Integrate Advance Directives into Client Plan of Care

Advance directives are legal documents that allow individuals to articulate their preferences regarding future medical care in the event they are unable to communicate these wishes themselves. In the healthcare continuum, registered nurses (RNs) play a vital role in integrating advance directives into the client’s plan of care. This integration ensures that patient autonomy is respected, ethical principles are upheld, and that care is aligned with the individual's values and beliefs. 

Identification and Verification

• Upon admission or initial assessment, the RN asks about the existence of an advance directive. This is often a standard part of intake procedures in many healthcare settings.
• If an advance directive is present, the RN obtains a copy and ensures it is placed in the client’s medical record. If not, the nurse can offer educational materials and resources to encourage the creation of one.
• The RN verifies the document’s validity, making sure it is signed, dated, and in accordance with applicable laws.

Assessment and Communication

• The RN discusses the contents of the advance directive with the client and, when appropriate, their designated healthcare proxy or family members.
• The nurse assesses the client’s understanding and wishes, clarifying any

 ambiguities and addressing questions. 

• Communication is continuous; as the client’s health status changes, the RN revisits and reviews the advance directive to ensure it remains consistent with current wishes.

Documentation

• The RN thoroughly documents the presence and content of the advance directive in the client’s chart, including any specific wishes or limitations regarding care (for example, do-not-resuscitate [DNR] orders, preferences for artificial nutrition, or other life-sustaining measures).
• If there are updates or changes, the documentation is promptly revised, and all members of the healthcare team are notified.

Care Planning and Implementation

• The RN ensures that the client’s advance directive is reflected in the individualized plan of care. This may involve collaborating with physicians, social workers, and other team members to align interventions with the directive’s stipulations.
• The registered nurse is responsible for ensuring that the client's advance directive is incorporated into the individualized plan of care. This process may include collaboration members of the interdisciplinary team to ensure that all interventions are consistent with the provisions of the advance directive.