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:
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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:
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Verification and Documentation:
- Staff will ensure an MD/RNP order for advanced directives is in place and documented in the EHR.
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Adherence to Directives:
- Staff will adhere to the advanced directive orders and ensure compliance.
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Communication:
- Staff will notify the responsible party of any significant changes in the patient’s condition.
-
Privacy and Dignity:
- Staff will maintain the patient’s privacy and dignity at all times.
-
Respect for Wishes:
- Staff will respect the patient’s treatment requests or refusals.
-
Quarterly Review:
- Staff will review advanced directives quarterly with the patient and/or responsible party.
-
Consent Management:
- Staff will ensure that consent forms are signed and documented.
-
Social Work Consultation:
- Staff will consult a social worker as needed.
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