PSDA, Advance Directives, Living Wills, Durable Power of Attorney, DNR

Patient Self-Determination Act (PSDA)

A U.S. federal law that gives patients the right to make decisions about their healthcare, including future care if they cannot speak for themselves.

NCLEX Tip for PSDA

Think: "The patient has the right to choose."

Purpose of the PSDA

Inform patients of their healthcare decision-making rights.

Purpose of the PSDA

Ask whether the patient has an advance directive.

Purpose of the PSDA

Document whether an advance directive exists.

Purpose of the PSDA

Educate staff and the community about advance directives.

Purpose of the PSDA

Respect the patient's healthcare decisions within the law.

Patient Right Under the PSDA

Accept medical treatment.

Patient Right Under the PSDA

Refuse medical treatment.

Patient Right Under the PSDA

Make decisions about their healthcare.

Patient Right Under the PSDA

Complete an advance directive.

Patient Right Under the PSDA

Choose a healthcare decision-maker if they become unable to decide.

Important Patient Right

A competent adult may refuse treatment even if refusal could result in serious harm or death.

Advance Directive

A legal document explaining a person's wishes about future medical care if they cannot communicate.

Purpose of an Advance Directive

Allows patients to make healthcare decisions ahead of time.

Purpose of an Advance Directive

Helps patients maintain control over future medical care.

Purpose of an Advance Directive

Reduces uncertainty for family members.

Purpose of an Advance Directive

Ensures healthcare providers know the patient's wishes.

Two Main Types of Advance Directives

Living Will and Durable Power of Attorney for Healthcare.

Living Will

A legal document stating what medical treatments the patient wants or does not want.

A Living Will may include decisions about

CPR.

A Living Will may include decisions about

Mechanical ventilation.

A Living Will may include decisions about

Tube feeding.

A Living Will may include decisions about

Dialysis.

A Living Will may include decisions about

Life-support measures.

Memory Trick for Living Will

Living Will = Wishes.

Durable Power of Attorney for Healthcare

A legal document naming someone to make healthcare decisions if the patient cannot.

Another name for Durable Power of Attorney

Healthcare Proxy.

Another name for Durable Power of Attorney

Healthcare Agent.

Another name for Durable Power of Attorney

Medical Power of Attorney (varies by state).

Memory Trick for Durable Power of Attorney

Power of Attorney = Person.

Nurse's Responsibility for Advance Directives

Ask whether the patient has an advance directive.

Nurse's Responsibility for Advance Directives

Place a copy in the medical record if available.

Nurse's Responsibility for Advance Directives

Respect the patient's decisions.

Nurse's Responsibility for Advance Directives

Educate the patient if requested.

Nurse's Responsibility for Advance Directives

Notify the healthcare provider if questions arise.

The nurse should NOT

Pressure a patient to complete an advance directive.

The nurse should NOT

Make healthcare decisions for a competent patient.

The nurse should NOT

Witness documents if prohibited by state law or facility policy.

Important NCLEX Fact

A patient does NOT have to have an advance directive.

Can patients refuse to complete an advance directive?

Yes.

Can family override a valid advance directive?

Generally no. The healthcare team should follow the patient's documented wishes according to law and policy.

DNR

Do Not Resuscitate.

What is a DNR?

A medical order directing healthcare providers not to perform CPR if the patient's heart or breathing stops.

Who writes a DNR?

An authorized healthcare provider according to state law.

Is a DNR the same as a Living Will?

No.

Does a DNR mean stop all treatment?

No.

Patients with a DNR still receive

Pain medication.

Patients with a DNR still receive

Oxygen when appropriate.

Patients with a DNR still receive

Comfort care.

Patients with a DNR still receive

Hygiene.

Patients with a DNR still receive

Nutrition and hydration when indicated.

Patients with a DNR still receive

Other treatments unless specifically limited.

Scenario: Patient says, "I don't want to be placed on a breathing machine if I can't recover."

Encourage the patient to discuss these wishes with the provider and consider documenting them in a Living Will.

Scenario: An unconscious patient arrives with a valid advance directive.

Follow the documented wishes and facility policy.

Scenario: A nurse asks every newly admitted patient if they have an advance directive.

This is appropriate and consistent with the PSDA.

Scenario: A patient has a DNR order.

Continue all appropriate nursing care; do not initiate CPR if the patient's heart or breathing stops.

Quick Review: PSDA

Protects the patient's right to make healthcare decisions.

Quick Review: Advance Directive

Legal document stating future healthcare wishes.

Quick Review: Living Will

States what treatments the patient wants or refuses.

Quick Review: Durable Power of Attorney

Names who makes healthcare decisions if needed.

Quick Review: DNR

Medical order directing that CPR not be performed.

Quick Review: Nurse's Role

Ask, document, respect patient wishes, educate if requested.

Memory Trick

PSDA = Patient Says, Decisions Apply.

Memory Trick

Living Will = What the patient wants.

Memory Trick

Power of Attorney = Who decides.

Memory Trick

DNR = No CPR, NOT No Care.

NCLEX Tip

If a question asks about patient rights, support the competent patient's informed decisions unless limited by law or ethics.

Requirement to Complete an Advance Directive

The patient must generally be an adult or otherwise legally authorized under state law.

Requirement to Complete an Advance Directive

The patient must have decision-making capacity.

Requirement to Complete an Advance Directive

The patient must sign voluntarily without coercion.

Advance Directive vs DNR

Advance Directive = Legal document. DNR = Medical order.

Advance Directive vs DNR

Advance Directive covers future healthcare wishes. DNR applies only if breathing or heartbeat stops.

Advance Directive vs DNR

Advance Directive may include a Living Will and Healthcare Proxy. DNR only directs no CPR.

Scenario: Patient asks, "Can my daughter make decisions if I'm unconscious?"

Yes, if she has been legally designated as the Durable Power of Attorney for Healthcare.

Scenario: A patient with a DNR develops pneumonia.

Treat the pneumonia unless the patient has declined that treatment. A DNR only prevents CPR.

NCLEX Pearl

A DNR means no CPR—not no medications, no oxygen, or no nursing care.