignity) and a practical part of postmortem care, since some traditions restrict who may bathe or move the body.