Running head: ADVANCED DIRECTIVES 1

Advanced Directives: Implications for Nursing

Isaiah Ross

University of Saint Mary

ADVANCED DIRECTIVES 2

Abstract

This paper relays the importance of advanced directives and the role nurses have in

providing knowledge of them as well as ensuring they are fulfilled. Also, one will gain a better

understanding on how difficult it can be for nurses regarding advance directives if they do not

possess the knowledge required to effectively communicate and answer questions. One will read

academic journals that go in-depth on how nurses are not as knowledgeable as one may think

about advanced directives. One will also see that if the knowledge is increased within the nurses

field, the more likely the advanced directive will be completed. The nurse-patient relationship is

vital and one can argue that it is the most important when it pertains to advanced directives. The

reader will be able to gain a better understanding of what a nurses role is when comes to

advanced directives and also how important advance directives are to have as a patient.

Keywords: Advanced directives, Nurses role, Nurse-patient relationship

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Advanced Directives: Implication of Nursing

Advanced directives provide a vital role in a patient's end-of-life care. Nurses can fulfill

patient wishes when an advance directive is provided. Advance directives can be difficult to

discuss as a nurse, however, possessing the proper knowledge can help assist in passing on

information to colleagues as well as patients. When establishing a nurse-patient relationship it is

imperative for nurses to communicate with patients, ensuring they completely understand the

importance of advanced directives. The reason that advance directives are important is because

they allow a patient to write down all of their medical wishes prior to them being unable to

communicate their wishes. By having an advance directive the patient is informing their

healthcare team of their medical wishes. Nurses, on occasions, may have to advocate on patients

behalf to ensure they are granted. The advanced directive is also an important document for the

patients medical records. If the patient has an advanced directive on file and it is not fulfilled the

hospital as well as healthcare professionals could possibly be held accountable financially. As a

nurse, one should be prepared to plan the absolute best care for the patient, meaning that all

medical wishes are fulfilled and not ignored. Nurses can play a vital role when it pertains to

accurately communicating and promoting the importance of an advanced directive.

According to Potter & Perry (2017) an advance directive is the patient's values of

consent, autonomy of end-of-life decisions, telling the truth, and having control over the dying

process. There is the Patient Self-Determination Act (PSDA) that came to life in 1991. The

PSDA requires the hospitals to provide information to patients under the state law involving the

making of advanced directives. The advanced directive can involve a living will, which allows

the patient to have written documentation that fulfills the wishes for their direct care if they are

terminally ill or in a condition where they are unable to respond. It also can involve a durable
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power of attorney for health. This is a document that designates a specific person or persons that

can make life decisions involving health care for the patient they can no longer make life

decisions for themselves. According to Abdelmalek (2013), a table that shows many options a

patient can choose to include in their advanced directive. The list includes, resuscitate and use

life-sustaining treatment, do not resuscitate, do not intubate, and trial of treatment/best medical

practice can be used in a typical advanced directive. It also includes options for patients that are

terminally ill, which include palliative care, hospice care, and do not hospitalize. These options

are not required at beginning of care, they can be chosen at any time.

There is a lack of knowledge when it comes to advance directives. Nurses and other

healthcare professionals, including the public, lack this knowledge. A study that was conducted

in New Zealand pertaining to advanced directives and the nurses role to encourage them.

(Davidson & Banister, 2013) The purpose for this study was to find 13 experienced nurses to

unveil the knowledge, attitude, and experiences with their role in providing information about

advance directives. One has to understand that a majority of the nurses in this survey has at

minimum 10 years of experience or more. The study revealed that some nurses had absolutely no

role at all with advanced directives and in turn, they did not engage in conversations about it with

patients. Other nurses believed that an advanced directive promotes better end-of-life care. They

also believe that by having an advanced directive it makes caring for the patients easier as one

knows exactly what the patients wishes are.

As the study progressed, (Davidson & Banister, 2013) one of the nurses experienced a

physician that completely ignored what the patient wishes were. This may be due to them being

unaware, unorganized or the nurse just felt as if they cannot override what a doctor says or does,

which can sometimes be the case. As a nurse one may feel that discussing an advanced directive
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is the first topic one should cover, especially if the patient is in a chronic state, but still able to

communicate and the outcome is certain death. One may think that this is not important,

however, as a hospital, this can be a costly mistake. Not only will the hospital end up paying

financially, but the healthcare professionals may have to deal with the repercussions of that

decision. The conclusion of the study (Davidson & Banister, 2013) shows that it is effective

when nurses communicate and engage in conversations about advanced directives and end-of-

life care to their patients as well as their healthcare team, in order to provide proper care and the

patients wishes are fulfilled.

