Editing Management of Care (section)

== Advance Directives ==

Advance directives are documents by which a person states health care preferences in advance or names a decision maker, to be used if the person later loses capacity.

* '''Living will:''' a written statement of which treatments the person does or does not want, typically in terminal or permanently unconscious states.
* '''Durable power of attorney for health care / health care proxy:''' names a person to make decisions when the patient cannot. This is generally the more flexible and more useful document, because a named person can respond to situations the living will did not anticipate.
* '''POLST or MOLST:''' a portable '''medical order''' set signed by a provider that translates goals into actionable orders across settings. Unlike a living will, it is an order and is followed immediately.
* '''Do-not-resuscitate (DNR) / allow natural death order:''' a provider order that cardiopulmonary resuscitation is not to be performed. It applies to resuscitation only.

The '''Patient Self-Determination Act of 1990''' requires facilities receiving Medicare or Medicaid funds to ask on admission whether the patient has an advance directive, to provide written information about the right to make one, to document its existence in the record, and not to discriminate based on whether one exists. Facilities may not require an advance directive as a condition of care.

'''Application notes.'''
* A DNR order is '''not''' an order to withhold care. Patients with DNR orders still receive pain control, oxygen, antibiotics, nutrition, positioning, suctioning, wound care, and every other indicated treatment unless separately limited. Confusing DNR with "do not treat" is a recurring examination distractor and a real source of harm.
* An advance directive '''only takes effect when the patient loses decision-making capacity'''. A conscious, competent patient's current expressed wish always overrides the document, and the patient may revoke or change the directive at any time, verbally or in writing.
* If a family member demands care that contradicts a valid directive, the nurse notifies the provider and, as needed, the ethics committee. The nurse does not simply comply with the louder voice.