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Advance Directives - What Role Should a Nurse P

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Question & Answer

Advance Directives--

What Role Should a Nurse Play?

Q&A icon Q: Recently I admitted an alert 80-year-old man for
heart surgery. During the admission process he
confided that he has no written advance directive because his family becomes upset when he begins to talk about his wishes. He told me, "If anything happens to me during surgery and I go into a coma, I don't want to be kept alive if there is no hope of recovery." As a nurse, what are my ethical responsibilities in this situation?

A: Your ethical responsibilities regarding the nurse caring
for this man are very clear, but the task of getting the patient and his family to talk may not be as easy. Today, most hospitals require all patients to either fill out an advance directive during admission or acknowledge that they have already completed one. Check with your institution's policy. Since this patient has not completed one, you should take some time and complete an advance directive with your patient. The process of doing the paper work isn't complicated, although some individuals do seek legal advice in having these types of documents drawn up.

The real problem in this case seems to be one of fearful family members and a big communication gap. Talking about the possibility of dying with one's family can evoke painful and sad emotions, which is a very normal reaction. It might be helpful to encourage your patient to talk with his family again and this time allow his family to verbalize their feelings. Quite possibly this man might be having difficulty tolerating the emotions his family needs to express. It might be helpful if you as the nurse offer to be present to assist in keeping communication open and honest.

Additionally, the family may need some support. Talking about death and dying is never an easy task, yet addressing potential problems before they arise will save the patient and the family a great deal of emotional pain. As a nurse, your job is to educate and advocate. In this case, you need to advocate for the patient. If you need to educate the family, do so. This patient's family may be unfamiliar with what an advance directive entails or actually means. Remember, the advance directive is the instrument that allows the patient's wishes to be known, if and when the patient can no longer communicate for himself. Remind the family that by allowing the patient to make these decisions now, when he is able, will in turn allow family members to simply follow his wishes.

Without an advance directive, families are often forced to choose if life support should be discontinued or nutrition and hydration should be stopped. With no advance directive, the family may be forced to guess what their family member would have wanted and then be faced with guilt over questioning if they made the "right decision." As long as the patient is competent to make such decisions, allow him to fill out his advance directive paper work and then provide the needed care to educate and support his family in acknowledging and hopefully supporting his decision.

--Richard A. Pessagno

A: Any health care professional who receives a patient
confidence about end-of-life treatment preferences has a serious moral obligation to find an effective means to advocate for the patient's wishes. Were this patient to suffer life-threatening complications, literally how he dies and his family's memories of his dying and death may be dramatically influenced by the advocacy competencies of the care giver entrusted with this confidence and by her willingness to get involved. Both are critical. The health care professional's relationship to the patient, the scope of her practice and related responsibilities, institutional policies and federal and state legislation may all influence the advocacy options available to the health care professional.

In this situation I would first explain to the patient that he can write an advance directive which expresses his wishes without involving his family members. The patient should understand the advantages of having his preferences on record, especially if he suspects that his family may not support these wishes. If this is the case he may also want to designate durable power of attorney for health care decisions to someone he trusts to respect his preferences. That said, it is also important that the family will ultimately feel peaceful about how decisions are made and it would be appropriate to offer the patient help in talking with his family. The nurse involved should be aware of in-house resources to help both health care professionals and patients/families deal with these issues.

--Carol R. Taylor


A: Given this situation, my ethical responsibility would
be to assist the patient in obtaining a proper advance directive. In most cases I would suggest that the patient make his wishes known to his family but in this particular situation it may not be practical, or possible. I would first make sure the patient has been given (by the physician) the needed information about the realistic outcomes and possible interventions of the procedure he is about to undergo (consent). If this has been done and the patient fully understands the implications of his advance directive, the patient should be encouraged without coercion to make his wishes known by way of a legal witnessed signed advance directive. If the patient's wishes are documented he can be assured that his decision will be honored.

The first provision of the code for nurses states that patients have the moral right to determine what will be done with their own accept, refuse, or terminate treatment without coercion. More frequently nurses are being held responsible for protecting their patient's well-being by using their professional judgment. Our sound professional judgment requires both clinical excellence and a strong belief that one of our first priorities is to ensure our patient's right to self-determination and also to ensure that the patient's best interests are carried out if self-determination is not possible.

In general, I have found that families and health care providers find it more difficult to withdraw treatment than to withhold it in the first place. I always encourage my patients to make their wishes known before the procedure if they don't already have advance directives so this does not become an issue for their family. In my experience I have also found that, due to the emotional nature of the situation, many times patients are heavily influenced by the needs and wishes of their family when it comes to advance directives. The patient should be reassured that the physicians and nurses are always willing and able to provide information to families regarding advance directives. They are available to speak to the family as a group in a "family conference" to give them focused attention, answer any questions and provide the support they will need. In the hospital where I work, if the patient does not have advance directives, they are given this information on admission. I have witnessed many families divide, become hostile with one another or become burdened with having to make the decision to keep a loved one alive or choosing to withdraw care. Having advance directives already clearly stating the patient's wishes allows the family to be there in support of the patient without being faced with a difficult decision in an already difficult time.

--Emily Rhee



Richard A. Pessagno, MSN, RN, CS, is a psychiatric clinical nurse specialist in private practice in Washington, DC.

Carol R. Taylor, PhD, RN, CSFN, is associate director at the Center for Clinical Bioethics, Georgetown University, Washington, DC.

Emily Rhee, BSN, RN, is a staff nurse at Suburban Hospital, Bethesda, MD.


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