8.4 Advance Directives, Ombudsman & End-of-Life

Advance Directives in Florida

An advance directive is a legal statement of a person's healthcare wishes made ahead of time, for a future moment when they cannot speak for themselves. Florida's advance directives are governed by Florida Statutes Chapter 765 (Health Care Advance Directives).

In Florida, the out-of-facility resuscitation order is the Do Not Resuscitate Order (DNRO), recorded on the state's official DH Form 1896 (printed on distinctive yellow paper so staff and EMS can spot it quickly). A DNR or DNRO means no CPR only. It does not mean stop feeding, giving fluids, bathing, repositioning, comfort measures, pain relief, oxygen for comfort, or emotional support. The CNA must know exactly which residents have a DNRO and must continue every other aspect of care fully and attentively.

CNA Role

The CNA follows the care plan and the directive, never decides whether to resuscitate based on personal opinion or feelings, and immediately reports any change in the resident's condition or any new statement the resident makes about their wishes to the nurse. The CNA does not witness or interpret legal documents; that is the nurse's and team's responsibility.

The Florida Long-Term Care Ombudsman

The Florida Long-Term Care Ombudsman Program is a state, largely volunteer-based program of independent advocates for residents of nursing homes, assisted living facilities, and adult family-care homes. Because the ombudsman works independently of the facility, residents can raise concerns without fear of retaliation. The ombudsman:

• Receives, investigates, and helps resolve resident and family complaints.
• Advocates for residents' rights, dignity, choice, and quality of care.
• Conducts annual facility assessments and visits.
• Helps residents understand and exercise their rights, including transfer and discharge appeals.

Residents have the right to contact the ombudsman, and the program's posted contact information must be available in the facility. The CNA's job is to support, not block, a resident's access to the ombudsman, to never retaliate, and to report serious concerns through the chain of command as well.

Resident concern path
Resident voices a concern
   -> CNA listens, does not retaliate, reports to the nurse
   -> Facility chain of command / grievance process
   -> Florida Long-Term Care Ombudsman (independent advocate)
   -> AHCA oversight and survey when required

If a resident says they want to file a complaint and asks for help reaching the ombudsman, the correct answer is always to help them, never to discourage them or take it personally.

End-of-Life and Palliative Basics

Palliative care focuses on comfort, dignity, and symptom relief rather than curing the illness. Hospice provides palliative care for residents near the end of life and supports the family before and after death. The CNA delivers much of the hands-on comfort care:

• Keep the resident clean, dry, and repositioned for comfort and to protect fragile skin.
• Provide gentle, frequent oral and lip care; the mouth and lips dry quickly near the end of life.
• Control the environment: calm, quiet, dignified, with privacy for the resident and family and favorite items nearby.
• Offer emotional presence: allow the resident and family to express feelings, and never impose your own religious or personal beliefs.
• Hearing is often the last sense to fade. Continue to speak gently, explain care before you touch, and never talk about the resident as if they cannot hear.
• After death, provide respectful postmortem care per facility policy, maintaining dignity, privacy, and the resident's cultural or religious wishes.

Report changes such as new or increased pain, restlessness, changes in breathing (including periods of no breathing), mottled skin, or the family's needs to the nurse promptly.

Exam Tip

Florida items: a DNR/DNRO stops only CPR, not other care; the ombudsman is an independent resident advocate you help residents reach; and comfort, dignity, and continued gentle communication are always the right end-of-life answers. Choices that withhold routine care because of a DNRO, or that let the CNA decide whether to resuscitate, are wrong.

Recognizing the Signs of Approaching Death

The CNA does not predict death, but recognizing common physical changes helps the team provide comfort and helps the CNA know what to report. As death approaches, a resident may show decreased appetite and thirst, increased sleeping and decreasing responsiveness, cooler, mottled (blotchy) skin in the hands and feet, changes in breathing such as irregular, shallow, or periodic breathing with pauses (sometimes called Cheyne-Stokes), noisy or congested breathing, decreased urine output, restlessness, and confusion.

None of these signs change the CNA's core job: keep the resident clean, comfortable, repositioned, and treated with dignity, and report changes to the nurse.

Supporting the Family and the Grief Process

Families grieve in many ways, and the CNA's role is to be a calm, respectful presence rather than to give medical information, which is the nurse's responsibility. People may move through reactions often described as denial, anger, bargaining, depression, and acceptance, not in a fixed order. " Cultural and religious practices around dying and the body vary widely, so the CNA follows the resident's and family's expressed wishes and the care plan, and asks the nurse when unsure. After death, the CNA continues to treat the body with the same dignity and privacy given in life while providing postmortem care per facility policy.