Course Book : #118 - Advance Directives Update

Advance Directives

Course 118

2 contact hours

By: Monica Oram, RN, BSN

 

Upon completion of this course the reader will be able to achieve the following objectives:

 

  1. Understand what advance directives are

  2. Understand why healthcare professionals need to be aware of advance directives

  3. Understand the Patient Self Determination Act (PSDA)

  4. Understand Key related terms associated with advance directives

  5. Learn ways in which to talk to patients and families about advance directives

  6. Learn answers to some frequently asked questions about advance directives

 

What Are Advance Directives?

 

Advance Directives are written documents that allow patients to give directions about future medical care. This is why they are called ADVANCE directives, it is a way to express medical wishes in ADVANCE, as to what they want and do want when faced with end of life issues.

 

There are two kinds of advance directives:

  1. Living wills

  2. Durable power of attorney for health care

 

Living Wills are written documents of instruction about medical care a person wants to receive - or not receive- if he or she has a terminal disease or other debilitating condition. They are called living wills because they are created while the person is still alive.

 

Durable power of attorney for health care - This is a document in which the patient names someone else, called a proxy or agent, to make medical care decisions if the patient becomes unable to do so.

In some states, these two types of advance directives can be combined into one document. A durable power of attorney (DPA) for health care is another kind of advance directive. A DPA states whom the patient has designated to make their healthcare choices. It becomes active anytime a patient becomes unconscious or unable to make healthcare decisions. A DPA is usually more useful than a living will, but a DPA may not be a good idea if the patient does not have someone they can trust to make the decisions on their behalf.

 

Realize that the patient has the right to refuse medical care. Advance Directives can protect this right if the patient becomes mentally or physically unable to choose or communicate their wishes due to an injury or illness.

 

Why should you learn about advance directives?

 

You should be well informed about advance directives because they are valuable tools and are legal documents implemented by your patients. We as health care professionals must know to honor the wishes and requests of our patients. We are often placed in a position to have to discuss advance directives with a patient or family member.

 

Advance directives benefit the patients by protecting their right to make their own health care choices. Advance directives benefit families by helping them make more informed medical decisions on behalf of their loved one. Advance directives help the healthcare workers because otherwise we would have no idea as to what the patient’s wishes are.

 

Patient Self Determination Act ( PSDA)

 

The Patient Self Determination Act requires health care facilities that receive federal funding to:

  • Discuss advance directives with patients

  • Find out if a patient has an advance directive

  • Have a written policy on advance directives

  • Educate staff and the community regarding advance directives.

 

 

At the time of admission, staff must provide patients with written information about their right to make health care decisions. The existence of an advance directive, or the absence thereof, must be documented into the patient’s permanent record.

In most cases, health care facilities must follow the instructions set out in a living will- or take directions from a healthcare proxy as designated by the patient.

 

Health care facilities can reach out to the community in a number of ways.

Examples of community involvement include:

  • Open houses

  • Health fairs

  • Health screenings

  • Community presentations

  • Information distributed to churches, libraries, and health care providers offices

  • Public service announcements on the radio or in a local newspaper

 

Healthcare workers should also make certain that the advance directive is kept in an appropriate place and easy to find.

 

Keep in mind that all patients have certain rights when it comes to advance directives.

 

The Patient Self Determination Act (PSDA) passed in 1990 and was instituted on December 1, 1991. This act encourages all people to make choices and decisions in advance on how they want to accept or refuse medical care should they become unable to do so due to illness.

 

The PSDA requires all hospitals, nursing homes, long term care facilities, home care agencies, and any others who receive federal funding from Medicare or Medicaid reimbursement to recognize the living will and power of attorney for health care as advance directives.

 

The PSDA does NOT create new rights for patients, but it does REAFFIRM the common law right to self determination as guaranteed by the fourteenth amendment. Under PSDA, health care facilities must ask if a patient has advance directives, and must provide educational materials about the patients rights under their state law.

 

State laws will vary accordingly. Be familiar what your state laws are regarding advance directives.

 

Patient Rights

 

This will include:

  • The right to privacy

  • Right to informed consent

  • Information about patient condition

  • Information on advance directives

 

Privacy:

Always remember that the patient medical record is held to a high standard of confidentiality. Medical records and communication between doctor and patient is protected as confidential. Nurses must also respect confidentiality by not sharing information with unauthorized individuals.

 

Informed consent:

The physician has the responsibility of clearly explaining to the patient the advantages and risks of any procedures, tests or treatments. The patient must give permission and has the right to refuse.

 

Information about condition:

It is the patients right to be kept up to date about medical conditions, treatments, and chances of recovery. It is the physicians responsibility to explain clearly to the patient this information. Nurses may be involved with some aspects of this, but most generally a doctor will be the one to explain treatment and recovery expectations.

 

Information about advance directives is required by law to be given to the patient upon admission to any healthcare facility or home care agency. In most cases, advance directives must be discussed, explained, and fully understood by the patient.

 

Some health care workers are hesitant to discuss advance directives because of uncertainty, fear or denial.

 

Uncertainty for most people, talking openly about death and dying or terminal disease does not come easily. Healthcare workers may not know how to start such a conversation about advance directives, or what to even say.

 

Fear is something some healthcare workers worry about because they may be fearful that talking about death and dying can make the patient uneasy or angry. In others it may bring on depression.

 

Denial is a factor in which both the patient and healthcare worker may prefer to ignore the need for an advance directive, especially if the patient has a terminal condition.