There was a nurse-led seminar which involved the public and nurse participants that did

not possess proper knowledge of advanced directives. (Hinderer & Mei, 2014) The seminar

discovered that the reason many advanced directives were not being discussed or filled out was

due to a lack of knowledge as well as not having a good understanding of the terminology

involved with advance directives. An issue that was discussed in the seminar showed that

communication about advance directives plays a vital role between a nurse and a patient.. Many

nurses that are unaware of advanced directives have a difficult time with talking about them

when it is time to decide on end-of-life care. This lack of communication can affect the way

treatment is determined. The lack of communication can also mean an absence of caring. If it is

difficult to talk to someone then it may also be difficult to care for them medically, thus, it is an

easier path to never inform a patient of an advanced directive and continue with medical

treatment. This seminar also taught some nurses to take the initiative by having a leading role

and influence patients on filling out advanced directives and explaining the importance. Hinderer

and Mei (2014) included studies that showed advanced directives are more likely to be

completed while family members are present or actively involved in the making of it. As a nurse
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this is something one will keep in mind as some patients may prefer being with family rather

than on their own. Having the family present and/or actively involved may give a patient the

emotional support they require while also giving the family a sense of peace by having closure

on how the end-of- life care should be. Having this nurse-led seminar provided the public with

the knowledge that they can answer family questions involving end of care life decisions and

know how vital advanced directives are. The conclusion of the seminar showed that more people

were now likely to fill out an advance directives after being provided with knowledge.

According to Rigan (2016), nurses provide assistance to patients in understanding the

importance for completing an advanced directive. She also includes that nurses that raise

awareness and give information can affect the patient in a positive way when an advanced

directive is completed. As a nurse, increasing awareness to the patient will allow one to correctly

plan and care for the patient and their wishes. To make the process easier nurses can utilize a tool

that is called the 5 wishes according to Rigan (2016). This tool is a document that is used in at

least 43 states and meets all of the requirements which are needed for the document to be legal

after signed. Some nurses, still, are not as comfortable as they should be when considering the

end-of-life discussion due to not receiving enough training in order to feel confident with the

topic as a whole. This topic, especially with the older community and their families, may be

difficult because some families may not be mentally prepared for the discussion.

Rigan (2016) then goes on to explain the difficulties of getting an advanced directive

returned and scanned into the system. This can be caused by the lack of encouragement. One

may say that if it wasnt scanned in then it was not done at all. This can be true in this case

because it plays a big role in the medical record. Rigan (2016) says Open communication with

the patients will more likely influence the patient to pursue an advanced directive. Having this
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communication may build some trust and strengthen the nurse-patient relationship. One may

think that if a patient is confident in talking about an advanced directive then the nurse can be

confident also. If a nurse and patient are all on the same page, this can make the completion of an

advanced directive easy. To the conclusion of the study one can see that there are many tools

used to help patients feel encouraged and even the 5 wishes method which allows a nurse to

have a template making the process of filling out an advanced directive more possible.

It all starts with the nurses. In order to educate patients about advanced directives one has

to have an understanding on the history of it. The problem one may have is that many patients

could believe that the end-of-life is far away, so they may be completely unaware of what their

medical wishes will be. The American Nurses Association (ANA) wants nurses to encourage

advance care planning with patients. Although ANA requires nurses to have enough knowledge

to understand and discuss with all types of patients about advanced directives. The down fall is

that many nurses are not prepared enough due to the lack of information they are provided on the

subject. This can make it difficult to answer questions for the patients who are in difficult

situations already. Miller (2017) pointed out several studies that were conducted which showed

that nurses had little to no confidence when it came to helping families understand advanced

directives. Nurses that lack the confidence may not even bring to the patients attention about

advanced directives or they may not even consider the topic at all. The nurses that do have a high

confidence with helping patients filling out the forms, actually decrease in confidence as the

patients face more complicated issues. The complicated issues may all be different depending on

the cases, as a nurse, one may gain that confidence back once they are more exposed to the

varying complications of a patients situation.

