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'Nurses are in an excellent position to assist their patients with living wills'

With the implementation of the final part of the Mental Capacity Act (2005), nurses need to be aware of its implications. One of the most important is that it has become statutory to recognise living wills, otherwise known as 'advance decisions'.

These are documents drawn up by patients stating what they wish to happen to them should they become mentally incapacitated. Their purpose is to enable greater patient choice at the end of life.

Providing the patient is mentally competent when the document is created, the Mental Capacity Act will give this statutory force. With an advance decision, patients can refuse any life-prolonging treatment or intervention.

It enables them not only to state what treatments they do not wish to receive but also those which they do want to receive, and to make a statement about their values and beliefs. However, while refusals of treatment are legally binding, requests for treatment are purely advisory. Also, nurses should be clear that an advance decision cannot be used to request something currently illegal, such as a medically assisted death.

With the increasing popularity of advance decisions, it is important that we fully understand their scope. Research commissioned last year by patient choice organisation Dignity in Dying shows that 13% of people already have an advance decision, with 51% considering making one.

There is overwhelming public support. Some 91% of people surveyed supported the inclusion of advance decisions in the Mental Capacity Act and believe that this will reassure people that their wishes will be respected. In addition, it is no longer just the terminally ill or the elderly who are making living wills. The same survey suggests 54% of people aged 18-64 are interested in making one and only 8% are unaware of what they are.

Making advance decisions statutory means that the patient is the one at the centre of all decision-making regarding their health. This is to be welcomed but it has serious implications for nurses because allowing patients to refuse specific treatments may result in their death.

Nurses must prepare not just for the emotions that may accompany this but also to advise patients of the seriousness of making a living will, and ensure they are aware of all the options. Effective communication is vital in the successful preparation of an advance decision.

Nurses, who have greater contact with patients and therefore a closer relationship with them than hospital doctors and GPs, are in an excellent position to assist their patients in this regard. This highlights the need for sufficient training in order to ensure nurses are fully informed to deal with such queries. For example, they must be able to explain to patients the importance of wording the document correctly so that it specifies precisely what treatments they do or do not wish to receive, in order for it to be put into force. Nurses may also need to explain to patients that a refusal of treatment is legally binding but that requests for certain treatments are not.

Advance decisions offer nurses an ideal opportunity to improve communication with their patients. Discussions about them can lead to wider discussions about their hopes, fears and values for the end of their lives, making care planning easier.

Nurses might take this opportunity to explain all of the options available in end-of-life issues. This will improve relationships between nurses and patients and, ultimately, will offer an opportunity to improve the patient's perception of the healthcare system as a whole.

For nurses who are providing end-of-life care, an advance decision can give them the confidence to carry out practice knowing that it is what their patient wants. However, nurses must also be prepared to respect the wishes of a patient, even if they go against their own opinions.

Provided nurses have a full understanding of the mechanics and procedures that are involved in drawing up and implementing advance decisions, I believe their recognition in the Mental Capacity Act will contribute towards more productive and rewarding nursing practice in which patients' wishes are more fully respected.

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