Leadership in Nursing: Advance Directive

According to Yadav et al. (2017), “the treatments Americans would choose near

the end of life are often different from the treatments they receive” (p. 1244). This

implies that there is a disconnect between the received care and the desired care, which

tends to lead to undesirable outcomes for both caregivers and patients. Consequently,

many Americans chose to have advance directives to ensure they avoid unwanted care in

case they are incapacitated. An advance directive is defined as “a legal document that

explains how one wants medical decisions about him/her to be made if her/she cannot

make the decisions him/herself” (Scholten et al., 2018, p. 1). In the US, one-third of the

adult population has an advance directive to cater to his/her end-of-life care (Yadav et al.,

2017). Although the document is legally binding, most nurses find it difficult to adhere to

an advance directive when their medical expertise and experience point to an alternative

solution to the medical problem. More so, many nurses have little experience dealing

with advance directives and are unable to address patients’ problems on their own

initiative.

PICOT Question: How do registered nurses who have to implement advance directives

perceive their impact in influencing patient outcomes during the end of life care?

Literature Review

An advance directive is designed to help a person plan for the future and ensure

that those around him/her are aware of the type of care he/she desires. Hence, when a

person is incapacitated and no longer has the ability to make clear medical/health-related

decisions, his/her loved ones and the healthcare professionals can know exactly what to

do based on the contents of the advance directive (Dowling, Kennedy, & Foran, 2020). It

is vital to note that advance directives are only applicable to healthcare decisions and

have no impact on financial issues (Scholten et al., 2018). In the US, the laws pertaining

to advance directives tend to vary from state to state. Hence, a person who wishes to have

an advance directive must consult with his/her healthcare provider or lawyer to get the

specifics of the legal document.

The Patient Self-Determination Act of 1990 (PSDA) is the legal foundation upon

which advance directives are created. This act encourages American citizens to “decide

ahead of time about the types and extent of medical care they want to accept or refuse if

they become unable to make those decisions due to illness” (Koss, 2018). The Act

requires all types of healthcare organizations to (a) find out if their clients have advance

directives, (b) offer their clients information regarding their right to make autonomous

decisions regarding their care, (c) honor the wishes of their clients, and (d), never

discriminate against their clients regardless of whether they have advance directives or

not (Koss, 2018).

Although advance directives provide a clear pathway to be followed regarding the

end of life care for patients, Peicius, Blazeviciene, and Kaminskas (2017) note that “the

increasing capacity among patients to choose advance directives due to scientific

advancements in health care reveals new ethical dilemmas” (p. 4). For example, the use

of advance directives ignites debates regarding the role of healthcare practitioners in

offering patients the best care possible based on their expert knowledge and experience.

This is because an advance directive may not necessarily offer the best solution to the

problem at hand. Additionally, the use of advance directives often results in conflicts

between the patients' loved ones and the medical team.

There are several issues that affect the effective utilization of advance directives.

For instance, there are nurses who have limited knowledge of advance directives. Also,

there are those who have reservations and hesitancy of implementing advance directives

due to their own personal values or their medical opinions (Portanova et al., 2017).

Hence, it is crucial to understand the perceptions that nurses have regarding the use of

advance directives. This is vital in reconciling their personal opinions of the use of

advance directives and their legal and professional responsibilities of the same.

Methodology

The target population for the study was comprised of registered nurses in a public

hospital. The objective of the study was to find out the perceptions of these nurses

regarding the use of advance directives in their institutions. The tool used to collect data

was a self-administered survey in form of a questionnaire. The role of the RN on this

issue is crucial since nurses play a central role in the care of end-of-life patients. Hence, it

is essential to understand the extent to which they understand advance directives and are

open to implementing them at all times. In this context, the change theory under

consideration is Lewin's Change Theory by Kurt Lewin. This theory is characterized by a

three-stage technique referred to as unfreezing-change-refreezing (McFarlan, O’Brien, &

Simmons, 2019). This theory can be used to help nurses who find it challenging to

implement advance directives at the workplace.

Ethics

The project was approved by the course instructor. The instructor approved the

topic for the project and provided clear guidelines for the project’s key deliverables.

There are certain ethical considerations for the project. For starters, there is the issue of

consent. All participants were to give consent before they were allowed to participate in

the study. They were informed of the objective of the study and all the intricacies of how

the project would be conducted to ensure they would offer informed consent.

Additionally, there is the issue of privacy and confidentiality. The questionnaires did not

collect any personal information of the nurses. This was to ensure they were comfortable

giving accurate answers and that their identifying information would not be known to

anybody, including the researchers.

