14.2 Advance Directives & Surrogate Decision-Making
Key Takeaways
- Advance directives document values and treatment preferences before incapacity; living wills and durable powers of attorney for health care are core tools
- A health care agent/proxy speaks for the patient when the patient lacks decision-making capacity—not merely when staff disagree with the patient
- POLST/MOLST forms translate goals into portable medical orders for seriously ill patients and should align with advance directives
- Surrogate hierarchy is state-specific; without a designated agent, default surrogates (spouse, adult children, etc.) may apply under statute
- Gerontological nurses facilitate conversations, verify copies on the chart, and ensure care matches documented goals across transitions
Advance Directives & Surrogate Decision-Making
Quick Answer: Under GERO-BC III-A-6 (Legal and ethical issues), know how advance directives, surrogate decision-makers, and portable medical orders (POLST/MOLST) guide care when older adults cannot speak for themselves. Nursing roles: initiate goals-of-care talks early, confirm documents are current and accessible, honor the designated agent, and apply substituted judgment (what the patient would want) before best-interest standards.
Advance care planning is both a legal and ethical nursing responsibility. Waiting until crisis—ICU intubation, sudden stroke, or terminal delirium—often forces guesses under time pressure and family conflict.
Core Documents Compared
| Tool | What it is | When it applies | Nursing notes |
|---|---|---|---|
| Living will | Written preferences about life-sustaining treatment in terminal/permanent unconscious states | Patient lacks capacity and clinical conditions named in the document are met | Language may be vague—clarify goals with patient while capacitated |
| Durable power of attorney for health care (DPOA-HC) / health care proxy | Names an agent to make health decisions | Patient lacks decision-making capacity | Agent authority usually stops if patient regains capacity |
| Advance directive (umbrella) | Often combines living will + proxy designation | Future incapacity | Encourage copies to PCP, hospital, agent, and EHR |
| POLST / MOLST / POST | Clinician medical orders (CPR, ventilation, transfer, artificial nutrition) | Seriously ill/frail patients; portable across settings | Must be signed per state rules; review after status change |
| DNR / DNAR order | Specific order about CPR | Current clinical episode / facility | Distinct from “do not treat”; other care continues |
Key distinction for exams: advance directives express patient preferences; POLST/MOLST create actionable orders. A living will alone does not automatically generate a DNR order—clinicians must translate goals into orders.
When Surrogates Activate
A surrogate or health care agent makes decisions only when the patient lacks decision-making capacity for the decision at hand (capacity is decision-specific—covered in 14.4). Disagreement with the care team, family convenience, or age alone does not transfer authority.
Typical activation sequence
- Assess capacity for the specific decision
- If capacitated → patient decides (even if family objects)
- If incapacitated → activate designated agent/proxy if one exists
- If no agent → follow state surrogate hierarchy (often spouse/partner → adult children → parents → siblings → other relatives/close friend)
- If no available surrogate → institutional ethics/legal pathways (guardian, public guardian, or court)
State law varies. On GERO-BC items, choose answers that follow the named proxy over the loudest relative, and that seek clarification of the patient’s known values.
Standards Surrogates Should Use
| Standard | Meaning | Prefer when… |
|---|---|---|
| Substituted judgment | Decide as the patient would have decided | Values, prior statements, or directives are known |
| Best interest | Choose what a reasonable person would judge best for welfare | Patient’s wishes are truly unknown |
Nursing coaching for surrogates: “What would your mother say about a feeding tube given how she lived?” is substituted judgment. “What do you want?” is not.
Facilitating Advance Care Planning Conversations
Gerontological nurses are often the most trusted clinicians to open the topic. Effective approaches:
- Normalize: “We ask every patient about preferences so we know how to honor you.”
- Focus on goals and unacceptable states, not only procedure checklists (CPR yes/no)
- Explore spiritual/cultural views of life-sustaining treatment and autopsy/organ donation if relevant
- Include the chosen agent in discussions while the patient can introduce them to the care philosophy
- Revisit after major diagnoses, hospitalizations, functional decline, or widowhood
Barriers and responses
| Barrier | Response |
|---|---|
| “I’m not dying” fear | Frame as planning for temporary incapacity (surgery, delirium), not only terminal care |
| Family conflict | Clarify legal agent; offer ethics consult; keep patient voice central |
| Cultural reluctance to discuss death | Use culturally congruent language; involve trusted clergy/community leaders with consent |
| Incomplete paperwork | Provide state forms; notary/witness rules; scan into EHR; give wallet card |
Transitions of Care: Continuity of Directives
Directives fail when they stay in a drawer. Across hospital ↔ SNF ↔ home ↔ hospice:
- Verify the most recent documents on admission
- Confirm POLST matches current goals (review after acute events)
- Communicate code status clearly in handoffs and EHR banners
- Educate receiving caregivers that “comfort-focused” still includes symptom treatment, positioning, oral care, and presence
- Watch for erroneous full-code defaults when prior DNR/POLST was not transferred
Special Situations
Dementia: Complete directives as early as possible while capacity for that planning decision remains. Later, the agent uses known values plus the person’s current experiential interests (comfort, relationships).
Guardianship/conservatorship: Court-appointed guardians may have health care authority; scope is defined by court order—do not assume unlimited power.
Conflict between living will and agent: Usually the agent interprets how written wishes apply to the current clinical picture; ethics involvement helps when interpretation is contested.
Emergency without documents: Provide indicated stabilizing care while urgently seeking agents and prior records; do not invent preferences.
Nursing Bottom Line
Your job is not to decide the goal of care for capacitated patients. Your job is to elicit, document, propagate, and defend the patient’s informed preferences—and to support lawful surrogates using substituted judgment when capacity is lost.
A capacitated older adult with a completed living will refuses a recommended surgery that her adult children insist she accept. What is the correct nursing/legal response?
How does a POLST/MOLST form differ from a living will?
An incapacitated patient has a designated health care agent, but a different relative demands full resuscitation contrary to the agent’s report of the patient’s wishes. Who should guide decisions?
Which nursing action best prevents advance-directive failures during hospital-to-SNF transfer?