A Patient Rights Module for Nurse Aides: Understanding ...

A Patient Rights Module for Nurse Aides:

Understanding & SupportingAdvance Directives

...Developing top-notch CNAs, one inservice at a time

A Patient Rights Module:Understanding & Supporting Advance Directives

WHAT IS AN ADVANCE DIRECTIVE?

Inside ThisInservice:

© 2016 In the Know, Inc.www.knowingmore.com

May be copied for use withineach physical location that

purchases this inservice fromIn the Know. All other copying

or distribution is strictlyprohibited.

Developing Top-Notch CNAs, One Inservice at a Time

Legal & Medical Terms 2

Advance Directive History 3

Types of AdvanceDirectives

4-5

Informed Consent 6

Legal Issues 7

Terminally Ill Clients 8

Do Not Resuscitate Orders 9

Supporting Your Clients 10-11

Q & A AboutAdvance Directives

12

As a health care worker, you’veprobably heard the term “advancedirective”. But, what is an advancedirective anyway? It is a document thatoutlines people’s preferences formedical care when, in the future, theyare unable to communicate theirwishes. It isparticularlyuseful whensomeone isterminally ill,critically ill orhas advancedAlzheimer’sdisease.

Consider this situation:

Mrs. Brown is 72 years old. Recently,she was hospitalized with pneumonia.During her stay in the hospital, shestopped breathing. She was put on aventilator to help her breathe and wasgiven antibiotics to fight thepneumonia.

Now, it’s three weeks later. Mrs. Brownhas been in the intensive care unit allthis time. She has developed bedsores and a bladder infection. She isconfused, and keeps trying to pull outher IV and feeding tubes. The nurseshave started tying up her hands tokeep her from removing the tubes.She still can’t breathe on her own, andthe doctors doubt if she ever will.

Unfortunately, Mrs. Brown never spoketo her family about her end-of-lifewishes. Her adult children are upset,watching their mother get worse andworse. They worry about her suffering,but don’t know what to do about it.

If Mrs. Brown had an advance directive,her family would know what theirmother wanted—and could takecomfort in doing the “right thing”.And, Mrs. Brown would still havecontrol over what is happening to herin the hospital.

However, advance directives are notjust for people who are sick or old.Advance directives are something thatall people should consider having.Keep in mind that having an advancedirective is not a sign that someone hasgiven up on life since it takes effectonly when people can no longercommunicate their own wishes.

REMEMBER: Advance directives givepeople a voice in their own medicaldecisions even after they have lost theability to speak for themselves.

Keep reading to learn moreabout the two main types ofadvance directives and howyou can support your clients’

end-of-life decisions.

Legal & Medical Words You Should Know

A Patient Rights Module: Understanding & Supporting Advance Directives © 2016 In the Know, Inc. Page 2

Your clients have the right to expect that you will supporttheir advance directives. (It’s the law!) Many people don’tlike talking about advance directives because they areconcerned with the end of someone’s life. If it’s hard foryou to talk about this subject, remember this: To providequality care to your clients, it’s important that you learn asmuch as possible about advance directives. You can startby becoming familiar with the following terms:

Advance Care Planning: The process of preparingfor one’s death. This usually involves completion ofadvance directives and an explanation sheet withspecific wishes for treatment and comfort care.

Advance Directive (or AD for short): A general termfor oral and written instructions about a person’sfuture medical care, primarily used when people areterminally ill and cannot speak for themselves.

Power of Attorney: A document that designatesanother person to make decisions for someone whocan no longer make his own decisions regardingbusiness or financial decisions.

Health Care Power of Attorney (HCPOA): Adocument that allows people to pick someone theytrust to make decisions about their medical care ifthey aren’t able to make the decisions themselves.

Health Care Proxy or Agent: Usually the same as aHCPOA. In some states this document is combinedwith a living will.

Living Will: A type of advance directive that usuallytells a doctor not to use “extra-ordinary” means tokeep someone alive if he or she is terminally ill.

CPR: This stands for cardiopulmonary resuscitation.It’s a technique for stimulating a stopped heart. It isusually unsuccessful, especially in elders or those whohave advanced chronic illness.

Do Not Resuscitate Order: An order on a client’smedical chart or on a special orderform to use at home or in a facilityadvising health professionals thatCPR should not be used to attemptto save the person’s life.