 

Ways in which to talk to patients about Advance Directives

 

There are a few good opportunities in which one can talk to patients about advance directives. Some of the best opportunities include:

 

Routine office visits- Talking about advance directives in a health care providers private office can be less threatening than bringing it up in a hospital or other health care facility.

 

At the time of admission- It can be reassuring to patients to know that everyone who is admitted receives information about advance directives. It is just a “standard policy,” and is not a reflection of the patient’s current state of health, often relieving anxiety on behalf of the patient.

 

Once the patient has settled in - Some patients would prefer to hear about advance directives details from a nurse or other health care worker who will be involved in providing their care.

 

Keep in mind.. It is never to early to draw up an advance directive. By the time an emergency hits, it may be too late.

 

When discussing advance directives with your patient, first follow your facilities policies on discussing, and remember to:

 

Focus on the positive: Explain that the patient has the right to make his or her own choices, and that an advance directive helps to protect that right.

 

Be reassuring: explain that creating an advance directive is a good idea for everyone- even people in good health. Having an advance directive does not mean it will ever have to be used.

 

Be sensitive to the patient’s feelings: Keep in mind that some patients may prefer not to think about death, dying, or the issue of the future. You can always encourage the patient to look over the information and get back with you or social services with questions they may have. Never pressure a patient into making an on the spot decision.

Listen carefully: Encourage all patients to talk about worries, fears, ect. Ask if there is anything you can do to make him or her feel more in control. This is one way to introduce the subject of advance directives.

 

Explain things clearly: For example, make a clear distinction between living wills and durable power of attorney. BE SURE YOU KNOW THE LAWS IN YOUR STATE REGARDING ADVANCE DIRECTIVES.

 

Keep in mind that most patients do want to know their options. Patients are often relieved and grateful to learn that they can plan their future medical care. Many patients like the idea of advance directives but do not know how to go about creating them.

 

Creating an Advance Directive

 

First, encourage your patient to be aware of the laws in your state, as they vary from state to state. Then have the patient put their wishes in writing, being as specific as possible. Some states have special forms that are required to be used for this purpose only. The patient would then sign and date the advance directive. It will need to be witnessed and notarized. ( In most states) The patient should then keep a card in their wallet stating that they have an advance directive. A copy should be provided to their physician and several other copies should be retained by the patient. If the advance directive is a durable power of attorney, then the proxy and attorney (if applicable) are to also receive a copy. Encourage the patient to discuss the advance directive with family members who are likely to be notified in case of an emergency.

The patient should then review the advance directive regularly and make changes as necessary, informing the physician, family and proxy of any changes.

 

Ways to help a patient get started with advance directives

 

Discuss medical possibilities: Help make patients aware of different kinds of medical situations they may face one day. In some states it is required that a physician be the one to discuss these issues. For example, explain some of the possible effects of a terminal illness as well as life sustaining measures that may be taken.

 

Ask some important questions. For example: “What kind of medical care would the patient prefer if he or she were unable to communicate or to meet his or her most basic physical needs?” “What would the patient wish for his or her family?”

 

Encourage the patient to talk with loved ones. A family discussion gives others a chance to discuss and express their wishes and views as well. This also a prime time for the family to understand what it is the patient wants in regards to their advance directive. It may be wise to have a member of the patients church or clergy present.

 

 

 

More

Details to advance directives

 

As healthcare providers it is important to fully understand what an advance directive can mean for a patient.

 

Advance Directives can limit life prolonging measures when there is little or no chance for recovery. For example, an advance directive may enable patients to make their wishes and feeling known about CPR, IV therapy, Feeding tubes, respirators, and dialysis. Advance directives can also address pain management issues.

 

The patient should also be aware of DNR orders. ( Do Not Resuscitate) and also organ donation options. Specific treatments and procedures.

 

It is important to help a patient “think through” advance directive choices.

Help them consider what is important to them.

 

 

 

 

Some important questions to discuss include:

It is important for me to _______:

  1. Die without pain and suffering

  2. Be able to make my own decisions

  3. Leave my family with good memories

  4. Not burden my family with difficult choices

  5. Act according to my religious beliefs

  6. Be with my loved ones at time of death

 

KEY TERMS TO KNOW

ABOUT ADVANCE DIRECTIVES

 

The following terms are probably familiar to all nurses, but are worth reviewing:

 

Cardiopulmonary resuscitation (CPR) this is an emergency procedure for reviving a patient whose heart has stopped beating.

 

Respirator- Also called ventilator, this machine keeps the lungs working when a patient has lost the ability to breathe on their own.

 

DNR- DO Not Resuscitate; A DNR order prevents the healthcare team from taking any measures to revive the patient. The DNR must be signed by a doctor, and be in the patient record.

 

Total Parental Nutrition- TPN; also called artificial nutrition and hydration. This is a method for supplying water and nutrients to a patient who can no longer eat or drink on their own.

 

Terminal illness- In general, a terminal illness is one that is terminal and the patient has less than a year to live.

 

Dialysis- This is the use of a special machine to help clean out the blood when the kidneys are not able to function properly.

 

 

 

 

 

Frequently Asked Questions About Advance Directives

 

Can an advance directive be changed?

  • Yes! As with a will, the patient can chance the content of an advance directive at any time by adding or removing items. The best way to amend an advance directive is to destroy the document, and all copies that are around, and make a new one.

 

Can a patient still get treatment for pain if they have an advance directive?

  • Yes! An advance directive gives the patient the ability to be very specific about what types of treatment they want and don’t want.

 

Does a patient have to have a lawyer draw up the advance directive?

