Postmortem,advanced directives,code status
Post-Mortem Care, Organ Procurement, Tissue Procurement, and Autopsies
Clinical Signs of Death: Absence of spontaneous heartbeat and respiration.
Post-Mortem Equipment Management:
Turn off and shut down all electronic monitors and machinery upon death confirmation.
Remove telemetry monitors from the patient in accordance with agency policy.
Follow facility-specific protocols for post-mortem body care.
Organ Procurement:
Systemic circulation and perfusion must be artificially maintained to keep solid organs viable for procurement.
Tissue Procurement:
Tissues do not require continuous systemic circulation preservation in the same manner as organs.
Preservation focuses on local moisture and thermal management (e.g., instilling eye drops to keep corneas moist, applying warmth to specified anatomical areas).
Tissues can be harvested hours after death and placed in specialized tissue banks.
Communication and Consent:
Provide accurate information and education to family members and patients regarding organ and tissue donation.
Specialized procurement coordinators typically conduct donation discussions.
Signed consent and final permission are required. In certain state jurisdictions, even if a donor signed consent prior to death, the surrogate or Durable Power of Attorney (DPOA) holds legal authority to refuse final permission, halting procurement.
Autopsies (Postmortem Examinations / Coroner's Cases):
Signed written consent is required from legal decision-makers, subject to statutory exceptions.
24-Hour Exception: Consent is not required, and an autopsy is typically automatic, if death occurs within 24 hours of admission to a hospital, nursing care center, or long-term care facility to legally determine the cause of death.
Family members may independently request an autopsy but may be required to pay the associated fees out-of-pocket.
Advance Directives and Legal Medical Orders
Legal Nature of Advance Directives:
Advance directives are legal documents specifying medical, emotional, spiritual, and personal desires regarding comfort and treatment during the dying process of a terminal condition.
Documents take effect when the patient becomes unconscious, incapacitated, or unable to speak for themselves.
Key Documents:
Living Will & Five Wishes: Documents detailing preferences for medical care, as well as emotional, spiritual, and personal wishes.
Durable Power of Attorney for Healthcare (DPOA / DPOA-HC):
Designates an agent or proxy authorized to make healthcare decisions on the patient's behalf.
Allows designation of a primary agent and a secondary (backup) agent.
POLST (Physician Orders for Life-Sustaining Treatment):
Official medical order form signed by a physician detailing specific end-of-life choices (e.g., CPR, artificial nutrition, interventions during active or imminent death).
Accessible through official state portals, such as the Illinois Department of Public Health (IDPH) website.
Do Not Resuscitate (DNR) Order:
Medical order signed by a physician detailing CPR restrictions.
Having a Living Will or DPOA does not automatically establish a DNR status or generate a POLST form; specific signed medical orders are required.
Updating and Renewal:
Advance directives, POLST forms, and DNR orders should be reviewed and renewed with the individual or family every 5 years to maintain currency and legal validity.
Code Status and Nursing Responsibilities in Clinical Practice
Documentation Requirements:
Verify whether an incoming patient has advance directives upon admission.
Obtain copies of valid advance directives, place them in the health record, and integrate them into the electronic health record (EHR).
Ensure code status (e.g., DNR) or advance directive flags are prominent in the electronic chart.
Patient and Family Education:
Encourage patients to inform family members regarding the existence and details of their advance directives.
Refer patients seeking information or creation of advance directives to the designated institutional specialist.
Code Status Management across Care Settings:
Long-Term Care / Nursing Care Centers: The majority of residents have DNR orders or POLST forms. Nurses must explicitly identify which assigned patients are Full Code.
Acute Care Settings: The majority of patients receive curative treatments and are Full Code. Nurses must explicitly identify which assigned patients are DNR or have active POLST orders.
Legal Liability and CPR:
Nurses acting in a clinical setting perform duties under professional licensure and are not protected by Good Samaritan provisions.
Performing CPR on a patient with a valid DNR order due to failure to verify code status can result in legal liability.
Illinois Health Care Surrogate Act
Applicability:
The Illinois Health Care Surrogate Act applies exclusively when an incapacitated patient lacks advance directives (no Living Will, no DPOA).
Health Care Surrogacy is a statutory legislative act, not an advance directive.
Statutory Order of Priority for Surrogates:
Guardian of the Person: Legally appointed guardian (applies to adults with severe or profound intellectual disabilities, not exclusively parents of minors).
Spouse.
Adult Children: Any adult child (defined legally as an individual over 18 years of age).
Adult Sibling.
Adult Grandchildren.
Close Friend.
Guardian of the Estate.
Restrictions on Withholding or Withdrawing Life-Sustaining Treatment:
A health care surrogate cannot direct healthcare providers to withhold or withdraw life-sustaining treatment (or execute a DNR) unless the patient is certified to have one of the following conditions:
Terminal condition/ailment.
Permanent unconsciousness.
Incurable or irreversible ailment.
Certification Requirement: Must be formally certified in writing by two physicians.
Witness Requirements:
Document signatures for advance directives or surrogate designations require an adult witness who is at least 18 years of age.
Euthanasia, Medical Aid in Dying (MAID), and Ethical Directives
National Registry:
Living wills and Five Wishes can be registered online through national registries.
American Nurses Association (ANA) Position Statements:
Maintained on topics including DNR orders, legal/ethical end-of-life care, and Medical Aid in Dying (MAID).
Euthanasia:
Defined as providing the means of death and directly acting as the instrument of death (e.g., a practitioner injecting undiluted potassium intravenously to induce cardiac arrest).
Legal Status: Illegal across the United States and classified as murder.
Medical Aid in Dying (MAID):
Defined as a physician writing a prescription for a lethal dose of medication, which the decisionally competent patient must self-administer. The clinician provides the means, but is not the instrument of death.
Permitted in select jurisdictions (including Oregon, Washington, California, Montana, and Illinois under the Bebics law effective September 2026).
Duration between self-administration and death varies, with reported cases lasting up to 18 hours.
Conscientious Objection and Nursing Obligations:
Nurses are not ethically or legally required to participate in MAID if it conflicts with personal, religious, or cultural beliefs.
Nurses exercising conscientious objection must notify management or a supervisor so patient care can be reassigned without abandonment.
Non-judgmental nursing care must be maintained for all patients regardless of end-of-life choices.
Refusal of Nutrition, Hydration, and Care Withdrawal
Legal Classification of Nutrition and Hydration:
Under United States law, artificially administered nutrition and hydration are formally classified as medical treatments.
Right to Refuse/Renounce:
A decisionally competent patient has the legal right to refuse or renounce nutrition and hydration.
Patients lacking decision-making capacity (e.g., patients with advanced dementia) cannot independently renounce nutrition or hydration; decisions fall to their designated DPOA proxy or certified surrogate.
Nursing Monitoring:
Continuous assessment of cognitive and decision-making capacity is required when a patient renounces nutrition or hydration.
Withdrawal of Care:
Ethically accepted when a patient is dying from an underlying terminal condition.
DPOA agents hold legal authority to request care withdrawal based on known patient preferences.
Terminal Condition Definition and Re-certification:
A terminal illness is defined as a chronic, progressive, incurable condition where a physician certifies death is anticipated within 6 months.
Hospice benefit re-certification intervals follow an initial 90-day period, followed by subsequent 60-day re-certification intervals (90-60-60), contingent on documented disease progression.
Preferred End-of-Life Setting:
Most hospice patients express a preference to die in their home environment.