We discuss Advance Directives, which give written guidelines on treatments a patient may want to receive or not receive. We get specific on what documents there are and how they differ.
***=might show up on the NCLEX Hey there, this is Cindy. I'm one of the nurses at NCLEX mastery and today we're going to talk about advanced directives. When you hear this sound*ding* it means this might show up on the NCLEX. Advanced Directives provide written guidelines to a document or a series of documents regarding a patient's desired healthcare treatment decisions. These documents can outline the treatment the patient would like to receive or not receive and who can make decisions for their care if they are unable to decide for themselves. It's important to know that state laws and regional laws might vary as to what is considered valid as far as a witness for these documents and whether the documents are recognized if completed in another state. Nurses must become familiar with the laws in their area. Documentation in the medical record of advanced directives is standard across all states. When in doubt, consult the organization, policies or ethics committee. The first type of advanced directive we're going to talk about today is a living will. It is perhaps the most common directive regarding treatment decisions. It is completed by a competent patient who is able to make decisions and it focuses on specific end of life healthcare decisions. This written document provides advanced guidance on what healthcare treatment is desired. All patients must be able to provide informed consent or express their wishes for treatment. The living will is signed by the patient and is designed to take effect only when the patient is unable to understand their condition and make informed decisions. Situations may include a persistent state of unconsciousness, serious injury, or an illness and severe cognitive impairment. It is helpful when decisions must be made regarding withholding or withdrawing life sustaining treatment that prolongs the dying process. In most cases, it addresses standard areas of concern such as whether to initiate artificial feeding and when to withhold mechanical ventilation.***All right. Here are some key points about living wills. A second clinician is required to confirm the patient is incapacitated. Ensure that the patient's care is consistent with their philosophy and religious beliefs. Serve as a guide to health providers and loved ones to honor the patient's wishes. A living will should address what the patient does or does not want, but it should only include that patient's wishes. Some patients may only want to designate with regard to nutrition and hydration. Others may include cardiac resuscitation, mechanical respiration, or blood or blood products. Always ask patients about organ and tissue donation. Ask all patients upon hospital admission and provide a copy to the clinician and in the patient's record. Maintain the most updated version and encouraged the patient to destroy all old versions. Encourage the patient to educate their family as to the existence and location of a living will. A living will does not mean that the patient will be denied pain medication or methods to maintain comfort. State Law may define when a living will goes into effect and whether it is recognized if it's completed in another state. Most states required the dated signature of two witnesses age 18 or older who are not blood relatives or beneficiaries. This cannot include health care providers, caring for the patient, including nurses. Document the location of the living will and the name of any assigned healthcare agents in the medical record.*** The next category of advanced directive is the power of attorney or durable power of attorney for healthcare. A power of attorney or a POA is a legal document that may have separate documents designated for finances and healthcare. On the other hand, a durable power of attorney for healthcare or DPOAH is a specific type of advanced directive just for governing health care decisions. As compared to a power of attorney or POA, the DPOAH is specific to the healthcare desires of the patient and does not address control over the patient's finances. These terms are not interchangeable. The word attorney is not used in the legal sense for DPOAH, but rather it is referring to a person designated to make medical decisions on the patient's behalf only if the patient is no longer able to make these decisions. This person is known as the patient's agent or healthcare proxy. In some regions the term healthcare proxy is used instead of DPOAH. The patient identifies and documents the name of a trusted friend or family member who is at least 18 years old to carry out their wishes. This ensures that their wishes for treatment are known through their proxy or agent rather than the healthcare personnel caring for them. As compared to a living will, a healthcare proxy does not list all potential medical scenarios, nor does it require the designated proxy to know how to proceed with specific medical situations. However, the recommendation is that the patient and proxy have had discussions about scenarios. There are a few situations in which a designated healthcare agent cannot consent to treatment for a patient. These include commitment to a state institution, sterilization or termination of treatment if there's a pregnancy and if withdrawal of that treatment is deemed likely to terminate the pregnancy. Nurses should encourage their patients to talk to their agent. They should encourage patients to ask permission to name them as their agent. They should discuss healthcare wishes, values, and fears with their agent and with their healthcare provider, and they should make sure the agent and the healthcare provider has a copy of the advanced directive.