One of the most difficult situations health care professionals face is treatment decision making for those who can no longer communicate their treatment preferences.  Decision-making capacity of older adults may be diminished, fluctuating, or lapsed.  The justification for advance care planning (ACP) is that a person with capacity can prospectively state their wishes, values, and treatment preferences so that their authentic voice will be heard when their capacity and/or ability to communicate has lapsed.  Approximately 30% of older adults do not have a relative, friend, or guardian who can make health care decisions for them.  The right to not complete an advance directive (AD) must also be respected. Patients should be informed (and in some cases, reassured) that neither providers nor the facility will abandon them or provide substandard care if they elect not to formulate an AD.  

Nursing Standard of Practice Protocol: Advance Directives

Ethel L. Mitty, EdD, RN

Reprinted with permission from Springer Publishing Company. Evidence-Based Geriatric Nursing Protocols for Best Practice, 4th Edition, © Springer Publishing Company, LLC. These protocols were revised and tested in NICHE hospitals. The text is available here.

The information in this "In Depth" section is organized according to the following major components of the NURSING PROCESS:

Guiding Principals
Assessment Parameters
Care Strategies
Evaluation of Expected Outcomes

Guiding Principals
  1. All people have the right to decide what will be done with their bodies
  2. All individuals are presumed to have decision-making capacity until deemed otherwise
  3. All patients who can participate in a conversation, either verbally or through an alternate means of communication, should be approached to discuss and record their treatment preferences and wishes
  4. Health care professionals can improve EOL care for older adult patients by encouraging the use of ADs
  1. Education About Advance Directives:

1. Patients uniformly state that they want more information about ADs.

2. Patients want nurses (and physicians) to approach them about ADs.

3. It is estimated that 19% to 36% of Americans have completed an AD.

B. Advance Directives

1. Allow individual to provide directions about the kind of medical care they do or do not want if they become unable to make or communicate their decisions;

2. Provide guidance for health care professionals, families, and substitute decision makers about health care decision making that reflect the person’s wishes; and

3. Provide immunity for health care professionals, families, and appointed proxies from civil and criminal liability when health care professionals follow the AD in good faith.

C. Two types of Advance Directives: DPAHC (also called HCP) and LW.

1. A durable power of attorney allows an individual to appoint someone, called HCP, agent, or surrogate, to make health care decisions for him or her should he or she lose the ability to make decisions or communicate his or her wishes.

2. A living will provides specific instructions to health care providers about particular kinds of health care treatment an individual would or would not want to prolong life. LWs are often used to declare a wish to refuse, limit, or withhold LST.

D. Instructional or Medical Directive: intended to compensate for the weaknesses of LWs. This kind of directive identifies specific interventions that are acceptable to a patient in specific clinical situations (e.g., POLST).

E. Oral Advance Directives (Verbal Directives): allowed in some states if there is clear and convincing evidence of the patient’s wishes. Clear and convincing evidence can include evidence that the patient made the statement consistently and seriously, over time, specifically addressed the actual condition of the patient, and was consistent with the values seen in other areas of the patient's life. Legal rules surrounding oral advance directives vary by state.

Assessment Parameters
  1. All adult patients regardless of age (with the exception of patients with persistent vegetative state, severe dementia, or coma) should be asked if they have an LW or if they have designated a proxy.
  2. All patients regardless of age, gender, religion, socioeconomic status, diagnosis, or prognosis should be approached to discuss ADs and ACP.
  3. Discussions about ADs should be conducted in the patient’s preferred language to enable information transfer and questions and answers.
  4. Discussions should be conducted with sensitivity to the patient's stage of wellness and illness, that is, to their temporal as well as physical status.
  5. Patients who have been determined to lack capacity to make other decisions may still have the capacity to designate a proxy or make some health care decisions. Decision-making capacity should be determined for each individual based on whether the patient has the ability to make the specific decision in question.

If an LW has been completed or proxy has been designated:

1. The document should be readily available on the patient’s current chart.
2. The attending physician should know that the directive exists and has a copy.
3. The designated HCP should have a copy of the document.
4. The directive should be reviewed periodically by the patient, attending physician/nurse, and the proxy to determine if it reflects the patient's current wishes and preferences.

Care Strategies
  1. Nurses should assist patients and families trying to deal with EOL care issues.
  2. Patients may be willing to discuss their health situation and mortality with a nurse or clergyman rather than with a family member and should be supported in doing so.
  3. Patients should be assisted in talking with their family/proxy about their treatment and care wishes.
  4. Patients should be assessed for their ability to cope with the information provided.
  5. Nurses must be mindful of and sensitive to the fact that race, culture, ethnicity, and religion can influence the health care 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 do not want to talk about their treatment wishes, or that they would not have conversations with their families about their treatment preferences.
  6. Patients must be respected for their decision to not complete an AD and reassured that they will not be abandoned or receive substandard care if they do not elect to formulate an AD.
  7. Nurses should be aware of the institution’s mechanism for resolving conflicts between family members and the patient or proxy or between the patient/family and care providers and assist the parties in using this resource.
  8. Nurses should be aware of which professional in their agency/institution is responsible for checking with the patient that copies of the AD have been given to their primary-care provider(s), to their proxy, and that the patient is carrying a wallet-size card with AD and contact information.
Evaluation of Expected Outcomes

To determine whether implementation of this protocol influenced the type as well as the number of ADs created, changes should be measurable and contribute to the facility's ongoing quality improvement program. Look at:

  1. As documented in the record

1. Whether patients are asked about ACP and directives
2. Whether patients do or do not have an AD

B. Of those patients with an AD, the percentage of ADs included in patient charts;

C. The use of interpreters to assist staff discussion of ADs with patients for whom English is not their primary language;

D. The number of ADs completed in association with admission to or receipt of services from the agency/institution;

E. The number of nurse referrals to the ethics committee of patient or staff situations regarding ADs.

For Definition of Levels of Quantitative Evidence Click Here

Reprinted with permission from Springer Publishing Company. Mitty, E.L. (2012). Protocol 29.1: Advance directives. In M. Boltz, E. Capezuti, T. Fulmer, & D. Zwicker, (Eds.) Evidence-Based Geriatric Nursing Protocols for Best Practice. (4th ed.) (pp. 592-594). New York: Springer Publishing Company, LLC.

Last updated - July 2012

The National Hospice and Palliative Care Organization:  State specific advance directives and advice for communicating wishes to family and close friends.

American Bar Association: Toolkit for Health Care Advance Planning