How can a nurse assist older adults or individuals with serious or life-limiting illnesses, such as cancer, heart disease, or dementia, in completing advance directives for end-of-life care?

How Nurses Can Help Patients Complete Advance Directives

Nurses should proactively initiate advance directive discussions early—ideally before any acute illness—by first building a trusting relationship with the patient, then providing clear information about treatment options in simple language, facilitating conversations between patients and their families, and ensuring proper documentation that is accessible across all care settings. 1, 2

Timing and Initiation of Conversations

Start conversations early, before crisis situations arise:

• Initiate advance care planning discussions before patients lose decision-making capacity, not during acute illness when emotions and fears may cloud judgment 1
• Begin discussions within one month of diagnosis for patients with terminal illness, and proactively for all adults aged 18 and older regardless of current health status 2
• Avoid waiting until hospitalization or acute deterioration, as this creates unnecessary stress for patients and families and may result in decisions that don't reflect true patient values 1

Building the Foundation: Relationship-Centered Approach

Establish a trusting nurse-patient relationship as the essential foundation:

• Develop rapport with patients and their families before diving into difficult end-of-life topics, as knowing each other enables nurses to sense readiness and determine appropriate timing 2, 3
• Listen first to understand the patient's worries, values, and wishes before providing medical information or discussing specific interventions 4, 3
• Recognize that advance care planning is not a one-time conversation but an ongoing process that requires time, effort, and genuine interest in the patient 3

Providing Information and Education

Deliver clear, accessible information tailored to patient understanding:

• Provide information and guidance to patients and families in simple, jargon-free language to facilitate discussions of wishes and care preferences 1
• Explain realistic outcomes of life-sustaining treatments like CPR (average survival rate 15%, with 44% of survivors experiencing significant functional decline) to ensure informed decision-making 2, 5
• Use decision aids as practical tools to support patients and proxy decision-makers in making difficult decisions 1
• Present information in multiple formats (written materials, verbal discussions, visual aids) at a reading level appropriate for the patient 6

Facilitating Family Conversations

Guide discussions within the patient-family unit:

• Facilitate conversations between patients and their loved ones about values, preferences, and end-of-life wishes, as advance care planning extends beyond the physician-patient relationship 1, 2
• Help families understand that knowing the patient's wishes reduces guilt and stress when making surrogate decisions on behalf of their loved one 1, 5
• Thoughtfully introduce sensitive topics by explaining that discussing potential scenarios proactively helps avoid undesirable treatments like unwanted hospitalizations 1

Essential Documentation Components

Ensure comprehensive and accessible documentation:

• Document both a living will specifying treatment preferences AND a durable power of attorney appointing a healthcare proxy/surrogate decision-maker 2, 5
• Include specific preferences regarding CPR, mechanical ventilation, ICU admission, artificial nutrition and hydration, and antibiotic use 2
• Ensure documentation is in transferable digital files accessible at all times to different care agencies and personnel (including emergency physicians) in acute situations 1
• Provide copies to the patient's family, loved ones, physician, and medical record, as written directives are more legally trustworthy than recollections of conversations 2, 5

Collaboration with the Healthcare Team

Work within an interprofessional framework:

• Collaborate with geriatricians, family doctors, and palliative care specialists to review existing advance care plans and discuss appropriate actions together 1
• Consult specialized palliative care teams when available to provide necessary support for complex cases 1
• Advocate for patients within the healthcare team to ensure their documented wishes are honored 6, 7

Ongoing Assessment and Follow-Up

Maintain continuity through regular reassessment:

• Conduct follow-up conversations or calls to respond to psychosocial or spiritual needs and questions that arise from discussing care plans 1
• Reassess advance directives regularly as medical conditions and treatment preferences change over time, ensuring discussions occur while patients retain capacity 2
• Identify anticipatory grief during advance care planning conversations and provide information on bereavement preparation 1

Common Pitfalls to Avoid

Critical mistakes that undermine the advance directive process:

• Never delay advance care planning until an acute crisis, as this results in hasty, emotionally-charged decisions that may not reflect patient values 1
• Avoid initiating first conversations during crisis situations (like COVID-19 diagnosis), as decisions may be colored by fears and emotions without adequate reflection 1
• Don't assume patients understand medical terminology—patients have significant functional health illiteracy about life-sustaining treatments, requiring clear explanations 2, 5
• Never complete advance directives without involving family members and loved ones in the conversation, as this increases surrogate decision-maker stress later 1, 5

Addressing Nurse-Specific Barriers

Overcome personal obstacles to initiating conversations:

• Conduct self-assessment of potential barriers, including discomfort discussing death, belief that "accepting mortality" means "giving up hope," or fear that discussing death will "make it happen" 1, 2
• Recognize that only 19% of patients report discussing advance directives with clinicians, and lack of healthcare provider initiative is the most frequently cited barrier 2, 5
• Advocate for your role as a nurse leader in facilitating these essential conversations, as nurses are ideally positioned by virtue of their relationships with patients and expertise as liaisons between patients, families, and the multidisciplinary team 6, 7