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The nurses can play an important role when it comes to advanced directives because they

are most likely to be around the patient more and are likely to build a strong nurse-patient

relationship versus doctors who are not in constant contact with the patient. According to Miller

(2017) patients often enter into care alone. This is seen more today than they did in the past

decades. By not having an advanced directive, healthcare professionals have to make the difficult

decisions regarding the patients medical care depending on the state the patient is in. The nurses

have to be open minded when taking in the knowledge of the advanced directives. By doing this,

it will allow them to make the patient feel comfortable about what exactly goes into the advanced

directive. As previously stated, it is possible that if a nurse does not take the time to understand

the advanced directive, they will not understand how to approach and encourage the completion

of one. Miller (2017) began to speak about a study that shows that by 2030 over half of

Americans will be diagnosed with dementia, with no spouse or kids to care for them. This leads

to less advanced directives being filled out and creating a huge obstacle for health care

professionals to make important healthcare decisions regarding the care for the patients. One

may dissect this study and conclude that it is nothing to be concerned about not realizing this can

place more undue stress on the doctors and nurses that have to provide care for these patients

with dementia. It can also come to the point where if the patient does not have an advanced

directive, how much is a hospital willing to pay out of pocket. Overall, if the patients are alone

with no knowledge of an advanced directive, as a nurse it is important to be there for the patient

and continue to encourage one to be completed.

The ANA codes of ethics according to provision 1.4 The role of the nurse is to advocate

for every individual to ensure that the right to self-determination, which includes cultural and

spiritual beliefs, is upheld (2015). As a nurse, it is ones responsibility that everything is

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followed when it pertains to the patients wishes. Nurses will also be the main ones who are

explaining and making sure the patient understands the decisions that they have made and

potential consequences that can come from those decisions. The way one can provide this

knowledge is to have the confidence in oneself and gain as much knowledge as they can when

regarding advanced directives. Having the knowledge will allow nurses to answer complex

questions, patients may have about advanced directives. If the patient has no power of attorney

they may be provided a healthcare surrogate, which is a healthcare professional that makes

medical decisions based on the patients wishes. This may also be difficult as some surrogates

may not feel they are making the right decisions. If there is no surrogate provided, the ANA

(2015) expects the nurse to advocate on the patients behalf to make the best decision for the

patient while ensuring all values are upheld. This can be a potential stressor as a nurse makes

these difficult decisions. As nurses, it is important to understand all policies and procedures

regarding advance directives. But having the knowledge and the understanding it can help

prevent any wrong doings. Nurses being more educated about advanced directives, will be more

likely to inform their patients and there will be a greater complete rate for them as well. The

ANA (2015) also believes that having an understanding on the origins of advanced directives and

options that are available for the patients can help address the patient about the subject. This can

allow a nurse to have a role to where they can promote the patient in completing the advance

directive, while providing quality care as to their wishes.

As one can see, advanced directives are important to patients as well as health care

providers. More importantly, nurses need to have intimate knowledge of them so they can

educate patients while providing accurate information to a patient in order to feel comfortable

when completing an advance directive. After reading the above material one can see that
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although there are many nurses that lack the knowledge of this important document there are

many ways to become more educated on the subject. By participating in educational seminars

and research can help provide the knowledge to the public as well as our colleagues. ANA is a

source in which nurses can use and follow when providing the correct information to patients

regard an advanced directive. Overall, the advanced directive will play a vital role with ones

life. Having the nurse-patient relationship will allow a nurse to feel confident and help fulfill the

patients medical wishes.

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References

Abdelmalek, C., Goyal, S., Narula, A., Paulino, R., & Thomas-Hemak, L. (2013). Advance

directives: Give teeth to end-of-life choices. Aging Well, 6(1), 24-27.

American Nurses Association (ANA). (2015). Code of ethics with interpretive statements.

Kansas City, MO: Author

Davidson, R., Banister, E., & de Vries, K. (2013). Primary healthcare NZ nurses experiences of

advance directives: Understanding their potential role. Nursing Praxis In New Zealand,

29(2), 26-33 Retrieved from Proquest.

Hinderer, K. A., & Mei Ching, L. (2014). Assessing a nurse-led advanced directive and

advanced care planning seminar. Applied Nursing Research, 27(1), 84-86.

doi:10.1016/j.apnr.2013.10.004

Miller, B., (2017) "Nurses in the Know: The history and future of advance

directives" OJIN: The Online Journal of Issues in Nursing Vol. 22, No. 3.

doi: 10.3912/OJIN.Vol22No03PPT57

Potter, P. A., Perry, A. G., Hall, A. M., & Stockert, P.A. (2017). Fundamentals of nursing (9th

ed.) St. Louis, MO: Mosby Elsevier.

Rigan, P. (2016). Advance Medical Directives: Medical-Surgical Nurses Can Make a

Difference. Med-Surg Matters, 25(3), 1-3. Retrieved from Ebscohost.

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Appendix

I. Abstract

II. Introduction

A. Why advanced directives important to nurses.

III. Content

A. Academic Journals

1. Definition and background of advanced directives

2. New Zealand Survey

3. Nurse- led Seminar

B. American Nurse Association

1. Provision 1.4

2. Nurses role

3. Confidence and knowledge

4. ANA code of ethics

IV. Conclusion

A. Overall view

V.