Advance Directive Training Manual


AdvanceDirective Training Manual





Introduction 2

Legislative Implications 2

Procedure/Interventions 3

Patient/Family Agent 3

Patient Registration/Emergency Department 3

Outpatient Settings/Clinics 3

Nursing and Inpatient Care 4

Care Coordination Department 4

Physician 4

Education 5

Ethics Committee 5

Procedural Documentation 5

Conclusion 5

References 6

AdvanceDirective Training Manual


This training manual is designed to help the staff to acquireadequate information about advance directives that will help themwhen dealing with patients and when helping them to make decisionsand complete forms to those who request the use of this service asrequired under the legislative law (Doukas&amp Reichel, 2007).This manual will help the service providers as well as patients tounderstand important policy requirements by using education materialsto discuss life-sustaining treatments as well as to describe theprocedure used when patients are requesting for advance directiveservices. At the end of reading this manual, the participants will beable to do the following:

  • Identify the policy requirements for all participants and staff members who provide patients with adequate information about advance directives and also when completing forms for patients who want to use the services.

  • Identify the legislative validity during this process and making sure that the procedures are in accordance with the law and statute of Colorado.

  • Access and give adequate details about the content of significant advance care planning documents including patient or client education materials.

  • Offer significant information to help clients and patients to make informed decisions about advance training decisions in accordance to the state legislative regulations.

  • Offer adequate information to clients and patients that will help them make decisions of whether to apply a Living Will, Durable Power of Attorney or the CPR directives.

  • Illustrate the procedure used during admission of patient with existing advance directives.

  • Identify ethical implications regarding to execution of the advance directives.

The manual is intended tooffer significant information about advance directives as statedunder the law of Colorado (Colorado Department of Public Health andEnvironment, n.d.). It will offer guidelines and illustrate how thestaff and service providers offer advance directives procedures topatients to make sure that they are successfully integrated andimplemented to achieve desired outcomes.


The law of Colorado provides various guidelines and regulations thatshould be considered during the formulation or execution of theadvance directives. Some of these regulations include:

  • The State of Colorado laws necessitates that the different types advance directs must meet some conditions. For example, the living will must be signed by two witnesses who are at least not patients of the same medical facility as the patient, patient’s doctor or any employee of the facility or employee of the doctor, or agency responsible for providing patient care, any creditors of the patient or anyone who may benefit financially from the patient (Colorado Department of Public Health and Environment. n.d.).

  • All advance directives must only be used for healthcare intentions and not for financial benefits or any other form of benefits that are not based on healthcare. This causes a breach of the laws put forward by the Colorado state.

  • All advance directives will be executed once confirmed that they are valid and current. At least not older than nine months.

  • All advance directives must provide the patient with their rights.

  • The patient, family or agent can revoke the advance directives at any time as long as it is the wish of the patient.

  • The presence or absence of an advance directive does not determine the provision of healthcare (Aulisio, 2013).

Procedure/Interventions Patient/FamilyAgent

  1. It is the legal responsibility of the patient/family/agent to give a copy of the advance directive details during admission to provide important medical records.

  2. Hospital staffs are not supposed to participate in the advance directive process or witness any advance directive documents.

PatientRegistration/Emergency Department

  1. The registration staff will provide patients of age 18 years and above written patient rights during the admission process of inpatients. The rights of the patients will include the right to make their own decisions pertaining medical care treatment, including the right to accept or revoke any advance directive at any time (Aulisio, 2013). The hospital facility should share this information with any medical practitioner that will be deal with the patients. If the patient/family/agent demands for extra information or requires assistance in preparing advance directives, the staff will recommend them to the Care Coordination Department. The staff responsible for patient registration must document whether the incoming patient has any advance directive.

  2. If a patient is admitted with an advance directive, the staff will ask the patient to provide the information and documents to the nurse or doctor in charge.

  3. For admissions that require immediate medical care due to life-threatening conditions or other serious health needs, the physician or nurse will start to evaluate the patient (Doukas &amp Reichel, 2007). However, if it is evident that the patient has a CPR directive that states application of the do-not-resuscitate order/form, then those wishes will be respected and executed.


  1. During registration process of outpatients with over 18 years, the staff will provide a written piece containing the rights of the patient to the patient, family or agent. The patients’ rights include the right to revoke the advance directive at any time that they wish. It is the responsibility of the staff to determine the existence of any advance directives and/or whether a patient requires more information concerning advance directives policies

  2. When an outpatient explains that they have any form advance directive, the staff should document the type of advance directive and also ask for a copy. If the outpatient has a directive of durable power of attorney, and does not provide a copy of the derivative information, then the staff will document the directive using the name of the patient’s agent, if it is known. On the other hand, if the outpatient has a CPR directive, then the staff will have to determine whether the patient is wearing a valid DNR necklace or bracelet, and if patient has signed the CPR directive or ask the returning outpatient to give a signed original form to clarify this directive (Doukas &amp Reichel, 2007). Therefore, if the patient gives an original signed form or is wearing a valid DNR bracelet or necklace, then the staff will inform patient and counsel them on their DNR wishes that eventually need to be respected, except when the staff has concerns or queries about the patient’s DNR. In cases where the staff has concerns about the valid DNR, the staff members are recommended to contact the patient’s doctor to explain the patient’s resuscitation status.

