Advance Directives and the Ethos of Good Nursing Care

Abstract

Advance directives have become increasingly visible in nursing practice over the past four decades. In many countries, they have been the subject of laws containing provisions on end-of-life issues. Accordingly, nursing research has investigated the impact of advance directives and the associated legal and ethical frameworks on nurses’ daily work. As members of a multiprofessional healthcare team in close contact with the patient, relatives and proxies, nurses take a systemic view of the process of advance planning and execution of care by means of advance directives. The basic moral premise underlying the binding character of advance directives is that the exercise of autonomy also encompasses future actions based on current preferences. This view has been fully endorsed by professional nursing bodies and nursing ethics. However, the privileged position of nurses, deriving from their proximity to patients, may give rise to moral ambiguity when there is a discrepancy of values between the content of advance directives, treatments ordered by physicians and the viewpoint of nurses involved in the delivery of care (typically in the context of dementia care). After analysing the theoretical and practical reasons for such discrepancies, this chapter formulates recommendations as to how nurses can constructively withstand this tension, guarantee the continuity of care, prevent moral distress and make a meaningful contribution to the process of interprofessional advance care planning. Tensions are likely to arise between the ethos of good nursing care, the preferences of patients and proxies, and the moral orientations of physicians and other professionals. It is important that such tensions should not be regarded as threats, but appreciated as opportunities for effective interprofessional learning.