NCLIP

Powers of Attorney and Advance Directives

3 min read

Powers of Attorney and Advance Directives

Key Points

  • Advance directives allow people to state treatment preferences before decision-making incapacity occurs.
  • Power of attorney and health care proxy designations authorize surrogate decision-making when capacity is lost.
  • Psychiatric advance directives can specify preferences for admission, medication, emergency interventions, and notification.
  • Nursing care includes education, coordination, documentation access, and advocacy for autonomy-consistent plans.

Pathophysiology

Mental health crises can temporarily impair capacity, creating urgent decision windows where prior planning improves safety and preserves autonomy. Lack of clear directives increases conflict, delay, and non-value-concordant care.

Advance-planning tools reduce ambiguity and support continuity during fluctuating clinical status.

Classification

  • Directive types: Power of attorney, living will, and health care proxy.
  • Psychiatric directive scope: Preferences for hospitalization, medication, restraint/seclusion, and contacts.
  • Activation logic: Surrogate authority applies when clinical incapacity criteria are met.

Nursing Assessment

NCLEX Focus

Verify existence, validity, and accessibility of directives before crisis escalates.

  • Assess whether directives exist, are current, and are state-compliant.
  • Assess who is designated as proxy/agent and scope limitations of authority.
  • Assess capacity status and whether activation criteria are currently met.
  • Assess client values and quality-of-life priorities documented in directives.
  • Assess family understanding and potential conflict around interpretation.

Nursing Interventions

  • Educate clients/families about directive options during stable periods.
  • Promote psychiatric advance directive completion and accessible storage.
  • Coordinate social work/legal referrals for documentation and witnessing requirements.
  • Integrate directives into care plans and interprofessional handoff routines.
  • Advocate for person-stated preferences when surrogate decisions are required.

Document Inaccessibility Risk

Valid directives are ineffective if not retrievable during emergencies.

Pharmacology

Psychiatric directives may include medication preferences and refusal boundaries. Nurses should reconcile directive guidance with current safety needs, legal standards, and prescriber decisions.

Clinical Judgment Application

Clinical Scenario

A client with bipolar disorder presents in acute mania and lacks capacity; a prior psychiatric advance directive specifies preferred medication class and a designated proxy.

Recognize Cues: Incapacity plus available directive creates actionable legal guidance. Analyze Cues: Using documented preferences may improve trust and treatment adherence after stabilization. Prioritize Hypotheses: Priority is safe treatment aligned with directive and legal requirements. Generate Solutions: Confirm document validity and involve designated proxy. Take Action: Implement crisis plan with directive-informed interventions and clear documentation. Evaluate Outcomes: Reassess stabilization, preference concordance, and care continuity.

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