Nurses in the Know: The History and Future of Advance Directives

Blanca Miller, PhD, RN


Online J Issues Nurs. 2017;22(3) 

In This Article

Abstract and Introduction


Health crises are unpredictable. Nurses have a role in promoting advance directives that is increasingly important. The aging population is increasing and individuals are living longer and often seeking healthcare alone. Nurses must understand the history and nature of advance healthcare directives to help patients make informed decisions prior to a crisis. Major milestones in the history of advance directives have resulted from cases of healthy, young people in their twenties. This article defines advanced directives, and discusses the evolution of patient self-determination as a concept and the Patient Self-Determination Act. Federal law and varied state laws, some still evolving, and the American Nurses Association Code of Ethics together define nurses' ethical obligations to educate patients and advocate for their legal right to self-determination.


Too often nurses in the United States (U.S.) find themselves caring for patients who, assuming the end of life to be far in the future, have made no indication of their wishes regarding treatment options, resuscitation, or the preservation of life through artificial means. Although conversations with patients and families about end-of-life decision-making are usually initiated by physicians, nurses are often left to discuss these topics in more depth, and during less than ideal circumstances (Giovanni, 2012).

Trying to educate patients and help them complete an advance healthcare directive in the midst of a crisis is inappropriate because they are not in an ideal state of mind to make competent decisions. In these circumstances, it is no longer an advance directive, but a crisis directive. Advance directives may seem a concern primarily for gerontological nurses. However, the unpredictability of crises means that all nurses need to understand the history and nature of advance directives to help patients and families make informed decisions about the end of life and advocate for themselves prior to an emergency situation.

The American Nurses Association (ANA) expects nurses to encourage advance care planning among patients. The ANA Code of Ethics with Interpretive Statements requires nurses to provide patient education about advance care planning and be knowledgeable enough to discuss different types of advance directive forms (ANA, 2015). Yet nursing education typically includes little content about these highly sensitive and emotional matters, and many nurses feel unprepared for the responsibility of answering questions and helping patients understand their options. In several studies, nurses attributed their low levels of confidence in helping patients and families understand advance directives to their own inadequate knowledge of, preparation for, or experience with advance directives (Attia et al, 2012; Casdorph et al, 2009; Reinke et al, 2010; Samara, Larkin, Chan, & Lopez, 2013). Nurses who do feel comfortable helping patients fill out basic forms say their confidence decreases as they try to help patients face more complex issues (Ryan & Jezewski, 2012). Since nurses attribute their lack of confidence to inadequate preparation, increasing their understanding will hopefully lead them to feel more comfortable and confident addressing these issues; more willing to advocate for their patients; and more likely to succeed in encouraging patients to discuss and plan for end-of-life care