Assisted Suicide: This is when aperson commits suicide with thehelp of a doctor or other person.

Life-Sustaining Therapy: Medicaltreatments that prolong a person’s life. They may notcure people or bring them back to the way they were,but they keep people alive. Examples of life-sustaining therapies include breathing machines,feeding tubes, and intravenous fluids.

Heroic Therapy: An “old-fashioned” term that meansthe same thing as life-sustaining therapy.

Terminal Illness: An illness that will lead to death inspite of all medical treatments. Medical care mayslow the disease, but will not stop it.

Persistent Vegetative State: An irreversiblecondition in which a person can’t communicate withothers but is able to breathe on his/her own. Thiscondition happens when the brain is damaged by alack of oxygen. People in vegetative states can nolonger think, make decisions, or communicate.

Brain Death: This is similar to a vegetative stateexcept that the person needs machines to breathe.Without life-support equipment, the person woulddie.

Hospice: This is specialized care for people withterminal illnesses. Hospice care involves caring forthe sick person and his/her family, including helpfrom doctors, nurses, nursing assistants, socialworkers, therapists, chaplains, and volunteers.

Studies have shown that:

Only 30% of American adults discuss life-sustaining treatments with their doctors—and only 20% havesome form of advance directive.

Half of the people who do have written advance directives have only one copy of the document—and it islocked away in a safety deposit box at the bank.

© 2016 In the Know, Inc. Page 3A Patient Rights Module: Understanding & Supporting Advance Directives

Centuries ago, when people got sick, there were noantibiotics or modern medical treatments. Manypeople died at an early age, mostly from infections.Ministers and priests worked together to bringcomfort and support to dying people and theirfamilies. Death was accepted as the natural end oflife and people usually died at home surrounded byfamily members.

In the 1940’s and 50’s, medicaladvancements (includingantibiotics, CPR and ventilationmachines) changed everything.People started to live longer.Doctors and their patientsstarted fighting death instead ofaccepting it.

Sometimes, physicians did not tell patients thetruth about their illness. Rather than askingpatients what their wishes were, doctors did whatthey thought was best.

As the 20th century wore on, people started livingeven longer and, due to advanced age, developedchronic illnesses, like Alzheimer’s and heart disease.Sometimes people’s lives were extended throughbreathing machines even though they were notable to recover or lead normal lives.

In the 1980’s, patients started to sue for the right torefuse the treatments recommended by theirdoctors. Some doctors responded by saying thatthe patients weren’t in their “right minds” whenthey refused treatment. This led to argumentsabout when a person is competent to make his/herown decisions.

The History Behind Advance Directives The courts decided that adults must be proven to

be incompetent (unable to make their own medicaldecisions). Just like people are “innocent untilproven guilty”, people are able to make their owndecisions unless it is proven otherwise in a court oflaw.

However, people may be considered incapable ofmaking medical decisions because of illness orinjury. For example, if John is in a terrible caraccident and is unable to make health caredecisions, the law allows the family and/or medicalprofessionals to make decisions for him.

All of these legal cases helped create the firstadvance directives. In the 1960’s, advancedirectives consisted of simple letters to familymembers, friends, physicians or ministers in whichpeople described their wishes for medical end-of-life treatments. These letters became known as“living wills”. They weren’t meant to be legaldocuments, but to serve as guidelines forcaregivers. Still, the people who wrote theseletters assumed that their wishes would behonored.

There were problems. The letters weren’t veryspecific. For example, a letter might say that Mr.Jones wants “no extraordinary measures”. But,what did this really mean? Family, caregivers anddoctors found the letters confusing. As a result,each state began to pass laws about advancemedical directives, including the specific languageto be used in writing them. The goal was to get ridof the confusion.

In 1991, the U.S. Congresspassed a law that supportedthe use of advance directives.And, the U.S. Supreme Courtrecognizes that living wills,health care powers of attorneyand other advance directivesshould be followed andprotected by our Constitution.

In 1950, about half of all Americans who dieddid so at home. Today, partly because of

medical advancements, about 85% of Americansdie in some type of health care setting:

a hospital, a nursing home or a rehabilitationcenter. At least one of every ten deaths occurs

in an intensive care unit.