  3. If the outpatient requires added information about advance directives, it is expected that the patient registration officials or clinic staff will offer the Hospital Shared Services of Colorado Your Right to Make Health Care Decisions pamphlet.

Nursingand Inpatient Care

  1. During the initial inpatient evaluation process, the patient’s nurse will identify the advance directive requirements on the Health Profile. In case the patient requests for additional information, the nurse or clinician will give the patient the yellow pamphlet, “Your Right to Make Health Care Decisions “, and may alert the Care Coordination Department whether the patients have inquiries and questions about the advance directives policies. In case the patient says that they already issued a copy of their Advance Directive for an earlier admission, then the nurse will search that copy from past medical records to the current situation and will confirm with the relevant patient or family whether it is still valid and current.

  2. In a case where the patient has a new advance directive that is not included in the previous advance directive or is not part of the medical record, then the staff will make logical efforts to try and obtain a current copy. This may involve requesting a family member or agent to bring in a current copy that includes all recent advance directives developed (Aulisio, 2013). This process will also be documented on the patient’s health profile.

  3. All advance directives will be respected and considered by the health facility depending on the current inpatient medical record.

  4. In case the patient is transferred to another health facility, a copy of the advance directives must be sent to the receiving health care facility and provider with the typical transfer documents.

CareCoordination Department

  1. The health social workers and counselors will give information and counseling to both inpatients and outpatients and families or agents concerning advance directives as demanded and will ensure that they document these practices in the medical record.


  1. Should it be required to execute a patient’s advance directive, the physician should evaluate the advance directive to confirm the content and its validity. The physician should also put in to consideration all document in the medical record before complying with the provisions, and notify the patient of the decision (King, 2012). In addition, the physician must also document the clinical condition, procedures and decisional capacity of the patient. He should also write down orders according to the provided provisions of the advance directives. In cases where a physician decides not to obey and execute the advance directive, he/she should notify the patient giving reasons for his/her noncompliance and transfer care to a physician who is ready to comply with the advance directives.

  2. In case that during the stay, considerable changes happen in the patient’s medical condition and in reference to the advance directive, the physician should review the advance directive, and explain to the patient, family or agent the decision (King, 2012). This should also be documented in the medical record.


  1. Advance directive certification training is included with Patient Assessment course for nursing.

  2. A patient right to acquire adequate information are part of the compulsory staff on-line training and learning programs and is usually presented at New Employee Orientation (Aulisio, 2013).

  3. In most cases members of the ethics committee including the Care Coordination Department may provide additional educational services regarding advance directives.


  1. Patients or any other concerned party may contact the Ethics Committee for discussions and consultation by calling the Administration during ordinary business hours or the Administrative Representative during afterhours (King, 2012).


  1. The present copy of the advance directive will be completed on the left side also called the outpatient side of the unit record folder.

  2. Before recording the advance directives, the processing staff will write down the account number and discharge date in the upper right corner of the advance directive copy. After this, the copy will be kept in a clear plastic envelope and stored on top of the most recent outpatient medical records. During re-admission, the earlier copy will be made accessible for patient care with the prior stay records (King, 2012).

  3. When an advance directive is amended, the existing copy will be filed on top in the clear plastic envelope.


An advance directive allowspatients to give instructions to their Designated ClientRepresentative (DCR) or an authorized representative to makehealthcare and treatment decisions as identified by the patient. Alladvance directives should be prepared and applied while consideringethical procedures. All advance directives must be used for medicalpurposes only and must confer with the legal requirements of thestate laws of Colorado (Colorado Department of Public Health andEnvironment. n.d.).


Aulisio,M. (2013). Advance Directives and the Physician-Patient Relationship:A Surprising Metamorphosis.&nbspAdvanceDirectives International Library of Ethics, Law, and the New Medicine,121-132.

ColoradoDepartment of Public Health and Environment. (n.d.). RetrievedNovember 22, 2015, from https://

King, N. (2012).&nbspMakingsense of advance directives&nbsp(Rev.ed.). Washington, D.C.: Georgetown University Press.

Doukas,D., &amp Reichel, W. (2007).&nbspPlanningfor uncertainty: Living wills and other advance directives for youand your family&nbsp(2nded.). Baltimore: Johns Hopkins University Press.