Results

Three main needs were identified: nurses’ information on advance directives,

decision-making, and criticism of advance directives. From the results of the

questionnaires, 90 percent of the respondents had adequate information about how

advance directives work. Also, 90 percent of the respondents agreed that the patients had

a right to be part of the decision-making process regarding how they receive healthcare

services. However, 85 percent of the nurses criticized advance directives with the

assertion that often, it went against their nature to save lives. this is mostly when there is

a high chance of saving a patient but the nurses have no option but to respect the wishes

of the patients not to resuscitate them or carry out procedures that will likely result in

positive healthcare outcomes.

Hence, there is a clear need for change in the healthcare institution. Although the

nurses acknowledge the importance of the advance directives, they find it difficult to

cope with situations where they are left helpless with no input into the final decision of

the patients. The need for change in this regard is that nurses should be educated and

sensitized not to see advance directives as death sentences but perceive them as the

opportunity to facilitate the autonomy of the patients and allow patients to be a part of the

decision-making process (Dowling, Kennedy, & Foran, 2020).

Discussion

Based on the findings of the data analysis, it is clear that most of the nurses in the

study have a good comprehension of what advance directives are and the importance they

play in allowing patients to have the final say over the healthcare services they receive.

However, the responses given by most of the respondents reveal that the majority of

nurses may not necessarily be in agreement with the decisions outlined in some of the

advance directives. According to Park and Kim (2018), “advance directives may fail in

practice since the personal values of a patient may change after the declaration, and

because biomedical technology may evolve and the description of clinical situations can

lead to inaccuracies of the person’s actual wishes” (p. 183). It is in the nature of an

ethical and professional nurse to save as many lives as possible. Hence, at times, it is

difficult to reconcile between respecting an advance directive and carrying out evidence-

based interventions to save a patient's life.

There are two recommendations to consider from these findings. First, it is crucial

that advance directives be updated yearly to ensure that clients have the option to alter

them based on the advances made in healthcare with regard to treatment options. Second,

it is vital that nurses learn how to put their feelings aside and adhere to the wishes of their

patients. This is not only professional but demonstrates that they value the opinions of

their patients, whether they are right or wrong. The limitation of this study is that only a

small sample size of the population was used. Therefore, the findings may not necessarily

reflect the perceptions of the entire nurse population in the country. A future study may

utilize a larger and diverse sample size in order to adequately generalize the findings to

the entire country.

Conclusion

The project sought to understand how the registered nurses who have to

implement advance directives perceive their impact in influencing patient outcomes

during the end of life care. Although advance directives provide a clear pathway to be

followed regarding end-of-life care for patients, they may create conflicts and ethical

dilemmas. From the study results, even though the nurses acknowledge the importance of

the advance directives, they find it difficult to cope with situations where they are left

helpless with no input into the final decision of the patients. The need for change in this

regard is that nurses should be educated and sensitized not to see advance directives as

death sentences but perceive them as the opportunity to facilitate the autonomy of the

patients and allow patients to be a part of the decision-making process. Also, it is crucial

that advance directives be updated yearly to ensure that clients have the option to alter

them based on the advances made in healthcare with regard to treatment options.

References

Dowling, T., Kennedy, S., & Foran, S. (2020). Implementing advance directives: An

international literature review of important considerations for nurses. Journal of

Nursing Management, 28(6), 1177-1190.

Koss, C. (2018). Encounters with health-care providers and advance directive completion

by older adults. Journal of Palliative Care, 33(3), 178-181.

McFarlan, S., O’Brien, D., & Simmons, E. (2019). Nurse-leader collaborative

improvement project: Improving patient experience in the emergency department.

Journal of Emergency Nursing, 45(2), 137-143.

Park, E. H., & Kim, N. Y. (2018). The influence of nursing professionalism, attitudes

toward advance directive, and death anxiety on terminal care performance of

nurses in long-term care hospitals. Korean Journal of Adult Nursing, 30(2), 183-

193.

Peicius, E., Blazeviciene, A., & Kaminskas, R. (2017). Are advance directives helpful for

good end of life decision making: A cross sectional survey of health

professionals. BMC Medical Ethics, 18(1), 1-7.

Portanova, J., Ailshire, J., Perez, C., Rahman, A., & Enguidanos, S. (2017). Ethnic

differences in advance directive completion and care preferences: What has

changed in a decade? Journal of the American Geriatrics Society, 65(6), 1352-

1357.

Scholten, G., Bourguignon, S., Delanote, A., Vermeulen, B., Van Boxem, G., &

Schoenmakers, B. (2018). Advance directive: does the GP know and address what

the patient wants? Advance directive in primary care. BMC Medical Ethics, 19(1),

1-7.

Yadav, K. N., Gabler, N. B., Cooney, E., Kent, S., Kim, J., Herbst, N., … & Courtright,

K. R. (2017). Approximately one in three US adults completes any type of

advance directive for end-of-life care. Health Affairs, 36(7), 1244-1251.