There are two main types of advance directives. Thefirst type is a living will. This document containswritten instructions in which people can describewhich life-sustaining treatments they want andwhich they don’t want—if a time should comewhen they are no longer able to make decisions.

Early living wills were simply letters people wrotelisting their wishes. Now, most states have aspecific form—or at least specific language—thatthey like people to use for a living will.

Keep in mind that living wills deal with medicalmatters as opposed to “regular” wills which concernbusiness and financial issues. All 50 states havesome form of living will.

Generally, a living will expresses someone’s wish notto be kept alive by artificial means—such as with aventilator—if he or she is terminally ill or in apersistent vegetative state.

However, it is helpful to have additional writteninformation attached to the living will that specifieswhat treatments are desired—and which are not.

With a living will, a person can communicatehis/her wishes for end-of-life care to familymembers and to doctors. These wishes mightinclude preferences about:

CPR

Tubes to provide nutrition and/or hydration

Kidney dialysis

Ventilators

Blood transfusions

Invasive procedures

Pain medication

Surgery

Organtransplantation

Chemotherapy

Antibiotics

Dying at home or at a medical facility

Living Wills All people have their

own beliefs about theend of life. Somecultures may not supportthe idea of a living will.However, leadingrepresentatives of manymajor religions have spoken out in favor of aperson’s right to die a natural and dignified death.

A living will becomes effective when it isdetermined that a person can no longer make hisor her own decisions. As long as the requests inthe living will are legal (and don’t go againstreasonable medical standards), doctors will usuallyhonor them.

However, this issue is never completely clear. Forexample, if a doctor has to choose between a livingwill that the patient never talked to him about anda recent discussion he had with the patient aboutend-of-life care, he will usually go with the recentdiscussion—even if it goes against the instructionsin the patient’s living will.

Living wills must be signed anddated. They must also be signed bytwo witnesses. Health care workersshould never be witnesses to aliving will! If a client asks you to be awitness, explain that it’s againstyour workplace policy.

A person must be at least 18 years old to sign aliving will. Children younger than 18 have theirmedical decisions made by their parents or legalguardians.

NOTE: People can also just tell someone abouttheir end-of-life wishes or they can write out theirwishes in a personal document. However, this is

much less common than using formal “living will”documents.

©2016 In the Know, Inc. Page 5A Patient Rights Module: Understanding & Supporting Advance Directives

The second kind of advance directive has a fewdifferent names, depending on your state. Forexample, you may hear it called a health carepower of attorney or a health care proxy or ahealth care agent. (Throughout this inservice,we’ll use the name “health care power ofattorney—or HCPOA, forshort.)

A HCPOA is a legal documentthat names a particular personto be in charge of futuremedical decisions. Manypeople choose their spouse or an adult child toserve as their health care power of attorney. Otherpeople choose a close family friend or even alawyer.

It is against the law for physicians or other healthcare employees to act as HCPOA for their patients.For example, Mr. Stone lives in a skilled nursingfacility. He has a favorite nurse, Marsha, withwhom he has discussed his end-of-life wishes. Hesays he trusts her the most and wants her to be hishealth care power of attorney. Marsha knows thisis against the rules so she asks the social worker todiscuss the matter with Mr. Stone. The socialworker helps Mr. Stone choose an appropriateperson to be his HCPOA.

The idea is that the person named in a HCPOA willmake the same decisions that the patient wouldhave made if he or she were able.

It is very important for people to discuss theirend-of-life wishes with whomever they choose astheir HCPOA. Good communication helps ensurethat those wishes will be honored when the timecomes.

It is wise for people to have both a living will andsomeone appointed as a HCPOA to makedecisions. The living willprovides generalinstructions and theHCPOA document namesthe person who will carryout those instructions.

HCPOA, Health Care Proxy or Health Care Agent Let’s say that Mr. Smith wants to

establish a health care power ofattorney. Who should he choose? Itshould be someone who:

Is trustworthy, knows Mr. Smithwell and agrees to represent him.

Is willing to have a conversationabout what Mr. Smith wants and doesn’t wantwhen faced with critical medical decisions.

Will stand up for Mr. Smith when doctors maybe making strong suggestions that he wouldnot want.

