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Advance Directive Paper

In Partial fulfillment of the requirements for Nrsg 309-

Monday, March 2, 2009

Submitted by

Jacqueline Horn

Mailbox #535
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When patients facing chronic or terminal illnesses reach a state in which they cannot

longer voice their end-of-life care decisions, it is common for relatives to end up having to face

the difficult duty of making decisions concerning the quality of life or possible death the patient

will experience. A legal form of representation for incapacitated patients has been created to

avoid this kind of situations and to ensure that patients’ decisions are explicitly followed. This

legal document by which incapacitated patients are allowed to dictate the direction of their care is

known as an advance directive. The main purpose of advance directives is to prevent patients’

decisions from being erroneously taken by people who do not know their expectations for end-of-

life care. They “express the desires of competent adults regarding terminal care, life-sustaining

measures, and other issues pertaining to their dying and death” (Eliopoulus, 2005, p111). In most

cases it provides patients with reassurance that their end-of-life wishes are taken into

consideration. This paper will explore the significance of the different types of advance directives

by analyzing an interview made to an older adult.

There are three different types of advance directives: living wills, medical directives and

Durable Power of Attorney for Health Care (DPAHC). Living wills can be described as

documents that “become effective when an individual is terminally ill and usually express the

individual’s desire to die without the institution of prolonging medical interventions” (Perrin,

1997, p20). Living wills give patients the option to refuse medical care if they become unable to

express their wishes (Inman, 2002). One advantage living wills provide is the option of refusing

treatment (Perrin, 1997). The disadvantages of this type of advance directive are that living wills

do not stipulate which treatment to follow, and it does not specify which circumstances should

make it appliable (Perrin, 1997).

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A different type of advance directive is a medical directive. Emanuel & Emanuel

described (as cited in Inman, 2005) medical directives ask patients questions regarding the

medical care desired in specific situations to avoid the vagueness of living wills. The advantages

patients obtain from medical directives are that they can be specific about which treatments they

decide to receive; medical directives reassure patients that they will receive whatever treatment is

appropriate depending on which circumstances they are facing (Perrin, 1997, p21). Although

medical directives give the patient an opportunity of choosing which treatments to opt for, they

bring various disadvantages that may make patients doubt about its benefits. Pellegrino

mentioned (as cited in Perrin, 1997), medical directives may not be appropriate for patients that

worry about changing their minds if new treatments become available. Since circumstances may

differ from the ones specifically described in the medical directive, it can be difficult to decide how

rigorously the directive should be followed (Perrin, 1997, p22).

A durable power of attorney is another kind of advance directive. As Perrin (1997) stated,

a durable power of attorney allows patients to appoint a designated individual to make decisions

for them if they become unable of voicing their desires for end-of-life care. The main advantage

of designating a surrogate decision-maker is that it gives patients the freedom of choosing an

agent who they trust can make decisions for them under different circumstances (Perrin, 1997).

According to Famble, McDonald, and Lichstein (as cited in Inman, 2002), although most elderly

people prefer to name a member of their family as the surrogate decision-maker, this can bring

serious disadvantages to the patient. Designating someone to act as a decision-maker without

discussing possible therapeutic options may result in the decision-maker opting for treatments that

the patient would not have approved. It is important to consider that in some instances decision-
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makers may be influenced by financial, emotional, or ethical conflicts (Perrin, 1997).

For this paper, I interviewed Scott Cashew, an 82 years old white man who has a durable

power of attorney. He said he decided to get an advance directive after being hospitalized as a

result of a stroke. He mentioned he was influenced by his daughter in making this decision. He

stated “my daughter is the most important person in my life, I don’t want to cause her much

trouble, so I told her I would trust her judgement if anything happens to me.” Scott mentioned he

told his daughter he did not want to be kept alive if there were no possibilities on him regaining

his independence. He openly made his point clear by stating, “why would I want to be kept alive

and dead at the same time? If I can’t live my life the way I’ve always lived it, then I don’t wanna

live.” He expressed his disagreement with prolonging someone’s life by means of life support. As

a Christian, he strongly felt it is not up to men to decide whether someone must remain alive or

not.

Scott completed his durable power of attorney directive while at Kaiser. One of the

nurses approached him with brochures for him to look at. He said he did not even look at them.

It was his daughter who asked the nurse for further details about the process of obtaining an

advanced directive. Scott also mentioned that his physician never took time to explain him he had

different options for end-of-life care decisions. Although he stated he would have preferred the

doctor approaching him to discuss this delicate matter, he was more than happy that the nurse

spend time explaining the process to him.

Scott’s decision on obtaining an advanced directive was strongly influenced by his desire

to not be kept alive if there was no hope for him to recover. His disagreement towards expanding

someone’s life coincides with Gamble, McDonald, and Lichstein research (as cited in Inman,
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2002, p42), as they explained that the majority of older adults that have advanced directives prefer

to limit the medical care they receive if they become terminally ill. Scott is part of this majority of

elders who believe quality of life should be placed before unnecessary life support in terminally ill

patients. He believes the utilization of mechanical devices to prolong the life of individuals in

chronic conditions is an inhumane way to feed hopeless illusions that only harm the patients’

quality of life and dignity.

One of the points that appeared to be surprising to Scott was the fact that his physician

never mentioned the possibility of him obtaining an advanced directive. According to Cotton (as

cited in Perrin, 1997, p 22), some physicians prefer not to discuss end-of-life care because of the

effects it could have on the patient (depression, stress, hopelessness). It is unfortunate that some

physicians do not even attempt to approach patients to discuss this matter. Scott mentioned he is

appreciative of nurses who take the time to explain to patients about their different options.

The influence of Scott’s daughter was essential for him to make the decision of obtaining

an advance directive. According to High (as cited in Perrin, 1997, p 23), elderly people tend to

choose family members to make end-of-life care decisions for them. Scott believes his daughter

would be his best option as a designated proxy because of the closeness he has with her. He said

he feels more comfortable knowing that a family member can make decisions for him. The

influence she had on him stemmed from the respect and love he has for her.

In this assignment, I learned that the role of nurses in providing education about advance

directives is essential to ensure our patients’ wishes regarding end-of-life care are heard. As

future nurses we have the important responsibility of advocating for the wellness of our patients.

Advanced directives are a delicate matter that need to be addressed to the patients. As nurses we
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have to ensure patients receive the best treatment possible which includes not only giving drugs or

taking vital signs but mainly providing them with education necessary to have their voices heard

regarding end-of-life care .

The impact I can have as a future nurse, regarding advanced directives, is that of

educating patients and physicians. Nurses have more power than they think on influencing the

improvement of patient care. Although some people still think nurses work strictly under

physicians’ supervision, it is our duty to break that chain of thought that has undermined nurses’

role over so many years. Physicians and nurses should work together towards optimizing

patients’ care. As nurses, we have the responsibility of educating patients regarding delicate

matters such as this one. The decisions concerning the quality of life or possible death a patient

will experience should be based on the end-of-life care decisions the patient makes on his advance

directive previous to the worsening of his or her condition.

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References

Eliopoulos, C. (2005). Gereontological nursing (6th ed.). Philadelphia: Lippincott-Raven

Publishers.

Inman, L. (2002). Advance Directives. Journal of Gerontological Nursing, 28(9): 40-46.

Perrin, K. (1997). Giving voice to the wishes of elders. Journal of Gerontological Nursing,

23(3): 18-27.