NCLEX-RN · Management of Care · 7 min read
Advance Directives, Ethics and Legal Duties
- Differentiate the roles, legal requirements, and clinical applications of advance directives, surrogate decision-makers, and resuscitation orders.
- Apply core ethical principles and professional boundaries to resolve ethical dilemmas, recognize moral distress, and ensure proper informed consent.
- Analyze mandatory reporting requirements, safe communication practices, and legal standards for nursing documentation.
Advance Directives and End-of-Life Planning
Advance directives allow individuals to state their healthcare preferences before a crisis occurs. These legal documents primarily include living wills and durable powers of attorney for healthcare. A living will details a client's specific wishes regarding life-sustaining treatments if they lose decision-making capacity and meet state-law criteria, such as facing a terminal illness or permanent unconsciousness. In contrast, a durable power of attorney for healthcare appoints a designated surrogate, also called a healthcare proxy, to make decisions when the client can no longer do so.
Under the Patient Self-Determination Act, Medicare- and Medicaid-participating healthcare facilities have clear legal obligations. They must ask all adult clients upon admission whether they have an advance directive and provide written materials explaining their right under state law to make healthcare choices and create these directives. The nurse must document whether an advance directive exists in the medical record. If asked to act as a witness for an advance directive document, the nurse must confirm whether this is allowed based on state law, the document's specific terms, and facility policy.
Clinical tools translate these preferences into active care plans. A Physician Orders for Life-Sustaining Treatment (POLST) form translates client preferences into actionable medical orders that transfer across different care settings. While these orders guide care, Do-Not-Resuscitate (DNR) instructions have strict rules: a DNR must be written as a formal medical order by an authorized prescriber following state law and facility policy. Unless a valid DNR or another applicable no-CPR medical order is in effect, healthcare workers must immediately start resuscitation according to protocol. Furthermore, care approaches differ at the end of life; palliative care focuses on symptom relief and quality of life alongside curative or disease-directed therapies, whereas hospice care is designated for terminally ill individuals with a certified medical prognosis of six months or less.
| Document or Approach | Primary Focus | Key Legal or Clinical Rule |
|---|---|---|
| Living Will | Specifies preferences for life-sustaining treatments | Guides care when the client lacks capacity and meets state-law conditions |
| Durable Power of Attorney for Healthcare | Appoints a surrogate decision-maker (healthcare proxy) | Authority to make decisions begins based on state law and the appointment document |
| POLST | Translates client values into medical orders | Produces actionable orders that transfer across care settings |
| DNR Order | Directs clinical staff to withhold resuscitation | Must be ordered by an authorized prescriber; without it, staff initiate resuscitation |
| Palliative Care | Relieves symptoms and enhances quality of life | Can be provided concurrently with curative or disease-directed treatment |
| Hospice Care | Care for terminally ill individuals | Requires a certified medical prognosis of six months or less |
Common mistakes
- Assuming an appointed healthcare proxy makes decisions while the client is still fully competent; a competent client always retains the right to decide and can revoke directives at any time.
- Attempting to re-explain surgical risks, alternatives, or procedural details to an uninformed client instead of notifying the provider who is legally responsible for obtaining informed consent.
- Mentioning that an incident or variance report was filed within the nursing notes of the client's legal medical record.
- Delaying a mandatory child or elder abuse report to investigate the situation and collect physical proof rather than reporting immediately based on reasonable suspicion.
Key points
- Advance directives may state healthcare preferences or appoint someone to make healthcare decisions during incapacity, including decisions unrelated to end-of-life care; a DNR requires an applicable medical order by an authorized prescriber.
- The Patient Self-Determination Act mandates asking adult clients about advance directives upon admission, providing written rights information, and documenting the response.
- A healthcare proxy uses substituted judgment (or best interests if wishes are unknown); a competent client's choices always supersede any proxy's opinion.
- Core ethical duties include autonomy, beneficence, nonmaleficence, justice, fidelity, and veracity; paternalism inappropriately overrides client autonomy.
- The clinician responsible for a procedure must ensure informed consent is obtained; who may conduct the consent discussion or obtain the signature depends on law and facility policy, while the nurse may witness the signature, assess for apparent understanding and voluntariness, and raise concerns with the responsible clinician.
- Mandated reporters require only reasonable suspicion to report child or vulnerable adult abuse, while reporting intimate partner violence for competent adults generally requires consent.
- Nursing records are legal documents requiring contemporaneous, objective charting; incident reports must never be referenced or placed inside the client's medical record.
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