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
Advance Directives and Self-Determination
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 cardiac arrest | 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 DNR only addresses cardiac arrest. 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?
A patient with a DNR order develops severe pneumonia. The nurse should understand that:
When does the healthcare proxy's decision-making authority become active?