  • NO! It is up to the patient as to if they want to have a lawyer involved or not. The patient can create and sign the advance directive without an attorney. Some states will require the documents to be notarized though. Some people feel more secure if a lawyer has looked it over for them.

 

Does an advance directive have an expiration time period?

  • Most states do not have time limits on advance directives. To be sure time limits do not apply, check the law in your state. You can ask a social worker in a hospital or check with a hospital ethics committee.

 

Are advance directives valid if the patient is hospitalized in a different state?

  • Because laws govern advance directives vary from state to state, there is no guarantee that an advance directive written in one state will be valid in another. If the patient spends a considerable amount of time in a different state, they may want to draw up an advance directive for that state as well.

Can a family member prevent the advance directive from taking effect?

  • In most cases, NO. Though it depends on the state law. When families object, hospital staff may be called in to help them understand that the right thing to do is to honor the patient’s wishes. The only time a family member may be successful in preventing the advance directive from being valid is if the patient was clearly not thinking coherently when he or she created the document.

 

 

Florida Law on Advance Directives

 

Though I can not offer a lot of information on other states, I can inform you on some of Florida laws. In the state of Florida it is required that there be TWO witnesses and a notary present at the signing of a living will, health care surrogate, or a durable power of attorney. Florida law states the witnesses and the notary are to be present BEFORE, and DURING THE ENTIRE PROCESS. The witnesses should NOT be mentioned in the documents. Witnesses need to be someone else other than those the documents pertain to. The notary public may act as a witness. The person signing the documents must produce photo I.D.

 

In regards to organ donation, the person signing needs to indicate yes or no on the legal forms.

 

In regards to durable power of attorney: Each attorney in fact should be given the affidavit that accompanies the durable power of attorney. The attorney in fact should NOT sign the affidavit until it becomes time to use the durable power of attorney. If it becomes necessary for the attorney in fact to utilize the document, the ORIGINAL durable power of attorney needs to be RECORDED with the CLERK OF CIRUIT COURT in the county in which the person executing the document resides.

 

Each person named in the living will and health care surrogate should be given a copy of these documents, notifying them that they have been so named. The person initiating the advance directive should supply a copy of these documents to their doctor and lawyer if applicable.

 

The ORIGINAL documents should be kept in a safe place, such as a safety deposit box. Make sure that the people named in the document are able to access the safety deposit box.

Where to get information

 

If the patient needs help in preparing an advance directive, suggest he or she talk to an attorney. They may also get help through a doctor, hospital, or hospice.

 

They may also contact their state attorney generals office.

 

Some states have specific forms that must be filled out. Anyone can write to the following address to request laws and forms for your state:

 

Choice in Dying

200 Varick Street

10th floor

New York, NY 10014-4810

Or call 1-800-989-WILL

1-800-989-9455

 

Or visit their web site at: www.echonyc.com

 

Summary

 

Advance directives should be an essential part of providing healthcare to our patients. Consider advance directives in your health care planning. Know your patients rights and take steps to protect them.

Discuss your patients wishes with them, their family, and the physician.

Review the advance directive to make certain they express clearly what the patient is requesting. Consider preparing your own advance directive. It makes good sense because it can help you have a better knowledge of advance directives. Going through the process yourself will help you explain it to others. Since you will be experiencing a lot of the same feelings patients do when they are faced with an advance directive, you will understand how the patient feels. If you are more at ease, the patient will be also. Drawing up an advance directive will also protect your right to make decisions about your own medical care.

 

REFERENCES:

 

www.agingconcepts.com

 

www.longtermcareliving.com

 

www.familydoctor.org

 

www.rclaw.com

 

 

Legal Nurses Handbook

Springhouse Publishing, 2001

 

Advance Directives Today

Mosby Publishing, 2002

Philadelphia, Pa.

Advance Directives

Course 118

2 contact hours

By: Monica Oram, RN, BSN

 

Upon completion of this course the reader will be able to achieve the following objectives:

 

  1. Understand what advance directives are

  2. Understand why healthcare professionals need to be aware of advance directives

  3. Understand the Patient Self Determination Act (PSDA)

  4. Understand Key related terms associated with advance directives

  5. Learn ways in which to talk to patients and families about advance directives

  6. Learn answers to some frequently asked questions about advance directives

 

What Are Advance Directives?

 

Advance Directives are written documents that allow patients to give directions about future medical care. This is why they are called ADVANCE directives, it is a way to express medical wishes in ADVANCE, as to what they want and do want when faced with end of life issues.

 

There are two kinds of advance directives:

  1. Living wills

  2. Durable power of attorney for health care

 

Living Wills are written documents of instruction about medical care a person wants to receive - or not receive- if he or she has a terminal disease or other debilitating condition. They are called living wills because they are created while the person is still alive.

 

Durable power of attorney for health care - This is a document in which the patient names someone else, called a proxy or agent, to make medical care decisions if the patient becomes unable to do so.

In some states, these two types of advance directives can be combined into one document. A durable power of attorney (DPA) for health care is another kind of advance directive. A DPA states whom the patient has designated to make their healthcare choices. It becomes active anytime a patient becomes unconscious or unable to make healthcare decisions. A DPA is usually more useful than a living will, but a DPA may not be a good idea if the patient does not have someone they can trust to make the decisions on their behalf.

 

Realize that the patient has the right to refuse medical care. Advance Directives can protect this right if the patient becomes mentally or physically unable to choose or communicate their wishes due to an injury or illness.

 

Why should you learn about advance directives?

