V4 · Wishes about end of life unclear
Actual Spiritual and values
Definition
The person has not decided or shared their wishes about end-of-life care.- No advance directive
- unclear values
- denial
- family conflict
- Avoids the discussion
- unsure choices
- conflicting statements
📋 Scenario
An older man has not told his family whether he wants resuscitation.
Subjective (S): "I haven't told my family what I want."
Objective (O): Avoids talking about end of life; family unsure; no advance directive.
Assessment tools for this scenario: CP-SPIRIT Spiritual & Values Check
Validated scales to consider: FICA spiritual screen
**CarePath diagnosis:** Wishes about end of life unclear related to no advance directive, as evidenced by avoids the discussion and unsure choices.
**Interventions and rationale**
| Intervention | Rationale |
|---|---|
| Open the conversation gently. | A gentle opening in a private moment lowers the fear that makes people avoid this topic and invites him to share what matters to him. |
| Explain options. | Plain explanation of options such as resuscitation, comfort care and directives helps him understand what each choice means before deciding. |
| Document wishes. | Written records of his wishes make sure the team and family can follow them if he cannot speak for himself later. |
| Involve family. | Including family, with his permission, helps them understand his choices and lowers the risk of conflict or guilt when decisions must be made. |
| Follow policy. | Following facility policy and law ensures that directives are valid, properly witnessed and available to every team member who needs them. |
**Expected outcomes**
- States wishes.
- Advance directive completed.
- Family informed.
**Linking the data to the diagnosis**
The older man says, "I haven't told my family what I want." He avoids talking about end of life, his family is unsure and he has no advance directive. This fits wishes about end of life unclear because his choices on resuscitation are not stated or recorded, and the lack of a directive is the clear cause. The problem exists now, so it is an actual diagnosis. The plan aims for him to state his wishes, complete an advance directive and inform his family, by opening the conversation gently, explaining options and following policy.
CarePath diagnosis
Wishes about end of life unclear related to no advance directive, as evidenced by avoids the discussion and unsure choices.
Interventions and rationale
Listed in priority order.
| Intervention | Rationale |
|---|---|
| 1. Open the conversation gently. | A gentle opening in a private moment lowers the fear that makes people avoid this topic and invites him to share what matters to him. |
| 2. Explain options. | Plain explanation of options such as resuscitation, comfort care and directives helps him understand what each choice means before deciding. |
| 3. Document wishes. | Written records of his wishes make sure the team and family can follow them if he cannot speak for himself later. |
| 4. Involve family. | Including family, with his permission, helps them understand his choices and lowers the risk of conflict or guilt when decisions must be made. |
| 5. Follow policy. | Following facility policy and law ensures that directives are valid, properly witnessed and available to every team member who needs them. |
Expected outcomes
- States wishes.
- Advance directive completed.
- Family informed.
Linking the data to the diagnosis
The older man says, "I haven't told my family what I want." He avoids talking about end of life, his family is unsure and he has no advance directive. This fits wishes about end of life unclear because his choices on resuscitation are not stated or recorded, and the lack of a directive is the clear cause. The problem exists now, so it is an actual diagnosis. The plan aims for him to state his wishes, complete an advance directive and inform his family, by opening the conversation gently, explaining options and following policy.