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Advance Directives

by Jessica Reuter
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    00:02 Hi, I'm Jessica Spellman and this is Advance Directives.

    00:08 After taking this course, you will be able to identify the most common types of advance directives.

    00:15 Understand some legal issues nurses face regarding advance directives.

    00:22 Recall the proper documentation that must be present when caring for a patient with advance directives.

    00:28 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.

    00:43 They have the right to accept or refuse medical care. And they have the right to make an advance directive for healthcare.

    00:49 Advance directives are legal documents that can allow individuals to write instructions regarding the care they want to receive or want to refuse.

    01:01 They can also designate a person to make decisions for them in the event they aren't able to do this for themselves.

    01:09 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.

    01:29 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.

    01:42 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.

    01:56 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.

    02:32 So some documentation issues that we come across in advance directives.

    02:39 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.

    02:57 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.

    03:13 If no, we are required to ask them if they would like to receive information about advance directives. 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.

    04:15 So until those documents can become available, the situation needs to be treated.

    04:21 Once the advance directives are completed, there are decisions that durable power of attorneys for healthcare may not make.

    04:26 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.

    04:45 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.

    05:11 Or if the patient specifies the refusal of such care in the living will.

    05:16 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.

    05:28 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.

    05:41 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.

    06:00 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.

    06:19 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.

    06:30 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.

    06:42 Advance directives may not apply in the surgery setting or an emergency situation.

    06:47 And there are certain circumstances in which the durable power of attorney for healthcare may not make decisions for the patient.

    06:54 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.


    About the Lecture

    The lecture Advance Directives by Jessica Reuter is from the course Management of Care. It contains the following chapters:

    • Advance Directives
    • Types of Advance Directives
    • Legal and Ethical Issues

    Included Quiz Questions

    1. The EMT's were not provided with the advanced directive at the time of assessment or treatment (intubation).
    2. It is the best thing for their father right now.
    3. There were no other options for the paramedics.
    4. The paramedics were not aware of the advance directives.
    1. DME
    2. Durable Power of Attorney
    3. Living Will
    1. Ask the patient for copies of the advance directives and place them on the chart.
    2. Make sure to tell the physician and other nurses that the patient has advanced directives.
    3. Place a note on the chart indicating the patient has advanced directives.
    4. There is no other interventions the nurse needs to complete at this point.

    Author of lecture Advance Directives

     Jessica Reuter

    Jessica Reuter


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