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The primary outcome is completion of four key ACP behaviours: identification of a surrogate decision maker, communication about goals, completing advance directives and ensuring documents are in the medical record.

An advance directive encompasses all legal orders which concern your wishes surrounding future medical care. The document will come into play in the case of severe medical situations in which you're not able to communicate your wishes or make decisions. These may include such conditions as a coma, stroke or dementia.

If there is evidence to suggest the person has changed his or her mind for example, if they have done something that goes against the advance directivethis would make the advance directive invalid.

Get the living will and medical power of attorney forms for your state, or use a universal form that has been approved by many states. Choose your health care agent. Fill out the forms, and have them witnessed as your state requires.

Types of Advance DirectivesThe living will.Durable power of attorney for health care/Medical power of attorney.POLST (Physician Orders for Life-Sustaining Treatment)Do not resuscitate (DNR) orders.Organ and tissue donation.May 13, 2019

CONCLUSION. The critical care nurse is bound by duty to protect the patient's rights, including the patient's decision concerning treatment or withdrawal of medical care. The Advance Directive is a legally binding document writtenby a competent adult and should be carried out as such in the health care facility.

Whether you write a living will, choose a medical power of attorney, or both, you will need to make those decisions legally binding, in writing. There are state-specific forms for advance directives like these; you do not need an attorney to prepare them. You can download the forms you need.