Advance Directives

Situation

L.H., an 84-yr-old man with end-stage COPD, is admitted to the

hospital in respiratory failure. He is intubated in the ED and placed

on a ventilator. L.H. sometimes responds by opening his eyes. His

advanced personal directive (AD) was drawn up 5 years ago, and

copies were given to his wife and HCP at that time. His wife brings

the documents to the critical care unit and tells you that the hospital

must stop treating her husband, and as per his request, allow him to

die. However, the patient’s oldest son is threatening the hospital with

a lawsuit if the staff does not provide full care to his father.

Ethical/Legal Points for Consideration

• A Living Will, one form of AD, permits persons to state their own

preferences and refusals should the person become terminally ill

or be in a situation in which there is no hope of recovery and the

person is not able to speak for themselves.

• The Durable Power of Attorney for Health Care, another form of

AD, permits persons to identify a proxy to make health care

decisions in the event the person is incapacitated.

• The National POLST Paradigm is an approach to end-of-life

planning that emphasizes documenting patients’ wishes about

the care they receive.

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• AD laws vary from state to state concerning the need for

witnesses and designating the proxy.

• Some families are deeply divided about decisions for their loved

ones, and conflicts often arise when feelings of remorse or guilt

and money and/or property are involved. This situation requires

you to notify the HCP, engage social work and spiritual care, and

ask for a family conference. In some circumstances, a consult

from the ethics committee may be needed.

• HCPs are obligated to follow the patient’s ADs when a patient is

no longer able to speak for himself or herself.

• In your scope of nursing practice, you need to (1) be informed

about the decision-making laws and regulations in your state, (2)

make AD documents available to patients, (3) teach patients and

families about ADs, (4) determine if all involved HCPs are aware

of the ADs, (5) assist the patient and family in communicating

with the HCP when a “no code” or “DNR” (do not resuscitate)

order is requested, and (6) assist the conflicted family in

obtaining appropriate counseling when needed.

Discussion Questions

1. What should you do next with the information provided by

L.H.’s wife?

2. The HCP has asked that you organize a family conference. How

should you address the needs of each member of this family in

L.H.’s plan of care?

3. What resources can you use to facilitate decision making in this

situation?

4. What would be your approach to L.H.’s plan of care?