 

You should be well informed about advance directives because they are valuable tools and are legal documents implemented by your patients. We as health care professionals must know to honor the wishes and requests of our patients. We are often placed in a position to have to discuss advance directives with a patient or family member.

 

Advance directives benefit the patients by protecting their right to make their own health care choices. Advance directives benefit families by helping them make more informed medical decisions on behalf of their loved one. Advance directives help the healthcare workers because otherwise we would have no idea as to what the patient’s wishes are.

 

Patient Self Determination Act ( PSDA)

 

The Patient Self Determination Act requires health care facilities that receive federal funding to:

  • Discuss advance directives with patients

  • Find out if a patient has an advance directive

  • Have a written policy on advance directives

  • Educate staff and the community regarding advance directives.

 

 

At the time of admission, staff must provide patients with written information about their right to make health care decisions. The existence of an advance directive, or the absence thereof, must be documented into the patient’s permanent record.

In most cases, health care facilities must follow the instructions set out in a living will- or take directions from a healthcare proxy as designated by the patient.

 

Health care facilities can reach out to the community in a number of ways.

Examples of community involvement include:

  • Open houses

  • Health fairs

  • Health screenings

  • Community presentations

  • Information distributed to churches, libraries, and health care providers offices

  • Public service announcements on the radio or in a local newspaper

 

Healthcare workers should also make certain that the advance directive is kept in an appropriate place and easy to find.

 

Keep in mind that all patients have certain rights when it comes to advance directives.

 

The Patient Self Determination Act (PSDA) passed in 1990 and was instituted on December 1, 1991. This act encourages all people to make choices and decisions in advance on how they want to accept or refuse medical care should they become unable to do so due to illness.

 

The PSDA requires all hospitals, nursing homes, long term care facilities, home care agencies, and any others who receive federal funding from Medicare or Medicaid reimbursement to recognize the living will and power of attorney for health care as advance directives.

 

The PSDA does NOT create new rights for patients, but it does REAFFIRM the common law right to self determination as guaranteed by the fourteenth amendment. Under PSDA, health care facilities must ask if a patient has advance directives, and must provide educational materials about the patients rights under their state law.

 

State laws will vary accordingly. Be familiar what your state laws are regarding advance directives.

 

Patient Rights

 

This will include:

  • The right to privacy

  • Right to informed consent

  • Information about patient condition

  • Information on advance directives

 

Privacy:

Always remember that the patient medical record is held to a high standard of confidentiality. Medical records and communication between doctor and patient is protected as confidential. Nurses must also respect confidentiality by not sharing information with unauthorized individuals.

 

Informed consent:

The physician has the responsibility of clearly explaining to the patient the advantages and risks of any procedures, tests or treatments. The patient must give permission and has the right to refuse.

 

Information about condition:

It is the patients right to be kept up to date about medical conditions, treatments, and chances of recovery. It is the physicians responsibility to explain clearly to the patient this information. Nurses may be involved with some aspects of this, but most generally a doctor will be the one to explain treatment and recovery expectations.

 

Information about advance directives is required by law to be given to the patient upon admission to any healthcare facility or home care agency. In most cases, advance directives must be discussed, explained, and fully understood by the patient.

 

Some health care workers are hesitant to discuss advance directives because of uncertainty, fear or denial.

 

Uncertainty for most people, talking openly about death and dying or terminal disease does not come easily. Healthcare workers may not know how to start such a conversation about advance directives, or what to even say.

 

Fear is something some healthcare workers worry about because they may be fearful that talking about death and dying can make the patient uneasy or angry. In others it may bring on depression.

 

Denial is a factor in which both the patient and healthcare worker may prefer to ignore the need for an advance directive, especially if the patient has a terminal condition.

 

Ways in which to talk to patients about Advance Directives

 

There are a few good opportunities in which one can talk to patients about advance directives. Some of the best opportunities include:

 

Routine office visits- Talking about advance directives in a health care providers private office can be less threatening than bringing it up in a hospital or other health care facility.

 

At the time of admission- It can be reassuring to patients to know that everyone who is admitted receives information about advance directives. It is just a “standard policy,” and is not a reflection of the patient’s current state of health, often relieving anxiety on behalf of the patient.

 

Once the patient has settled in - Some patients would prefer to hear about advance directives details from a nurse or other health care worker who will be involved in providing their care.

 

Keep in mind.. It is never to early to draw up an advance directive. By the time an emergency hits, it may be too late.

 

When discussing advance directives with your patient, first follow your facilities policies on discussing, and remember to:

 

Focus on the positive: Explain that the patient has the right to make his or her own choices, and that an advance directive helps to protect that right.

 

Be reassuring: explain that creating an advance directive is a good idea for everyone- even people in good health. Having an advance directive does not mean it will ever have to be used.

 

Be sensitive to the patient’s feelings: Keep in mind that some patients may prefer not to think about death, dying, or the issue of the future. You can always encourage the patient to look over the information and get back with you or social services with questions they may have. Never pressure a patient into making an on the spot decision.

Listen carefully: Encourage all patients to talk about worries, fears, ect. Ask if there is anything you can do to make him or her feel more in control. This is one way to introduce the subject of advance directives.

 

Explain things clearly: For example, make a clear distinction between living wills and durable power of attorney. BE SURE YOU KNOW THE LAWS IN YOUR STATE REGARDING ADVANCE DIRECTIVES.

 

Keep in mind that most patients do want to know their options. Patients are often relieved and grateful to learn that they can plan their future medical care. Many patients like the idea of advance directives but do not know how to go about creating them.

