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2.2 Advance Directives and Self-Determination

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NCLEX-RN Registered Nurse

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1 Introduction

About the NCLEX-RN Exam Next Generation NCLEX (NGN) Clinical Judgment Measurement Model (NCJMM) How to Use This Course

2 Chapter 2: Management of Care

2.1 Legal Rights and Responsibilities 2.2 Advance Directives and Self-Determination 2.3 Informed Consent Protocols 2.4 Client Advocacy and Rights (HIPAA) 2.5 Assignment, Delegation, and Supervision 2.6 Five Rights of Delegation 2.7 Scope of Practice (RN vs LPN vs UAP) 2.8 Ethical Practice Principles

3 Chapter 3: Safety and Infection Prevention and Control

3.1 Standard Precautions and Hand Hygiene 3.2 Transmission-Based Precautions (Contact, Droplet, Airborne) 3.3 PPE Donning and Doffing Sequences 3.4 Fall Prevention and Restraints 3.5 Fire Safety (RACE/PASS) 3.6 Disaster Triage and Emergency Response

4 Chapter 4: Health Promotion and Maintenance

4.1 Growth and Development (Erikson/Piaget) 4.2 Developmental Stages: Infancy through Older Adult 4.3 Maternal and Newborn Care (Antepartum) 4.4 Intrapartum Care and Fetal Monitoring 4.5 Postpartum Care (BUBBLE-HE) 4.6 Health Screening Guidelines 4.7 Immunization Schedules

5 Chapter 5: Psychosocial Integrity

5.1 Therapeutic Communication Techniques 5.2 Non-Therapeutic Communication (What to Avoid) 5.3 Anxiety Disorders and Mental Health Concepts 5.4 Schizophrenia: Hallucinations and Delusions 5.5 Depression and Suicide Assessment 5.6 Substance Misuse and Withdrawal 5.7 Grief and End-of-Life Care

6 Chapter 6: Basic Care and Comfort

6.1 Mobility and Hazards of Immobility 6.2 Assistive Devices (Crutches, Canes, Walkers) 6.3 Nutrition and Diet Therapy 6.4 Enteral Nutrition (Tube Feeding) 6.5 Bowel Elimination and Ostomy Care 6.6 Urinary Elimination and Catheter Care

7 Chapter 7: Pharmacological and Parenteral Therapies

7.1 Medication Administration Rights 7.2 Medication Calculations 7.3 High-Alert Medications: Insulins 7.4 High-Alert Medications: Anticoagulants 7.5 High-Alert Medications: Opioids 7.6 High-Alert Medications: Digoxin and Electrolytes 7.7 IV Therapy and Complications 7.8 Blood Product Administration 7.9 Total Parenteral Nutrition (TPN)

8 Chapter 8: Reduction of Risk Potential

8.1 Laboratory Values: Hematology (CBC) 8.2 Laboratory Values: Metabolic Panel (BMP) 8.3 Laboratory Values: Coagulation Studies 8.4 Vital Signs and Trend Recognition 8.5 Perioperative Care (Pre-Op and Post-Op) 8.6 Nasogastric Tubes and Therapeutic Procedures

9 Chapter 9: Physiological Adaptation

9.1 Fluid Imbalances (Hypovolemia and Hypervolemia) 9.2 Arterial Blood Gases (ABGs) and Acid-Base Balance 9.3 Medical Emergencies: Stroke (CVA) 9.4 Medical Emergencies: Myocardial Infarction (MONA) 9.5 Diabetic Emergencies (Hypoglycemia and DKA) 9.6 Respiratory Conditions (COPD, Pneumonia) 9.7 Cardiac Conditions (Heart Failure) 9.8 Neurological Conditions (Seizures)

2.2 Advance Directives and Self-Determination

Key Takeaways Explain This Topic AI

The Patient Self-Determination Act (PSDA) requires healthcare facilities to ask patients about advance directives upon admission

A Living Will specifies which medical treatments a patient wants or does not want if they become incapacitated

Durable Power of Attorney for Healthcare designates a proxy decision-maker who can only act when the patient is deemed incompetent

Do Not Resuscitate (DNR) orders must be signed by a provider and reviewed periodically; they apply only to cardiopulmonary arrest

  • Advance directives can be changed or revoked by a competent patient at any time
  • Last updated: October 2026

The Patient Self-Determination Act (PSDA) of 1990 requires all healthcare facilities receiving Medicare/Medicaid funding to inform patients of their right to make advance directives. The RN plays a crucial role in ensuring these documents are current, correctly filed, and communicated to the interdisciplinary team.

