8.3 Interdisciplinary Team Communication, Advance Directives, and the Care Plan

Interdisciplinary Team, Advance Directives, and the Care Plan

Quick Answer: Indiana LTC facilities deliver care through an interdisciplinary team — RN, LPN, PT, OT, ST, dietitian, social worker, activities director, and CNA — each with a defined scope. Advance directives (living will, durable power of attorney for health care, and Indiana's POST form) let residents state their treatment wishes before they lose decision-making capacity. Every resident has a comprehensive care plan developed by the RN with the team within 7 days of the comprehensive assessment; the CNA contributes direct-care observations and implements the plan but does not author it independently.

The Interdisciplinary Team in Indiana LTC

Indiana facilities are required under 410 IAC 16.2 to deliver care through an interdisciplinary team. The CNA is the team member with the most hands-on time at the bedside and is the primary observer of day-to-day changes. Each member has a defined scope:

The CNA communicates with each member through the licensed nurse. Direct physician, PT, or dietitian orders are not taken by the CNA; the CNA relays requests or observations to the LPN/RN, who processes the order or contact.

How the Team Communicates

• Shift report (SBAR): between CNAs at change of shift; between nurses at change of shift
• Care plan meetings: scheduled interdisciplinary reviews, attended by the resident and/or family, the RN, and team members as relevant
• Stand-up/huddle: brief team check-in at start of shift to flag acute residents, new admissions, falls, infections
• Direct verbal report: CNA reports any acute change to the licensed nurse immediately, before charting
• Written communication: chart entries, care plan updates, Kardex or EHR summaries

The chain of command (Chapter 1.1) governs escalation: CNA → LPN → RN Charge Nurse → DON → Administrator → IDOH. The CNA does not bypass the licensed nurse to call a physician or family directly unless the nurse is unreachable and the situation is an emergency — and even then, the CNA reports the contact to the nurse as soon as possible.

Advance Directives

An advance directive is a written document that states a resident's wishes about medical treatment in case they become unable to make or communicate decisions. Federal law (the Patient Self-Determination Act, effective 1991) requires facilities to inform residents of their right to make advance directives and to document whether the resident has one. Indiana facilities must comply under 410 IAC 16.2.

Living Will

A living will is a written statement of the resident's wishes for end-of-life medical treatment — typically whether to receive life-sustaining treatment such as mechanical ventilation, feeding tubes, or CPR — if the resident becomes terminally ill or permanently unconscious and cannot speak for themselves. In Indiana, a living will takes effect when the resident is certified as terminal or permanently unconscious by two physicians. The CNA's role is to know the directive exists (noted in the chart and on the POST form), to follow the nurse's direction in any situation that triggers the directive, and to support the resident's and family's wishes without judgment.

Durable Power of Attorney for Health Care

A durable power of attorney for health care (also called a health care proxy or representative) designates a person — usually a family member or trusted friend — to make health care decisions for the resident if the resident loses decision-making capacity. In Indiana, this is a separate document from a financial durable power of attorney; a CNA should not assume the resident's spouse or adult child is automatically the surrogate — the designation must be on file.

When the designated surrogate is making decisions, the CNA still reports to the licensed nurse, not directly to the surrogate. The nurse or social worker handles communication with the surrogate; the CNA shares clinical observations through the chain of command.

Indiana POST Form and DNR

Indiana's Physician Orders for Scope of Treatment (POST) form translates a resident's advance-directive wishes into actionable medical orders signed by a physician. The POST form travels with the resident between settings (hospital, nursing facility, home) and is the operational instruction clinicians follow in an emergency.

A DNR (Do Not Resuscitate) order is a physician order — not a CNA instruction, not a resident request, and not a family request. If a resident with a DNR order stops breathing or loses a pulse, the CNA does not start CPR; the CNA calls the licensed nurse immediately and follows facility code protocol. The nurse confirms the DNR and directs the response.

If there is any doubt whether a DNR is in effect — the order is not in the chart, the POST form is missing, or family members are giving conflicting instructions — the CNA defaults to starting CPR and calling the code. The principle is: in uncertainty, resuscitate.

The CNA's Role With Advance Directives

• Know where the advance directive and POST form are documented in the chart
• Do not discuss the directive with the resident or family — route questions to the nurse or social worker
• Do not express personal opinions about a resident's choice ("I wouldn't want to live like that")
• Follow the nurse's direction in any situation that triggers the directive
• Never override or ignore a DNR — and never perform CPR on a resident with a valid DNR
• Report immediately if the POST form is missing or family dispute arises

The Comprehensive Care Plan

Under OBRA 1987 (enforced by Indiana under 410 IAC 16.2), every resident must have a comprehensive care plan within 7 days of the completion of the comprehensive assessment. The comprehensive assessment is done by the RN within 14 days of admission; the care plan follows within 7 days of that assessment. The care plan is then reviewed and updated at least quarterly, and after any significant change in the resident's condition.

The care plan is the resident's individualized roadmap for care. It addresses:

• ADL needs (bathing, dressing, toileting, eating, mobility, transfer assistance)
• Nutrition and hydration
• Skin integrity and pressure ulcer prevention
• Bowel and bladder management
• Psychosocial needs and mental health
• Restorative and rehabilitation goals
• Medications, treatments, and monitoring
• Resident preferences and cultural needs
• Goals and measurable outcomes

Who Writes the Care Plan

The RN coordinates the care plan with the interdisciplinary team. Each discipline contributes its piece — PT contributes mobility goals, RD contributes the diet plan, ST contributes swallowing precautions, the social worker contributes psychosocial needs. The CNA contributes observations — actual ADL performance, intake, skin changes, mood, sleep, behaviors — but does not independently write the plan or set clinical goals.

Care Plan Meetings

Care plan meetings are scheduled interdisciplinary reviews. They include the RN, relevant team members, and — when appropriate — the resident and family. The CNA may be asked to attend to share direct-care observations. The CNA's role in a care plan meeting is to report what the CNA actually saw and did during care, in objective terms:

• "Mrs. R ate 60% of lunch, mostly the protein and vegetables; left the bread."
• "She required a two-assist transfer with a gait belt today, down from one-assist last week."
• "She turned herself in bed twice this shift without being asked."
• "She had no bowel movement for the past two days; reported to LPN."

The CNA does not make clinical decisions in the meeting ("I think we should increase her pain medication") and does not speak for the resident or family. The RN integrates the team's observations and updates the plan.

Implementing the Care Plan

The CNA implements the care plan in daily care: following the turning schedule, using the ordered transfer technique, offering the ordered diet, encouraging fluids to the intake goal, reporting deviations. If the care plan says "turn every 2 hours" and the CNA finds the resident already turned by family at the 1-hour mark, the CNA charts the actual finding and follows the schedule. If the resident refuses a care-plan element (declines a bath, refuses fluids), the CNA charts the refusal, reports it, and the nurse updates the plan as needed.

Common Care-Plan and Directive Traps

• Assuming the spouse is the surrogate: the durable power of attorney must be on file; never assume
• Discussing a DNR with a resident or family: route all such questions to the nurse or social worker
• Inverting the chain at a care plan meeting: speaking directly to the physician or family about clinical decisions instead of routing through the RN
• Charting care plan compliance instead of actual care: "care plan followed" is not documentation; chart what was actually done and observed
• Missing the POST form: if the directive is not visible in the chart in an emergency, default to resuscitating and reporting immediately
• Treating advance directives as CNA decisions: the CNA's role is observation, reporting, and following the nurse's direction — not interpreting the directive