It is common for people to select an alternateperson to serve as HCPOA—just in case their “firstchoice” is not available when decisions need to bemade. For example, Mrs. Walters named herdaughter as her HCPOA and her son as thealternate HCPOA.

The simplest way to complete advance directives isto obtain the forms and take them to a bank wherea notary is usually available. For people who are ina healthcare facility, the social worker or chaplainmay be able to help complete the appropriatedocuments.

Remember that clients who have completed aHCPOA form have not given up the right to maketheir own medical decisions. A HCPOA takescharge only if and when clients are unable tocommunicate their own wishes.

As medical technology has become moreadvanced over the years, doctors have been ableto keep people alive longer and longer. Manypeople have wanted to say “enough is enough”!This is where advanced directives come in. Livingwills and health care powers of attorney givepeople control over what happens to them.

In most states, advance directivedocuments must be signed anddated in the presence of a notary.


The idea behind informed consent is that peopleneed to be able to make medical treatmentdecisions for themselves. In order for this tohappen, they must be given all the necessaryinformation—including the benefits and the risksof choosing any treatment. If a person is not ableto make decisions, their next of kin or HCPOAmust be completely informed before making amedical decision.

Here is an example: Mr. Jones hasbeen admitted to the hospital for hipreplacement surgery. Before Mr.Jones signs an informed consentdocument, the doctor and nursemeet with him to tell him about:

His current medical condition.

What will happen if he decides not to havesurgery.

The procedure for hip replacement surgery.

All the risks and all the benefits of therecommended surgery.

Any alternatives to surgery that Mr. Jonesmight want to consider.

Informed Consent To give informed consent, Mr.

Jones must:

Be given enoughinformation.

Understand the information.

Be free to say yes orno...without anyone forcing him into a certaindecision.

Along with informed consent, came the right torefuse treatment. If a physician wants to use acertain treatment on a patient but the patient isinformed and does not agree with the doctor, thepatient has the right to say “no”.

For example, if, after hearing all the information,Mr. Jones decides not to have the hip replacementsurgery, he would not sign the informed consent.His doctor may ask him to sign an informed refusaldocument to prove that Mr. Jones made aneducated decision.

All these changes in patient rights have comeabout because people wanted to make their owndecisions instead of having physicians in charge.

The rule of informed consent is not followed as closely in emergency situations. Inan emergency room, for example, doctors can make life or death decisions for

patients based on their best medical judgment (unless they know a patient has aDo Not Resuscitate order).

Hospitalize” and “No Tube Feeding” orders.

This type of doctor’s order usually happens when aperson is critically or terminally ill. If a personcannot ask for these orders, the HCPOA or a familymember can. Check it out at http://www.ohsu.edu/polst/resources/educational-materials.htm, the Physician Orders for Life-Sustaining Treatment web site. Over one millionof these forms are in use.

Five Wishes is a new advance directive thatcombines wishes about medical treatment withwishes for comfort care. It is accepted as anofficial AD in 40 states. Check it out at:www.agingwithdignity.org/5wishes.html.

Medical orders are what makes one’s wishes turninto actions. It is possible for people to discusstheir wishes with their physicians so they can bewritten up as “doctor’s orders” for the health carestaff to follow. Examples include “DNR”, “Do Not

What’s New With Advance Directives?


Although most states have both kinds of advancedirectives (living wills and health care proxies), insome states, the two forms may be combined intojust one document. You can find your state’sadvance directive on http://www.caringinfo.org.

It is important to know the requirements forcompletion of the documents. In most states:

A person must be 18 years or older.

A lawyer is not required, but some statesrequire witnesses and/or notarization.

A witness must be a person who is not arelative, not on the health care team, and notsomeone who will benefit from the person’sestate or will.

If people travel back and forth, living part of theyear in one state and part in another, it is best tohave advance directives in both states. An advancedirective for one state may not be honoredanywhere else.

There are both federal and state laws aboutadvance directives. The federal law, the PatientSelf-Determination Act (PSDA), took effect inDecember of 1991. It requires that patients/clients/residents:

Must be asked if they have advance directiveson admission to a health care organization.

Must be informed of their rights to refusetreatment and to prepare advance directives.

Must have documentation of their advancedirective status in their charts.

