Care Plan for Advanced Directives

Category / Primary Body System

• Legal/Ethical Considerations

Problem

• Patient has advanced directives.

Goal

• Patient or responsible party will participate in decision-making about advanced directives at least quarterly and as needed for 90 days.

Plan/Approach

1. Order Verification and Adherence

   • Ensure there is an MD/RNP order for advanced directives
   • Adhere to the advanced directive order

2. Communication and Documentation

   • Notify the responsible party of any significant changes in the patient's medical condition
   • Review advanced directives quarterly and as needed with the patient and/or responsible party
   • Ensure consent for the advanced directive is signed by the patient or responsible party

3. Patient Rights and Privacy

   • Maintain privacy and dignity of the patient at all times
   • Respect the patient's wishes and treatment requests or refusals

4. Consultation and Support

   • Consult a social worker as needed

Rationale

1. Order Verification and Adherence

   • Ensuring that there is an official order for advanced directives guarantees that the patient's end-of-life care preferences are recognized and respected.
   • Adhering to the advanced directive order ensures that care aligns with the patient's wishes.

2. Communication and Documentation

   • Notifying the responsible party of significant changes in the patient’s condition keeps them informed and involved in decision-making.
   • Regular review of advanced directives ensures they remain up-to-date and reflective of the patient’s current wishes.
   • Ensuring consent for advanced directives is documented provides legal and ethical clarity.

3. Patient Rights and Privacy

   • Maintaining privacy and dignity protects the patient’s personal and medical information, fostering a sense of respect and trust.
   • Respecting the patient’s treatment preferences honors their autonomy and personal values.

4. Consultation and Support

   • Social worker consultations provide additional support and resources for both the patient and their family, helping them navigate complex decisions.

Actions

1. Order Verification and Adherence

   • Verify that an MD/RNP order for advanced directives is in the patient's medical record.
   • Ensure all staff adhere to the advanced directive order, reviewing it regularly and following the specified care instructions.

2. Communication and Documentation

   • Notify the responsible party immediately of any significant changes in the patient’s condition, documenting all communications.
   • Review advanced directives with the patient and/or responsible party quarterly and as needed, documenting any updates or changes.
   • Ensure that consent for advanced directives is signed by the patient or responsible party, and properly filed in the medical record.

3. Patient Rights and Privacy

   • Maintain patient privacy by ensuring confidential handling of all personal and medical information.
   • Respect the patient’s treatment preferences by following their wishes as documented in the advanced directives, and documenting any treatment refusals or specific requests.

4. Consultation and Support

   • Schedule consultations with a social worker as needed to support the patient and their family, providing additional guidance and resources.