Discussions of death, dying and end of life care preferences are difficult for most people even nurses. As nurses we know that death is as much a part of life as living. Culture, personal experiences and perceptions gleaned from television and other media all impact our understanding and acceptance of death.

Patients and families may misconstrue an offer to discuss end of life care or living wills as meaning death is imminent.

Lets look at how professional nurses may assist patients to understand living wills and power of attorneys (POA). Assisting patients to understand the importance of making end of life care decisions before needed is urgent and helps remove some fear surrounding death. Discussions may open the door to in-depth family or physician dialogue.

All hospitals are required to ask patients if they have a living will and offer information and assistance in preparing one if they do not. Many hospitals meet this requirement by having the admitting clerk ask the patient and later during the admission process an RN will ask for more details.

Knowing what a living will is, what care decisions are included and how they can be implemented will allow the professional nurse to positively impact a patient's knowledge and ability to assert their right of autonomy.

The term advance directives is used to cover the five distinct forms which a patient can prepare to make their wishes known including:

- Durable Health Care Power of Attorney
- Durable Mental Health Care Power of Attorney
- Living Will (End of Life Care)
- Letter to My Agent (Representative)
- Pre-Hospital Medical Directives (Do Not Resuscitate) AND must be printed on
orange colored paper

In most states a person is able to implement any of the above items without an attorney. Most states provide easy to print forms and a life care planning packet through the Office of the Attorney General. As an example Arizona's Attorney General website provides the ability to download and print the life care plan packet or to have a packet mailed to you free of charge.

The Durable Health Care and Durable Mental Health Care Powers of Attorney allow a person to designate someone to be their representative if the patient becomes unable to express their wishes. Many patients choose family members but the choice must be carefully considered. Patients may consider choosing a family member such as a spouse or adult child, especially if the family member is in the health care field. Encourage patients to have an in-depth discussion with their primary care physician concerning choices in end of life care.

Various care options are discussed and the patient must choose which care options to agree to or reject.

Care Decision Topics include:

- CPR
- Intubation and Ventilator Use
- Antibiotic Use at End of Life
- Hydration at End of Life (including IV insertion for hydration purposes only)
- Feeding tube placement
- Under what circumstances care can and cannot be provided
- Organ Donation
- Autopsy Consent

Some living wills also include disposal of the body after death such as cremation or burial and funeral arrangements and wishes may be included.

In order for the living will and other advance directives to be considered legal and binding one of two things must be done: the patient has his/her signature notarized or two witnesses sign attesting to the mental competence of the patient. A person being designated as a POA, who may benefit from the death of the patient or is a direct care provider may not act as a witness.

Some final key items to consider include:

Encourage patients to put the original advance directives copy in a safe place and give copies to their primary care physician, any specialists seen routinely, area hospital, the POA and/or close family members such as spouse or adult children. Some also provide a copy to their spiritual leader.

It is recommended that patients carry a copy of the advance directives with them if they are traveling.

Placing a copy of the advance directives on the refrigerator is encouraged as first responders are taught to look in this location for special medical information.

This is a quick overview of important topics to discuss with your patients. Look at your state's Attorney General Website or speak to the patient representative or social worker at your work or local hospital for further information about advance directives.

Helping our patients know how to exercise their right of autonomy empowers the patient to be an active and informed participant in making health care decisions.

REFERENCES

- Arizona Office of the Attorney General:
https://www.azag.gov/life_care/LCP_Packet.pdf

- Advance Directive Forms from MedicAlert:
www.medicalert.org/

- The National Hospice and Palliative Care Organization will provide free
state-specific Advance Directive forms:
https://www.nhpco.org/i4a/forms/form.cfm?id=88