Nursing Field Notes / Nursing Core · Legal & Ethics Series
Advance Directives 📜
Living wills, durable power of attorney for healthcare, code status, and the PSDA
NG-212NURSING CORESeries: Legal & Ethics 4 of 5ADHD-friendly visual edition
Advance directives are legal documents that spell out a client's wishes for medical care before they become unable to speak for themselves — think a client with a GCS < 7 or aphasia from an intracerebral hemorrhage. This is autonomy (page 1) exercised in advance, so it survives even after the client can no longer voice a choice.
📜 2 main typesLiving Will (treatment wishes) + DPOA-HC (a person to decide).
👥 2 witnessesNot the treating nurse/HCP, not the named proxy.
❓ No AD found?Default is FULL treatment / full code.
📋 PSDAFacilities MUST ask every admitted client about advance directives.
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WHAT THEY ARE
STEP 1 · TWO MAIN TYPES
One document says what you want; the other says who decides for you.
📜 From client wishes to the chart
🧠 Documentation goes TWO places: the client's medical record, AND copies handed out to family, friends, and everyone named as a healthcare proxy. A living will locked in a safety-deposit box does neither.
📝 Living Will
A document, separate from a final will, that describes the kind of treatment wanted if the client becomes incapacitated or unable to communicate — e.g., whether they want life-sustaining measures like a ventilator or tube feeding.
🧠 It's about what — the treatments themselves.
🖋️ Durable Power of Attorney for Healthcare (DPOA-HC)
Assigns another person — a health care proxy / surrogate — to make medical decisions for the client if they become incapacitated.
NCLEX TIP There are many types of general Power of Attorney — always clarify it's specifically the healthcare POA that's needed.
🧠 It's about who — the decision-maker, not the decisions themselves.
👥 Witnessing requirements
✅ Commonly does NOT need to be notarized — can typically be completed right in the healthcare setting
✅ Commonly requires 2 witnesses
❌ Witnesses cannot be the nurses or HCPs directly involved in that client's care
❌ Witnesses cannot be individuals named as the healthcare proxy
Exact witness count and notarization requirements are set by state law and vary — always verify the specific state's requirements rather than assuming one universal rule.
🧠 The witness has to be neutral — not treating, not benefiting from the decision.
🚨 Portable orders: POLST / MOLST & DNR bracelet
POLST (Physician's Orders for Life-Sustaining Treatment) — actual medical orders, signed by a provider, that summarize the client's wishes and travel with them across care settings (home, EMS, hospital). Terminology varies by state — some regions use MOLST or another name.
A DNR bracelet is a portable, visible way to communicate code status outside the hospital record.
🧠 A living will is a wish; a POLST is a standing medical order — that's why POLST can be acted on immediately by EMS.
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CODE STATUS & LEVELS OF CARE
STEP 2 · KNOW THE LADDER
From everything to nothing — know exactly what each order does and does not include.
🚦 Code status ladder
🧠 DNR/DNI/AND are NOT "do not treat." Comfort measures, oxygen by nasal cannula, IV fluids, and symptom-relief medications can still be given — those are not considered resuscitative efforts.
❓ No advance directive found?
Default is full treatment / full code. The law requires the facility to give written information outlining the client's rights and options for stating their wishes.
🧠 Silence defaults to "do everything," not "do nothing."
📋 PSDA — Patient Self-Determination Act
A federal law that protects and ensures client rights in determining end-of-life care. It requires facilities to ask every admitted client whether they already have an advance directive.
🧠 The PSDA is a process requirement (ask on admission), not a guarantee every client will have one.
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THE NURSE'S ROLE
STEP 3 · FACILITATE, DON'T STALL CARE
When code status is unclear, the nurse verifies without abandoning the client.
🌳 Client's condition is worsening — code status unclear. What now?
🧠 Two things happen in parallel, not in sequence. The nurse does NOT stop caring for the client while the chart is searched — assessment and verification happen at the same time.
💬 Facilitating the conversation
The nurse's role is to open the door for advance care planning discussions, provide facility information, answer process questions, and notify the provider or ethics resources as needed — not to pressure a client toward a specific choice.
🧠 This mirrors the informed consent rule from page 3: the nurse supports the process, the client (or their legal decision-maker) makes the actual choice.
🗺️ Where the ethics of dying live on this site
🔗 The euthanasia, DNR ethics, grief, and end-of-life communication angle is covered in depth on the Mental Health batch's NG-065 · Death & Dying and NG-222 · Death, Dying, Grief & Loss pages — this page focuses on the legal document itself.
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NCLEX TRAPS
STEP 4 · DON'T GET FOOLED
These exact questions have appeared on Kaplan, HESI, and Saunders-style review material.
🚨 "My living will is secured in a safety-deposit box"
This is the most concerning statement a client can make — an advance directive that no one can access in an emergency is functionally useless. The correct nursing response is to encourage a copy in the chart and with family/proxies.
🧠 A perfect document with zero accessibility = zero protection.
⭐ Newly diagnosed with mild Alzheimer's — priority teaching
Encourage the client to complete an advance directive BEFORE cognitive abilities decline further — this is one of the most frequently missed NCLEX questions on this topic.
🧠 Capacity to complete an AD requires being competent at the time of signing — waiting until symptoms progress may mean it's too late.
✅ Timing matters — plan early, not in crisis
Advance care planning conversations are ideally started at a calm, non-emergent time — not in the middle of an acute decline, when stress and impaired capacity make truly informed decisions harder.
🧠 If the exam gives you a chance to teach proactively, that's usually the better answer than waiting.