The intent of this position statement is to provide clarification about the role of the registered nurse (RN) in end-of-life decision making.
It is the position of the New York State Nurses Association that:
Nursing care involves a ‘privileged intimacy’ allowing for direct physical and interpersonal contact with patients (ANA, Nursing’s Social Policy Statement, 2nd Ed., 2003). It is through this professional closeness that RNs establish partnerships with patients in order to collaboratively coordinate the care provided. RNs often face ethical dilemmas concerning confusing or conflicting end-of-life decisions, especially with regards to DNR orders. End-of-life decisions, or advance directives (AD), should reflect what the patient desires with regard to medical and/or surgical interventions at the time of a life-threatening event.
According to Public Health Law, adults in New York State have the right to accept or refuse medical treatment, including life-sustaining treatments (Public Health Law §2803-C, 3e). In addition, a competent adult may appoint a healthcare agent to make decisions for him or her in the event the patient is incapable of doing so (Public Health Law §2962). The Patient Self-Determination Act (PSDA), part of the Federal Omnibus Budget Reconciliation Act of 1990, requires that all individuals receiving medical care must be given written information about their rights under state law to accept or refuse medical or surgical treatment and their right to formulate advance directives. The PSDA was designed to foster discussion about end-of-life issues between patients, their families, and primary care providers, however, it is estimated that only 5% to 20% of the nation’s population have executed an advance directive (Bunting, 2000).
The reasons for not completing an advanced directive are varied; therefore RNs play a primary role in communicating with patients and their families these rights and facilitating end-of-life decisions at the earliest time possible and preferably before the immediate need arises. The determination of advanced directives is an important decision and RNs can be most effective in ensuring these informed decisions are made within the context of patient’s own values and beliefs. RNs must also exercise their role as patient advocate to ensure that patients are not coerced into signing documents against their will or when incompetent, to ensure that patient rights are protected, and to ensure all healthcare providers adhere to the expressed wishes of the patient (Bunting, 2000).
In order to facilitate timely and informed end-of-life decision making for the patient, the New York State Nurses Association recommends that:
End-of-life decisions: Decisions impacting the choice of medical or surgical intervention(s) or palliative care at the time when death is imminent.
Advanced directives: The means used to document and communicate a person’s preferences regarding life-sustaining treatment in the event they become incapable of expressing those wishes for themselves.
Living Will: A written document that specifies what life-sustaining treatments a person would want or not want in given situations.
Healthcare proxy: A written document that identifies who is to make healthcare decisions if the person becomes incompetent.
Do Not Resuscitate (DNR): A DNR order is another kind of advance directive. A DNR is a request not to have cardiopulmonary resuscitation (CPR) if your heart stops or if you stop breathing.
Patient Self-Determination Act (PSDA): Law passed as part of the Omnibus Budget Reconciliation Act of 1990 mandating patient participation in medical decision-making.
Patient: Intended to be generic and reflects that of patient, client and/or resident.
Approved by the Board of Directors on 9/27/83, 3/31/89 and 6/8/06; Reviewed/revised by the NYSNA Council on Ethical Practice/Council on Human Rights on 05/01/06.
Note: The use of the term “patient” anywhere in this document is intended to be generic and refers to the recipient of nursing care.
American Nurses Association. (2001). Code of Ethics for Nurses with Interpretive Statements. Silver Spring, MD: Author.
American Nurses Association. (1991). Ethics and human rights position statements: Nursing and the patient self-determination acts. Retrieved April 12, 2006, from http://www.nursingworld.org/readroom/position/ethics/prtetsdet.htm
American Nurses Association. (2004). Position statement on nursing care and do-not-resuscitate (DNR) decisions. Washington, DC: Author.
American Nurses Association. (2004). Nursing: scope & standards of practice. Washington, DC: Author.
American Nurses Association. (2003). Nursing’s social policy statement. (2nd Ed.). Washington, DC: Author.
Bunting, R. F., & Benton, J. (2000). Advanced directives: what every nurse needs to know. The Journal of Nursing Risk Management 2000. Retrieved April 11, 2006, from http://www.afip.org/departments/legalmed/jnrm2000/directives.htm
Canadian Nurses Association. (1998, May). Advance directives: the nurse’s role. Ethics in Practice. Retrieved April 20, 2006, from http://www.cnanurses.ca/cna/documents/pdf/publications/Ethics_Pract_Advance_Directives_May_1998_e.pdf
Habel, M. (2006). Advanced directives: an unrealized goal. Retrieved April 11, 2006, from http://www2nursingspectrum.com/ce/self-study_modules/tools/print.html?id=339
New York State. (2005). Health care proxy. Appointing your health care agent in New York State. Retrieved April 17, 2006, from http://www.health.state.ny.us/nysdoh/hospital/healthcareproxy/intro.htm
New York State. (2002). Your rights as a hospital patient in New York State. Planning in advance for your medical treatment. Retrieved April 17, 2006, from http://www.health.state.ny.us/nysdoh/hospital/english3.htm
New York State Nurses Association. (2005). Planning for care at the end of life. Latham, NY: Author.
For more information on nursing practice, contact NYSNA's Education, Practice and Research Program at 518.782.9400, ext. 282 or by e-mail.