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Geriatric Protocol 29.1: Advanced Directives, Essay Example

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Abstract

Students are expected to familiarize themselves with their assigned nursing practice standard protocol, which has been developed for advanced directives. This must be accomplished through research based recommendations in the acute care and long-term settings. Subsequently, students are required to visit a unit in the hospital to collect data. This is in pursuance of developing appropriate skills for evaluating quality nursing care that relates advanced directive geriatric nursing standard. In the process students examined patient record(s), assessment flow sheets, policies and procedures, and observe selected patient(s) who are representative of those who would benefit from the protocol. Students also visited with key nursing staff responsible for implementing/ developing various nursing policies or clinical pathways related to advanced directives geriatric protocols in acute care and long-term settings. This document was generated as a report of my experiences fulfilling this requirement. It compares the evidenced hospital care with the geriatric advanced directive best practice protocol.

Introduction

Summary to background, epidemiology, etiology, and risk factors related geriatric advance directives

In 1990 the United States congress issued advance directives legislation being part of the OBRA 1990 initiative. The intention of this law was to provide adult patients with an opportunity to express health care wishes should they become incapable of doing so during an illness. While not providing any new patients’’ rights the law holds health care providers accountable to communicating this information to their patients’. Precisely, advance health care directives are classified in health care terminology also as personal directives living will, advance decision, advance directive. Essentially, they written statements instructing health care providers desired actions the patient/ resident/ client wish to be taken regarding his/her health in if consciousness is lost or circumstances make them incapable of making such decisions (Lambert, Gibson & Nathanson, 2000).

Importantly, Geriatric Protocol 29.1: Advanced Directives emerged from patients’ desire for more knowledge concerning advance directives generally. Patients wanted nurses and physicians to discus options with them and thirdly it was discovered that 19-36% of American completed advanced directives. They are of two types Durable power attorney (DPAC) allowing the patient to appoint a surrogate to make decisions when incapable of doing so prior to death. The next one is a living will offering a limit or withhold list (Boltz, Capezuti, Fulmer & Zwicker, 2012).

Lawrence S Wissow, Amy Belote and Janathan P Weiner (2004) evaluated applications of Geriatric Protocol 29.1: Advanced Directives in geriatric health care settings in their study ‘Promoting Advance Directives among Elderly Primary Care Patients’ Their aim was to discern efficient strategies in ‘promoting advance directives among heterogeneous populations of elderly ambulatory patients’( Wissow, Belote & Weiner, 2004, p.994). They conducted a one year quasi experimental project sampling 10 large managed care organizations and one control site. Participants were 65 years and older. They concluded that while advanced directives are important to maintaining dignity while in acute and long term care facilities only 15% to 25% of patients completed them (Wissow, et.al, 2004).

