To help client with advance directives, know thyself

By Sharon Newton, MS, RN, CDMS

Assistant Director of State Programs

Outreach Health Services, Forney, TX

Most regulatory bodies require medical and home care agencies to provide information on advance directives to their clients. This stems from the federal Patient Self-Determination Act passed in 1992. There are several advance directives common among all the states; there are some specific to certain states. It’s important for managers to know what is pertinent to their states so they can help their staff implement these rules. It is also important for them to be able to cope with death so they can support their staff when a beloved client is at the end stage of life.

Advance directives: Essentially, competent individuals can express their choice(s) for life-sustaining medical treatment before they become incapacitated and unable to do so. Additionally, a client may make a declaration for mental health treatment in some locations, such as Texas.

The common choices a client may make include the directive to physicians (living will), the durable power of attorney for health care, and the do-not-resuscitate order. Some states, California and Texas for example, have added the out-of-hospital do-not-resuscitate order and the declaration for mental health treatment.

The witnesses who sign these forms usually must not be related to or caring for the client; nor can they benefit from the client’s will.

Directive to physicians (living will): This choice directs the individual’s physician to withhold procedures that would prolong life in the event of a terminal illness. The document is signed in front of witnesses and the original provided to the physician.

It is a good idea for the individual to discuss the decision with family members in order to avoid the initiation of procedures the client did not want. Usually two physicians have to certify that the client is terminally ill.

The procedures to be withheld may include cardiopulmonary resuscitation, intubation, and artificial feedings.

Durable power of attorney for health care: In this choice, clients designate someone to make health care decisions for them if they become incapacitated and are unable to do so. It applies only to health care, not finances.

Do-not-resuscitate order (DNR): The competent client can tell the physician that a DNR order should be placed on the chart in the event of admission to a hospital, nursing facility, or hospice. The client does not have to have a terminal condition. The order would go into effect in the institution should the client stop breathing or not have a heartbeat.

Out-of-hospital DNR: It is now possible for clients to have a DNR order in place while they are at home. This advance directive usually would apply specifically to emergency medical service or other health care personnel.

Declaration for mental health treatment: A competent adult may choose certain mental health treatments to be used in the event of incapacitation. These include psychoactive medications, electroconvulsive treatment, emergency medical care, and other preferences. Two witnesses must sign the form.

The manager’s role: Managers must be familiar with the rules and regulations on end-of-life issues in their states. They must be familiar with their feelings toward these issues. They must be able to support their staff and be able to comfortably discuss the agency’s expectations and then allow the staff time to become comfortable with their own mortality so they, in turn, can support the clients during the decision making process.

Above and beyond the manager’s feelings toward these end-of-life issues, however, is the clients’ autonomy to choose what is best for them based on their culture, religious beliefs, and own acceptance or avoidance of these topics. Managers should empower their staff to be client advocates.

The nurse’s role: The nurse usually is the agency’s representative who gives the client written information about state-designated advance directives. The nurse must be familiar with the advance directives and must be able to explain them to the client in easily understandable terms.

Some agencies do not routinely provide the specific forms unless the client requests them. Since people often are uncomfortable discussing matters related to incapacitation and death, the nurse must be sensitive to the client’s needs when making these explanations.

Nurses’ attitudes: In order to discuss adequately these end-of-life issues with the client, nurses must face their own incapacitation and/or deaths. A shared emotion is fear of death. What do people fear as they ponder the fact they will die? Nothingness? Abandoning loved ones? Unfinished business? Losing control? As nurses come to grips with the answers, they will be better able to be empathetic in discussing death and advance directives with their clients.

Caregivers’ attitudes: In the home setting, providers often encounter family members and friends who care for and about the client. With the client’s permission, include them in teaching, too. In the event of an out-of-hospital DNR, family understanding and cooperation are vital.

Caregivers should be prepared to know how they will handle the situation if clients who have this in place cease to breathe while caregivers are in the home and the family wants them to call emergency medical services. What are they ethically bound to do? To whom or what is their responsibility now? If clients have included the caregiver and other significant people in making the decision, the client’s wishes can be honored with dignity and assurance.

According to regulations, home care clients must be given information about advance directives. The agency manager and staff must know and understand the advance directives required in their state in order to educate the clients adequately.

Managers should know their own feelings about death in order to be understanding of the needs and sensitivities of the nurses and staff who will be working closely with clients and caregivers.

The staff should also know their own feelings about death in order to be aware of the needs and sensitivities of clients and caregivers. The staff, operating from an ethical standpoint, are in an enhanced position to aid clients in this period of end-of-life transition.