 

Creating an Advance Directive

 

First, encourage your patient to be aware of the laws in your state, as they vary from state to state. Then have the patient put their wishes in writing, being as specific as possible. Some states have special forms that are required to be used for this purpose only. The patient would then sign and date the advance directive. It will need to be witnessed and notarized. ( In most states) The patient should then keep a card in their wallet stating that they have an advance directive. A copy should be provided to their physician and several other copies should be retained by the patient. If the advance directive is a durable power of attorney, then the proxy and attorney (if applicable) are to also receive a copy. Encourage the patient to discuss the advance directive with family members who are likely to be notified in case of an emergency.

The patient should then review the advance directive regularly and make changes as necessary, informing the physician, family and proxy of any changes.

 

Ways to help a patient get started with advance directives

 

Discuss medical possibilities: Help make patients aware of different kinds of medical situations they may face one day. In some states it is required that a physician be the one to discuss these issues. For example, explain some of the possible effects of a terminal illness as well as life sustaining measures that may be taken.

 

Ask some important questions. For example: “What kind of medical care would the patient prefer if he or she were unable to communicate or to meet his or her most basic physical needs?” “What would the patient wish for his or her family?”

 

Encourage the patient to talk with loved ones. A family discussion gives others a chance to discuss and express their wishes and views as well. This also a prime time for the family to understand what it is the patient wants in regards to their advance directive. It may be wise to have a member of the patients church or clergy present.

 

 

 

More

Details to advance directives

 

As healthcare providers it is important to fully understand what an advance directive can mean for a patient.

 

Advance Directives can limit life prolonging measures when there is little or no chance for recovery. For example, an advance directive may enable patients to make their wishes and feeling known about CPR, IV therapy, Feeding tubes, respirators, and dialysis. Advance directives can also address pain management issues.

 

The patient should also be aware of DNR orders. ( Do Not Resuscitate) and also organ donation options. Specific treatments and procedures.

 

It is important to help a patient “think through” advance directive choices.

Help them consider what is important to them.

 

 

 

 

Some important questions to discuss include:

It is important for me to _______:

  1. Die without pain and suffering

  2. Be able to make my own decisions

  3. Leave my family with good memories

  4. Not burden my family with difficult choices

  5. Act according to my religious beliefs

  6. Be with my loved ones at time of death

 

KEY TERMS TO KNOW

ABOUT ADVANCE DIRECTIVES

 

The following terms are probably familiar to all nurses, but are worth reviewing:

 

Cardiopulmonary resuscitation (CPR) this is an emergency procedure for reviving a patient whose heart has stopped beating.

 

Respirator- Also called ventilator, this machine keeps the lungs working when a patient has lost the ability to breathe on their own.

 

DNR- DO Not Resuscitate; A DNR order prevents the healthcare team from taking any measures to revive the patient. The DNR must be signed by a doctor, and be in the patient record.

 

Total Parental Nutrition- TPN; also called artificial nutrition and hydration. This is a method for supplying water and nutrients to a patient who can no longer eat or drink on their own.

 

Terminal illness- In general, a terminal illness is one that is terminal and the patient has less than a year to live.

 

Dialysis- This is the use of a special machine to help clean out the blood when the kidneys are not able to function properly.

 

 

 

 

 

Frequently Asked Questions About Advance Directives

 

Can an advance directive be changed?

  • Yes! As with a will, the patient can chance the content of an advance directive at any time by adding or removing items. The best way to amend an advance directive is to destroy the document, and all copies that are around, and make a new one.

 

Can a patient still get treatment for pain if they have an advance directive?

  • Yes! An advance directive gives the patient the ability to be very specific about what types of treatment they want and don’t want.

 

Does a patient have to have a lawyer draw up the advance directive?

  • NO! It is up to the patient as to if they want to have a lawyer involved or not. The patient can create and sign the advance directive without an attorney. Some states will require the documents to be notarized though. Some people feel more secure if a lawyer has looked it over for them.

 

Does an advance directive have an expiration time period?

  • Most states do not have time limits on advance directives. To be sure time limits do not apply, check the law in your state. You can ask a social worker in a hospital or check with a hospital ethics committee.

 

Are advance directives valid if the patient is hospitalized in a different state?

  • Because laws govern advance directives vary from state to state, there is no guarantee that an advance directive written in one state will be valid in another. If the patient spends a considerable amount of time in a different state, they may want to draw up an advance directive for that state as well.

Can a family member prevent the advance directive from taking effect?

  • In most cases, NO. Though it depends on the state law. When families object, hospital staff may be called in to help them understand that the right thing to do is to honor the patient’s wishes. The only time a family member may be successful in preventing the advance directive from being valid is if the patient was clearly not thinking coherently when he or she created the document.

 

 

Florida Law on Advance Directives

 

Though I can not offer a lot of information on other states, I can inform you on some of Florida laws. In the state of Florida it is required that there be TWO witnesses and a notary present at the signing of a living will, health care surrogate, or a durable power of attorney. Florida law states the witnesses and the notary are to be present BEFORE, and DURING THE ENTIRE PROCESS. The witnesses should NOT be mentioned in the documents. Witnesses need to be someone else other than those the documents pertain to. The notary public may act as a witness. The person signing the documents must produce photo I.D.

 

In regards to organ donation, the person signing needs to indicate yes or no on the legal forms.

 

In regards to durable power of attorney: Each attorney in fact should be given the affidavit that accompanies the durable power of attorney. The attorney in fact should NOT sign the affidavit until it becomes time to use the durable power of attorney. If it becomes necessary for the attorney in fact to utilize the document, the ORIGINAL durable power of attorney needs to be RECORDED with the CLERK OF CIRUIT COURT in the county in which the person executing the document resides.

