Advance Directives and Legal Rights: Practice Questions & Explanations

A DNR order specifically directs that CPR (chest compressions, defibrillation, intubation, advanced cardiac medications) will not be performed if the client experiences cardiac or respiratory arrest. The order does NOT mean: no treatment at all (the client continues to receive all other ordered treatments — antibiotics, IV fluids, pain management, comfort care); no nursing care; no medical attention. DNR is specific to resuscitation. Other related orders include: DNI (Do Not Intubate); AND (Allow Natural Death); POLST/MOLST (Physician/Medical Orders for Life-Sustaining Treatment, a more comprehensive form); 'comfort measures only' or 'comfort care' orders. The nurse must understand the specific scope of the order and continue to provide all care within those limits. Discussion of advance directives is required upon hospital admission under the Patient Self-Determination Act.

A durable power of attorney for healthcare (also called a healthcare proxy or healthcare surrogate) is a legal document in which a competent adult designates another person to make healthcare decisions if the client becomes incapacitated and unable to make decisions themselves. The 'durable' aspect means it remains in effect during the client's incapacity. The designated proxy should: know the client's wishes and values; be willing to advocate per those wishes; be available and engaged when needed. The proxy operates based on either: substituted judgment (what the client would have wanted) or best interest (what is in the client's best interest if their wishes are unknown). A living will documents the client's specific treatment preferences, while the healthcare proxy designates a decision-maker. Together they form advance directives. The nurse documents whether the client has advance directives and ensures documentation is in the chart.

When an adult client is unable to consent due to incapacity and has no advance directive identifying a healthcare proxy, state law establishes a hierarchy of surrogate decision-makers. The typical order: spouse, adult children, parents, adult siblings, other relatives, close friends, court-appointed guardian. The exact order varies by state. The surrogate decision-maker is expected to apply 'substituted judgment' — making the decision the client would have made if able. In an emergency where consent cannot be obtained and delay would be life-threatening, 'emergency consent' (implied consent) allows necessary treatment to proceed. For non-emergency situations where surrogates cannot agree or are unavailable, courts may appoint a guardian. Healthcare facilities have ethics committees that consult on complex consent situations. The nurse documents the consent process carefully, including who consented, their relationship, and the basis for their authority.

ADVANCE DIRECTIVES AND EMERGENCY RESUSCITATION create a complex situation when a client arrives in extremis and the advance directive is not immediately available as a formal medical order.

Key principles: AN ADVANCE DIRECTIVE is a legal document expressing the patient's wishes, but it must be CONVERTED INTO A PHYSICIAN'S ORDER (DNR/DNI order, POLST/MOLST form) to be immediately enforceable in an emergency. A living will in the patient's wallet is not the same as an active DNR order in the chart.

In the absence of a current medical order: Standard protocol is to BEGIN RESUSCITATION while simultaneously: verifying the advance directive exists; locating the document; contacting the designated healthcare proxy; the attending physician reviews and makes a decision.

Why not automatically withhold: (1) The document may be outdated, revoked, or misapplied; (2) 'No heroic measures' is ambiguous — the physician must interpret what it means for this specific situation; (3) Families may have critical information; (4) The legal standard in most states requires a CURRENT physician's order to withhold CPR — not just the presence of an advance directive. POLST (Physician Orders for Life-Sustaining Treatment): POLST/MOLST forms are physician orders that are transportable between settings — these DO have immediate force. A POLST in the chart stating 'DNR' is immediately actionable. NURSE'S ROLE: Know your facility's policy; retrieve any existing orders rapidly; notify the physician immediately; document all actions; communicate respectfully with family.

Clients have a RIGHT to ACCESS their own medical records (under HIPAA and patient rights). The nurse should recognize this right and FOLLOW FACILITY POLICY/PROCEDURE to facilitate the request (which may involve a formal request, a designated process, and the provider/medical records department). NCLEX safe care/legal-ethical. The record's physical/electronic form belongs to the facility, but the client has the right to access and obtain a copy of the information. The nurse facilitates, doesn't refuse. HIPAA protects health information privacy AND grants patients rights to access their own information. Knowing clients have the right to access their records (and the nurse facilitates per policy) is a tested patient-rights concept.

INFORMED CONSENT is the responsibility of the PROVIDER performing the procedure (physician/surgeon), who must explain: the PROCEDURE, its RISKS, BENEFITS, and ALTERNATIVES (including the option of no treatment), in terms the client understands. The NURSE'S ROLE: WITNESS the client's VOLUNTARY signature, verify the client appears to UNDERSTAND, confirm consent is voluntary (no coercion), and ensure the client's questions are answered (referring unanswered questions back to the provider). NCLEX safe care/legal-ethical. The nurse does NOT obtain the consent by explaining the procedure themselves, and never signs for the client. Consent must be informed, voluntary, and from a competent adult (or legal surrogate). Knowing the provider obtains informed consent and the nurse witnesses/verifies understanding is a heavily tested NCLEX legal concept.

A nurse who witnesses or suspects drug DIVERSION (theft of controlled substances) by a coworker has an ETHICAL and LEGAL obligation to REPORT it through proper channels (supervisor/manager, per facility policy; reporting to the board of nursing/authorities may be required). NCLEX safe care/legal-ethical.

Why: diversion endangers patients (who may not get their medication or receive contaminated drugs), and an impaired nurse is a safety risk; it's also illegal. The nurse should NOT ignore it (failure to report can have consequences), handle it only privately, or take the medications themselves. Reporting protects patients and may help the impaired colleague get treatment. Many states have mandatory reporting and confidential programs for impaired nurses. Knowing the obligation to report drug diversion is a tested NCLEX ethical/legal concept.