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## Complete Summary

#### GUIDELINE TITLE

Advance directives. In: Evidence-based geriatric nursing protocols for
best practice.

#### BIBLIOGRAPHIC SOURCE(S)

Mitty EL, Ramsey G. Advance directives. In: Capezuti E, Zwicker D, Mezey
M, Fulmer T, editor(s). Evidence-based geriatric nursing protocols for
best practice. 3rd ed. New York (NY): Springer Publishing Company; 2008.
p. 539-63. \[62 references\]

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: Ramsey G, Mitty E. Advance
directives: protecting patient\'s rights. In: Mezey M, Fulmer T, Abraham
I, Zwicker DA, editor(s). Geriatric nursing protocols for best practice.
2nd ed. New York (NY): Springer Publishing Company, Inc.; 2003. p.
265-91.

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

End-of-life condition(s)

#### GUIDELINE CATEGORY

Evaluation\
Management

#### CLINICAL SPECIALTY

Geriatrics\
Nursing

#### INTENDED USERS

Advanced Practice Nurses\
Allied Health Personnel\
Health Care Providers\
Hospitals\
Nurses\
Physician Assistants\
Physicians\
Utilization Management

#### GUIDELINE OBJECTIVE(S)

To provide a standard of practice protocol for assisting older adults to
make decisions and provide directions about the kind of medical care
they do or do not want if they become unable to make decisions or
communicate their wishes

#### TARGET POPULATION

-   Hospitalized older adults

-   Nursing home residents

-   General elderly population

#### INTERVENTIONS AND PRACTICES CONSIDERED

**Assessment**

1.  Determination if patient has a completed an advance directive

    -   Durable power of attorney

    -   Living will

2.  Advance care planning

3.  Decision-making capacity

4.  Ability to cope

**Management**

Assist patients and families with end-of-life care issues

-   Culture- and language-appropriate discussions with/education for
    patient and family/health care proxy about their treatment and care
    wishes

-   Advance directive forms

-   Decisions to not complete an advance directive

-   Instructional or medical directive

-   Oral advance directives

-   Conflict mediation

-   Referrals to social work, patient advocate, or hospital ethics
    committee

#### MAJOR OUTCOMES CONSIDERED

-   Number of advance directives completed at or received upon admission
    to hospital

-   Number of referrals to Ethics Committee

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Hand-searches of Published Literature (Primary Sources)\
Hand-searches of Published Literature (Secondary Sources)\
Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

Although the AGREE instrument (which is described in Chapter 1 of the
original guideline document) was created to critically appraise clinical
practice guidelines, the process and criteria can also be applied to the
development and evaluation of clinical practice protocols. Thus the
AGREE instrument has been expanded for that purpose to standardize the
creation and revision of the geriatric nursing practice guidelines.

**The Search for Evidence Process**

Locating the best evidence in the published research is dependent on
framing a focused, searchable clinical question. The PICO format---an
acronym for population, intervention (or occurrence or risk factor),
comparison (or control), and outcome---can frame an effective literature
search. The editors enlisted the assistance of the New York University
Health Sciences librarian to ensure a standardized and efficient
approach to collecting evidence on clinical topics. A literature search
was conducted to find the best available evidence for each clinical
question addressed. The results were rated for level of evidence and
sent to the respective chapter author(s) to provide possible
substantiation for the nursing practice protocol being developed.

In addition to rating each literature citation to its level of evidence,
each citation was given a general classification, coded as \"Risks,\"
\"Assessment,\" \"Prevention,\" \"Management,\"
\"Evaluation/Follow-up,\" or \"Comprehensive.\" The citations were
organized in a searchable database for later retrieval and output to
chapter authors. All authors had to review the evidence and decide on
its quality and relevance for inclusion in their chapter or protocol.
They had the option, of course, to reject or not use the evidence
provided as a result of the search or to dispute the applied level of
evidence.

