NURS 519 Week 3 Discussion Board Forum 2 on Advance Care Planning Example

Discussion Board Forum 2: Advance Directives, POLST and Preferences That Shift

NURS 519 Strategies for End of Life Care, Discussion Board Forum 2

Thread by [Student Name]

The patient example and the classmate replied to are composites written for a model discussion.

We often treat a signed advance directive as the finish line of advance care planning. This week's reading and a recent review persuaded me that it is closer to a starting point, and that nurses are well placed to keep the conversation going.

Three documents are often confused. An advance directive is the person's own statement, which may include a living will describing treatments they would or would not want and a health care power of attorney naming an agent to decide if they cannot. Physician Orders for Life-Sustaining Treatment, known as POLST, work differently: it is a medical order, signed by a clinician, for a person with serious illness, and it travels with the patient so that emergency crews and hospitals can act on it (Matzo & Sherman, 2018). The directive speaks for the future; the medical order governs care now.

The difficulty is that preferences change. In a systematic review of 25 studies involving 5,711 seriously ill patients in seven countries, Murali et al. (2025) found that in 10 studies at least half of patients changed their end-of-life goals or preferences over time. Changes in health, emotions and understanding of prognosis drove the shifts, and studies that asked more often detected more change. Prior advance care planning did not make preferences more stable, which suggests that a document signed months ago may not reflect what a patient wants today. The authors argue that advance care planning should be reframed as ongoing preparation for decisions made in real time.

I have seen this. A composite patient with chronic obstructive pulmonary disease signed a directive refusing intubation after a frightening admission, then, a year later and feeling better, told me they would accept a short trial of a ventilator to see a grandchild's wedding. Neither choice was wrong; they reflected different moments. If no one had asked, the earlier document would have guided care.

For nurses, the implication is practical: revisit goals at every transition, such as admission, a new diagnosis or decline, and discharge. A simple question, "Has anything changed about what matters most to you?", can reveal shifts, and documenting the answer and alerting the team keeps orders current. Preparing the health care agent matters just as much, because the agent will face decisions no form anticipated.

The psalmist wrote, "My times are in your hand" (English Standard Version Bible, 2001/2016, Psalm 31:15). Our patients' futures are uncertain to them and to us. Advance care planning cannot remove that uncertainty, but walking with patients through it, and helping them prepare their families, is a way of honoring both their choices and the One who holds their times.

Reply to Jordan

Jordan, your point that advance care planning conversations happen too late, often in a crisis, matches what I see, and I agree nurses could start them earlier. One study suggests nurses can lead them even in a busy emergency department. Bigelow et al. (2024) trained experienced emergency department nurses, each with three or more years in that setting, to hold goals-of-care conversations with seriously ill adults, such as those with heart failure, advanced lung or kidney disease, or metastatic cancer. Of 133 patients approached, 94 agreed; every conversation was documented in the record, and half of the patients who arrived without a portable medical order left with one. Satisfaction was high, with 95% of surviving patients rating the experience 4 or 5 out of 5. Hospitalizations and intensive care admissions did not change significantly, which reminds us that a conversation is a means of respecting wishes, not a cost-saving tool. Combined with the evidence that preferences change, this supports your idea of making goals a standing nursing question rather than a one-time physician task. Did your unit consider scripting a goals question into the admission assessment, and would the nurses on your floor feel prepared to ask it?

References

Bigelow, S., Medzon, R., Siegel, M., & Jin, R. (2024). Difficult conversations: Outcomes of emergency department nurse-directed goals-of-care discussions. Journal of Palliative Care, 39(1), 3-12. https://doi.org/10.1177/08258597221149402

English Standard Version Bible. (2016). Crossway. (Original work published 2001)

Matzo, M., & Sherman, D. W. (Eds.). (2018). Palliative care nursing: Quality care to the end of life (5th ed.). Springer Publishing Company.

Murali, S., Poco, L. C., & Malhotra, C. (2025). Instability in end-of-life goals and preferences of patients who are seriously ill: A systematic review. JAMA Network Open, 8(11), Article e2541264. https://doi.org/10.1001/jamanetworkopen.2025.41264