Clinical meaning
Advance directives are legally recognized documents that allow competent adults to communicate their healthcare preferences in advance, ensuring their wishes are respected if they become unable to make or communicate decisions due to illness, injury, or cognitive decline. The legal and ethical foundation of advance directives rests on four core bioethical principles: autonomy (the right of individuals to make informed decisions about their own healthcare), beneficence (acting in the patient's best interest), non-maleficence (avoiding harm), and justice (fair and equitable allocation of healthcare resources). Patient autonomy is the primary ethical principle underlying advance directives, recognizing that every competent adult has the fundamental right to accept or refuse any medical treatment, including life-sustaining interventions. There are two primary types of advance directives. A living will is a written document in which an individual specifies the types of medical treatments they do or do not want if they become terminally ill or permanently unconscious and are unable to communicate. A living will may address preferences regarding mechanical ventilation, cardiopulmonary resuscitation, tube feeding, dialysis, blood transfusions, and organ donation. A durable power of attorney for healthcare (also called a healthcare proxy or substitute decision-maker) is a document in which an individual designates another person to make healthcare decisions on their behalf if they become incapacitated. The designated person (agent, proxy, or substitute decision-maker) is legally authorized to make decisions consistent with the patient's known wishes or, if wishes are unknown, in the patient's best interest. A do-not-resuscitate (DNR) order is a physician order, not an advance directive itself, that instructs healthcare providers not to perform cardiopulmonary resuscitation (CPR) if the patient's heart stops beating or they stop breathing. Similarly, a do-not-intubate (DNI) order specifies that the patient should not be placed on a mechanical ventilator. Code status refers to the level of resuscitative interventions desired: full code (all resuscitative measures), DNR only (no CPR but other treatments continue), DNR/DNI (no CPR and no intubation), and comfort measures only (CMO, focus entirely on symptom management and comfort rather than curative treatment). Medical assistance in dying (MAID) is legal in Canada for eligible adults with serious and irremediable medical conditions causing enduring and intolerable suffering. The practical nurse must understand that advance directives are legally binding documents that must be followed by the healthcare team. It is NOT within the practical nurse's scope to determine code status or witness advance directives in most jurisdictions, but the practical nurse has a critical role in identifying patients who do not have advance directives, facilitating conversations about advance care planning, ensuring that existing directives are accessible in the medical record, and advocating for the patient's documented wishes. The practical nurse must also understand mandatory reporting obligations, informed consent requirements, and the difference between withholding treatment (not starting a treatment) and withdrawing treatment (stopping a treatment already in progress) -- both are ethically and legally equivalent when consistent with the patient's wishes.