In the skilled nursing setting, few topics are as important—yet as frequently postponed—as advance care planning. Advance directives serve as essential guides for ensuring that the care provided to residents aligns with their personal values, goals, and preferences. They are not just legal documents; they are powerful tools for honoring autonomy, reducing stress for families and staff, and improving the quality of end-of-life care. This post explores why advance directives are crucial in skilled nursing, how to approach conversations about them, how to assist residents and families in completing them, and how to incorporate them meaningfully into care plans.

What Are Advance Directives?

Advance directives are legal documents that communicate a person’s wishes regarding medical care if they become unable to communicate for themselves. Common types include:

• Living Wills – Specify the types of medical treatments a person wants or does not want at the end of life.
• Durable Power of Attorney for Healthcare (Healthcare Proxy) – Appoints someone to make healthcare decisions on the person’s behalf.
• POLST (Physician Orders for Life-Sustaining Treatment) – A medical order reflecting a patient’s preferences for treatment, particularly useful in long-term care settings.

While the terminology and forms can vary by state, the purpose is universal: to ensure that care aligns with the individual’s desires.

Why Are Advance Directives Essential in Skilled Nursing?

1. Respect for Resident Autonomy Many residents enter skilled nursing at a vulnerable stage in life. Honoring their choices about treatment is a cornerstone of ethical care. Advance directives offer a structured way to document and honor these choices.
2. Reducing Emotional Burden on Families When a resident becomes unable to speak for themselves, family members are often asked to make difficult decisions. If the resident’s preferences are not clearly documented, loved ones may experience guilt, conflict, or regret. Advance directives relieve that pressure by making the resident’s wishes known in advance.
3. Clarity for Staff Clinical teams benefit from knowing the resident’s values and goals, especially in emergencies. A clearly documented advance directive ensures that treatment plans align with what the resident would have wanted, reducing uncertainty and moral distress among staff.
4. Regulatory Compliance and Risk Management Federal and state regulations require that healthcare facilities inquire about advance directives upon admission. Documenting these efforts protects the facility legally and ensures adherence to professional standards of care.

How to Ask Residents About Advance Directives

Starting conversations about advance directives can feel daunting, but it doesn’t have to be. Skilled nursing professionals are in a unique position to normalize these discussions and build trust through empathy and clear communication.

Timing Matters

The best time to introduce the topic is early—ideally during the admission process or within the first care planning meeting. Delaying until a health crisis arises limits the resident’s ability to participate fully in decision-making.

Use Clear and Compassionate Language

Avoid jargon and be sensitive to cultural or emotional reactions. Try something like:

“Part of our responsibility is to make sure we understand your wishes for medical care—especially in situations where you might not be able to speak for yourself. Have you already filled out any advance directive forms, like a living will or a healthcare proxy?”

If they haven’t, continue with:

“Would you like help learning more about how to create one? We’re here to support you with that.”

Normalize the Process

Position advance directives as a standard part of high-quality care:

“Just like we ask about medications and allergies, we ask everyone if they have an advance directive. It helps us care for you in the way that matters most to you.”

How to Offer Assistance in Creating Advance Directives

Once the conversation is started, residents and families may need support in understanding their options and completing the necessary paperwork.

Provide Educational Materials

Have user-friendly handouts available in multiple languages that explain the types of advance directives, how they work, and why they matter. These materials should be simple, culturally sensitive, and written at an accessible reading level.

Involve Social Workers or Chaplains

Interdisciplinary team members can offer additional support, including helping residents reflect on their values, beliefs, and goals. Chaplains, for instance, may provide spiritual guidance that informs end-of-life preferences, while social workers can walk residents through the legal and logistical steps.

Host Advance Care Planning Workshops

Group sessions or family nights dedicated to advance directives can demystify the process and create space for questions. These sessions can be scheduled monthly or quarterly and may feature guest speakers such as elder law attorneys or palliative care nurses.

Offer One-on-One Support

Some residents may need more personalized assistance. Designate a staff member—such as a nurse, social worker, or admissions coordinator—as the point person for advance directives. Ensure they are trained in having these sensitive conversations and know the legal requirements in your state.

Incorporating Advance Directives into the Plan of Care

Advance directives are not “set it and forget it” documents. To be truly useful, they must be integrated into the resident’s clinical care and revisited regularly.

Step 1: Make Them Accessible

Once completed, ensure that a copy of the resident’s advance directive is:

• Placed in the medical record
• Available at the nurse’s station
• Noted in the care plan
• Shared with the resident’s attending physician

A POLST form, if present, should be clearly visible, especially in emergency situations.

Step 2: Translate Wishes into Clinical Actions

If a resident has specified “Do Not Resuscitate” (DNR), the care plan must reflect this preference in:

• Code status orders
• Nursing notes
• Emergency protocols

If they have expressed wishes to avoid hospital transfers, consider adding:

• “Treat in place” language
• Comfort-focused interventions
• Regular palliative care consultations

Step 3: Communicate with the Care Team

Every member of the interdisciplinary team should be aware of the resident’s preferences. Regular care plan meetings should include discussion of advance directives, especially if the resident’s condition changes.

Use documentation tools like SBAR (Situation, Background, Assessment, Recommendation) or interdisciplinary progress notes to share updates.

Step 4: Review Periodically

Advance directives should be reviewed:

• Upon admission
• At quarterly care plan meetings
• After a significant change in condition
• When the resident expresses new wishes

Encourage residents and families to update their directives as needed and communicate any changes to the care team immediately.

Common Barriers and How to Overcome Them

Despite the benefits, several barriers can hinder advance care planning in skilled nursing settings.

Resident Reluctance

Some residents may avoid discussing end-of-life care due to fear, cultural beliefs, or mistrust.

Solution: Use motivational interviewing techniques and reinforce that these conversations are about ensuring control and dignity, not about “giving up.”

Family Disagreements

Family members may disagree with the resident’s expressed wishes, especially in emotionally charged situations.

Solution: Emphasize the legal and ethical primacy of the resident’s autonomy and offer mediated family meetings facilitated by social workers or chaplains.

Staff Discomfort or Lack of Training

Not all staff feel confident initiating advance care planning discussions.

Solution: Provide regular in-service training and scripting examples. Normalize advance directive conversations as part of holistic nursing care.

How We Can Help

Advance directives are much more than forms—they are expressions of what matters most to our residents. In skilled nursing facilities, where complex medical needs intersect with deeply personal values, we have a duty to advocate for advance care planning as a standard of excellence.

By asking about advance directives early, assisting in their creation with compassion and clarity, and embedding them into daily care, we not only meet regulatory expectations—we foster a culture of respect, dignity, and person-centered care.

Interested in more training or templates for facilitating advance directive conversations? The Compliance Store has a library of resources, policies and procedures, and tools to assist you in caring for your residents’ in their planning and for educating your team to compassionately support these vital documents. For more information, contact us online or by calling us at 1-877-582-7347.