advanced directives

[mmc51264, BSN, MSN, RN]

I am confused. I have tried to understand the structure of this topic.

This is not a HW assignment, I am a nurse already and I was trying to explain to a pt the difference between all of the documents.

When we ask upon admission about advance directives, is that an umbrella for all future wishes?

I get the HCPOA, but does that give POA unlimited decision making rights? What if pt is A&O x4? Who decides that.

Where I work, many of the nurses document that a mental health care directive is not applicable, but I would think that is a very important document.

I am trying to wrap my head around these terms and documents; which ones, if any, are more binding than others.

I work on a floor that gets older people and it is fuzzy sometimes when family demands certain things. I want to know who to listen to LOL.

[tnbutterfly - Mary, BSN]

There are two basic documents that allow a person to set out his/her wishes for medical care: a living will and a durable power of attorney for health care. In some states, the living will and the power of attorney are combined into a single form -- often called an advance directive. (In fact, both of these documents are types of health care directives -- that is, documents that let one specify his/her wishes for health care in the event that he/she becomes unable to speak for him/herself.)

A durable power of attorney is not the same as the healthcare power of attorney. The durable power of attorney deals with financial and legal issues/decisions.

The health care documents take effect if thedoctor determines that one lacks the ability -- often called the "capacity" -- to make his/her own health care decisions. Lacking capacity usually means that:

• a person can't understand the nature and consequences of the health care choices that are available, and
  
• a person is unable to communicate his/her own wishes for care, either orally, in writing, or through gestures.
  

Practically speaking, this means that if one is e so ill or injured that he/she cannot express his/her health care wishes in any way, the documents will spring immediately into effect. If, however, there is some question about one's ability to understand his/her treatment choices and communicate clearly, the doctor (with the input of the health care agent or close relatives) will decide whether it is time for his/her health care documents to become operative.

In some states, it is possible to give the health care agent the authority to manage the medical care immediately. If one's state allows this option, one may prefer to make an immediately effective document so that the agent can step in to act at any time, without the need to involve a doctor in the question of whether or not one's health care document should take effect.

Making the document effective immediately will not give the agent the authority to override what one wants in terms of treatment; the person will always be able to dictate his/her own medical care if he/she has the ability to do so. And even when one is no longer capable of making his/her own decisions, the health care agent must always act in the person's best interests and diligently try to follow any health care wishes expressed in the patient's health care declaration or otherwise.

You need to look at the laws for your state. There are different titles in different states.

[RainMom]

I also often find that when a pt has a living will stating they don't want life-saving measures, ie CPR, intubation etc, the pt & family will think that means they are a DNR. Not true (at least in my state). A DNR form has to be in the chart or an MD order to make pt DNR. Otherwise, if pt codes with no immediate family/next of kin present to instruct staff, the pt will receive CPR. Very confusing for pts & family.

[mmc51264, BSN, MSN, RN]

Thank you! I live in NC and I had instructors say that they have had DNR overidden by other family members. I have seen some documents that don't give permissions for pain medication! People really don't understand. At my facility we don't have the option of "you can do this, but not that" We have DNAR do not attempt resuscitation. And they have have new forms b/c the orange-y ones that come from a LTC are recognized.

Thank you for your help!!!!

[LGRN]

OK, so I understand fully the principles that you wrote about. But, what if the patient likely has capacity, and it could be determined with assessment that they have adequate cognitive function, but that while they are able to think for themselves, they are not able to speak for themselves. Consider the patient with rapidly progressing MS, guilliane barre, ALS or cervical spine injury with intubation. What if there is technology that could allow them to communicate, but the facility failed to provide it?