1. SAFE AND EFFECTIVE CARE ENVIRONMENT Management of Care: Advance directives Advocacy Monica Saldivar & Lorelei Sepulveda 1

2. Types of Advance Directives  Living Will  A written legal document detailing a person’s desires regarding medical treatment when they are no longer able to make informed decisions for themselves.  Comes into effect when a person is in a vegetative state or has a terminal medical condition.  Healthcare Proxy/Durable Power of Attorney  A legal document naming someone the responsible party for making all healthcare decisions on behalf of the patient when the patient is unable to make his/her own informed decisions. 2

3. INTEGRATING ADVANCE DIRECTIVES INTO CARE  Always ask the patient whether he/she has an advance directive.  If there is an advance directive, go over the clauses with the patient  Verify patient wishes  Patient’s can make changes to existing advance directives.  Follow facility protocol to do so  Make sure there is a copy of the advance directive in the patient’s chart. 3

4. IF THERE IS NO ADVANCE DIRECTIVE…  Provide information regarding advance directives and how to arrange them.  Talk to patient about the importance of:  Life planning  Self-care  Advance directives are for everyone but they are especially important with the terminally ill patient.  Non-terminally ill patients often get scared or don’t want to talk about the subject.  Be clear in your approach  Make sure patients understand that it is a “what if” subject 4

5. NCLEX QUESTION The nurse notes that an advance directive is in the client’s medical record. Which of the following statements best represents the best description of guidelines a nurse would follow in this case?  A durable power of attorney for healthcare is invoked only when the client has a terminal condition or is in a persistent vegetative state.  A living will allows an appointed person to make health care decisions when the client is in an incapacitated state.  A living will is invoked only when the client has a terminal condition or is in a persistent vegetative state.  The client cannot make changes in the advance directive once the client is admitted into the hospital. 5

6. NCLEX QUESTION Answer:  A living will is invoked only when the client has a terminal condition or is in a persistent vegetative state. Rationale: A living will directs the client’s healthcare in the event of a terminal illness or condition. A durable power of attorney is invoked when the client is no longer able to make decisions of his or her own behalf. The client may change an advance directive at any time. 6

7. ADVOCACY: “PROTECTION AND SUPPORT OF ANOTHER’S RIGHTS” (TAYLOR, 2015). History  Internal values or beliefs influence the type of approach assumed by nurses before interacting with a client. The nursing-client interaction can produce a positive outcome where the patient is one step closer to achieve his/ her short term and long term goals; but also, it can result in a negative one jeopardizing his recovery.  As a result, nurses have the ethical responsibility to discern between good healthcare practices and contaminated ones.  In order to create continuity on the standards of care, the American Association of Colleges of Nursing categorized the professional values of nursing as:  Altruism – genuine and unselfish concern for the well-being of other people. Regardless if they are patients or other healthcare professionals. This includes: Showing respect towards the client’s personal values, preferences, and beliefs Protecting the patients’ rights, giving special attention to the vulnerable clients (children and elderly). This is a detailed definition of ADVOCACY 7

8. History cont., Taking necessary risks in order to defend the client’s safety Serving as a positive role model to other professionals helping them to respect the client’s rights  Autonomy- respecting the individual’s decisions in regards of future treatments or continuity of care.  Human dignity – demonstrating professional behavior at all times. Proven by: Being knowledgeable and respectful of multicultural differences Protecting the clients’ rights to confidentiality and discretion Attending to the individuals’ needs.  Integrity – adhering to the organizations' code of ethics and their accepted standards of practice  Social justice – promoting equality of treatment  Once the principles of ethics and a systems of values for the nursing profession were established, advocacy took a more formal role into the nursing common practice. 8

9. NCLEX QUESTION A nurse manager is reviewing the function of the “Code of Ethics for Nurses with Interpretive Statements” during a staff meeting. The nurse manager recognizes that this document is:  Legally binding  Mandatory for the practice of nursing  A description of requirements for licensure  A guide for professional actions 9

10. NCLEX QUESTION Answer:  A guide for professional actions Rationale: The American Nurses Association’s “Code of Ethics for Nurses with Interpretive Statements” is a guide for fulfilling nursing responsibilities in a way that reflects quality in nursing care and the ethical obligations of the nursing profession. 10