 

Each person named in the living will and health care surrogate should be given a copy of these documents, notifying them that they have been so named. The person initiating the advance directive should supply a copy of these documents to their doctor and lawyer if applicable.

 

The ORIGINAL documents should be kept in a safe place, such as a safety deposit box. Make sure that the people named in the document are able to access the safety deposit box.

Where to get information

 

If the patient needs help in preparing an advance directive, suggest he or she talk to an attorney. They may also get help through a doctor, hospital, or hospice.

 

They may also contact their state attorney generals office.

 

Some states have specific forms that must be filled out. Anyone can write to the following address to request laws and forms for your state:

 

Choice in Dying

200 Varick Street

10th floor

New York, NY 10014-4810

Or call 1-800-989-WILL

1-800-989-9455

 

Or visit their web site at: www.echonyc.com

 

Summary

 

Advance directives should be an essential part of providing healthcare to our patients. Consider advance directives in your health care planning. Know your patients rights and take steps to protect them.

Discuss your patients wishes with them, their family, and the physician.

Review the advance directive to make certain they express clearly what the patient is requesting. Consider preparing your own advance directive. It makes good sense because it can help you have a better knowledge of advance directives. Going through the process yourself will help you explain it to others. Since you will be experiencing a lot of the same feelings patients do when they are faced with an advance directive, you will understand how the patient feels. If you are more at ease, the patient will be also. Drawing up an advance directive will also protect your right to make decisions about your own medical care.

 

REFERENCES:

 

www.agingconcepts.com

 

www.longtermcareliving.com

 

www.familydoctor.org

 

www.rclaw.com

 

 

Legal Nurses Handbook

Springhouse Publishing, 2001

 

Advance Directives Today

Mosby Publishing, 2002

Philadelphia, Pa.

Advance Directives

Course 118

2 contact hours

By: Monica Oram, RN, BSN

 

Upon completion of this course the reader will be able to achieve the following objectives:

 

  1. Understand what advance directives are

  2. Understand why healthcare professionals need to be aware of advance directives

  3. Understand the Patient Self Determination Act (PSDA)

  4. Understand Key related terms associated with advance directives

  5. Learn ways in which to talk to patients and families about advance directives

  6. Learn answers to some frequently asked questions about advance directives

 

What Are Advance Directives?

 

Advance Directives are written documents that allow patients to give directions about future medical care. This is why they are called ADVANCE directives, it is a way to express medical wishes in ADVANCE, as to what they want and do want when faced with end of life issues.

 

There are two kinds of advance directives:

  1. Living wills

  2. Durable power of attorney for health care

 

Living Wills are written documents of instruction about medical care a person wants to receive - or not receive- if he or she has a terminal disease or other debilitating condition. They are called living wills because they are created while the person is still alive.

 

Durable power of attorney for health care - This is a document in which the patient names someone else, called a proxy or agent, to make medical care decisions if the patient becomes unable to do so.

In some states, these two types of advance directives can be combined into one document. A durable power of attorney (DPA) for health care is another kind of advance directive. A DPA states whom the patient has designated to make their healthcare choices. It becomes active anytime a patient becomes unconscious or unable to make healthcare decisions. A DPA is usually more useful than a living will, but a DPA may not be a good idea if the patient does not have someone they can trust to make the decisions on their behalf.

 

Realize that the patient has the right to refuse medical care. Advance Directives can protect this right if the patient becomes mentally or physically unable to choose or communicate their wishes due to an injury or illness.

 

Why should you learn about advance directives?

 

You should be well informed about advance directives because they are valuable tools and are legal documents implemented by your patients. We as health care professionals must know to honor the wishes and requests of our patients. We are often placed in a position to have to discuss advance directives with a patient or family member.

 

Advance directives benefit the patients by protecting their right to make their own health care choices. Advance directives benefit families by helping them make more informed medical decisions on behalf of their loved one. Advance directives help the healthcare workers because otherwise we would have no idea as to what the patient’s wishes are.

 

Patient Self Determination Act ( PSDA)

 

The Patient Self Determination Act requires health care facilities that receive federal funding to:

  • Discuss advance directives with patients

  • Find out if a patient has an advance directive

  • Have a written policy on advance directives

  • Educate staff and the community regarding advance directives.

 

 

At the time of admission, staff must provide patients with written information about their right to make health care decisions. The existence of an advance directive, or the absence thereof, must be documented into the patient’s permanent record.

In most cases, health care facilities must follow the instructions set out in a living will- or take directions from a healthcare proxy as designated by the patient.

 

Health care facilities can reach out to the community in a number of ways.

Examples of community involvement include:

  • Open houses

  • Health fairs

  • Health screenings

  • Community presentations

  • Information distributed to churches, libraries, and health care providers offices

  • Public service announcements on the radio or in a local newspaper

 

Healthcare workers should also make certain that the advance directive is kept in an appropriate place and easy to find.

 

Keep in mind that all patients have certain rights when it comes to advance directives.

 

The Patient Self Determination Act (PSDA) passed in 1990 and was instituted on December 1, 1991. This act encourages all people to make choices and decisions in advance on how they want to accept or refuse medical care should they become unable to do so due to illness.

 

The PSDA requires all hospitals, nursing homes, long term care facilities, home care agencies, and any others who receive federal funding from Medicare or Medicaid reimbursement to recognize the living will and power of attorney for health care as advance directives.

