Module Components

• Overview

Topics

• Ethical Health Care Issues
• Basic Concepts of Law in the Healthcare Workplace
• The Legal Environment: Healthcare Law
• Legal & Clinical Incapacity and Informed Consent
• Confidentiality and HIPPA
• Advance Directives
• Labor Relations
• Human Resources: Related Legislation

Nurs 692 Administration of Nursing and Health Care Services

Module 10: The Ethical & Legal Environment and Labor Relations

Advance Directives

Health care advance directives are legal documents that communicate a person’s wishes about health care decisions in the event the person becomes incapable of making health care decisions. There are two basic kinds of advance directives: living wills and health care powers of attorney.

• A living will expresses, in advance, a person’s instructions or preferences about future medical treatments, particularly end-of-life care, in the event the person loses capacity to make health care decisions.
• A health care power of attorney appoints a person (called a health care agent or proxy, health care representative, or other name depending on the state) to make decisions for the person (the principal) in the event of incapacity (temporary or permanent) to make health care decisions.

Normally, people communicate their wishes directly to their doctors. But when a person no longer has the capacity to make or communicate a health care decision, another way to make and communicate a decision is needed. That is the role advance directives play. If no advance directive has been prepared, someone else not of the person's choosing may be called on to make health care decisions. Many states authorize default surrogate decision makers, usually next of kin when the patient lacks capacity and has not appointed a health care agent. When state law does not authorize a default surrogate decision maker, doctors and hospitals still usually turn to next of kin, although the extent of their legal authority becomes less clear. In the rare event that the issue is referred to a court, courts generally prefer to name a family member as guardian or conservator to make health care decisions, but they may also turn to a friend or a stranger to direct care. A health care power of attorney (and, in some cases, a living will) eliminates almost any need for the courts to get involved and helps ensure that the person’s health care decisions will be respected.

Living Will
A living will is a limited document that expresses a person’s preferences for future medical care. It is called a “living" will because it is in effect while the person is still alive. In many states, the document is more formally called a medical directive to doctors or a declaration. The focus of a living will is usually end-of-life care, but it can include instructions about any aspect of care or treatment. Living wills become effective only when the person has lost capacity to make health care decisions and the person has a particular condition defined by state law—usually a terminal condition or permanent unconsciousness. Some states recognize additional conditions such as an end-stage condition (for example, advanced Alzheimer disease) or any condition specified in the living will.

Many people believe that death is preferable to being perpetually dependent on medical equipment or having no hope of returning to a certain quality of life. Others feel just as strongly that extreme heroic measures and technology should be used to extend life as long as possible, regardless of the degree of medical intervention required or the quality of life that results. A living will allows a person to express either of these preferences (or any intermediate measure that the person finds acceptable). To be legally valid, a living will must comply with state law requirements such as those regarding how the document is signed and witnessed or what must be included in the text of the document. Many states have specific forms available for people to use if they choose. People can usually find examples of acceptable forms from hospitals and other health care practitioners, local offices on aging, or law (bar) association web sites.

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