***Here's some key points to remember for durable power of attorney for healthcare. The DPOAH is completed by the patient when they are deemed competent and must be completed in front of a witness. The patient can update this document at any time and may designate one or more individuals to serve as alternates. The DPOAH is broader than a living will or an advanced directive in that it is providing the agent the authority to act on the patient's behalf and make healthcare decisions for them. The patient does not have to be terminally ill to enact a DPOAH patients too confused to make decisions may have an agent involved, and then resume decision making once they are competent. State laws can vary as to who is permitted to be a designated agent or proxy. Some states don't allow it to be a clinician or other healthcare provider or anyone who works for the facility where the patient receives care. The DPOAH can make decisions regarding the following situations: admissions and discharges from healthcare facilities, access to medical records, authorization for organ donation, and accepting or refusing physical or mental health treatment.*** Now let's talk about a do not resuscitate order. A do not attempt resuscitation or DNAR are is a medical order that must be signed by a physician to be valid. It directs medical personnel to allow natural death in the event of cardiopulmonary arrest, either by not starting CPR or ceasing CPR ff it's ongoing. It does not address other life sustaining measures such as nutrition or medicines. A patient may choose a DNAR or DNR if the risk of performing CPR is higher than the benefit due to frailty, severe illness or if CPR would cause additional suffering or if the probability of successful resuscitation is poor based on their medical condition. Most states require that emergency medical services start cardiopulmonary resuscitation unless there is a medical order limiting treatments such as a portable DNR.***Now for some key points about DNR. A living will is a document but is not a medical order like a DNR. Although they are both part of the medical record, a DNR gives specific direction for care in a specific situation. Any advanced directive such as the living well may include the patient's wishes regarding DNAR, but it can also deal with many other medical situations. The DNR addresses only the patient's wishes regarding CPR and does not address other necessary treatment or pain relief. In some facilities there is the option to select a DNAR I, which is do not attempt resuscitation or intubation. DNR may be issued on a bracelet and necklace or wallet card. Patients may choose to suspend DNR orders during surgery when cardiac or pulmonary arrest may occur due to circumstances of the surgery. Nurses should always ask about these advanced directives when transitioning care. DNR orders are not binding to bystanders who might initiate CPR in an emergency. Ensure the portable DNR order is properly documented and displayed at each facility or during transfer or in the patient's home.*** Now, let's talk about a newer type of order. This is called a POLST or a MOLST. A physician order for life sustaining treatment or POLST, also known as medical orders for life sustaining treatment, is considered when a patient's life expectancy is one year or less. The POLST gives the patient more control over their care, especially during an emergency or crisis or when their condition deteriorates by turning their medical treatment wishes into a physician order. A POLST is one step in the end of life decision making process and management, and is not intended to replace an advanced directive document. It can be utilized instead of a do not attempt resuscitation order because it often includes directives about resuscitation. Like a DNR, a POLST is completed by a physician or a clinician based upon the wishes of the patient or the patient's assigned agent if the patient is incapable or incompetent. Most states have a standard form that is uniquely identifiable, has standardized language in a distinctive and easily recognizable format, and lists patient treatment preferences as a medical order that is portable between healthcare systems. The POLST must be signed by both the patient and the clinician. For the orders to become active. A POLST may include specific instructions regarding CPR, medical interventions, antibiotics, and artificially administered hydration and nutrition, or anything else that the patient wishes. A POLST can have a range of implications, including the following: comfort measures only, life enhancing measures. This can include that they prefer not to go to the hospital for life sustaining treatment or a focus on maximizing comfort with symptom management and pain relief. This can also include patients with hospice care. Other patients may use a POLST to have life supporting treatment, but limited intervention. This can include that they might be hospitalized for basic medical treatment. They might avoid intensive care, advanced airway insertion, or mechanical ventilation only. These patients may still desire CPR. Lastly, some patients may opt for full life sustaining treatment, including advanced airway intervention. They may instruct medical personnel to transfer them to the hospital if indicated. These patients may desire full treatment even if their illness is incurable.***Alright, key points about POLST: the patient can change or cancel their treatment choices on the POLST form any time by talking to their clinician, keep the POLST form with the patient in the hospital or longterm care facility or at home in a place where emergency medical services can easily find it. It should stay with the patient, much like a DNR. A POLST should be reviewed at least annually or if there is a substantial change in the patient's health status or their preferences change. I hope you enjoyed this podcast on advanced care documents. For more, go to nclexmastery.com or look us up on facebook at Nursing and NCLEX Mastery.