1. All decisionally capable persons have the right to decide, in consultation with their healthcare providers, what will be done with their bodies.
2. All individuals are presumed to have decision-making capacity unless and until they are determined to lack this capacity.
3. All adults who can participate in a conversation, either verbally or through alternate means of communication, should be offered the opportunity to engage in ACP and document their healthcare goals and preferences.
4. Healthcare professionals can promote enhanced quality of life for older patients and residents, including care at the end of life, by encouraging ACP and the creation of advance directives.
A. Education about ACP and advance directives
- Patients clearly indicate that they want information about advance directives.
- Patients indicate that they want nurses and physicians to engage them in discussions about ACP and advance directives.
- Despite indications of interest in ACP, only 19% to 36% of Americans have completed an advance directive.
- Documentation of treatment preferences is insufficient unless individuals discuss their health goals and values with their healthcare providers, families, and appointed healthcare agents.
B. Advance directives
- Enable capable individuals to designate and legally appoint trusted persons—a healthcare agent/representative/proxy/POA and one or more alternates—who will be authorized to make healthcare decisions on behalf of the individuals during any period of temporary or permanent decisional incapacity.
- Ensure legal mechanisms that enable capable individuals to articulate and document their health goals and preferences regarding the kind of medical care they would or would not want in specified clinical circumstances if they lack the capacity to make or communicate their decisions.
- Provide guidance for healthcare professionals, families, and surrogate decision-makers about healthcare decisions that reflect an individual’s goals, values, and preferences.
- Provide immunity from civil and criminal liability for healthcare professionals, families, and appointed healthcare agents who follow in good faith the provisions of advance directives.
C. Types of advance directives
- An appointment directive (also known as a healthcare proxy or DPOAHC) enables a decisionally capable individual to designate and legally appoint trusted persons—a healthcare agent/representative/proxy/POA and one or more alternates—who will be authorized to make healthcare decisions on behalf of the individual during any period of temporary or permanent decisional incapacity. An appointment directive enables the agent or alternate to confer with the care team in real time and respond to clinical conditions that are changing or were unanticipated by the now-incapacitated individual. Because the agent and alternate will have the same decisional authority as the individual to start, stop, or forgo treatment, the appointment directive is the preferred type of advance directive.
- An instruction directive (also known as a living will) enables a decisionally capable individual to provide instructions about medical treatment that would or would not be acceptable in specified clinical circumstances, typically at the end of life. The provisions of a living will are limited to what the individual thought that he or she might want in clinical circumstances that have not yet occurred.
D. An instructional or medical directive is intended to compensate for the weaknesses of living wills by posing hypothetical medical scenarios and asking the individual to indicate specific medical interventions that would or would not be acceptable. They suffer from the same limitations as living wills.
E. Verbal advance directives are honored in some states if there is clear and consistent evidence of the capable individual’s preferences for care in current specific clinical circumstances. Legal rules governing oral advance directives vary by state.
A. All decisionally capable adults, regardless of age or health status, should be engaged in discussion about ACP and asked whether they have created advance directives. If they have an advance directive, a copy should be requested for the medical record. If they have not created an advance directive, information and assistance should be offered.
B. Discussions about ACP and advance directives should be an integral part of routine healthcare throughout the arc of the healthcare continuum.
C. Discussions about advance directives should be conducted in the patient’s preferred language to promote the exchange of information, questions, and answers.
D. Discussions should be conducted with sensitivity to the individual’s health status, capacity to understand and process information, and degree of interest in participating in care planning.
E. Because capacity is decision specific rather than global, individuals who have been determined to lack the capacity to make specific decisions may still have the capacity to make less complex decisions or to designate an agent and alternate(s) to make healthcare decisions on their behalf.
F. When an advance directive has been completed:
- A copy of the document should be accessible in real time in the patient’s current medical record.
- The primary care doctor should have a copy of the directive and be familiar with its provisions.
- The appointed healthcare agent and alternate agent(s) should have copies of the document and be familiar with its provisions.
- The directive should be reviewed periodically by the individual in consultation with the primary care doctor to determine whether it reflects the patient’s current health status and preferences.
A. Nurses should assist patients/residents, appointed agents, and families in addressing ACP, including end-of-life care issues.
B. Patients should be encouraged to discuss their health goals, values, preferences, and concerns with their primary care physician, family, or other trusted surrogates.
C. In some instances, patients/residents may be more willing to discuss their health goals, values, preferences, and concerns with a nurse or clergy than a family member or other surrogate, and should be supported in doing so.
D. Patients should be assessed for their capacity to understand and process the provided information about their health status, prognosis, and treatment options.
E. Nurses must be mindful of and sensitive to the factors of race, culture, ethnicity, and religion that can influence the healthcare decision-making process. The fact that patients from non-Western cultures may not subscribe to Western notions of autonomy does not mean that these patients may not want to talk about their treatment preferences or concerns, or that they would not have conversations with their families about these matters.
F. Patients’/residents’ decisions not to complete an advance directive must be respected, with the understanding that these decisions will be revisited at a later time. They should be reassured that they will not be abandoned or receive substandard care if they elect not to formulate an advance directive at this time.
G. Nurses should be aware of the institution’s mechanisms for resolving conflicts between and among the patient/resident, family members, and the appointed healthcare agent or alternate, and should assist the parties in using these resources to achieve resolution.
H. Nurses should be aware of the professional(s) responsible for managing introduction, explanation, assistance in creating, and storage of advance directives in their institution. These responsibilities may include checking with the patient/resident to ensure that a copy of the advance directive has been given to the primary healthcare provider(s), the appointed agent and alternate(s), and that the patient/resident is carrying a wallet-size card that includes advance directive and agent/alternate contact information.
EVALUATION OF EXPECTED OUTCOMES
To determine whether implementation of this protocol has influenced the type, as well as the number, of advance directives created, changes should be measurable and contribute to the facility’s ongoing quality-improvement program. Special attention should be paid to the following:
A. Documentation in medical records of:
- Whether patients have been engaged in discussion about ACP and advance directives
- What was learned during the discussions about patients’ health goals, values, preferences, and concerns
- Whether patients have completed advance directives
B. Presence of advance directives in patients’ medical records, including
1. Whether copies of patients’ advance directives are in their medical records
2. Whether the directives are easily accessible for reference by the care team
C. The use of trained or certified interpreters to assist staff in ACP discussions with patients whose primary language is not English
D. The number of requests by nurses for ethics committee consultation regarding questions, concerns, or conflicts related to advance directives
ACP Advance care planning
DNR Do not resuscitate
DPOAHC Durable power of attorney for healthcare
POA Power of attorney
Updated: November 2020
Boltz PhD, RN, GNP-BC, FGSA, FAAN, M., Capezuti PhD, RN, FAAN, E., Zwicker DrNP, APRN, BC, D., & Fulmer PhD, RN, FAAN, T. T. (2020). Evidence-Based Geriatric Nursing Protocols for Best Practice (6th ed.). Springer Publishing. Retrieved November 4, 2020, from https://www.springerpub.com/evidence-based-geriatric-nursing-protocols-for-best-practice-9780826188144.html#description
Chapter 17: Jones, J. & Boltz, M. (2021) Advance Care Planning. In M. Boltz, E. Capezuti, D. Zwicker & T. Fulmer (eds.). Evidence-Based Geriatric Nursing Protocols for Best Practice (6th ed. pp 259-278). New York: Springer.