Give staff these tips on advance directives

It can be more than a little confusing for patients when nurses begin teaching them about advance directives such as living wills and durable power of attorney.

These advance directives add another complication to patients’ lives, and yet, home care agencies are obligated to discuss and educate patients about these instruments because of the 1991 Patient Self-Determination Act.

So what can education managers do to help?

For one thing, experts suggest, you can begin by making sure nurses understand what advance directives are and why they are used.

Professional Care Nursing System of Somers Point, NJ, teaches staff about advance directives during orientation, handing out booklets to each employee, says Christine Wright, RN, director of nursing and client services for the private for profit full-service agency that serves seven counties in southern New Jersey.

"We do the same thing with clients on admission, providing them with information on advance directives," Wright says. (See Resources on advance directives, p. 110.)

The Davie County Home Health and Hospice of Mockville, NC, tells clients that a living will is related to their health care, whereas the will is related to their material possessions, says Janet Blair, RN, BSHE, home health supervisor and executive director of hospice for Davie County. The county agency is in the center of North Carolina, between Winston-Salem and Statesville.

"Elderly people get very confused about the differences," Blair adds.

Advance directives can refer to living wills, durable powers of attorney, and health care treatment directives. (See advance directive glossary, p. 109.)

Davie County nurses also have to explain how a durable power of attorney relates to patients’ health care, while the regular power of attorney is related to their finances.

The durable power of attorney identifies to whom patients would like to make their health care decisions when they are unable to do so themselves. Blair suggests patients discuss various possible health decisions with the family member or friend they choose to represent them.

The issues could include "whether they want to be put on a respirator; the types of antibiotics to use; whether they want to go to a nursing home," Blair says.

Davie County staff takes the living will and durable power of attorney forms to patients’ homes and leaves them there. If a patient chooses to fill out a form, then the staff notifies the physician and advises the patient to place the form in a place where it would be easy for the family to find it, Blair says.

Blair, Wright, and other experts offer these tips to helping staff and patients understand advance directives:

Use simple terminology that all patients will understand.

Santa Barbara Visiting Nurse Association of Santa Barbara, CA, routinely checks patient satisfaction surveys to see how well patients have understood advance directives. What the agency found was this had been one of the lower scores, says Christina Burton, RN, BSN, MSN, CPHQ, performance improvement manager of the nonprofit agency that serves a 50-mile area of the mid-southern-California coast.

Burton says the agency’s nurses now give patients written information that was geared to a 7th or 8th grade reading level. This has improved the patients’ understanding of the concept.

"What we’ve done is have an editor review everything, and we made the print bold enough for people to read and understand," Burton adds.

Also, the Santa Barbara Visiting Nurse staff was taught to ask employees very clear questions to make sure they understand. For example, "Were you aware you have a right to make decisions about your health care or to have someone else make those decisions if you are not able to do so yourself?"

Explain how patients can change their minds anytime after they sign the living will or durable power of attorney forms.

Blair has found that this is a big concern among patients.

"If they sign it, does it mean it’s forever and ever? They want to be sure that if they change their minds they can change the status of their commitment," Blair says.

The answer to that concern is simply that all they have to do is change their minds and tell someone this, and both forms are null and void, Blair adds.

Discuss the employees’ obligation to honor the advance directives.

Wright says that agencies sometimes have an employee who feels that he or she cannot honor an advance directive because of religious or moral concerns.

Professional Care Nursing System has a policy that if clients have an advance directive, then it’s "absolutely necessary" that the staff honor it and support the client, Wright explains.

"But any staff member who cannot honor an advance directive must let the clinical staff know," she adds. The staff member could be given a different patient.

Tell patients that advance directives are very different from code status.

Patients sometimes confuse advance directives with code status, so nurses should try to explain how the two terms are different, experts suggest.

Professional Care Nursing System nurses give patients handouts that describe both advance directives and code status.

The code status handout explains that this is the agency’s policy on the termination or modification of life support systems, and it discusses the procedure. The advance directive handout describes how this form’s purpose is to help clients plan their own health care. (See Client advance directives and Client code status, inserted in this issue.)

Remind nurses to ask clients to put the advance directives in a place where the family can find them easily.

"One of the biggest concerns our staff has is that the client will sign these and put them someplace that nobody knows about, and we will have no way of finding it," Blair says.

"We know of situations where a client has had a living will, and the family couldn’t find it, so the hospital had to disallow the living will because they didn’t have it," Blair adds.

So it’s important for nurses to ask patients for a copy of the living will and durable power of attorney and to ask the patient to put these in a place where family members can find them, Blair and Burton say.

"The patients are aware that we can’t follow the advance directive unless we have it in writing," Burton says. "So if they have one and they don’t intend to give it to us, then they must understand that we can’t honor it."

Sometimes patients who are admitted into home care for the short term might not choose to give the agency a copy of their advance directives. "A lot of patients think that it’s too personal," Burton says.

Make sure a patient’s advance directive wishes are communicated to other staff on the team.

"One of the more difficult things is once we know what their wishes are, how do we communicate it to the team?" Burton says.

Santa Barbara Visiting Nurse Association answers this question by sharing the advance directive information on the patient’s record and on hand-held computers nurses use.