**Developing a Search Strategy**

Development of a search strategy to capture best evidence begins with
database selection and translation of search terms into the controlled
vocabulary of the database, if possible. In descending order of
importance, the three major databases for finding the best primary
evidence for most clinical nursing questions are the Cochrane Database
of Systematic Reviews, Cumulative Index to Nursing and Allied Health
Literature (CINAHL), and Medline or PubMed. In addition, the PsycINFO
database was used to ensure capture of relevant evidence in the
psychology and behavioral sciences literature for many of the topics.
Synthesis sources such as UpToDate^®^ and British Medical Journal (BMJ)
Clinical Evidence and abstract journals such as *Evidence Based Nursing*
supplemented the initial searches. Searching of other specialty
databases may have to be warranted depending on the clinical question.

It bears noting that the database architecture can be exploited to limit
the search to articles tagged with the publication type
\"meta-analysis\" in Medline or \"systematic review\" in CINAHL.
Filtering by standard age groups such as \"65 and over\" is another
standard categorical limit for narrowing for relevance. A literature
search retrieves the initial citations that begin to provide evidence.
Appraisal of the initial literature retrieved may lead the searcher to
other cited articles, triggering new ideas for expanding or narrowing
the literature search with related descriptors or terms in the article
abstract.

#### NUMBER OF SOURCE DOCUMENTS

Not stated

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Weighting According to a Rating Scheme (Scheme Given)

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

**Levels of Evidence**

**Level I**: Systematic reviews (integrative/meta-analyses/clinical
practice guidelines based on systematic reviews)

**Level II**: Single experimental study (randomized controlled trials
\[RCTs\])

**Level III**: Quasi-experimental studies

**Level IV**: Non-experimental studies

**Level V**: Care report/program evaluation/narrative literature reviews

**Level VI**: Opinions of respected authorities/Consensus panels

Reprinted with permission from Springer Publishing Company: Capezuti,
E., Zwicker, D., Mezey, M. & Fulmer, T. (Eds). (2008) *Evidence Based
Geriatric Nursing Protocols for Best Practice*, (3^rd^ ed). New York:
Springer Publishing Company.

#### METHODS USED TO ANALYZE THE EVIDENCE

Systematic Review

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

Not stated

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

Not stated

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

Not applicable

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

External Peer Review\
Internal Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

Not stated

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

**Note from the National Guideline Clearinghouse (NGC)**: In this update
of the guideline, the process previously used to develop the geriatric
nursing protocols has been enhanced.

Levels of evidence (I -- VI) are defined at the end of the \"Major
Recommendations\" field.

**Guiding Principals**

-   All people have the right to decide what will be done with their
    bodies.

-   All individuals are presumed to have decision-making capacity until
    deemed otherwise.

-   All patients who can participate in a conversation, either verbally
    or through alternate means of communication, should be approached to
    discuss and record their treatment preferences and wishes.

-   Health care professionals can improve the end-of-life care for
    elderly patients by encouraging the use of advance directives (ADs).

**Advance Directives**

-   Allow individuals to provide directions about the kind of medical
    care they do or do not want if they become unable to make decisions
    or communicate their wishes (Rodriquez & Young, 2006 **\[Level
    V\]**).

-   Provide guidance for health care professionals, families, and
    substitute decision makers about health care decision making that
    reflects the person\'s wishes.

-   Provide immunity for health care professionals, families, and
    appointed proxies from civil and criminal liability when health care
    professionals follow the AD in good faith.

***[Two Types of Advance Directives]{.underline}*: Durable Power of
Attorney for Health Care (DPAHC) (also called a Health Care Proxy) and
Living Will (LW)**

-   A *Durable Power of Attorney* allows individuals to appoint someone,
    called a health care proxy, agent, or surrogate, to make health care
    decisions for them should they lose the ability to make decisions or
    communicate their wishes.

-   A *Living Will* provides specific instructions to health care
    providers about particular kinds of health care treatment an
    individual would or would not want to prolong life. Living wills are
    often used to declare a wish to refuse, limit, or withhold
    life-sustaining treatment.

-   Instructional or Medical Directive: Intended to compensate for the
    weaknesses of LWs, this kind of directive identifies specific
    interventions that are acceptable to a patient in specific clinical
    situations.

