Advanced Directives

Care Plan for Advanced Directives

Category / Primary Body System:

Legal/Ethical Considerations

Problem:

Patient has advanced directives in place and needs ongoing support to ensure these directives are followed and reviewed regularly.

Goal:

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

Plan/Approach:

1. Verification and Documentation:

   • Step-by-Step Approach: Ensure there is an MD/RNP order for advanced directives and that these orders are documented in the patient’s medical record.
   • Technological Aids: Utilize electronic health records (EHR) to document and track advanced directives.
   • Educational Efforts: Educate the patient and family about the importance and implications of advanced directives.

2. Adherence to Directives:

   • Step-by-Step Approach: Ensure all staff are aware of and adhere to the advanced directive orders.
   • Educational Efforts: Provide training to staff on respecting and implementing advanced directives.

3. Communication:

   • Step-by-Step Approach: Notify the responsible party regarding any significant changes in the patient’s medical condition.
   • Technological Aids: Use secure communication tools to inform the responsible party promptly.

4. Privacy and Dignity:

   • Step-by-Step Approach: Maintain the patient’s privacy and dignity at all times.
   • Educational Efforts: Train staff on privacy and dignity protocols.

5. Respect for Wishes:

   • Step-by-Step Approach: Respect the patient’s wishes and treatment requests or refusals.
   • Educational Efforts: Reinforce the importance of respecting patient autonomy with staff.

6. Quarterly Review:

   • Step-by-Step Approach: Review advanced directives quarterly and as needed with the patient and/or responsible party.
   • Technological Aids: Schedule reminders in the EHR for quarterly reviews.

7. Consent Management:

   • Step-by-Step Approach: Ensure that consent for advanced directives is signed by the patient or responsible party.
   • Technological Aids: Maintain electronic copies of consent forms in the EHR.

8. Social Work Consultation:

   • Step-by-Step Approach: Consult a social worker as needed for additional support and resources.
   • Educational Efforts: Inform the patient and family about the role of the social worker in managing advanced directives.

Rationale:

• Verification and Documentation: Ensures clarity and accessibility of the patient’s wishes.
• Adherence to Directives: Guarantees that patient preferences are respected and followed.
• Communication: Keeps the responsible party informed and involved.
• Privacy and Dignity: Protects the patient’s rights and personal integrity.
• Respect for Wishes: Honors patient autonomy and ethical standards.
• Quarterly Review: Regularly updates and reaffirms patient preferences.
• Consent Management: Ensures legal compliance and patient consent.
• Social Work Consultation: Provides additional support and resources for complex situations.

Actions:

1. Verification and Documentation:

   • Staff will ensure an MD/RNP order for advanced directives is in place and documented in the EHR.

2. Adherence to Directives:

   • Staff will adhere to the advanced directive orders and ensure compliance.

3. Communication:

   • Staff will notify the responsible party of any significant changes in the patient’s condition.

4. Privacy and Dignity:

   • Staff will maintain the patient’s privacy and dignity at all times.

5. Respect for Wishes:

   • Staff will respect the patient’s treatment requests or refusals.

6. Quarterly Review:

   • Staff will review advanced directives quarterly with the patient and/or responsible party.

7. Consent Management:

   • Staff will ensure that consent forms are signed and documented.

8. Social Work Consultation:

   • Staff will consult a social worker as needed.