2.2 Advance Directives and Self-Determination
Key Takeaways
The Patient Self-Determination Act (PSDA) requires healthcare facilities to ask patients about advance directives upon admission
A Living Will specifies which medical treatments a patient wants or does not want if they become incapacitated
Durable Power of Attorney for Healthcare designates a proxy decision-maker who can only act when the patient is deemed incompetent
Do Not Resuscitate (DNR) orders must be signed by a provider and reviewed periodically; they apply only to cardiopulmonary arrest
Advance directives can be changed or revoked by a competent patient at any time
The Patient Self-Determination Act (PSDA) of 1990 requires all healthcare facilities receiving Medicare/Medicaid funding to inform patients of their right to make advance directives. The RN plays a crucial role in ensuring these documents are current, correctly filed, and communicated to the interdisciplinary team.
Types of Advance Directives
| Type | Purpose | Key Features |
|---|---|---|
| Living Will | Specifies treatment preferences | Written instructions about life-sustaining treatment |
| Durable Power of Attorney for Healthcare | Designates a decision-maker | Proxy authority activated only when patient is incapacitated |
| Do Not Resuscitate (DNR) | Addresses CPR if breathing or the heartbeat stops | Provider order; applies only to CPR |
| POLST/MOLST | Provider orders for life-sustaining treatment | Medical orders; portable across settings |
Living Will (Instructional Directive)
A Living Will contains specific instructions about what medical treatments the patient chooses to accept or refuse if they become unable to make decisions.
Common provisions include:
- Mechanical ventilation preferences
- Artificial nutrition and hydration
- Dialysis
- Antibiotics for life-threatening infections
- Comfort measures/palliative care
Important: A Living Will only takes effect when:
- The patient cannot make decisions (lacks capacity)
- The patient has a terminal condition or is permanently unconscious (varies by state)
Durable Power of Attorney for Healthcare
A Durable Power of Attorney for Healthcare (DPAHC) designates a healthcare proxy (agent) to make medical decisions when the patient cannot.
| Aspect | Description |
|---|---|
| Activation | Only when patient is deemed incompetent by a provider |
| Scope | Can make all healthcare decisions not addressed in Living Will |
| Hierarchy | Follows patient's expressed wishes first, then proxy decides |
| Revocation | Patient can revoke at any time while competent |
Key Point: The proxy's authority is only activated when the patient lacks decision-making capacity. While the patient is competent, they make their own decisions.
Do Not Resuscitate (DNR) Orders
A DNR order is a provider order that directs staff not to perform CPR if the patient experiences cardiac or respiratory arrest.
Critical Points:
- Must be a written provider order (not just patient request)
- Applies only to cardiopulmonary arrest (not other treatments)
- Should be reviewed periodically and when condition changes
- Patient can revoke at any time
- DNR does NOT mean "do not treat"
The Nurse's Role
| Responsibility | Action |
|---|---|
| Assessment | Ask about advance directives on admission (PSDA requirement) |
| Education | Provide information about types and purposes of advance directives |
| Documentation | Ensure directives are in the medical record |
| Communication | Alert the healthcare team to advance directive status |
| Advocacy | Ensure patient's wishes are followed |
When Advance Directives Are Unclear or Absent
| Situation | Action |
|---|---|
| No advance directive | Decisions made by next of kin following state hierarchy |
| Family disagrees with directive | Follow the patient's documented wishes |
| Directive unclear about current situation | Ethics committee consultation may be needed |
| Patient regains capacity | Patient resumes decision-making authority |
Typical Surrogate Decision-Maker Hierarchy
When no healthcare proxy is designated, most states follow this order:
- Legal guardian
- Spouse or domestic partner
- Adult children
- Parents
- Adult siblings
- Other relatives or close friends
Cultural Considerations
Some cultures prefer family-centered decision-making over individual autonomy. The nurse should:
- Assess patient's preference for involvement in decisions
- Respect cultural values while ensuring legal requirements are met
- Involve interpreter services when needed
- Document patient's stated preferences
On the NCLEX
Expect questions about:
- The nurse's role in educating patients about advance directives
- When healthcare proxy authority is activated
- Appropriate actions when family disagrees with documented wishes
- Difference between DNR and comfort measures
Exam Tip: Remember that a DNR addresses only CPR when breathing or the heartbeat stops. A patient with a DNR can still receive all other treatments including surgery, antibiotics, and blood transfusions.
A patient with a valid living will requesting no mechanical ventilation develops respiratory failure. The family insists on intubation. What should the nurse do?
Follow the family's wishes since they are present
Follow the patient's advance directive since the patient is incapacitated
Wait for an ethics committee consultation before acting
Let the provider decide which directive to follow
A patient with a DNR order develops severe pneumonia. The nurse should understand that:
The patient should receive comfort measures only
Antibiotics should not be administered
The DNR applies only to cardiopulmonary arrest, not pneumonia treatment
The patient should be transferred to hospice
When does the healthcare proxy's decision-making authority become active?
When the advance directive is signed
When the patient is admitted to the hospital
When a provider determines the patient lacks decision-making capacity
When the family requests that the proxy make decisions
Sections you finish are checked off in the contents.