Advanced Directives are intended to communicate the wishes of a person in the area of their future health care. They are usually written in the forms of a "Health Care Proxy" or "Living Will". Occasionally, a written affidavit is provided and accepted as a legitimate substitute for the above. These documents can be specific regarding health care choices or can leave all decisions to the appointed health care agent(s).

Health care decision-making capacity (DMC) describes "a personís ability to make practical decisions about health related issues in his or her own interest, regardless of any judicially defined status (competence)". [Kapp, MB]


All residents must have their health care decision-making capacity (DMC) determined, certified and documented. The process of determining capacity is started by the MD or NP while completing the admission history and physical examination. Input from other disciplines should be considered. Specific observations made by staff and/or statements made by the resident should be documented. The certification of capacity is made and documented by the M.D. This certification can be completed at the time of admission or during the first few weeks of stay. It should be reviewed whenever there is a significant change in condition and with the annual physical examination. Certification can be changed at any time.



When determining capacity the resident should be free from treatable acute illness, delirium and/or the effects of pharmaceutical toxins.

Specific questions to consider: Yes No


Can the resident express or communicate their preferences in any way?


Can the resident understand the extent or probable consequence of treatment?


Can the resident remember information given and treatment decisions made?


Can the resident relate information to their self, values and circumstances?


Can the resident give a reason for their decision?

* If unable to check "Yes" for A, decision-making capacity cannot be determined. This should be documented and the resident is certified "without capacity" for health care decisions. If A = "Yes", questions B-E should be answered with at least two answered as "Yes" to certify the resident "with capacity" for health care decisions.

If unsure of the residentís decision-making capacity or if disagreement arises, a psychiatric evaluation should be completed.


  • Obtain copies of any existing written advance directives. Review them and discuss with resident.
  • Copies should be maintained on the chart and sent with the resident for off premise evaluations.
  • If no advance directives exist, the MD, NP, and SWA should aggressively pursue the decision regarding resuscitation (DNR) and appointing of a health care agent (HCP).
  • Facility paperwork, in compliance with the state statutes, must be completed.
  • When the capacity status changes the HCP should be activated or de-activated by the MD.
  • Status of the DNR order and HCP should be reviewed and documented with each annual physical examination.
  • Accompanying documentation is required for any change in capacity certification.
  • When an activated HCP is in place, health care decisions should be made by the appointed agent(s).

References for Advanced Directives

  1. Gallagher, SM: Competency In Informed Consent in Ostomy/Wound Management, 45(12), 1999, 10-12.
  2. Kapp, MB: Informed Consent and truth telling in Kapp MB, ed. Geriatrics and the Law, 2nd ed. New York, NY; Springer; 1990:38-40.
  3. Levenson, SA, Feinsod, FM: Determining Decision-Making Capacity and Selecting a Primary Decision Maker in Annals of Long-Term Care, Vol.6, No.11, October, 1998, 370-375.
  4. National Guideline Clearinghouse: Management of decision-making incapacity in nursing homes in Nursing Home Medicine, 4(3), 1996, 78-92.
  5. Pelligrino, ED: Decisions to Withdraw Life-Sustaining Treatment A Moral Algorithm in JAMA, Vol. 283, No. 8, February 23, 2000, 1065-1067.
  6. Rhymes, JA, McCullough, LB et al: Withdrawing Very Low-Burden Interventions in Chronically Ill Patients in JAMA, Vol. 283, No. 8, February 23, 2000, 1061-1063.



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