Must have their advance directives honored.

In addition, all health care organizations (thataccept Medicare and/or Medicaid funding) must

Some Legal Issues Regarding Advance Directiveshave a policy on advance directives. This policymust be available in writing to all people who areadmitted to the facility/agency. And, all staffmembers must be taught about advancedirectives.

The public needs to knowthat asking about advancedirectives is a federalrequirement. It supports therights of every client to beinvolved in decisionsregarding their medical care—whether it concernsa simple procedure or the end of life.

In order for a person to legally complete anadvance directive, he or she must have “decision-making capacity”. In the past, someone withdecision-making capacity was said to be“competent”, but that term is no longer commonlyused when it comes to making medical decisions.

Decision-making capacity means that theperson:

Understands the situation.

Knows what the options and consequencesare.

Can make a decision with understanding.

Can communicate his/her decision.

People with early dementia or Alzheimer’s diseasemay still have decision-making capacity. They maybe forgetful, but they continue to know what theirvalues are and what they want tohappen to them.

The process of making medicaldecisions is often a joint effortbetween the physician, the patientand the family. Bypreparing advancedirectives ahead of time,people can guarantee thattheir ability to makedecisions won’t bequestioned.

Remember...a nurse aide cannot officially be awitness for the signing of an advance directive. Ifa client asks you to be a witness, explain that it’s

against your workplace policy.

Terminally Ill Clients


People who are terminally ill can die several ways:

When aggressive, life-sustainingtreatments fail. A minority ofterminally ill people decide theywant “everything” done in order tostay alive as long as possible. Theywant every treatment, includingbeing put on a ventilator. Theywant every infection treatedwith intravenous antibiotics andevery serious drop in bloodpressure treated with drugs toraise it temporarily. They wantCPR attempted if their heart orbreathing stops, though in mostcases, this proves to beunsuccessful. In the hospital, for every 100patients who receive a CPR attempt, 15 will survive.

In the nursing home, for every 100 patientswho receive a CPR attempt, 2-5 will survive.

For patients over 90, almost none will survive aCPR attempt.

Some of these individuals can survive for months,but eventually either their terminal illness, failureof their vital organs or an overwhelming infectionwill lead to death.

From a “natural death”. For most people, whenthere is no more treatment that will cure them andthey have no hope of returning to a healthy life,they want to die comfortably without prolongingthe dying stage or being a burden on others. Theyreceive no “extraordinary treatment” such as CPR,ventilators, and often, no feeding tubes. Instead,they are treated with “comfort measures” to maketheir death as easy as possible.

By assisted suicide. Some people who areapproaching the end of life do not want to wait fordeath to come. They want a physician to prescribeenough medicine to cause their death when theyare ready. Oregon is the only state that allowsdoctors to assist terminally ill persons to commitsuicide. In 1998, the Oregon Health Departmentreceived reports of 23 cases of assisted suicide.

Most were male and had cancer. All were white.When asked why they were choosing to end theirlives, most of the patients talked about beingafraid of losing control over their bodilyfunctions—and not about being afraid of severepain or of costing their families too much money.Some experts in end-of-life care feel that if thesepeople had received adequate comfort care, theywould have chosen to die a natural death.

By mercy killing. This is when a person actuallyhastens another’s death by actively killing them,whether by administering carbon monoxide from aclosed up car or shooting someone. Themotivation of people who do this is to end thesuffering of someone who has asked for their helpto end their lives. “Mercy killing” is not legal in thiscountry. Dr. Jack Kevorkian, nicknamed “DoctorDeath”, has helped over 100 people end their lives.Dr. Kevorkian has been arrested several times andwas found guilty of manslaughter for one of thesecases. He served time in prison.

What Do Our Laws Say?Across the United States,suicide is not against the law.However, attempted suicide isconsidered a crime in somestates (though no one hasbeen prosecuted for it for thelast thirty years). Assistedsuicide is against the law—except in Oregon. Yet, court cases continue tocome before judges in many states. For example,in 1997, the Florida Supreme Court rejected a claimthat choosing assisted suicide should be the rightof every individual. The Florida judges voted 5 to 1against the case.

This inservice focuses on caring for people inthe first two categories. When patients have

completed advance directives, it helps thehealth care team and family members carry out

their end-of-life instructions.