Types of Advance Directives

  • Type Purpose Key Features
  • Living Will Specifies treatment preferences Written instructions about life-sustaining treatment

Durable Power of Attorney for Healthcare Designates a decision-maker Proxy authority activated only when patient is incapacitated

  • Do Not Resuscitate (DNR) Addresses CPR if breathing or the heartbeat stops Provider order; applies only to CPR
  • POLST/MOLST Provider orders for life-sustaining treatment Medical orders; portable across settings
  • Living Will (Instructional Directive)

A Living Will contains specific instructions about what medical treatments the patient chooses to accept or refuse if they become unable to make decisions.

Common provisions include:

  • Mechanical ventilation preferences
  • Artificial nutrition and hydration
  • Dialysis
  • Antibiotics for life-threatening infections
  • Comfort measures/palliative care

Important: A Living Will only takes effect when:

  • The patient cannot make decisions (lacks capacity)
  • The patient has a terminal condition or is permanently unconscious (varies by state)
  • Durable Power of Attorney for Healthcare

A Durable Power of Attorney for Healthcare (DPAHC) designates a healthcare proxy (agent) to make medical decisions when the patient cannot.

  • Aspect Description
  • Activation Only when patient is deemed incompetent by a provider
  • Scope Can make all healthcare decisions not addressed in Living Will
  • Hierarchy Follows patient's expressed wishes first, then proxy decides
  • Revocation Patient can revoke at any time while competent

Key Point: The proxy's authority is only activated when the patient lacks decision-making capacity. While the patient is competent, they make their own decisions.

Do Not Resuscitate (DNR) Orders

A DNR order is a provider order that directs staff not to perform CPR if the patient experiences cardiac or respiratory arrest.

Critical Points:

  • Must be a written provider order (not just patient request)
  • Applies only to cardiopulmonary arrest (not other treatments)
  • Should be reviewed periodically and when condition changes
  • Patient can revoke at any time
  • DNR does NOT mean "do not treat"
  • The Nurse's Role
  • Responsibility Action
  • Assessment Ask about advance directives on admission (PSDA requirement)
  • Education Provide information about types and purposes of advance directives
  • Documentation Ensure directives are in the medical record
  • Communication Alert the healthcare team to advance directive status
  • Advocacy Ensure patient's wishes are followed
  • When Advance Directives Are Unclear or Absent
  • Situation Action
  • No advance directive Decisions made by next of kin following state hierarchy
  • Family disagrees with directive Follow the patient's documented wishes
  • Directive unclear about current situation Ethics committee consultation may be needed
  • Patient regains capacity Patient resumes decision-making authority
  • Typical Surrogate Decision-Maker Hierarchy

When no healthcare proxy is designated, most states follow this order:

  • Legal guardian
  • Spouse or domestic partner
  • Adult children
  • Parents
  • Adult siblings
  • Other relatives or close friends
  • Cultural Considerations

Some cultures prefer family-centered decision-making over individual autonomy. The nurse should:

  • Assess patient's preference for involvement in decisions
  • Respect cultural values while ensuring legal requirements are met
  • Involve interpreter services when needed
  • Document patient's stated preferences
  • On the NCLEX

Expect questions about:

  • The nurse's role in educating patients about advance directives
  • When healthcare proxy authority is activated
  • Appropriate actions when family disagrees with documented wishes
  • Difference between DNR and comfort measures

Exam Tip: Remember that a DNR addresses only CPR when breathing or the heartbeat stops. A patient with a DNR can still receive all other treatments including surgery, antibiotics, and blood transfusions.