When it comes to long-term care facilities, advance directive planning allows seniors to have a say in their own future medical treatment. It’s vital that senior care administrators know what advance directives are, why they’re needed, and how to use them in their own communities. By taking the time for advance directive planning, facilities can provide the best assistance to their residents while respecting their medical wishes.

Advance Directive Overview

What are Advance Directives?

Advance directives are documents that state what type of medical treatment an individual desires in the event that they cannot communicate to request or deny treatment. These documents are drawn and signed ahead of time to prepare for the possibility of life-threatening accidents or age-related health issues that may result in death.

Advance directives often include a living will and an appointed healthcare power of attorney. A living will details what kind of medical treatment (if any) a patient wishes to receive if they can no longer make their own medical decisions. The healthcare power of attorney, (also known as a healthcare proxy, appointment of healthcare agent, or durable power of attorney for healthcare) is the person a patient selects to make their medical decisions if they are unable to do so.

Why is Advance Directive Planning Important?

someone sitting beside a patient with a heart monitor attached to their hand, holding handsPlanning ahead is always important, but it’s even more so for advance directives. Advance directives allow individuals to request or deny a specific type of medical treatment if they are nearing the end-of-life. If a patient is in medical distress, cannot communicate, and has no record of an advance directive, living will, or power of attorney, medical decisions fall on the shoulders of the default surrogate. Surrogate decision makers are appointed by a designated list that generally begins with a spouse and ends with a physician and ethics committee. Keep in mind that the list hierarchy for default surrogates can vary by state.

According to the Institute of Medicine, 40% of adult patients, 69% of nursing home residents, and 70% of older adults are not able to communicate their own decisions about their care when faced with medical treatments. In addition, older patients who are in distress and need end-of-life care are seen by doctors that don’t know them and aren’t aware of their medical wishes. Having an advance directive relieves the emotional burden that would otherwise be put on family, close friends, and medical staff making decisions on a patient’s behalf.

The Main Issues with Advance Directives

1. Many People Still Don’t Have Advance Directives

As of 2017, two-thirds of the American adult population hasn’t created advance directives for end-of-life care. Furthermore, reports indicate that the treatments Americans would choose for end-of-life care are often different from treatments they actually would have received. Due to this disconnect, unnecessary and prolonged suffering may occur.

It’s incredibly important that all individuals (even those who don’t have a chronic illness) fill out an advance care plan form to express their wishes. By doing so, patients can ensure that they receive the medical treatment that they would ultimately want.

2. Emergency Personnel May Not Be Aware of Advance Directives

When 9-1-1 is called for medical emergencies, responders are focused on performing life-saving procedures. Advance directives are rarely even a thought in their minds, which may lead to medical treatment that goes against an individual’s wishes.

Some states have worked to minimize this issue with a Physician Orders for Life-Sustaining Treatment (POLST) program. POLST programs are electronic registries that provide emergency workers and hospitals with 24/7 online access to individual advance directive files. With the program, people are very likely to have their medical wishes granted.

3. Advance Directives Can Be Ignored

While it’s strongly encouraged that everyone complete and provide an advance directive to healthcare providers and family members, they can be ignored.

A resident of the Golden Hill Care Center in Kingston, New York went into respiratory distress. Patricia Smithmyer, a registered and supervising nurse, was called to the room. When the resident stopped breathing, the nurse failed to administer Cardio Pulmonary Resuscitation (CPR), and the resident passed away. Here are the problems with the case:

  • Problem #1: The resident and resident’s family specifically indicated on an advance directive that medics should do whatever they can to sustain the resident’s life. Smithmyer did not perform adequate procedures to stabilize the resident.
  • Problem #2: Golden Hill Care Center’s protocol stated that life-saving procedures should be used unless the resident has a known advance directive stating otherwise. Smithmyer did not perform CPR, which may have allowed the resident to breathe again.
  • Problem #3: Smithmyer lied to investigators after the incident occurred. She stated that she was not in the room when the resident stopped breathing and passed away, but detectives found that wasn’t true.

In the end, Smithmyer was charged with falsifying records and willfully violating health laws. She pled guilty under a plea agreement and was sentenced to conditional discharge which required her to give up her nursing license and complete 150 hours of community service.

Advance Directives & Senior Care

Advance Directive Planning for Senior Care Facilities

Here’s the good news! A new strategy is being put in place to increase the number of advance care directives being created. Starting in 2019, doctors will be financially penalized based on whether or not they have advance directives on file for their Medicare patients.

In order to avoid a 4% cut in their funding, healthcare providers will need to discuss advance care plans with patients and talk about naming a surrogate decision maker. Doctors will also need to document the outcome of the discussion and report it.

This new strategy will benefit assisted living and senior care communities because most healthcare providers will want to refer to facilities that take the time to discuss advance directives. It will essentially relieve doctors of the added responsibility, thus making it important for senior care facilities to have a program in place for creating advance directives and filing them correctly.

4 Advance Directive Tips for Senior Care Administrators

Discuss the Implementation of an Advance Directive Program

  • Will you require an advance directive from new residents prior to them moving into your community?
  • How will you go about obtaining advance directives from your current residents?
  • Where will you file the advance directive information?
  • Who will have access to the advance directive information?
  • Who and/or what organizations will you report the documents to?
  • How often will you revisit each resident’s advance directive information for updates?

Be Aware of the Most Common End-Of-Life Medical Decisions

  • CPR | Cardio Pulmonary Resuscitation — Procedure used to restart an individual’s heart and breathing.
  • DNR | Do Not Resuscitate Order — Written order provided by a doctor (at the request of a patient or their family) that instructs medical teams not to attempt CPR on the specified individual.
  • DNI | Do Not Intubate Order — Order that allows medical teams to perform CPR and use cardiac drugs to revive an individual, but restricts them from using a breathing tube.
  • Artificial Nutrition & Hydration — Provides individuals with a balanced mix of nutrients and fluids via a tube placed in the stomach, upper intestine, or vein.

Know the Steps for Advance Directive Planning

  1. Obtain the legal advance directive paperwork from a healthcare provider, attorney, your local area agency on aging, or your state health department.
  2. Discuss end-of-life treatment options with residents.
  3. Document each resident’s wishes on the legal paperwork.
  4. Make copies of the advance directives and ensure they’re stored where they can easily be found.
  5. Send copies of the advance directives to healthcare proxies, healthcare providers, hospitals, and family members of the resident.
  6. Make it clear (in files, on assisted living bedroom doors, etc.) what advance directives have been indicated so medical staff can be aware of each resident’s wishes.
  7. Set reminders to review and update residents’ advance directives each year as necessary.

Provide Senior Care Staff with Proper Training

Administrator Level 1 Manual

A Management Reference for Executive Directors

This resource covers:

  • Advance directive basics
  • Informed consent
  • How to discuss advance directives with residents

Want more information? Be sure to check out our in-depth manual on End-of-Life Care in Assisted Living and the other resources we offer that are specifically designed for administrators and managers.