How much do your nursing assistants know about advance directives? Are they aware of the difference between a living will, a health care power of attorney and a DNR order? Do they know that all clients must be asked about advance directives...and must be given the opportunity to create one? To make sure that your CNAs understand the basics, consider giving them the following important information:
What Is an Advance Directive?
As a health care worker, you've probably heard the term "advance directive". But, what is an advance directive anyway? It is a document that outlines people's preferences for medical care when, in the future, they are unable to communicate their wishes. It is particularly useful when someone is terminally ill, critically ill or has advanced Alzheimer's disease.
Advance directives are not just for people who are sick or old. Advance directives are something that all people should consider having. Keep in mind that having an advance directive is not a sign that someone has given up on life since it takes effect only when people can no longer communicate their own wishes.
REMEMBER: Advance directives give people a voice in their own medical decisions even after they have lost the ability to speak for themselves.
What Is a Living Will?
A living will contains written instructions detailing a person's wishes for end-of-life care to family members and to doctors. These wishes might include preferences about:
- CPR
- Tubes to provide nutrition and/or hydration
- Kidney dialysis
- Ventilators
- Blood transfusions
- Invasive procedures
- Pain medication
- Surgery
- Organ transplantation
- Chemotherapy
- Antibiotics
- Dying at home or at a medical facility
A living will becomes effective when it is determined that a person can no longer make his or her own decisions. As long as the requests in the living will are legal (and don't go against reasonable medical standards), doctors will usually honor them.
Living wills must be signed and dated. They must also be signed by two witnesses. Health care workers should never be witnesses to a living will! If a client asks you to be a witness, explain that it's against your workplace policy.
What Is a Health Care Power of Attorney?
The second kind of advance directive has a few different names, depending on your state. For example, you may hear it called a health care power of attorney (HCPOA, for short) or a health care proxy or a health care agent.
A HCPOA is a legal document that names a particular person to be in charge of future medical decisions. Many people choose their spouse or an adult child to serve as their health care power of attorney. Other people choose a close family friend or even a lawyer.
It is against the law for physicians or other health care employees to act as HCPOA for their patients. For example, Mr. Stone lives in a skilled nursing facility. He has a favorite nurse, Marsha, with whom he has discussed his end-of-life wishes. He says he trusts her the most and wants her to be his health care power of attorney. Marsha knows this is against the rules so she asks the social worker to discuss the matter with Mr. Stone. The social worker helps Mr. Stone choose an appropriate person to be his HCPOA.
The idea is that the person named in a HCPOA will make the same decisions that the patient would have made if he or she were able. It is very important for people to discuss their end-of-life wishes with whomever they choose as their HCPOA. Good communication helps ensure that those wishes will be honored when the time comes.
Remember that clients who have completed a HCPOA form have not given up the right to make their own medical decisions. A HCPOA takes charge only if and when clients are unable to communicate their own wishes.
What Is a DNR Order?
Advance directives give important directions for medical care, but to be official, a person's wishes need to be put into medical orders. An important medical order that many people want when they are very old and/or terminally ill is a Do Not Resuscitate order.
A Do Not Resuscitate order tells medical professionals to suspend action even if someone's heart and breathing stops. This means that doctors, nurses and emergency medical personnel will not use emergency CPR to try to revive someone.
DNR orders are designed to help people who are in the final stages of a terminal illness, who suffer from a chronic serious condition, or who are old and ready to die. Often, the process of establishing a DNR order helps people begin to come to terms with death-whether it is their own or the death of a loved one.
DNR orders must be signed and dated by a physician. They may be written for people in hospitals, nursing homes, assisted living facilities-and, in most states, for people living in their own homes.
Generally, paramedics working in the community have a duty to perform CPR when a person's heart or breathing stops. For people still living at home, many states have a special DNR order-called a "Prehospital DNR", an "Out-of Hospital DNR" or a "Portable DNR". If you are a home health aide, you may see one of these forms. It is usually written on brightly colored paper and should be posted in an obvious place so that the paramedics know not to resuscitate the person.
Some states have portable DNR bracelets that alert paramedics that a DNR order has been written by the person's physician.
A Final Word about Advance Directives
As medical technology has become more advanced over the years, doctors have been able to keep people alive longer and longer. Many people have wanted to say "enough is enough"! This is where advanced directives come in. Living wills and health care powers of attorney give people control over what happens to them.
There are both federal and state laws about advance directives. The federal law, the Patient Self-Determination Act (PSDA), took effect in December of 1991. It requires that patients/clients/residents must:
- Be asked if they have advance directives on admission to a health care organization.
- Be informed of their rights to refuse treatment and to prepare advance directives.
- Have documentation of their advance directive status in their charts.
- Have their advance directives honored.
In addition, all health care organizations (that accept Medicare and/or Medicaid funding) must have a policy on advance directives. This policy must be available in writing to all people who are admitted to the facility/agency. And, all staff members must be taught about advance directives.
The public needs to know that it is a federal requirement that healthcare workers ask about advance directives. By doing so, you support the rights of every client to be involved in decisions regarding their medical care-whether it concerns a simple procedure or the end of life.
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