 

The PSDA does NOT create new rights for patients, but it does REAFFIRM the common law right to self determination as guaranteed by the fourteenth amendment. Under PSDA, health care facilities must ask if a patient has advance directives, and must provide educational materials about the patients rights under their state law.

 

State laws will vary accordingly. Be familiar what your state laws are regarding advance directives.

 

Patient Rights

 

This will include:

  • The right to privacy

  • Right to informed consent

  • Information about patient condition

  • Information on advance directives

 

Privacy:

Always remember that the patient medical record is held to a high standard of confidentiality. Medical records and communication between doctor and patient is protected as confidential. Nurses must also respect confidentiality by not sharing information with unauthorized individuals.

 

Informed consent:

The physician has the responsibility of clearly explaining to the patient the advantages and risks of any procedures, tests or treatments. The patient must give permission and has the right to refuse.

 

Information about condition:

It is the patients right to be kept up to date about medical conditions, treatments, and chances of recovery. It is the physicians responsibility to explain clearly to the patient this information. Nurses may be involved with some aspects of this, but most generally a doctor will be the one to explain treatment and recovery expectations.

 

Information about advance directives is required by law to be given to the patient upon admission to any healthcare facility or home care agency. In most cases, advance directives must be discussed, explained, and fully understood by the patient.

 

Some health care workers are hesitant to discuss advance directives because of uncertainty, fear or denial.

 

Uncertainty for most people, talking openly about death and dying or terminal disease does not come easily. Healthcare workers may not know how to start such a conversation about advance directives, or what to even say.

 

Fear is something some healthcare workers worry about because they may be fearful that talking about death and dying can make the patient uneasy or angry. In others it may bring on depression.

 

Denial is a factor in which both the patient and healthcare worker may prefer to ignore the need for an advance directive, especially if the patient has a terminal condition.

 

Ways in which to talk to patients about Advance Directives

 

There are a few good opportunities in which one can talk to patients about advance directives. Some of the best opportunities include:

 

Routine office visits- Talking about advance directives in a health care providers private office can be less threatening than bringing it up in a hospital or other health care facility.

 

At the time of admission- It can be reassuring to patients to know that everyone who is admitted receives information about advance directives. It is just a “standard policy,” and is not a reflection of the patient’s current state of health, often relieving anxiety on behalf of the patient.

 

Once the patient has settled in - Some patients would prefer to hear about advance directives details from a nurse or other health care worker who will be involved in providing their care.

 

Keep in mind.. It is never to early to draw up an advance directive. By the time an emergency hits, it may be too late.

 

When discussing advance directives with your patient, first follow your facilities policies on discussing, and remember to:

 

Focus on the positive: Explain that the patient has the right to make his or her own choices, and that an advance directive helps to protect that right.

 

Be reassuring: explain that creating an advance directive is a good idea for everyone- even people in good health. Having an advance directive does not mean it will ever have to be used.

 

Be sensitive to the patient’s feelings: Keep in mind that some patients may prefer not to think about death, dying, or the issue of the future. You can always encourage the patient to look over the information and get back with you or social services with questions they may have. Never pressure a patient into making an on the spot decision.

Listen carefully: Encourage all patients to talk about worries, fears, ect. Ask if there is anything you can do to make him or her feel more in control. This is one way to introduce the subject of advance directives.

 

Explain things clearly: For example, make a clear distinction between living wills and durable power of attorney. BE SURE YOU KNOW THE LAWS IN YOUR STATE REGARDING ADVANCE DIRECTIVES.

 

Keep in mind that most patients do want to know their options. Patients are often relieved and grateful to learn that they can plan their future medical care. Many patients like the idea of advance directives but do not know how to go about creating them.

 

Creating an Advance Directive

 

First, encourage your patient to be aware of the laws in your state, as they vary from state to state. Then have the patient put their wishes in writing, being as specific as possible. Some states have special forms that are required to be used for this purpose only. The patient would then sign and date the advance directive. It will need to be witnessed and notarized. ( In most states) The patient should then keep a card in their wallet stating that they have an advance directive. A copy should be provided to their physician and several other copies should be retained by the patient. If the advance directive is a durable power of attorney, then the proxy and attorney (if applicable) are to also receive a copy. Encourage the patient to discuss the advance directive with family members who are likely to be notified in case of an emergency.

The patient should then review the advance directive regularly and make changes as necessary, informing the physician, family and proxy of any changes.

 

Ways to help a patient get started with advance directives

 

Discuss medical possibilities: Help make patients aware of different kinds of medical situations they may face one day. In some states it is required that a physician be the one to discuss these issues. For example, explain some of the possible effects of a terminal illness as well as life sustaining measures that may be taken.

 

Ask some important questions. For example: “What kind of medical care would the patient prefer if he or she were unable to communicate or to meet his or her most basic physical needs?” “What would the patient wish for his or her family?”

 

Encourage the patient to talk with loved ones. A family discussion gives others a chance to discuss and express their wishes and views as well. This also a prime time for the family to understand what it is the patient wants in regards to their advance directive. It may be wise to have a member of the patients church or clergy present.

 

 

 

More

Details to advance directives

 

As healthcare providers it is important to fully understand what an advance directive can mean for a patient.

 

Advance Directives can limit life prolonging measures when there is little or no chance for recovery. For example, an advance directive may enable patients to make their wishes and feeling known about CPR, IV therapy, Feeding tubes, respirators, and dialysis. Advance directives can also address pain management issues.

 

The patient should also be aware of DNR orders. ( Do Not Resuscitate) and also organ donation options. Specific treatments and procedures.

 

It is important to help a patient “think through” advance directive choices.

