How to integrate advance directives into client plan of care

Photo of author
Written By Naren S Jayas

Naren's expertise lies in the fields of Nursing, Medical, and competitive exam training. 

An advance directive is a legal document that enables an individual to plan and make decisions about their future medical care, especially in the event that they become incapacitated and unable to communicate their wishes. Advance directives are important because they allow individuals to express their preferences for medical treatment and end-of-life care. There are two primary types of advance directives: living wills and durable power of attorney for healthcare.
A living will is a written document that outlines an individual’s healthcare wishes, including their preferences for life-sustaining treatment, pain management, and end-of-life care. It becomes effective only if the individual is unable to communicate their wishes.
Durable power of attorney for healthcare, on the other hand, is a legal document that designates someone to make medical decisions on behalf of the individual if they become unable to do so. This person is known as the healthcare proxy.
By completing an advance directive, individuals can ensure that their wishes regarding their medical care are respected, even if they become unable to communicate those wishes themselves. It is important for nurses and other healthcare providers to understand the significance of advance directives and to assist individuals in creating advance directives that accurately reflect their wishes.

Why are advance directives important?

Advance directives are important because they enable individuals to plan and make decisions about their future medical care, particularly in the event that they become unable to make decisions for themselves. Here are some reasons why advance directives are important:
Empowerment: Advance directives empower individuals to express their healthcare wishes, values, and preferences, and to ensure that their wishes are respected even if they cannot communicate those wishes themselves.
Autonomy: Advance directives allow individuals to exercise their autonomy by making decisions about their own medical care. This can be particularly important for individuals with chronic illnesses or disabilities who may need to plan for future medical care.
Reduction of stress: Advance directives can reduce stress and uncertainty for individuals and their families by providing clear guidance about the individual’s healthcare wishes.
Reduced family conflict: Advance directives can help reduce family conflict by providing clear guidance about the individual’s healthcare wishes, which can help prevent disagreements and disputes among family members.
Improved end-of-life care: Advance directives can help ensure that individuals receive the medical care they want at the end of their life, and can help prevent unwanted interventions or unnecessary suffering.

How to integrate advance directives into client plan of care?

As a nurse, it is crucial to incorporate advance directives into a client’s plan of care. Advance directives are legal documents that allow individuals to make decisions about their healthcare in advance, in case they become unable to make decisions for themselves in the future. There are two primary types of advance directives: living wills and durable power of attorney for healthcare.
Integrating advance directives into a client’s plan of care should be done early in the care process. Here are some steps to follow:

Step 1: Assess the Client’s Understanding of Advance Directives

Before integrating advance directives into the client’s plan of care, assess the client’s understanding of advance directives. Ask open-ended questions such as:

  • Have you heard of advance directives before?
  • Do you know what they are?
  • Have you ever thought about what kind of medical treatment you would want if you were unable to communicate your wishes?

It is essential to assess the client’s understanding before proceeding to the next steps.

Step 2: Provide Education on Advance Directives

If the client is not familiar with advance directives, provide education on what they are and their importance. Explain the different types of advance directives and how they work.

Step 3: Document the Client’s Wishes

Once the client understands advance directives, document their wishes in their medical record. This can be done by having the client complete a living will and/or durable power of attorney for healthcare form. Provide the client with a copy of their completed forms.

Step 4: Communicate the Client’s Wishes to the Healthcare Team

It is vital to communicate the client’s wishes to the healthcare team. Include the advance directive forms in the client’s medical record and discuss the client’s wishes with other members of the healthcare team. Ensure that all members of the healthcare team are aware of the client’s wishes.

Step 5: Revisit the Client’s Wishes Regularly

Advance directives should be revisited regularly to ensure that the client’s wishes are still the same. Update advance directives if the client’s wishes change.

Conclusion

In conclusion, incorporating advance directives into a client’s plan of care is crucial for providing patient-centered care. As a nurse, it is your responsibility to ensure that your clients understand what advance directives are and to help them document their wishes. By following the steps outlined in this blog post, you can help ensure that your clients’ wishes regarding their healthcare are respected.