Guest Column
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 you, as manager, to know what is pertinent to your state so you can help your staff implement these rules. It is also important for you to be able to cope with death so you can support your staff when a beloved client is at the end stage of life.
• Advance directives
Essentially, a competent individual can express his or her choice(s) for life-sustaining medical treatment before s/he becomes 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 (DNR) 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 (CPR), intubation, and artificial feedings.
• Durable power of attorney for health care
In this choice, the client designates someone to make health care decisions for him or her if s/he becomes incapacitated and is 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 do-not-resuscitate order
It is now possible for a client to have a DNR order in place while s/he is at home. This advance directive would usually apply specifically to emergency medical service (EMS) 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
As a manager, you must be familiar with the rules and regulations concerning end-of-life issues in your state. You must be familiar with your feelings toward these issues. You must be able to support your nurses and staff and be able to comfortably discuss your agency’s expectations and then allow the nurses time to become comfortable with their own death so they, in turn, can support the clients during the decision making process.
Over and above your feelings toward these end-of-life issues, however, is the client’s autonomy to choose what is best for him/her based on his/her culture, religious beliefs, and his/her own acceptance or avoidance of these topics. Empower your nurses and staff to be client advocates.
• The nurse’s role
The nurse usually is the agency’s representative who gives the client the written information about the advance directives designated in that state. 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, the nurse must face his/her own incapacitation and/or death. Take time now to assess your feelings. A shared emotion is fear of death. What are you afraid of as you ponder the fact you will die? Nothingness? Abandoning loved ones? Unfinished business? Losing control? As you come to grips with the answers, you will be better able to be empathetic in discussing death and advance directives with your client.
• Caregivers’ attitudes
In the home setting, you often encounter family members and friends who care for and about the client. With the client’s permission, include them in your teaching, too. In the event of an out-of-hospital DNR, family understanding and cooperation is vital. Be prepared to know how you will handle the situation if the client who has this in place ceases to breathe while you are in the home and the family member wants you to call EMS. What are you ethically bound to do? To whom or what is your responsibility now? If you have included the caregiver and other significant people, the client’s wishes can be honored with dignity and assurance.
• Conclusion
According to regulations, clients must be given information about advance directives. The agency manager and nurse must know and understand the advance directives required in his/her state in order to educate the client adequately. The manager should know his/her own feelings toward death in order to be sensitive to the needs and sensitivities of the nurses and staff who will be working closely with the client and caregivers. The nurse should also know his/her own feelings toward death in order to be aware of the needs and sensitivities of the client and caregivers. The nurse, operating from an ethical standpoint, is in an enhanced position to aid the client in this period of end-of-life transition.
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