Hi, I'm Jessica Spellman and this is Advance Directives.
After taking this course, you will be able
to identify the most common types of advance directives.
Understand some legal issues nurses face
regarding advance directives.
Recall the proper documentation that must be present
when caring for a patient with advance directives.
So let's talk about what an advance directive is.
The Patient Self Determination Act of 1990
states that individuals have some specific rights.
They have the right to facilitate their own healthcare decisions.
They have the right to accept or refuse medical care.
And they have the right to make an advance directive for healthcare.
Advance directives are legal documents that can allow individuals
to write instructions regarding the care they want
to receive or want to refuse.
They can also designate a person to make decisions for them
in the event they aren't able to do this for themselves.
So there are two types of advance directives. The first type is a
living will, which states what medical treatment the client
wishes to omit or refuse in the event
that they become terminally ill,
permanently unconscious or in a vegetative state
and they are unable to make their own decisions.
The second type is a durable power of attorney for healthcare.
This is a document that designates a proxy
to make healthcare decisions for an individual
in the event they are unable to make decisions for themselves.
So why are advance directives important?
Well, they outline individual preferences regarding medical treatment
and they prevent administration of care to patients
that do not want to receive that care.
They also can designate an individual that can make decisions about
a patient's care based upon the living will that they have filled out
and in the case the patient is not able to make those
decisions for themselves. If advance directives
are not available and the individual becomes incompetent
or unable to communicate their decisions to their physician,
the individual wishes may not be honored.
We have to remember that these documents
need to be drawn up in advance of a patient
becoming incompetent and not after
they are already incompetent.
So some documentation issues that
we come across in advance directives.
Patients must be asked whether or not
they have an advance directive. Advance directives
must be noted in the medical record
and healthcare providers are not allowed
to make decisions to admit or treat patients based
upon whether or not they have advance directives.
Specifically the nursing role
in regards to advance directives are
on admission we need to ask patients
if they have advance directives. If yes,
then we need to supply copies
and place them on the chart.
If no, we are required to ask them
if they would like to receive information about
During the hospitalization, if they receive
documentation or education regarding advance directives,
we need to document that and then place
the copies of the advance directives on the chart.
A few legal and ethical issues
about advance directives.
There are times when an advance directive may be suspended
or not honored.
Two times in particular are: during surgery
and while in an emergency vehicle.
And let me explain to you why the advance directive
may not be honored. During surgery,
physicians need to treat the circumstances
that arise during the surgery with some
degree of flexibility. When the surgery is completed,
the advance directives will be applicable again.
In an emergency vehicle,
documents may not be available to the
first responders or even the emergency room.
So until those documents can become available,
the situation needs to be treated.
Once the advance directives are completed, there are
decisions that durable power of attorneys for healthcare may not make.
I wanna review those with you. The first is
they cannot make the decision to withdraw a life sustaining treatment
unless it's been determined by the attending physician
and one other physician that the
patient will not regain the ability or
capacity to make informed healthcare decisions.
Second, they cannot withdraw or
refuse comfort care measures. Third,
they cannot refuse or withdraw treatment
for a patient that is pregnant. Fourth,
they cannot refuse or withdraw hydration and nutrition
to the patient unless it's determined by the attending physician
and one other physician that the measures are
no longer providing comfort to the patient.
Or if the patient specifies the refusal
of such care in the living will.
They also cannot withdraw care for a patient
that has previously consented to receive care
unless a significant change has occurred in
the patient's condition and that treatment is no longer effective.
So what is a DNR? A DNR, or a Do not Resuscitate Order,
is a written order placed on the patient's chart that
informs healthcare personnel not to perform CPR or intubate the patient.
It allows the patient to die naturally without
any heroic measures and it is written by the physician
based upon the information that the patient has
supplied in their living will or through their durable power of attorney
that this is what they would like to be done.
So summarize what we've learnt about advance directives.
Advance directives are legal documents
that address the healthcare treatment that patients
do not want to receive in the event they are
unable to make their healthcare decisions due to illness, injury,
or disease. Living will and durable power of attorney
for healthcare are the two forms of advance directives.
The Patient Self Determination Act, the PSDA of 1990
has given patients the right to make decisions
about their healthcare and refuse treatment if desired.
Nurses are accountable to document education
provided to patients about advance directives
as well as place copies of those advance directives on the
charts so they are available to the entire healthcare team.
Advance directives may not apply
in the surgery setting or an emergency situation.
And there are certain circumstances in which the durable
power of attorney for healthcare may not make decisions for the patient.
The DNR is the written order placed on the medical record
that indicates the patient should not receive CPR or intubation
in the event that the person's heart and breathing stop
if it is written after the healthcare team
and family have reviewed the advance directive and
it complies with the wishes of the patient.