Advance directives give importantdirections for medical care, but tobe official, a person’s wishes need tobe put into medical orders. Animportant medical order that manypeople want when they are very oldand/or terminally ill is a Do NotResuscitate order.

A Do Not Resuscitate order tells medicalprofessionals not to take action even if someone’sheart and breathing stops. This means thatdoctors, nurses and emergency medical personnelwill not use emergency CPR to try to revivesomeone.

DNR orders are designed to help people who arein the final stages of a terminal illness, who sufferfrom a chronic serious condition, or who are oldand ready to die.

Often, the process of establishing a DNR orderhelps people begin to come to terms with death—whether it is their own or the death of a loved one.

Consider these examples:

Mr. Smith is in the hospital suffering fromsevere kidney disease. After discussions withhis doctor and his family, Mr. Smith has askedhis doctor to sign a DNR order. He knows thatif his heart and breathing stop, no one willattempt CPR or use a ventilator to keep himalive. In addition, he has asked that he not beput on kidney dialysis. Mr. Smith is ready todie.

Mrs. Turner lives in a skilled nursing home. Shehas severe Alzheimer’s disease. Eight yearsago, Mrs. Turner created a living will. Herliving will states that shedoes not want CPRperformed on her. Tohonor these wishes, andafter speaking with thefamily, her doctor haswritten a DNR order. Thismeans that if Mrs. Turner

Do Not Resuscitate Ordersstops breathing, the staff of the nursing homewill not attempt CPR and will not call 911 totransfer Mrs. Turner to a hospital. If Mrs.Turner had not had a living will, her HCPOA orfamily could have made the decision for her tobe a “DNR” because they believe this to bewhat she wanted.

Mr. Jones is 90 years old and in fairly goodhealth for his age. He says he has had a goodlife and if his heart or lungs should stopworking, he wants people to wish him wellwith thankfulness and allow death to comeundisturbed.

DNR orders must be signed and dated by aphysician. They may be written for people inhospitals, nursing homes, assisted livingfacilities—and, in most states, for people living intheir own homes.

Generally, paramedics working in the communityhave a duty to perform CPR when a person’s heartor breathing stops. For people still living at home,many states have a special DNRorder—called a “PrehospitalDNR”, an “Out-of Hospital DNR”or a “Portable DNR”. If you are ahome health aide, you may seeone of these forms. It is usuallywritten on brightly coloredpaper and should be postedin an obvious place so thatthe paramedics know not toresuscitate the person.

Some states have portableDNR bracelets that alertparamedics that a DNR order has been written bythe person’s physician.

NOTE: A person’s advance directive might includeinstructions about not wanting CPR or other formsof resuscitation. However, to be official, that wishmust be written as a physician’s order. This givesthe entire health care team specific instructionswhich they must follow.


There are times when clients may start talkingabout dying. It may be when they get very sicksuddenly or are gradually, but steadily, declining. Itmay be when a loved one or a friend dies. This isnormal so don’t let it scare you. If aclient starts to talkabout dying, the mostimportant thing youcan do is LISTEN.

Think of it as an honorthat they have chosenyou to hear theirthoughts and concerns. It is good for them toexpress their feelings without anyone judgingthem. Remember you do not have to fix anythingor tell them not to worry. Just LISTEN, look at them,and nod your head that you hear them.

Your Role in End of Life Conversations If your client seems worried, you may want to say

that you notice their feelings by saying, “You seemworried about this.” Pause and listen.

Other supportive responses may be:

“I hear you.”

“Tell me more about that.”

“This must be hard for you.”

You can ask, “Where do you find strength in hardtimes?”

Then, support them—whatever they say. They maytalk about their faith or relationships. Do not try toinfluence them with your beliefs. If someone says, “Iwould never want to die on machines like my neighbordid,” you could ask, “Have you ever talked with yourfamily or doctor about you wishes?”

Maintain confidentiality! Keep information aboutyour client’s advance directives to yourself. Onlyco-workers who are working directly with a clientneed to know if the client has a living will or a DNRorder.

Be sure to notify your supervisor immediately ifclients tell you they have changed their mindsabout their advance directives. They have the rightto cancel or change an advance directive at anytime.