Help them consider what is important to them.

 

 

 

 

Some important questions to discuss include:

It is important for me to _______:

  1. Die without pain and suffering

  2. Be able to make my own decisions

  3. Leave my family with good memories

  4. Not burden my family with difficult choices

  5. Act according to my religious beliefs

  6. Be with my loved ones at time of death

 

KEY TERMS TO KNOW

ABOUT ADVANCE DIRECTIVES

 

The following terms are probably familiar to all nurses, but are worth reviewing:

 

Cardiopulmonary resuscitation (CPR) this is an emergency procedure for reviving a patient whose heart has stopped beating.

 

Respirator- Also called ventilator, this machine keeps the lungs working when a patient has lost the ability to breathe on their own.

 

DNR- DO Not Resuscitate; A DNR order prevents the healthcare team from taking any measures to revive the patient. The DNR must be signed by a doctor, and be in the patient record.

 

Total Parental Nutrition- TPN; also called artificial nutrition and hydration. This is a method for supplying water and nutrients to a patient who can no longer eat or drink on their own.

 

Terminal illness- In general, a terminal illness is one that is terminal and the patient has less than a year to live.

 

Dialysis- This is the use of a special machine to help clean out the blood when the kidneys are not able to function properly.

 

 

 

 

 

Frequently Asked Questions About Advance Directives

 

Can an advance directive be changed?

  • Yes! As with a will, the patient can chance the content of an advance directive at any time by adding or removing items. The best way to amend an advance directive is to destroy the document, and all copies that are around, and make a new one.

 

Can a patient still get treatment for pain if they have an advance directive?

  • Yes! An advance directive gives the patient the ability to be very specific about what types of treatment they want and don’t want.

 

Does a patient have to have a lawyer draw up the advance directive?

  • NO! It is up to the patient as to if they want to have a lawyer involved or not. The patient can create and sign the advance directive without an attorney. Some states will require the documents to be notarized though. Some people feel more secure if a lawyer has looked it over for them.

 

Does an advance directive have an expiration time period?

  • Most states do not have time limits on advance directives. To be sure time limits do not apply, check the law in your state. You can ask a social worker in a hospital or check with a hospital ethics committee.

 

Are advance directives valid if the patient is hospitalized in a different state?

  • Because laws govern advance directives vary from state to state, there is no guarantee that an advance directive written in one state will be valid in another. If the patient spends a considerable amount of time in a different state, they may want to draw up an advance directive for that state as well.

Can a family member prevent the advance directive from taking effect?

  • In most cases, NO. Though it depends on the state law. When families object, hospital staff may be called in to help them understand that the right thing to do is to honor the patient’s wishes. The only time a family member may be successful in preventing the advance directive from being valid is if the patient was clearly not thinking coherently when he or she created the document.

 

 

Florida Law on Advance Directives

 

Though I can not offer a lot of information on other states, I can inform you on some of Florida laws. In the state of Florida it is required that there be TWO witnesses and a notary present at the signing of a living will, health care surrogate, or a durable power of attorney. Florida law states the witnesses and the notary are to be present BEFORE, and DURING THE ENTIRE PROCESS. The witnesses should NOT be mentioned in the documents. Witnesses need to be someone else other than those the documents pertain to. The notary public may act as a witness. The person signing the documents must produce photo I.D.

 

In regards to organ donation, the person signing needs to indicate yes or no on the legal forms.

 

In regards to durable power of attorney: Each attorney in fact should be given the affidavit that accompanies the durable power of attorney. The attorney in fact should NOT sign the affidavit until it becomes time to use the durable power of attorney. If it becomes necessary for the attorney in fact to utilize the document, the ORIGINAL durable power of attorney needs to be RECORDED with the CLERK OF CIRUIT COURT in the county in which the person executing the document resides.

 

Each person named in the living will and health care surrogate should be given a copy of these documents, notifying them that they have been so named. The person initiating the advance directive should supply a copy of these documents to their doctor and lawyer if applicable.

 

The ORIGINAL documents should be kept in a safe place, such as a safety deposit box. Make sure that the people named in the document are able to access the safety deposit box.

Where to get information

 

If the patient needs help in preparing an advance directive, suggest he or she talk to an attorney. They may also get help through a doctor, hospital, or hospice.

 

They may also contact their state attorney generals office.

 

Some states have specific forms that must be filled out. Anyone can write to the following address to request laws and forms for your state:

 

Choice in Dying

200 Varick Street

10th floor

New York, NY 10014-4810

Or call 1-800-989-WILL

1-800-989-9455

 

Or visit their web site at: www.echonyc.com

 

Summary

 

Advance directives should be an essential part of providing healthcare to our patients. Consider advance directives in your health care planning. Know your patients rights and take steps to protect them.

Discuss your patients wishes with them, their family, and the physician.

Review the advance directive to make certain they express clearly what the patient is requesting. Consider preparing your own advance directive. It makes good sense because it can help you have a better knowledge of advance directives. Going through the process yourself will help you explain it to others. Since you will be experiencing a lot of the same feelings patients do when they are faced with an advance directive, you will understand how the patient feels. If you are more at ease, the patient will be also. Drawing up an advance directive will also protect your right to make decisions about your own medical care.

 

REFERENCES:

 

www.agingconcepts.com

 

www.longtermcareliving.com

 

www.familydoctor.org

 

www.rclaw.com

 

 

Legal Nurses Handbook

Springhouse Publishing, 2001

 

Advance Directives Today

Mosby Publishing, 2002

Philadelphia, Pa.