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Advance Directives &
Surrogate Decision-Making

How nurses honor patient autonomy when patients can no longer speak for themselves.

NCLEX-RN

What Is an Advance Directive?

An advance directive is a legal document in which a competent adult states their wishes about future medical care before they lose the ability to decide. It protects the ethical principle of autonomy: the patient's right to self-determination.

The Two Core Types

Living Will
Specifies what treatments a patient does or does not want (e.g., no mechanical ventilation, no tube feeding) if they are terminal or permanently unconscious.
Durable Power of Attorney for Health Care
Names a health care proxy (agent) who makes decisions on the patient's behalf when they cannot. Broader than a living will.

When Directives Take Effect

Patient has capacity? (competent & able to decide) YES Patient decides Spoken wishes rule NO Advance Directive Exists? YES Directive Activates Proxy / living will NO Use Surrogate Follow legal priority

Surrogate Decision-Making

When a patient lacks capacity and has no appointed proxy, a surrogate decision-maker is chosen following a legal hierarchy that varies by state but typically follows this priority order:

1
Legal guardian (if appointed by a court)
2
Spouse (or domestic partner)
3
Adult children (majority agreement)
4
Parents, then adult siblings, then other relatives

The Guiding Standard

A surrogate or proxy is not asked what they would want, nor what is medically convenient. They must apply the substituted judgment standard:

Don't Confuse These Documents

Advance Directive
Patient-written, future-oriented. Activates only when capacity is lost. Not a medical order.
DNR Order
A physician order in the chart. Means no CPR. Must be written by a provider, not the patient alone.
POLST / MOLST
A portable medical order for seriously ill patients, signed by both patient and provider.

The Nurse's Step-by-Step Approach

1
Assess capacity. Does the patient understand and communicate decisions right now?
2
Check for a directive. Is there a living will, proxy, or POLST in the chart?
3
Honor the patient first. A competent patient's current wishes override everything.
4
Identify the correct surrogate using the legal priority order if no proxy exists.
5
Document and notify the provider. Advocate; do not impose your own values.

Worked Example: Competent Patient

An alert, oriented 70-year-old has a living will refusing intubation. Today he tells the nurse he has changed his mind and wants full treatment if needed. What rules?

Worked Example: No Directive

An unconscious 55-year-old woman has no advance directive. Present are her spouse, an adult son, and her sister. Who is the surrogate?

Worked Example: Conflict

A patient's living will refuses tube feeding. The appointed proxy demands the feeding tube be placed anyway. What should the nurse recognize?

Common Mistakes

✕ Overriding a competent patient
Following the old directive when the alert patient has stated a new wish. Current wishes always win.
✕ Confusing DNR with a directive
A DNR is a provider order. An advance directive alone does not equal a DNR order.
✕ Letting the surrogate impose their values
The surrogate must use substituted judgment, not personal preference.
✕ Skipping the priority order
Choosing whoever is loudest instead of following the legal surrogate hierarchy.

Quick Comparison

Living Will Durable POA DNR
Created byPatientPatientProvider
Names a person?NoYesNo
A medical order?NoNoYes
Activates whenCapacity lostCapacity lostImmediately

Question 1 of 5

A competent, alert patient with a living will refusing ventilation now tells the nurse he wants to be ventilated if needed. What should the nurse do?

Question 2 of 5

An unconscious patient has no advance directive and no court guardian. Present are a spouse, an adult daughter, and a brother. Who is the legal surrogate?

Question 3 of 5

Which standard should a surrogate use when making decisions for an incapacitated patient with known values and prior statements?

Question 4 of 5

A patient's appointed proxy requests a treatment that directly contradicts the patient's valid living will. What is the nurse's best understanding?

Question 5 of 5

Which statement about a Do Not Resuscitate (DNR) order is correct?

Key Takeaways

1
Autonomy first. A competent patient's current wishes override any document.
2
Living will = what; durable POA = who. Both activate only when capacity is lost.
3
No proxy? Follow the legal surrogate hierarchy (spouse first).
4
Surrogates use substituted judgment; directives outrank surrogate preference.

You're Ready to Advocate

Honor autonomy, know the document types, and follow the surrogate hierarchy with confidence.