In this section of the NCLEX-RN examination, you will be expected to demonstrate your knowledge and skills of advance directives in order to:

  • Assess client and/or staff member knowledge of advance directives (e.g., living will, health care proxy, Durable Power of Attorney for Health Care [DPAHC])
  • Integrate advance directives into the client plan of care
  • Provide the client with information about advance directives

Assessing the Client and/or Staff Members' Knowledge of Advance Directives

When a learning need in respect to advance directives is assessed by the registered nurse, education should be planned to correct any identified knowledge deficits in reference to all aspects of advance directives including living wills, health care proxies, and durable power of attorney for health care [DPAHC] .

For example, when a client asks the registered nurse if they can change their advance directives, the registered nurse should know that the client has a knowledge deficit relating to the fact that advance directives can be changed at any time and when the supervising registered nurse manager audits client medical records and documentation and learns that the staff are not including complete information about whether or not the clients have or do not have advance directives, the supervising registered nurse manager should know that the staff have a knowledge deficit relating to the fact that the presence or absence of advance directives must be assessed and documented.

When such learning needs are identified, appropriate patient or staff education should be planned, implemented, evaluated and documented as was previously discussed and detail with the Integrated Process of Teaching and Learning.

The registered nurse is responsible and accountable for assessing educational needs in respect to advance directives and to insure that the clients and staff members have the sufficient knowledge to make sound and knowledgeable decisions relating to these important aspects of client care. This knowledge enables the clients to make knowledgeable decisions about their own advance directives and it enables other members of the nursing team to integrate the principles of advance directives into the care that they provide to their clients.

Integrating Advance Directives into the Client Plan of Care

Advance Directives are integrated into the client's plan of care by nurses and other healthcare professionals. Any and all information about advance directives is also documented and communicated with other members of the healthcare team so that all of these client's choices are upheld in all aspects of care and all clients should be encouraged to initiate advance directives whenever they have failed to generate these important documents in the past.

The ultimate purpose of advance directives is to guide professional decision making and direct the client's care and treatments at the end of life. Advance directives also provide the legal basis for all clients to accept or reject care as they wish because they have the innate right to autonomous decision making without coercion and self-determination even when they are no longer competent to do so.

Nurses must review and verify the patient's advance directive status with their first patient contact because an emergency life threatening situation like a cardiac or respiratory arrest can occur at any time with little or no time to review these documents at that time. If, for example, the patient has an advance directive to NOT have CPR, the nurse may administer CPR because they have failed to review the client's advance directive. This CPR, then, is contrary to the patient's wishes.

The Elements and Components of End of Life Decisions and Advance Directives

The elements and components of The Patient Self Determination Act, which was passed by the US Congress in 1990, gives Americans the right to make decisions relating to future care and treatments when the person is no longer able to give informed consent and/or the refusal of care and treatments because the person is incapacitated to do so. These decisions are documented with an advance directive and/or made by the legally appointed health care proxy or surrogate according to this national law.

The Patient Self Determination Act also mandates public education about advance directives and the fact that all hospitals, including psychiatric facilities, and all health insurance plans have to follow and adhere to state law specific relating to advance directives.

The Uniform Determination of Death Act, approved by most states in our nation, also provides healthcare facilities and healthcare professionals with some guidance and direction relating to end of life decisions. The Uniform Determination of Death Act defines death as either the irreversible cessation of respiratory and circulatory functions OR the irreversible cessation of all brain functions including brain stem function.

The elements and components of end of life choices and advance directives can include:

  • An election to donate some or all bodily organs according to the US Uniform Anatomical Gift Act
  • A living will
  • A health care proxy
  • A durable power of attorney for health care (DPAHC) which is separate and distinct from a durable power of attorney relating to financial and monetary decisions

The Uniform Anatomical Gift Act of the United States, simply stated, sets the regulations revolving around organ donations and organ transplantations, including prohibitions against the sale and trafficking of human organs. According to this law of the land, living people can elect to donate one or more of their bodily parts; and it also contains mechanisms that enable surviving spouses and other relatives to donate organs after the loss of love of a loved one when that person has not made a decision about whether or not they want to participate in an organ donation.

A living will, which is often referred to as an advance directive, is a well thought out document that lists the types of things and interventions that the client wants and does not want at the end of life when they are no longer able to give knowledgeable consent or reject these things and interventions as the result of their loss of their legal ability to consent to or reject these things. It should be as specific and as detailed as necessary. Treatments and aspects of care that were not anticipated and included in the living will then become the responsibility of the surrogate health care proxy to make.

Some of the most commonly aspects of care that are addressed in living wills are choices relating to whether or not the client wants CPR, tube feedings, surgeries and other invasive procedures. Many living wills also address the client's desire to have comfort and pain relief interventions at the end of life.

The health care proxy, or surrogate, is also referred to as the health care power of attorney and the durable power of attorney for healthcare. The durable power of attorney for healthcare is separate and distinct from any durable power of attorney for financial matters.

People with a legal power of attorney for healthcare can make decisions relating to healthcare decisions when the client is no longer able to make these decisions and these decisions were not anticipated and documented in the person's living will.

Despite the fact that all of these end of life decisions and documents can be acceptably and legally done and executed by the client themselves or by the client and their family members, some elect to have an attorney at law to perform this role.

Providing the Client With Information About Advance Directives

Clients should be provided with complete information about advance directives and they should also have the opportunity to discuss all of their alternatives and options. This education should also include the benefits and risks associated with their choices in the same manner that is done with all informed consent.

Some of the specific information that should be provided to the client, in writing and/or orally include understandable information about:

  • The Patient Self Determination Act
  • The Uniform Determination of Death Act
  • The Uniform Anatomical Gift Act
  • Living wills
  • Health care proxies and surrogates
  • Durable powers of attorney for health care (DPAHC)

Another piece of useful information for both the client/family members and healthcare providers in terms of advance directives is the Five Wishes which was developed with a Robert Wood Johnson Foundation grant. The Five Wishes, which can and should be considered and addressed in the client's advance directive, include the client's choices in respect to:

  1. Who they desire to make healthcare related decisions for them about their care when they are no longer able to make these important decisions
  2. All medical care and treatments that the patient ELECTS TO HAVE and all of those that the client does NOT want
  3. How the client wants to be treated and cared for by others at the end of life
  4. Decisions relating to the promotion of comfort and the relief of pain
  5. Things that they want their loved ones to know

Another decision and document that may be highly useful to clients and their healthcare decisions makers is a values history. Although not mandated by law, value histories are recommended and highly beneficial when it comes to end of life care and decision making, particularly when a person is appointed as a health care proxy or durable power of attorney for healthcare.

Values histories contain and consist of the client's general basic beliefs, values, opinions and principles relating to these principles and beliefs in addition to others:

  • The quality of life versus the quantity of life
  • The management of pain even if it may shorten the duration of life
  • Surgical procedures and associated alterations of the body image
  • "Being a guinea pig"
  • Dignity and maintaining dignity at the end of life


SEE – Management of Care Practice Test Questions

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