Joan M. Nelson

University of Colorado, USA

Title: Advance directives: More than just a good idea?


Joan M. Nelson is an adult nurse practitioner with an active geriatric practice. She earned a DNP in 2005 from the University of Colorado where she is currently and associate Professor and teaches in both the master’s and DNP programs. She has multiple publications in the area of quality improvement and gerontology. She has served as a test writer for the American Nurses Credentialing center and is currently an evaluator for the Commission on Collegiate Nursing Education.


The evolution of advance directives paralleled technologic developments in healthcare which have made it possible to preserve life, at times at the expense of quality and dignity. Written directives were conceived as a means of empowering patients to prospectively direct their own end of life care in the event that decision making capacity was not preserved. Unfortunately, these directives have been inadequately incorporated into healthcare decisions due to less than optimal execution and implementation. Th e Patient Self Determination Act of 1990 requires that hospitals, skilled nursing facilities, home care agencies and nursing facilities that accept Medicare or Medicaid funding discuss advance directives with patients (Library of Congress, 1990). Many have advocated for the role of primary care providers in assuming responsibility for these discussions and, in fact, the National Committee for Quality Assurance (NCQA) has proposed quality indicators related to percentage of completed advanced directives within a primary care practice. In this presentation, we explore issues with advanced directives and discuss with which patients, by whom and when these discussions should occur. Strategies for improving end of life decision making are also explored.

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