End-of-life conversations sometimes move naturallyinto conversations about advance directives. Ifpeople start expressing theirdesire for a certain kind ofdeath or not wanting certaintreatments, this is an idealtime to say one of thefollowing:

“Do you have a living willor other advance directive?”

“You can write out your wishes in an advancedirective so that they will be followed. Would youlike me to help you learn more about this?”

If your clients have questions about advancedirectives, encourage them to talk to theirphysicians. Also, let your supervisor know aboutany end-of-life discussion you have with a client.

Your Role in Advance Directives

You may hear the word euthanasia and wonder exactly what it means. Some people think it meanshastening death while actually the dictionary says euthanasia literally means “an easy and painless

death.” This term means different things to different people, so it’s best to avoid it.

Find out from your supervisor before you workwith a client if he/she has advance directives or

a DNR order. Especially if you work in clients’homes, you need to know what their end-of-life

wishes are.

Your Role in Comfort Care


As part of the health care team, it is yourresponsibility to provide comfort whether your clientwants only to be kept comfortable at the end of lifeor wants to have “everything done” tostay alive.

Most importantly, yourrole is to observe yourclients and report thethings you notice to anurse or supervisor. Yourobservations can helpyour clients get what theyneed to be morecomfortable.

Pain control is an important part of keeping clientscomfortable. Watch for signs that a dying client maybe in pain. The first way to know is to ask: “Are you inpain?” or “Are you uncomfortable?” If the answer is“yes”, try to get an idea of how bad the pain is. Ask“Is your pain a great amount? A moderate amount? Ora little amount?” Report the answer to yoursupervisor.

Sometimes we ask clients to rate their pain on a scalefrom 1-5 or 1-10 with the highest number beingexcruciating and the lowest number being very mild.Report this promptly. You may be asked to recordthe client’s response on a pain sheet so the healthcare team can keep track of the client’s pain.

Another way to know if your clients are in pain is tonotice—and report—their actions:

Does their face look like they are grimacing orfrowning? Are they moaning, crying or wincingwhen moved? Are they lying very still or beingvery agitated when they are usually theopposite? Are they holding a body part?

If someone gives your clients pain medicine, watchto see what their response is and report it. They mayneed more medication.

If clients can still drink fluids or eat, offer whateversounds good to them. Check on the consistencythat is ordered; liquids may need to be thickened toprevent aspiration. Sit them straight up and offerthem small amounts at a time.

Sometimes clients cannot move by themselves.Helping them turn every two hours and positioningthem with pillows is important for their skin—andtheir comfort. Range of motion exercises may beordered for bedridden clients. Ask your supervisor ifthese exercises are appropriate for your client.

By keeping your clients clean, dry and gentlymassaged with lotion, if desired, you can bring themgreat comfort.

Provide a pleasant environment, surrounding yourclients with their favorite flowers, their favorite musicor pictures of loved ones.

For patients having life-sustaining care:

If you are ordered to take vital signs, be sureto report any abnormal signs. If a client stopsbreathing and/or has no pulse, be sure youknow what to do. Does the client have anadvance directive or a DNR order? Are youtrained in CPR? What is your workplacepolicy about performing CPR? Be sure youknow the answers to these questions beforeyou begin working with a client.

Never touch any buttons ordials on a ventilator/respiratory machine. But, ifthe machine soundsdifferent to you or its alarmsare beeping, tell yoursupervisor right away!

Remember that feeding tubes may gothrough the nose to the stomach or they maybe surgically inserted into the stomach orintestines. Some patients may also be fedthrough an IV needle. You may be ordered tochange or “pad” a dry dressing on a feedingtube. Be sure you are comfortable dealingwith the dressing and that you use standardprecautions. Always report a wet dressing.

Questions & Answers About Advance Directives


Q: Mr. Marks has an advance directive.Does this mean he wants to beallowed to die?

A: It’s true that many people use advancedirectives so that they won’t be keptalive when death is near. But, advancedirectives are also used to spell out all the medicaltreatments that a person does want. Just becauseMr. Marks has an advance directive doesn’t meanhe has decided to refuse life-saving treatment.

Q: Mrs. Brown has made her son her health carepower of attorney. Does this means that shehas no right to make any of her own decisions?

