Make future-care preferences accessible
Advance care planning is a discussion about future decisions if a person cannot make or communicate them. The National Institute on Aging distinguishes a living will, which records treatment preferences, from a durable power of attorney for health care, which names a decision maker. The documents serve related but different purposes.
For nurses, a practical concern is whether the current team can find the relevant documents and understand what still needs clarification. The legal effect of a document, its activation and the authority of a named agent depend on the instrument and applicable law.
Ask about documents and conversations
Use the organization’s admission or review process to find out whether advance-care documents exist, where copies are located and whom the patient has asked to participate. A document at home may be unavailable when a decision is needed; help the team follow its process for obtaining and recording it.
Useful review questions include:
- Is the available copy complete and readable?
- Is there a newer document or a reported change in preferences?
- Who is named, and are contact details available?
- Does the current clinical situation raise a question about applicability?
- Has the responsible clinician reviewed the preferences with the patient or appropriate decision maker?
Do not try to resolve an unclear legal document by guessing from its title. Bring uncertainty to the designated clinical, social-work, ethics or legal resource.
Separate preferences from implementation
The AMA’s advance-directive guidance calls for documenting goals, incorporating available directives into the record and entering orders that implement treatment decisions. This distinction matters: finding a living will is not the same task as confirming the current orders governing care.
In a fictional admission, a family brings a document expressing broad preferences while the electronic chart contains an older care plan. The nursing task is to make the discrepancy visible and obtain clarification through the responsible team. It is not to assume that either document automatically settles every current intervention.
Check that relevant decisions and documents are communicated during transfer. Ask where the receiving team will find them and who will address unresolved questions.
Keep planning open to revision
NIA encourages people to revisit advance planning as life and health change. Treat the conversation as an opportunity to understand the person’s values, rather than merely complete a form requirement.
If the patient has decision-making capacity for the current decision, ask about their present wishes. The AMA’s ethics guidance states that an advance directive does not override those wishes. Continue to involve patients whose capacity is limited to the extent they can participate. If relatives disagree about an earlier preference, record the issue and use the appropriate decision-making process. Surrogate decision makers and ethics consultation cover those related situations. This article supports document handling and communication; it does not prescribe an individual treatment choice.
Sources
- National Institute on Aging: Advance Directives for Health Care (accessed 2026-09-17).
- AMA Code of Medical Ethics: Advance Directives (accessed 2026-09-17).