11. ADVOCACY IN NURSING PRACTICE  Nurses as advocators are responsible for:  Accommodate patients’ needs and expectations with the current changes of the healthcare system.  Maintain a balance between the allegiance with the employer and the commitment towards the client  Prioritized the individual’s wellbeing above any other demand of society  Evaluate the cognitive level of each client claiming self-determination to determine if additional teaching / education is needed, but respect the client’s decision  Whenever necessary, act as a liaison between the client and his / her family members using therapeutic communication to express the client’s wishes Assess verbal and nonverbal communication between client and family members Identify external factors (family dynamics, financial issues, separation issues) that might endanger the client’s recovery Nurses help identify resources if the patient or the family cannot make a final decision.  Join forces with multiple interdisciplinary teams (social workers, physical therapy, spiritual counselors, case managers, and the nursing chain of command) to ensure quality of care 11

12. NCLEX QUESTION A nurse is admitting a child who has autistic disorder to a medical unit with a diagnosis of gastroenteritis. Which of the following actions should the nurse take to assist the child in adjusting to the hospital environment?  Provide activities to stimulate the child’s interest in the environment.  Make frequent eye contact when talking to the child  Offer the child choices when scheduling planned care  Ensure that staff’s visits with the child are kept short. 12

13. NCLEX QUESTION Answer:  Ensure that staff’s visits with the child are kept short. Rationale: Ensuring that staff’s visits with the child are kept short whenever possible will assist him in adjusting to the hospital environment. Children diagnosed with autistic disorder have difficulty adjusting to new situations; therefore, routines should be maintained as similarly to that of the home, and people new to the child should slowly acquaint themselves with the child. 13

14. ADVOCACY IN NURSING PRACTICE Nurses can also advocate for patients when they take on other professional roles, such as:  Educators – nurses do not make the final decisions on the healthcare treatment. However, nurses should provide educated information to facilitate the client’s decision-making process.  Policy makers – nurses serve as active and influential voice in politics, representing the forgotten ones.  Case managers – nurses identify the client’s special needs (physical disabilities, mental illness, language barriers, and others), serving as a liaison within interdisciplinary groups.  Researchers – nurses suggest much needed changes to existing policies based on observable and measurable data.  Active member of the ethic committees – nurses identify ethical dilemmas and help to find moral and humane solutions. 14

15. NCLEX QUESTION A nurse suspects that a coworker might be in an impaired state when providing care to clients. Which of the following is the appropriate action by the nurse?  Ask other coworkers if they feel the same way  Speak directly with the impaired coworker  Report these observations to the nurse manager  Refuse to work with the impaired coworker 15

16. NCLEX QUESTION Answer:  Report these observations to the nurse manager Rationale: The nurse who observes an impaired coworker’s performance should report this behavior to the nurse manager. This is the only way to help ensure the coworker, if impaired, will obtain the appropriate intervention and support, and the clients will be protected from the outcomes of the coworker’s impairment. 16

17. NCLEX QUESTION A client recently diagnosed with end-stage breast cancer gives the nurse a handwritten living will and states, “I have been afraid to have a living will because I may change my minds.” The nurse’s response should be based on which of the following information?  A living will informs the provider of the client’s wishes in the event the client becomes incapacitated. The client has the right to change the living will at any time.  The client should be certain of the decision because the document establishes guidelines to not be resuscitated.  A living will is no longer an accepted document but advance directives are legally binding and would be an appropriate alternative.  The handwritten living will is not a legal document and cannot be included in the client’s medical record. The nurse should contact the hospital attorney for assistance. 17

18. NCLEX QUESTION Answer:  A living will informs the provider of the client’s wishes in the event the client becomes incapacitated. The client has the right to change the living will at any time. Rationale: A living will is one component of an advance directives. It is a legal document that expresses the client’s wishes regarding medical treatment in the event the client becomes incapacitate and is facing end-of-life issues. The client does have the right to change her mind at any time. A durable power of attorney for health care is the second component of advance directives. This is a legal document designating an authorized individual to make health care decisions for a client who is unable. 18

19. REFERENCES National Council of State Board of Nursing, Inc. (2016). NCLEX-RN detailed test plan: Candidate version. Chicago: Author. Taylor, C., Lillis, C., Lynn, P., and Lemone, P. (2015). Fundamentals of nursing: The art and science of person-centered nursing care. (8 th ed.). Pennsylvania, PA: Wolters Kluwer Health. 19