-   Oral Advance Directives (verbal directives) are allowed in some
    states if there is clear and convincing evidence of the patient\'s
    wishes. Clear and convincing evidence can include evidence that the
    patient made the statement consistently and seriously over time,
    specifically addressed the actual condition of the patient, and was
    consistent with the values seen in other areas of the patient\'s
    life. Legal rules surrounding oral ADs vary by state.

**Assessment Parameters**

-   All adult patients regardless of age (with the exception of patients
    with persistent vegetative state, severe dementia, or coma) should
    be asked if they have a LW or if they have designated a proxy.

-   All patients, regardless of age, gender, religion, socioeconomic
    status, diagnosis, or prognosis, should be approached to discuss ADs
    and advance care planning.

-   Discussions about ADs should be conducted in the patient\'s
    preferred language to enable information transfer and questions and
    answers.

-   Patients who have been determined to lack capacity to make other
    decisions may still have the capacity to designate a proxy or make
    some health care decisions. Decision-making capacity should be
    determined for each individual based on whether the patient has the
    ability to make the specific decision in question (Mezey et al.,
    2002 **\[Level IV\]**).

-   If a LW has been completed or proxy has been designated:

    -   The document should be readily available on the patient\'s
        current chart.

    -   The attending physician should know that the directive exists
        and has a copy.

    -   The designated health care proxy should have a copy of the
        document.

    -   The AD should be reviewed periodically by the patient, attending
        physician/nurse, and the proxy to determine if it reflects the
        patient\'s current wishes and preferences.

**Care Strategies**

-   Nurses should assist patients and families trying to deal with
    end-of-life care issues (Schwartz, et al., 2002 **\[Level II\]**;
    Engel, Kiely, & Mitchell, 2006 **\[Level II\]**).

-   Patients may be willing to discuss their health situation and
    mortality with a nurse or clergyman rather than with a family member
    and should be supported in doing so.

-   Patients should be assisted in talking with their family/proxy about
    their treatment and care wishes.

-   Patients should be assessed for their ability to cope with the
    information provided.

-   Nurses must be mindful of and sensitive to the fact that race,
    culture, ethnicity, and religion can influence the health care
    decision-making process. The fact that a patient from non-Western
    cultures may not subscribe to Western notions of autonomy does not
    mean that these patients do not want to talk about their treatment
    wishes or that they would not have conversations with their families
    about their treatment preferences.

-   Patients must be respected for their decision to not complete an AD
    and reassured that they will not be abandoned or receive substandard
    care if they do not elect to formulate an AD.

-   Nurses should be aware of the institution\'s mechanism for resolving
    conflicts between family members and the patient or proxy or between
    the patient/family and care providers and assist the parties in
    using this resource.

-   Nurses should be aware of which professional in their
    agency/institution is responsible for checking with the patient that
    copies of the AD have been given to their primary-care provider(s),
    to their proxy, *and* that the patient is carrying a wallet-size
    card with AD and contact information.

**Definitions**:

**Level I**: Systematic reviews (integrative/meta-analyses/clinical
practice guidelines based on systematic reviews)

**Level II**: Single experimental study (randomized controlled trials
\[RCTs\])

**Level III**: Quasi-experimental studies

**Level IV**: Non-experimental studies

**Level V**: Care report/program evaluation/narrative literature reviews

**Level VI**: Opinions of respected authorities/Consensus panels

Reprinted with permission from Springer Publishing Company: Capezuti,
E., Zwicker, D., Mezey, M. & Fulmer, T. (Eds). (2008) *Evidence Based
Geriatric Nursing Protocols for Best Practice*, (3^rd^ ed). New York:
Springer Publishing Company.

#### CLINICAL ALGORITHM(S)

None provided

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### REFERENCES SUPPORTING THE RECOMMENDATIONS

[References open in a new
window](http://www.guideline.gov/summary/select_ref.aspx?doc_id=12264)

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of supporting evidence is identified and graded for selected
recommendations.

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

**Overall Benefits**

Health care professionals, especially nurses, can improve end-of-life
decision making for elderly patients by talking about and encouraging
the completion of advance directives before the individual loses
decisional capacity.

