3.4 Advance Directives, DNR Orders, and End-of-Life Care

Advance Directives in Illinois

An advance directive is a legal or medical instruction that states what care a person wants if they later cannot speak for themselves. Illinois law recognizes four main forms, and the INACE expects you to know which is which — and, more importantly, that a CNA never interprets them. You follow the care plan, which translates the directive into day-to-day orders.

The key distinction: a living will and healthcare power of attorney are documents the resident creates; a POLST is an actual medical order a clinician signs based on those wishes, so it directly drives the care team's actions across settings.

Code Status and Comfort Terms You Must Know

The most-tested misconception: DNR does not mean "do not treat." A resident with a DNR still receives food, fluids, hygiene, repositioning, pain medication, antibiotics if ordered, and full comfort care. DNR only withholds CPR at the moment the heart or breathing stops.

Your Scope: What a CNA Can and Cannot Do

A CNA CAN:

• Note that a directive or code status is on the chart and follow the care plan exactly.
• Provide comfort care, report condition changes, and offer emotional support.
• Maintain dignity and document the care given.

A CNA CANNOT:

• Interpret a directive or decide whether to start CPR by reading a document.
• Give medical or legal advice about directives to residents or families.
• Witness or notarize a directive in most facility roles.
• Override a nurse's orders based on personal interpretation.

Providing End-of-Life Care

When a resident is dying, your goal shifts entirely to comfort and dignity. Recognizing the late physical signs helps you respond calmly: cool, mottled skin; slowed or irregular (Cheyne-Stokes) breathing; a "death rattle" from pooled secretions; decreased intake; reduced responsiveness. Hearing is believed to be the last sense to fade, so always speak gently and assume the resident can hear you.

Physical comfort measures:

1. Reposition gently every 2 hours (or per plan) to prevent skin breakdown and ease discomfort.
2. Provide frequent mouth care — moisten lips, tongue, and mucous membranes; the mouth dries quickly near death.
3. Keep skin clean and dry; change linens promptly; manage incontinence with dignity.
4. Report any sign of pain (grimacing, restlessness, moaning) to the nurse so medication can be given.
5. Keep the room calm — soft lighting, low noise, comfortable temperature.

Emotional and spiritual support:

• Be present; simply sitting quietly is meaningful care.
• Listen without judgment; do not give false reassurance like "everything will be fine."
• Welcome family, give them privacy, and respect religious and cultural practices.
• Route every prognosis or directive question to the nurse or physician.

After death (post-mortem care):

• Follow facility policy; treat the body with respect at all times.
• Position the body in normal alignment, close the eyes if appropriate, and provide privacy for the family to grieve.
• Handle personal belongings carefully and account for them.
• Document the time you were notified and the actions you took.
• Care for yourself and your coworkers — supporting dying residents is emotionally demanding work.

Worked Scenarios and Frequent Traps

Scenario 1 — the directive on the chart. You see a POLST marking the resident DNR, and during your shift the resident stops breathing. You do not decide on your own — you follow the established care plan and code status and call for the nurse per facility policy. A CNA never starts or withholds CPR based on personally reading a document; the order and care plan govern.

Scenario 2 — the dehydration worry. Family is distressed that a dying, comfort-measures-only resident is barely eating. You provide gentle mouth care, keep the lips moist, and report concerns to the nurse, who addresses the family. Forcing food or fluids on someone whose body is shutting down can cause harm and is not your call.

Scenario 3 — "can you hear me?" Because hearing is thought to be the last sense lost, you keep speaking softly, explain care before you give it, and avoid talking about the resident as though they cannot hear — even when they appear unresponsive.

Common traps: thinking DNR means stop all care (it withholds only CPR), giving false reassurance such as "you'll be fine" instead of honest presence, and interpreting a directive yourself. When a question pits your judgment against the care plan or the nurse, the correct answer is to follow the plan and direct clinical or legal questions to the nurse or physician.