Advance Directives
CLINICAL GUIDELINES
On admission to the healthcare facility, all patients receive the following:
A patients’ rights brochure regarding patient rights, advance directives, surrogate decision making, and the forgoing of life-sustaining procedures (see Chart 10-1 for common terms);
Healthcare facility policies with respect to patients’ rights, advance directives, surrogate decision making, and the forgoing of life-sustaining procedures.
Facility protocol determines who distributes the above information (e.g., admitting personnel, nursing personnel). During the admission process, or as soon as reasonably possible thereafter, ask the family whether or not an advance directive has been completed for the child.
If the child has an advance directive, place a copy in the medical record. If the healthcare provider believes the child’s condition/circumstances have changed and that this should be reflected in the advance directive, it is the provider’s responsibility to initiate the conversation with the parent/guardian or child.
File advance directives in the medical record in a consistent section. Mark the chart on the exterior that an advance directive has been completed and is in the chart.
If no advance directive exists for a child, the healthcare team collaborates to discuss development of one with the family.
Advance directives are jointly determined by the parent/guardian and child and are followed by healthcare professionals.
An attempt should be made to resolve concerns regarding the feasibility of an advance directive order with the immediate parties involved. If unable to reach resolution, consult the institution’s ethics committee or equivalent.
Advance directives should always be developed considering the child’s best interests.
When a patient who lacks present decision-making capacity (as determined by the admitting healthcare prescriber in consultation with the patient’s family members and close friends) is admitted to the hospital, the person responsible for documenting the admission must provide information regarding advance directives and direct questions regarding the existence of an advance directive to a relative or friend accompanying the patient, if such a person is present.
Those who can complete the advance directive for a child include the following:
Parent
Legal guardian
Emancipated minor (includes adolescent parent of child of any age)
A child who demonstrates the cognitive, abstract, and thinking ability to comprehend the terms of the advance directive. The advance directive requires the cosignature of a parent or legal guardian.
When requested to do so, the healthcare team should respect the privacy and confidentiality of patients legally entitled to their own decisions (emancipated minors or those judged mature).
Based on state law, determine who (e.g., patient representative, individual with durable power of attorney) has legal right to participate in planning care and access patient health information beyond involvement in care/treatment, who has decision-making rights and can give consent regarding the patient’s care.
CHART 10-1 Common Terms Used with Advance DirectivesAdvance Directive: A legal document that identifies the patient’s wishes for end-of-life care and may include naming of a healthcare agent for the patient. Laws vary from state to state.
Durable Power of Attorney for Healthcare: A legal document created by a competent adult that authorizes another competent adult to make healthcare decisions on their behalf; also called a healthcare power of attorney.
Living Will Declaration: A legal document that has been executed by a competent adult that becomes operable under certain conditions defined by state law and that governs the use of life-sustaining treatment when the individual no longer can make an informed medical decision.
Physician Orders for Life-Sustaining Treatment (POLST)/Medical Orders for Life-Sustaining Treatment (MOLST): A medical order form that incorporates patient’s preferences into medical orders for life-sustaining treatment. These orders are typically written when patients are seriously ill or nearing the end of life. They apply immediately, hold across settings/patient location, and are in effect unless another healthcare prescriber examines the patient, reviews the orders, and changes them. POLST require review if the patient changes location to receive care, the patient changes his or her mind about treatment, or has a major change in health status. POLST differ from Advance Directives in that they summarize the patient’s wishes as medical orders.
Patient Representative: Parent of a minor child, Guardian, Durable Power of Attorney of a patient who is incapacitated, or a support person who is identified by an adult patient. It can be whoever shows up and claims to be the patient representative (i.e., spouse, partner, friend, parent of adult patient, etc.), if the patient has no Advance Directive on file.
EQUIPMENT
A copy of the advance directive form or a copy of previously established advance directives for that child.
As a resource, the family should have an institutional or other guide on establishing advance directives.
CHILD AND FAMILY ASSESSMENT AND PREPARATION
Determine the child’s cognitive, developmental, and legal ability to participate in the determination of advance directives. Regardless of the legal particulars, weight should be given to the child’s wishes regarding life-sustaining medical treatment.
Determine the presence of the parent or legal guardian who is responsible for making healthcare decisions for the child. Generally, parents give permission for the treatment of children who cannot do so themselves.
Determine the family’s ability to understand the concept and consequence of advance directive formation. Competency to make decisions at a particular time under particular circumstances must be determined. Elements of this evaluation include (1) the ability to understand and communicate information relevant to a decision, (2) the ability to reason and deliberate concerning the decision, and (3) the ability to apply a set of values to a decision that may involve conflicting elements.
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