Advance directives play a critical role in patient care, ensuring that individuals receive medical treatment that aligns with their wishes when they can no longer communicate their decisions.
For respiratory therapists and students preparing for the board exam, understanding these legal documents is essential, as they directly impact life-sustaining interventions such as mechanical ventilation.
This article will cover the key types of advance directives, including living wills, durable power of attorney for healthcare, and do-not-resuscitate (DNR) orders, highlighting their importance for both clinical practice and exam preparation.
What is an Advance Directive?
An advance directive is a legal document that allows patients to express their medical treatment preferences in situations where they are no longer able to communicate their wishes.
These documents play a crucial role in ensuring patient autonomy, guiding healthcare providers, and reducing uncertainty for families and caregivers. For respiratory therapists, understanding advance directives is essential, as they often encounter patients who require life-sustaining treatments such as mechanical ventilation.
Types of Advance Directives
There are several types of advance directives, each serving a specific purpose in medical decision-making. The most common ones include:
- Living Will – A legal document that outlines a patient’s preferences regarding life-prolonging treatments. It specifies which interventions (e.g., mechanical ventilation, feeding tubes, resuscitation) the patient wants or does not want in terminal or irreversible conditions.
- Durable Power of Attorney for Healthcare (Healthcare Proxy) – This document designates a trusted individual to make medical decisions on the patient’s behalf when they are unable to do so. The appointed healthcare proxy is expected to follow the patient’s wishes and act in their best interest.
- Do-Not-Resuscitate (DNR) Order – A physician-signed order that instructs healthcare providers not to perform cardiopulmonary resuscitation (CPR) if a patient’s heart stops or they stop breathing. DNR orders are often found in hospital records, nursing homes, or patient homes.
- Do-Not-Intubate (DNI) Order – Similar to a DNR, a DNI order specifically states that the patient does not wish to be intubated or placed on mechanical ventilation if they experience respiratory failure.
The Role of Respiratory Therapists
Respiratory therapists must be aware of and respect advance directives when providing patient care. During the TMC exam, candidates may be tested on how to identify, interpret, and apply these directives in clinical scenarios.
Respiratory therapists should ensure that advance directives are documented in the patient’s medical record and communicate with the healthcare team to honor the patient’s choices.
Impact of Advance Directives on Respiratory Therapy Interventions
Respiratory therapists play a critical role in managing patients who require life-sustaining treatments. However, when a patient has an advance directive in place, the RT must adjust their care plan accordingly to respect the patient’s wishes. Understanding these situations is essential for success on the TMC exam.
Mechanical Ventilation and Advance Directives
One of the most common dilemmas RTs face is determining whether to initiate or continue mechanical ventilation. If a patient has a Do-Not-Intubate (DNI) order, invasive mechanical ventilation should not be started, even if the patient experiences respiratory failure.
However, noninvasive ventilation (NIV), such as bilevel positive airway pressure (BiPAP) or continuous positive airway pressure (CPAP), may still be an option depending on the patient’s preferences and physician recommendations.
For patients with a living will that specifies no life-prolonging interventions, mechanical ventilation should not be initiated unless explicitly stated otherwise. However, if a patient with an existing DNR order requires ventilatory support for a reversible condition (e.g., drug overdose, pneumonia, or exacerbation of COPD), the healthcare team must review the patient’s specific wishes and discuss options with the healthcare proxy or family.
Resuscitation and Do-Not-Resuscitate (DNR) Orders
A DNR order specifically prohibits cardiopulmonary resuscitation (CPR) in the event of cardiac or respiratory arrest. However, it does not necessarily mean that other treatments, such as oxygen therapy, medication administration, or noninvasive ventilation, should be withheld.
RTs must clarify whether the patient wishes to receive supportive care, such as bronchodilators or supplemental oxygen, while avoiding invasive procedures like chest compressions or defibrillation.
During the TMC exam, a candidate may be presented with a scenario where a patient with a DNR order experiences acute respiratory distress. In this case, the correct action would be to provide comfort measures, such as oxygen therapy, secretion management, or nebulized bronchodilators, rather than initiating advanced life support interventions.
End-of-Life Care and Palliative Respiratory Support
For terminally ill patients, RTs often focus on symptom management rather than curative treatment. This approach, known as palliative respiratory care, includes:
- Oxygen therapy for dyspnea relief, even if oxygen saturation levels are within a normal range.
- Morphine or other medications to reduce the sensation of breathlessness.
- Humidified air or fan therapy to ease respiratory discomfort.
- Secretion management using gentle suctioning or medications like glycopyrrolate to reduce excessive secretions.
Note: The board exam may test your ability to differentiate between aggressive, life-sustaining measures and comfort-based care approaches in patients with advance directives.
Board Exam Tips for Advance Directives
When answering exam questions related to advance directives, remember these key points:
- Check the medical record – Before initiating invasive procedures, verify if a DNR, DNI, or other advance directive is documented.
- Understand the limitations of a DNR order – It applies specifically to CPR, but does not mean withholding all forms of treatment.
- Recognize reversible conditions – Some patients with DNR/DNI orders may still benefit from temporary respiratory support for conditions that are treatable.
- Communicate with the healthcare team – If there is any uncertainty about a patient’s advance directive, consult the physician or healthcare proxy before proceeding.
- Prioritize patient comfort – If life-sustaining treatment is not an option, focus on symptom management and palliative care.
Key Takeaways for the TMC Exam
- DNR orders prohibit CPR but do not restrict other forms of care unless specified.
- DNI orders prohibit intubation but may allow for noninvasive ventilation.
- Patients receiving palliative care may still require oxygen therapy, secretion management, or medications for comfort.
- Always verify advance directives before initiating life-sustaining interventions.
- Communicate with the healthcare team or surrogate decision-maker when the advance directive details are unclear.
Final Thoughts
Understanding advance directives is essential for respiratory therapists, both in clinical practice and on the board exam. These directives ensure that patient wishes are honored, guiding healthcare professionals in making ethical and appropriate decisions.
By familiarizing yourself with DNR, DNI, living wills, and healthcare proxies, you will be better prepared to navigate patient care scenarios on the exam and in real-life practice.
For further preparation, consider reviewing additional case studies, practicing with exam-style questions, and reinforcing your knowledge of ethical and legal considerations in respiratory care.
Written by:
John Landry is a registered respiratory therapist from Memphis, TN, and has a bachelor's degree in kinesiology. He enjoys using evidence-based research to help others breathe easier and live a healthier life.
References
- House SA, Schoo C, Ogilvie WA. Advance Directives. [Updated 2023 Aug 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025.