Report immediately if care being delivered conflicts with the documented advance directive.
Before you read
Test yourself first: 4 questions
Question 1 of 4
A client with early-stage dementia who has decision-making capacity wishes to complete advance directives. What is the nurse's best action?
Answer: A. While the client retains capacity, the nurse should support and facilitate completion of advance directives and a durable power of attorney, ensuring the client's wishes are documented. Waiting until capacity is lost or having the family decide ignores the client's right to self-determination.
Question 2 of 4
A client with advanced dementia and a limited life expectancy is enrolling in hospice. Which goal best reflects the focus of care?
Answer: A. Hospice and palliative care for advanced dementia focus on comfort, dignity, symptom relief, and quality of life rather than curative or aggressive measures. Pursuing aggressive cure-directed treatment or routine restraints conflicts with the comfort-focused goal.
Question 3 of 4
A client with a valid advance directive specifying do-not-resuscitate (DNR) status goes into cardiac arrest. The adult child at the bedside shouts for the nurse to start CPR. What should the nurse do?
Answer: B. A valid DNR order based on the client's advance directive must be honored; the client's documented wishes take precedence over a family member's request. The nurse follows the DNR order and supports the family. Initiating CPR would violate the client's autonomy and the legal directive.
Question 4 of 4
A client returns from surgery for a large bowel obstruction with a nasogastric tube in place. Which finding indicates that peristalsis is returning and the client may be ready to progress?
Answer: B. Return of bowel function after abdominal surgery is signaled by the passage of flatus or stool and the return of bowel sounds, which indicate peristalsis has resumed and oral intake may be advanced per orders. Continued absence of bowel sounds, persistent abdominal distention, and ongoing large bilious NG output indicate that the ileus or obstruction has not resolved. Passage of flatus is a key marker for diet progression.
Keep the streak going with more questions like these, each with a full rationale.
What is advance directives?
The two main types are the living will (treatment preferences) and the durable power of attorney for healthcare (proxy). The Patient Self-Determination Act requires facilities to ask about and document advance directives on admission.
Key points to remember
- An advance directive only takes effect when the patient loses decision-making capacity.
- The two components are a living will (specifies wanted/unwanted treatments) and a durable power of attorney for healthcare (names a proxy).
- A competent patient's current expressed wishes always override a previously written advance directive.
- Advance directives can be changed or revoked by the patient at any time while competent.
- The Patient Self-Determination Act requires hospitals to inform patients of their right to make advance directives at admission.
- Having an advance directive is voluntary and cannot be a condition of receiving care.
Nursing priorities
- Ask every patient on admission whether they have an advance directive and place a copy in the chart.
- Offer information and resources to patients who wish to create an advance directive.
- Communicate the patient's documented wishes to the healthcare team and ensure the plan of care reflects them.
- Notify the provider and update orders if the patient verbally changes their wishes.
- Support the patient's right to make decisions without imposing personal or family values.
Patient teaching
- An advance directive lets your wishes be followed if you cannot speak for yourself.
- You can update or cancel your advance directive at any time.
- Give copies to your proxy, your provider, and the hospital so everyone has the same instructions.
Red flags: report now
- Report immediately if care being delivered conflicts with the documented advance directive.
- Never pressure a patient to complete or not complete an advance directive.
- Do not let family members override a competent patient's stated wishes.
References
Clinical references for this topic
