Advance directives In: Evidence-based geriatric nursing protocols for best practice

Guideline Developer(s)

Hartford Institute for Geriatric Nursing

Date Released

2003 (revised 2012)

Evidence Supporting the Recommendations

Type of Evidence Supporting the Recommendations

The type of evidence supporting the recommendations is not specifically stated.

Implementation of the Guideline

Description of Implementation Strategy

An implementation strategy was not provided.

Implementation Tools

Mobile Device Resources

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits


Improved end-of-life decision making by talking about the completion of advance directives (ADs) before the individual loses decisional capacity


  • Increased understanding of ethical and legal aspects of ADs
  • Improved ability to discuss/educate patient and family/health care proxy on ADs


  • Increased number of patients approached about ADs
  • Increased number of patients with completed ADs in chart
Potential Harms

Not stated

Rating Scheme for the Strength of the Recommendations

Not applicable


Methods Used to Collect/Select the Evidence

Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases

Description of Methods Used to Collect/Select the Evidence

Although the Appraisal of Guidelines for Research and Evaluation (AGREE) instrument (described in Chapter 1 of the original guideline document, Evidence-based Geriatric Nursing Protocols for Best Practice, 4th ed.) was created to critically appraise clinical practice guidelines, the process and criteria can also be applied to the development and evaluation of clinical practice protocols. Thus, the AGREE instrument has been expanded (i.e., AGREE II) for that purpose to standardize the creation and revision of the geriatric nursing practice guidelines.

The Search for Evidence Process

Locating the best evidence in the published research is dependent on framing a focused, searchable clinical question. The PICO format—an acronym for population, intervention (or occurrence or risk factor), comparison (or control), and outcome—can frame an effective literature search. The editors enlisted the assistance of the New York University Health Sciences librarian to ensure a standardized and efficient approach to collecting evidence on clinical topics. A literature search was conducted to find the best available evidence for each clinical question addressed. The results were rated for level of evidence and sent to the respective chapter author(s) to provide possible substantiation for the nursing practice protocol being developed.

In addition to rating each literature citation as to its level of evidence, each citation was given a general classification, coded as "Risks," "Assessment," "Prevention," "Management," "Evaluation/Follow-up," or "Comprehensive." The citations were organized in a searchable database for later retrieval and output to chapter authors. All authors had to review the evidence and decide on its quality and relevance for inclusion in their chapter or protocol. They had the option, of course, to reject or not use the evidence provided as a result of the search or to dispute the applied level of evidence.

Developing a Search Strategy

Development of a search strategy to capture best evidence begins with database selection and translation of search terms into the controlled vocabulary of the database, if possible. In descending order of importance, the three major databases for finding the best primary evidence for most clinical nursing questions are the Cochrane Database of Systematic Reviews, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Medline or PubMed. In addition, the PsycINFO database was used to ensure capture of relevant evidence in the psychology and behavioral sciences literature for many of the topics. Synthesis sources such as UpToDate® and British Medical Journal (BMJ) Clinical Evidence and abstract journals such as Evidence Based Nursing supplemented the initial searches. Searching of other specialty databases may have to be warranted depending on the clinical question.

It bears noting that the database architecture can be exploited to limit the search to articles tagged with the publication type "meta-analysis" in Medline or "systematic review" in CINAHL. Filtering by standard age groups such as "65 and over" is another standard categorical limit for narrowing for relevance. A literature search retrieves the initial citations that begin to provide evidence. Appraisal of the initial literature retrieved may lead the searcher to other cited articles, triggering new ideas for expanding or narrowing the literature search with related descriptors or terms in the article abstract.