Assessment

Date	Observation	Assessment	Comparative features
On October 17^th, 2013 2p.m – 7p.m I reviewed the nursing care and chart of 85 year old Mr. M.S. who was diagnosed with hemorrhagic cerebro vascular accident In this section I will compare what I observed with the Geriatric Protocol 29.1: Advanced Directives standard	After seeking permission from the nursing manager in the intensive care unit I made the following observations pertaining to practices regarding advance directives for patients who were unconscious; on life support and incapable of making decisions for themselves. 1. Six(6) out of twelve patients were on life support machines for two weeks to date 2. 85 year old Mr. M.S. was diagnosed with hemorrhagic cerebro vascular accident and was one of the six patients on life support’s 3. Mr. M.S primary care contemplates discussing with relatives the possibility of removing the life support since the patient is unresponsive except when on the machine	Patients on Life support in the intensive care unit. In assessment of how this institution applied the Geriatric Protocol 29.1: Advanced Directives : 1. It was discovered after seeking permission to peruse these six patients’ charts that none of them had signed advanced directives. 2. Discussion with the nursing manager revealed that it was not mandatory that this is done. Only if the patient request the service then it would be initiated	My observation/assessment proved that:- 1. The institution did not make it a rule that patients be told and given any opportunity to write advanced directives according to the Geriatric Protocol 29.1: Advanced Directives regulations. 2. This is a long term acute care facility whereby according to protocol all clients/patients ought to be informed regarding the option of advanced directive during their care in the institution
On October 21^st, 2013 10 a.m. – 3 p.m. I interviewed the medical unit nursing manager and reviewed 23 patients’ charts. In this section I will compare what I observed with the 11 Geriatric Protocol 29.1: Advanced Directives standard	Interview with nursing manager medical unit, 1. The unit contains a total of 23 patients; 10 males and 13 females in separate departments. 2. Further demarcations observed were patients recovering from stoke episodes were housed separately according to gender/condition respectively 3. Patients requiring long term care for complications of diabetes and hypertension were nursed separately also Infectious disease cases were found in another section of the clinical unit away from the immediate environment of non-infectious patients. 4. After a brief discussion regarding basic clinical medical unit management, I sought permission to review the 23 patients’ charts. My intention was to discover how many of them had signed the advance Directives in their charts. These patients were between the ages of 65-76 years old 5. None of the patients reviewed had signed directives in their charts. 6. Subsequently, I discussed my observation with the nursing manager.	Interview with nursing manager medical unit 1. The nursing manager reported that when asked about advanced directives that while administration knew about it patients were not informed concerning the opportunity to write or sign one. 2. Personal she expressed as a nursing manager she felt that it was too sensitive an issue to be discussed with a patient since he/she may start thinking that death is near	OBRA 1990 law holds health care providers accountable for transmitting information concerning advanced directives. While the legislation does not add any new patients’ rights health care providers must communicate this information to their patients giving them an opportunity of making such decisions (Lambert et.al, 2000).
On October 30^th.October 30^th,2013 10a.m- 1p.m I interviewed 20 patients in the surgical unit of the institution. In this section I will compare what I observed with the Geriatric Protocol 29.1: Advanced Directives standard	Interview patients on the surgical unit 1. On my third and final visit I asked the surgical unit supervisors permission to interview a sample of patients on the unit. Age ranges of these patents were 67-87 years old. 2. This unit contained a total of 30 patients; 10 males were nursing hip replacement complications; 5 males had colostomy insertions due to lower bowel carcinomas and the remaining 15 women had end stage diabetic ankle ulcers 3. A sample of 20 patients was interviewed. They were between the ages of 70-87 years old.	Interview patients on the surgical unit 1. Patients were asked if they knew that they could request beforehand the type of health care they received if they cannot make the decision during their illness. 2. Two of the oldest patients interviewed knew. Eighteen did not know. 3. None of them ever heard about the word advanced directives.	Geriatric Protocol 29.1: Advanced Directives emerged from patients’ desire for more knowledge concerning advance directives generally. Patients wanted nurses and physicians to discuss options with them and thirdly it was discovered that only 9-36% of American completed advanced directives (Boltz et.al, 2012)

Nursing Care Strategies

Nurses ought to assist patients and their families in coping with end of life issues. In the case of 85 year old Mr. M.S. who was diagnosed with hemorrhagic cerebro vascular accident and on life support. it is the responsibility of the primary care physician and nurse to meet with relatives to discuss this end of life issue. More importantly, this is an acute long term care facility. Discussion of advanced directives should be a routine practice upon admission. Copies of the document should be in the patient’s chart when they decide to make that decision. Recommendations are that the attending physician ought to be knowledgeable about this protocol and always have available for patients or surrogates a document exhibit when discussing advance directives (Boltz et.al, 2012).

However, patients ought to be assessed before offering this information to them since some may react inappropriately to the nurse/physician being incapable of dealing with the realities of life. When they decide not to complete the directive the decisions must be respect and their integrity maintained. At the same time it is the nurse’s responsibility to assist patients in discussing the issue with relatives when thinking about making this decision (MySeniorCare, 2013).

Evaluation of Outcomes

There is no specific evaluation process for discussing advanced directives with clients. It is expected that physicians and nurses expose all adult patients/clients to the information, especially, those in long term care facilities or when patients have been have been placed hospice care. In the foregoing clinical experience nursing strategies hope to improve patients’ knowledge of the word and what it really means. In the case of 85 year old Mr. M.S doctors would have known exactly what to do soon after he was not responding without life sup[port had he written an advanced directive.

Conclusion

Summary

In summarizing my experience it is clear that the administration of this health care institution does not think that discussing advanced directives are useful nursing interventions as any other aspect of nursing care. One manager thinks that it is too sensitive an issue to discuss with patients. In such circumstances maybe the patients’ case worker could be the medium though which this information could get to patients if nurse and physician are too emotional about the subject. Ultimately it will have to be shared by someone since Geriatric Protocol 29.1: Advanced Directives makes it mandatory.

References

Boltz, M. Capezuti, E. Fulmer, T., & Zwicker, D. (2012). Evidence Based Geriatric Nursing Protocols for Best practices. Springer Publishing Company

Lambert P, Gibson, JM, Nathanson, P (2000). The Values History: An Innovation in Surrogate Medical Decision-Making, Med. & Health Care, 202-212

MySeniorCare (2013). Advanced Directives Explained. Retrieved on December 1^st, 2013fromhttp://www.myseniorcare.com/finance-and-legal/advisory-services/advanced-directives-explained-article

Wissow, L. Amy Belote, A., Weiner, L (2004). Promoting Advance Directives among Elderly Primary Care Patients. Journal of General Internal Medicine. 19(9); 994-991