A: No. As long as Mrs. Brown is able to make her owndecisions, she can continue to do so. However, ifshe becomes too ill to decide for herself, her sonwill be responsible for making decisions thatsupport her wishes.

Q: Do people have to go to lawyers to make up anadvance directive?

A: No, lawyers are not necessary, but they can comein handy since they are familiar with both thefederal law and the state laws.

Q: Once a person signs an advance directive, is itpermanent?

A: Yes and no. An advance directive is permanentbecause it stays in effect year after year (thoughsome states recommend that people review andre-sign their advance directives every few years).However, a person can revoke—or cancel—his/heradvance directive at any time. This can be done bycrossing out and initialing parts of the documentor by completely destroying it. A person can alsosign and date a new document to take the place ofan older advance directive.

Q: Aren’t advance directives just for old people?

A: It’s natural to think of death and dying going withold age, but tragedy can happen to anyone. Forexample, a twenty-five year old could be in aserious car accident and, without an advancedirective, might be kept alive on life support. Ifyoung people have strong feelings about end-of-life issues, they should consider having an advancedirective.

Q: Isn’t it better for people to depend on theirfamily members than to worry about creatingadvance directive documents?

A: Family involvement is very important whenmedical decisions are being made. However, manypeople never talk to their loved ones about theirend-of-life wishes. For example, it might be aheavy burden to expect Cynthia to tell the doctorto “pull the plug” on her mother unless she knowsfor sure that’s what her mother would want. And,even if Cynthia feels okay with the decision, otherfamily members may not agree. Fights or hardfeelings could develop within the family. This justadds to the stress of the situation. It’s probablybetter to spell things out in an advance directive.

Q: What should I do if I’minterested in having anadvance directive for myself?

A: You can obtain blankdocuments for free fromwww.caringinfo.org. Follow the process your staterequires for completion—such as having a witnessand/or using a notary. Often, bank personnel canhelp you complete the forms officially. Be sure tomake copies and give one to anyone who wouldmake medical decisions for you.

Q: Where should people keep their completed advance directives?A: People should keep their advance directives in a readily accessible place wherefamily/friends can find them. They should make sure their family members, physicianand lawyer, if they have one, know where the documents are located. If they areadmitted to a health care facility, they should bring a copy with them.

Are you “In the Know” about advance directives? Circle the best choice,or fill in your answer. Then check your answers with your supervisor!

1. TRUE or FALSEAdvance directives help people have control over their health care decisions whenthey can no longer speak for themselves.

2. The two main types of advance directives are a ___________________ anda ______________________________________________________.

3. TRUE or FALSEThe Patient Self-Determination Act (PSDA) is a national law that requires that advancedirectives be discussed with every client who is admitted to your facility/agency.

4. TRUE or FALSEA person who serves as a Health Care Power of Attorney can make decisions aboutsomeone else’s finances.

5. TRUE or FALSEPeople with Alzheimer’s Disease can complete advance directives if they still have thedecision-making capacity to express their wishes for end-of-life care.

6. TRUE or FALSEIn addition to a living will, it is helpful to attach another document that explainsspecific wishes in more detail.

7. TRUE or FALSEA living will is not legal unless it was written by a lawyer.

8. TRUE or FALSEPeople who have advance directives will automatically have a “DNR” order if theyenter the hospital.

9. TRUE or FALSE“Comfort care” is the term for measures that help dying clients be more comfortableand without pain.

10. How can you best help your clients when they talk about end-of-lifedecisions?A. Give advice. B. Remind them that they might not live much longer.

C. Listen. D. Tell them about your own advance directive.

Inservice Credit:

Self Study1hour

Group Study1hour

File completed testin employee’spersonnel le.

EMPLOYEE NAME(Please print):

________________________

DATE: __________________

I understand theinformation presented inthis inservice.

I have completed thisinservice and answered atleast eight of the testquestions correctly.

EMPLOYEE SIGNATURE:

________________________

SUPERVISOR SIGNATURE:

________________________

A Patient Rights Module:Understanding & Supporting Advance Directives

Developing Top-Notch CNAs, One Inservice at a Time

A Patient Rights Module for Nurse Aides: Understanding ...

Documents

Transcript of A Patient Rights Module for Nurse Aides: Understanding ...