Number of Source Documents

Not stated

Methods Used to Assess the Quality and Strength of the Evidence

Weighting According to a Rating Scheme (Scheme Given)

Rating Scheme for the Strength of the Evidence

Levels of Evidence

Level I: Systematic reviews (integrative/meta-analyses/clinical practice guidelines based on systematic reviews)

Level II: Single experimental study (randomized controlled trials [RCTs])

Level III: Quasi-experimental studies

Level IV: Non-experimental studies

Level V: Care report/program evaluation/narrative literature reviews

Level VI: Opinions of respected authorities/consensus panels

AGREE Next Steps Consortium (2009). Appraisal of guidelines for research & evaluation II. Retrieved from

Adapted from: Melnyck, B. M. & Fineout-Overholt, E. (2005). Evidence-based practice in nursing & health care: A guide to best practice. Philadelphia, PA: Lippincott Williams & Wilkins; and Stetler, C.B., Morsi, D., Rucki, S., Broughton, S., Corrigan, B., Fitzgerald, J., et al. (1998). Utilization-focused integrative reviews in a nursing service. Applied Nursing Research, 11(4) 195-206.

Methods Used to Analyze the Evidence

Review of Published Meta-Analyses
Systematic Review

Description of the Methods Used to Analyze the Evidence

Not stated

Methods Used to Formulate the Recommendations

Expert Consensus

Description of Methods Used to Formulate the Recommendations

Not stated

Cost Analysis

A formal cost analysis was not performed and published cost analyses were not reviewed.

Method of Guideline Validation

External Peer Review
Internal Peer Review

Description of Method of Guideline Validation

Not stated

Identifying Information and Availability

Bibliographic Source(s)

Mitty EL. Advance directives. In: Boltz M, Capezuti E, Fulmer T, Zwicker D, editor(s). Evidence-based geriatric nursing protocols for best practice. 4th ed. New York (NY): Springer Publishing Company; 2012. p. 579-99.


Not applicable: The guideline was not adapted from another source.

Guideline Developer Comment

The guidelines were developed by a group of nursing experts from across the country as part of the Nurses Improving Care for Health System Elders (NICHE) project, under sponsorship of the Hartford Institute for Geriatric Nursing, New York University College of Nursing.

Source(s) of Funding

Hartford Institute for Geriatric Nursing

Guideline Committee

Not stated

Composition of Group That Authored the Guideline

Primary Author: Ethel Mitty, EdD, RN, Adjunct Clinical Professor, New York University, New York, NY

Financial Disclosures/Conflicts of Interest

Not stated

Guideline Status

This is the current release of the guideline.

This guideline updates a previous version: Mitty EL, Ramsey G. Advance Directives. In Capezuti E, Zwicker D, Mezey M, Fulmer T, editor(s). Evidence-based geriatric nursing protocols for best practice. 3rd ed. New York (NY): Springer Publishing Company, Inc.; 2008. p. 539-63.

Guideline Availability

Electronic copies: Available from the Hartford Institute for Geriatric Nursing Web site.

Copies of the book Evidence-Based Geriatric Nursing Protocols for Best Practice, 4th edition: Available from Springer Publishing Company, 536 Broadway, New York, NY 10012; Phone: (212) 431-4370; Fax: (212) 941-7842; Web:

Availability of Companion Documents

The following is available:

  • Try This® - issue D9: Decision making and dementia. New York (NY): Hartford Institute for Geriatric Nursing; 2 p. 2012. Electronic copies: Available in Portable Document Format (PDF) from the Hartford Institute for Geriatric Nursing Web site.

The ConsultGeriRN app for mobile devices is available from the Hartford Institute for Geriatric Nursing Web site.

Patient Resources

None available

NGC Status

This summary was completed by ECRI on February 2, 2004. The information was verified by the guideline developer on February 26, 2004. This summary was updated by ECRI Institute on June 23, 2008. The updated information was verified by the guideline developer on August 4, 2008. This NGC summary was updated by ECRI Institute on June 24, 2013. The updated information was verified by the guideline developer on August 6, 2013.

Copyright Statement

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.