**Specific Benefits**

-   Increased understanding of ethical and legal aspects of advance
    directives

-   Increased number of patients approached about advance directives

-   Improved ability to discuss/educate patient and family/health care
    proxy on advance directives

-   Increased number of patients with completed advance directives in
    chart

#### POTENTIAL HARMS

Not stated

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

To determine whether implementation of this protocol influenced the type
as well as the number of advance directives (ADs) created, changes
should be measurable and contribute to the facility\'s ongoing quality
improvement program. Look at:

-   As documented in the record:

    -   Whether patients are asked about advance care planning and
        directives

    -   Whether patients do or do not have an AD

-   Of those patients with an AD, the percentage of ADs included in
    patient charts

-   The use of interpreters to assist staff discussion of ADs with
    patients for whom English is not their primary language

-   The number of ADs completed in association with admission to, or
    receipt of services from, the agency/institution

-   The number of nurse referrals to the Ethics Committee of patient or
    staff situations regarding ADs

#### IMPLEMENTATION TOOLS

Staff Training/Competency Material

For information about
[availability](#identifying-information-and-availability), see the
\"Availability of Companion Documents\" and \"Patient Resources\" fields
below.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

End of Life Care\
Living with Illness

#### IOM DOMAIN

Effectiveness\
Patient-centeredness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Mitty EL, Ramsey G. Advance directives. In: Capezuti E, Zwicker D, Mezey
M, Fulmer T, editor(s). Evidence-based geriatric nursing protocols for
best practice. 3rd ed. New York (NY): Springer Publishing Company; 2008.
p. 539-63. \[62 references\]

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

2003 (revised 2008 Jan)

#### GUIDELINE DEVELOPER(S)

Hartford Institute for Geriatric Nursing - Academic Institution

#### GUIDELINE DEVELOPER COMMENT

The guidelines were developed by a group of nursing experts from across
the country as part of the Nurses Improving Care for Health System
Elders (NICHE) project, under sponsorship of The John A. Hartford
Foundation Institute for Geriatric Nursing.

#### SOURCE(S) OF FUNDING

Supported by a grant from The John A. Hartford Foundation.

#### GUIDELINE COMMITTEE

Not stated

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Primary Authors*: Ethel L. Mitty and Gloria Ramsey

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Not stated

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: Ramsey G, Mitty E. Advance
directives: protecting patient\'s rights. In: Mezey M, Fulmer T, Abraham
I, Zwicker DA, editor(s). Geriatric nursing protocols for best practice.
2nd ed. New York (NY): Springer Publishing Company, Inc.; 2003. p.
265-91.

#### GUIDELINE AVAILABILITY

Electronic copies: Available from the [Hartford Institute for Geriatric
Nursing Web
site](http://consultgerirn.org/topics/advance_directives/want_to_know_more).

Copies of the book *Geriatric Nursing Protocols for Best Practice*, 3rd
edition: Available from Springer Publishing Company, 536 Broadway, New
York, NY 10012; Phone: (212) 431-4370; Fax: (212) 941-7842; Web:
[www.springerpub.com](http://www.springerpub.com/).

#### AVAILABILITY OF COMPANION DOCUMENTS

The following is available:

-   Advance directives post-test instructions and evaluation: advanced
    directives. Continuing education activity. Available from the
    [Hartford Institute for Geriatric Nursing Web
    site](http://consultgerirn.org/continuing_ed#instr).

#### PATIENT RESOURCES

None available

#### NGC STATUS

This summary was completed by ECRI on February 2, 2004. The information
was verified by the guideline developer on February 26, 2004. This
summary was updated by ECRI Institute on June 23, 2008. The updated
information was verified by the guideline developer on August 4, 2008.

#### COPYRIGHT STATEMENT

This NGC summary is based on the original guideline, which is subject to
the guideline developer\'s copyright restrictions.

### DISCLAIMER

#### NGC DISCLAIMER

The National Guideline Clearinghouse™ (NGC) does not develop, produce,
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<http://www.guideline.gov/about/inclusion.aspx> .

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© 1998-2008 National Guideline Clearinghouse

Date Modified: 11/3/2008