NURS 445 Week 6 Discussion Board Forum 5 Example

Discussion Board Forum 5: Advance Care Planning With Older Adults

NURS 445 Contemporary Issues in Nursing and Healthcare, Discussion Board Forum 5

Thread by [Student Name]

The patients and classmates are composites; the textbook and journal articles cited are real.

During my senior mentor interviews, Mr. R., who is 84, asked me what an advance directive was and whether he needed one. We talked for twenty minutes about what he would want if he could not speak for himself, and he decided to bring it up with his doctor. A month earlier, at work, I had cared for a 91-year-old woman admitted with pneumonia who suddenly needed a decision about intubation. She had no advance directive and had never told her children what she wanted. Her son wanted everything done; her daughter said, "Mama would never want a machine." They argued in the hallway while the respiratory therapist waited, and the physician finally asked the son and daughter to decide together within the hour. They chose intubation. She died four days later on the ventilator, and her daughter told me on the last day that she would always wonder whether they had done what her mother wanted.

Mauk (2018) describes advance directives, including living wills and the appointment of a health care agent, as tools that let older adults guide their care when they cannot speak, and stresses that the conversations behind them matter as much as the documents. The difference between my two patients was not the form. It was whether anyone had asked the question while there was still time to think about it.

I had assumed advance care planning meant helping an individual state their own wishes. Putker et al. (2026) challenged that assumption. Interviewing patients with an Islamic migration background receiving palliative cancer treatment in the Netherlands, along with cultural experts and clinicians, they found that decision-making was predominantly family-driven and that patients relied on relational autonomy through their families, though preferences varied by generation. The cultural and religious meaning of illness shaped how patients understood the end of life. The authors recommend asking patients what role they want their families to play rather than assuming individual decision-making is the default. My 91-year-old patient's family might have been spared their hallway argument if anyone had asked her, years before, who should decide and how.

I want to start these conversations earlier and differently. Nurses can ask, during routine admissions, "If you became too sick to speak for yourself, who would you want to make decisions for you?" We can ask whether the person has talked with that person about their wishes. And we can ask how the person's family usually makes important decisions. These questions take less than two minutes, can be repeated at each admission and do not require a nurse to complete any form. They simply start the conversation that the documents depend on, and they let the patient decide how far to take it. When a patient says, "I've never thought about that," the most helpful response may be to suggest talking it over with family before the next visit. A good plan for the end of life is usually made in a kitchen, not an intensive care unit.

Reply to Nadia

Nadia, you described physicians on your unit who rarely refer older Arab patients to palliative care and wondered why. Natour Hleihel and Sperling (2026) explored exactly this question through interviews with 26 Arab physicians and nurses in Israel and found that cultural and religious factors, including religiosity and anxieties related to death, shaped clinicians' decisions about whether and when to refer patients to palliative care. That suggests the barrier may lie partly in the clinicians, not only in patients or families. Mauk (2018) stresses that palliative care focuses on comfort and quality of life and can be offered alongside other treatment, which might be a helpful way to reframe referral for clinicians who hear "palliative" as "giving up." Would your unit be open to a case review in which the palliative team discusses how referral helped a family? Hearing from a family who benefited might persuade colleagues more than any policy.

Reply to Logan

Logan, I appreciated your honesty that you avoid end-of-life conversations because they make you anxious. Many nurses feel the same way. Kayikci et al. (2026) studied palliative care nurses and found moderate levels of death anxiety alongside high spiritual care perceptions and positive attitudes toward caring for the dying; spiritual care perceptions, education level and end-of-life care training predicted more positive attitudes. That suggests the anxiety is not a fixed trait. Training and reflection on our own beliefs about death may make these conversations easier. Mauk (2018) presents end-of-life care as a core gerontological competency, which means it is a skill we can learn rather than a gift some nurses have. Have you had any end-of-life communication training, and would your educator offer it if several nurses asked? Practicing a few opening questions with a colleague, before using them with a patient, might also take some of the anxiety out of the first real conversation.

References

Kayikci, E. E., Savci, C., Cil Akinci, A., & Dincer, B. (2026). Death anxiety, spiritual care perceptions, and attitudes toward caring for the dying among palliative care nurses. Journal of Hospice and Palliative Nursing, 28(4), E155-E161. https://doi.org/10.1097/NJH.0000000000001200

Mauk, K. L. (Ed.). (2018). Gerontological nursing: Competencies for care (4th ed.). Jones & Bartlett Learning.

Natour Hleihel, N., & Sperling, D. (2026). Cultural, religious, and demographic factors shaping Arab healthcare providers' decisions on referring Arab patients to palliative care in Israel: A qualitative study. BMC Medical Ethics, 27(1). https://doi.org/10.1186/s12910-026-01383-w

Putker, A., Haddane, A., Engels, Y., Kuip, E., & Perry, M. (2026). Advance care planning with patients of Islamic migration background: A qualitative study identifying the need for relational autonomy and hope-sustaining communication. BMC Palliative Care, 25(1). https://doi.org/10.1186/s12904-026-02207-9