End-of-life condition(s)

Guideline Category


Clinical Specialty

Family Practice

Intended Users

Advanced Practice Nurses
Allied Health Personnel
Health Care Providers
Physician Assistants

Guideline Objective(s)

To provide a standard of practice protocol for assisting older adults to make decisions and provide directions about the kind of medical care they do or do not want if they become unable to make decisions or communicate their wishes

Target Population
  • Hospitalized older adults
  • Nursing home residents
  • General elderly population
Interventions and Practices Considered


  1. Determination if patient has a completed an advance directive (AD) (living will [LW] or proxy)
  2. Advance care planning (ACP)
  3. Determination of decision-making capacity
  4. Assessment of ability to cope


  1. Assisting patients and families with end-of-life (EOL) care decision making
  2. Culture- and language-appropriate discussions with/education for patient and family/health care proxy about their treatment and care wishes
  3. AD forms/instructions
  4. Respecting decisions to not complete an AD
  5. Mediation of conflict between patients and family members/proxies
  6. Referrals to social work, patient advocate, or hospital ethics committee
Major Outcomes Considered
  • Number of advance directives (ADs) completed at or received upon admission to hospital
  • Number of referrals to Ethics Committee


Major Recommendations

Guiding Principles

  • All people have the right to decide what will be done with their bodies.
  • All individuals are presumed to have decision-making capacity until deemed otherwise.
  • All patients who can participate in a conversation, either verbally or through alternate means of communication, should be approached to discuss and record their treatment preferences and wishes.
  • Health care professionals can improve end-of-life (EOL) care for elderly patients by encouraging the use of advance directives (ADs).

Assessment Parameters

  • All adult patients regardless of age (with the exception of patients with persistent vegetative state, severe dementia, or coma) should be asked if they have a living will (LW) or if they have designated a proxy.
  • All patients regardless of age, gender, religion, socioeconomic status, diagnosis, or prognosis should be approached to discuss ADs and advanced care planning (ACP).
  • Discussions about ADs should be conducted in the patient's preferred language to enable information transfer and questions and answers.
  • Discussions should be conducted with sensitivity to the patient's stage of wellness and illness, that is, to their temporal as well as physical status.
  • Patients who have been determined to lack capacity to make other decisions may still have the capacity to designate a proxy or make some health care decisions. Decision-making capacity should be determined for each individual based on whether the patient has the ability to make the specific decision in question.
  • If an LW has been completed or proxy has been designated:
    • The document should be readily available on the patient's current chart.
    • The attending physician should know that the directive exists and have a copy.
    • The designated health care proxy (HCP) should have a copy of the document.
    • The directive should be reviewed periodically by the patient, attending physician/nurse, and the proxy to determine if it reflects the patient's current wishes and preferences.

Care Strategies

  • Nurses should assist patients and families trying to deal with EOL care issues.
  • Patients may be willing to discuss their health situation and mortality with a nurse or clergyman rather than with a family member and should be supported in doing so.
  • Patients should be assisted in talking with their family/proxy about their treatment and care wishes.
  • Patients should be assessed for their ability to cope with the information provided.
  • Nurses must be mindful of and sensitive to the fact that race, culture, ethnicity, and religion can influence the health care decision-making process. The fact that patients from non-Western cultures may not subscribe to Western notions of autonomy does not mean that these patients do not want to talk about their treatment wishes, or that they would not have conversations with their families about their treatment preferences.
  • Patients must be respected for their decision to not complete an AD and reassured that they will not be abandoned or receive substandard care if they do not elect to formulate an AD.
  • Nurses should be aware of the institution's mechanism for resolving conflicts between family members and the patient or proxy or between the patient/family and care providers and assist the parties in using this resource.
  • Nurses should be aware of which professional in their agency/institution is responsible for checking with the patient that copies of the AD have been given to their primary health care provider(s), to their proxy, and that the patient is carrying a wallet-size card with AD and contact information.
Clinical Algorithm(s)

None provided

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need

End of Life Care
Living with Illness

IOM Domain



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