Clinical meaning
Advance care planning is a process by which patients, in consultation with their healthcare providers and loved ones, make decisions about their future medical care in the event they become unable to communicate their wishes. The legal and ethical framework supporting advance care planning is rooted in the bioethical principle of autonomy -- the right of every competent individual to make informed decisions about their own body and medical treatment, including the right to refuse life-sustaining treatment. In Canada, advance directives are governed by provincial legislation, and terminology varies by jurisdiction. The most common terms include Do Not Resuscitate (DNR), Allow Natural Death (AND), Do Not Intubate (DNI), and Medical Orders for Scope of Treatment (MOST, used in British Columbia and other provinces). A DNR order specifically instructs healthcare providers not to perform cardiopulmonary resuscitation (CPR) -- including chest compressions, defibrillation, and advanced cardiac life support -- in the event of cardiac or respiratory arrest. It is important to understand that a DNR order does NOT mean 'do not treat.' Patients with DNR orders should continue to receive all appropriate medical and nursing care, including pain management, antibiotics, IV fluids, and other treatments consistent with their goals of care. A DNI (Do Not Intubate) order specifies that the patient does not wish to have an endotracheal tube placed for mechanical ventilation. A patient may have a DNI order but still wish to receive CPR (chest compressions and defibrillation) without intubation, or may have both DNR and DNI in place. Allow Natural Death (AND) is a term increasingly used as an alternative to DNR because it frames the decision in a more positive, patient-centered manner. AND communicates that the goal is to allow the natural dying process to occur without artificial interference, focusing on comfort and dignity. Research suggests that families are more receptive to AND terminology than DNR because it emphasizes what will be done (comfort care, symptom management) rather than what will not be done (resuscitation). Medical Orders for Scope of Treatment (MOST) forms in British Columbia, or similar provincial equivalents such as Goals of Care Designation (GCD) in Alberta, provide a more comprehensive framework that addresses not just resuscitation but the full spectrum of care interventions. These forms typically categorize care into levels: full resuscitative care (Level R or C1), medical interventions including hospital transfer but no CPR (Level M or C2), and comfort care only (Level C or C3). The practical nurse must understand several critical legal and ethical concepts related to advance directives. Informed consent requires that the patient (or substitute decision-maker) receives complete, accurate information about the benefits, risks, and alternatives to proposed treatments, including the option of no treatment. The patient must demonstrate understanding and make the decision voluntarily without coercion. Capacity assessment determines whether a patient can understand the information provided, appreciate how it applies to their situation, reason through the options, and communicate a decision. Capacity is decision-specific and time-specific: a patient may have capacity for some decisions but not others, and capacity may fluctuate. When a patient lacks capacity, a substitute decision-maker (SDM) -- identified through a power of attorney for personal care, provincial hierarchy legislation, or court appointment -- makes decisions based on the patient's previously expressed wishes or, if no wishes are known, the patient's best interests. The practical nurse's role in advance care planning includes identifying patients who may benefit from advance care planning discussions, ensuring that the patient's code status and advance directives are clearly documented and communicated to the healthcare team, advocating for the patient's wishes when conflicts arise, and providing emotional support to patients and families navigating these difficult decisions.