Comprehensive Nursing Fundamentals: Advanced Directives, Ethics, and History

Advanced Directives and Medical Orders for Life-Sustaining Treatment (MOLST)

• Decision-Making Responsibility: Individuals must make their own medical decisions while they are still capable (alert and oriented). Waiting until one is unable to make decisions necessitates the appointment of a surrogate, which may not reflect the patient's personal wishes.
• Living Will Definition: A legal document that outlines a patient's wishes regarding medical treatment in circumstances where they can no longer communicate. In New York, the living will has historically not been recognized as a strictly legal document; doctors may use it to understand patient preferences, but it is often superseded by the MOLST or health care proxy.
• MOLST (Medical Orders for Life-Sustaining Treatment):     * Scope: In New York, this is a $4$ to $5$ page form covering all advanced directives.     * Specific Orders Covered:         * CPR (Cardiopulmonary Resuscitation).         * Intubation and mechanical ventilation (including short-term trials versus long-term use).         * Transfer to hospital from a nursing home.         * Nutrition and hydration (including feeding tubes and IV fluids).         * Antibiotics.         * Comfort care.     * Physical Appearance: Historically printed on bright purple paper so it stands out immediately in a patient's physical chart.     * Validity: The form must be signed by the patient (or surrogate) and a physician to be valid. It is an actionable medical order, legal across all clinical settings, including the community (e.g., EMTs must follow it if found on a refrigerator).     * Updates: Patients can review and change the MOLST at any time as long as they remain alert and oriented.
• POLST (Physician Orders for Life-Sustaining Treatment): Used in other states; functionally identical to MOLST, but uses "Physician" instead of "Medical" in the title.
• Health Care Proxy: A designated person chosen to make medical decisions if the patient becomes incapacitated.     * Example Case: The instructor discusses choosing her son (a scientist) as a proxy over her husband because the son thinks medically/rationally, whereas the husband might insist on keeping her alive at all costs regardless of quality of life.
• Hierarchy of Surrogate Decision Makers (New York Law):     1. Spouse (unless legally separated) or domestic partner.     2. Son or daughter ($18$ years or older).     3. Patient's parents.     4. Brother or sister ($18$ years or older).     5. Close friend ($18$ years or older).

Grief, Loss, and Palliative Care

• Types of Loss:     * Maturational/Developmental Loss: Loss resulting from normal life transitions (e.g., a child moving out).     * Situational Loss: Loss brought on by external, often unpredictable events (e.g., loss of a limb, sudden job loss).     * Anticipatory Grief: Grief experienced before the actual loss occurs.
• Stages of Grief (Kübler-Ross): Stages include Denial, Anger, Bargaining, Depression, and Acceptance.
• Complicated Grief: A form of grief that is intense and long-lasting; criteria include symptoms lasting at least $6$ months, involving suicidal ideation, extreme guilt, or loss of self-esteem.
• Palliative Care: Focuses on "quality of life" and symptom management. It is not necessarily for the terminally ill; it helps patients live best with their current conditions.
• Hospice Care: Specialized care for patients with a terminal diagnosis and an expected life span of $6$ months or less. Focuses on a "peaceful and dignified death" and comfort care (e.g., using morphine to ease breathing and pain).
• Assisted Suicide: Explicitly stated as not legal in New York.
• Signs of Impending Death:     * Decreased level of consciousness.     * Cool, pale skin.     * Decreased pulse and dropping blood pressure.     * Diminished sense of touch (though pressure may still be felt).     * Labored breathing and the "death rattle" (pulmonary secretions).     * Non-reactive pupils.

Nursing History and Professional Roles

• Historical Figures:     * Clara Barton: Founder of the American Red Cross.     * Mary Mahoney: The first professionally trained Black nurse in the United States ($1879$).     * Mary Seacole: A Jamaican nurse who provided battlefield care during the Crimean War (mentioned as the nurse from Kingston).
• Nursing Shortage: A significant wave of retirements is projected for the year $2030$, necessitating a focus on recruiting replacements.
• Nursing Roles:     * Advocate: Supporting and protecting the patient's safety and rights (e.g., ensuring informed consent is truly understood).     * Collaborator: Working with the interdisciplinary/multidisciplinary team (Physical Therapy, Speech Therapy, etc.).     * Researcher: Engaging in evidence-based practice to change protocols based on current literature and studies.
• ANA (American Nursing Association) Healthy Nurse, Healthy Nation: A program with initiatives to improve nurse health in five areas: physical activity, sleep, nutrition, safety, and quality of life.

Clinical Practice and Documentation

• Documentation Models:     * PIE: Problem, Intervention, Evaluation (e.g., giving IV medication for nausea is an "Intervention").     * SOAP: Subjective (what the patient says), Objective (measurable data), Assessment (diagnosis/finding), Plan.     * Morse Risk Assessment: A specific tool used to assess a patient's risk for falls.
• Communication Protocols:     * Always ask patients what they prefer to be called; avoid informal terms like "mama," "papa," or "sweetie."     * Teach-Back Method: A way to verify patient understanding by asking them to demonstrate a skill (e.g., watching a patient self-administer insulin).
• Informed Consent: The nurse's role is to witness the signature and act as an advocate. If a patient expresses lack of understanding after the doctor leaves, the nurse must call the doctor back to explain before the patient signs.
• Clinical Ethics and Technology:     * Nurses should never share computer passwords.     * Some facilities use GPS-enabled devices (often worn around the neck) that track staff movement and can alert management if a staff member leaves the building.

Questions & Discussion

• Question: Do you have to go to a lawyer to get a MOLST?
• Answer: No. It is done at the hospital with a doctor because it is a medical order that requires a physician's signature.
• Question: Does the MOLST supersede a living will?
• Answer: In New York, the MOLST is much more precise and carries more weight as a medical order than a living will.
• Question: How does a nurse verify if a MOLST is valid?
• Answer: Check for the signatures of the patient and the physician and ensure the form is fully completed; it should be kept in the front of the paper chart or on the refrigerator if the patient is at home.
• Question: Can the patient change the form at any time?
• Answer: Yes, as long as they are alert and oriented (not delirious or suffering from advanced dementia).
• Question: What is the "insider's viewpoint" in cultural terms?
• Answer: The "emic" viewpoint. The "etic" viewpoint is the outsider's perspective.