| Course | NR 579 Palliative Care in Adult-Gerontology Across the Spectrum |
|---|---|
| Week | 4 |
| Paper type | Advance care planning note |
| Length | About 910 words, 5 pages |
| Format | APA 7 student paper |
| School | Chamberlain University |
| Program | MSN, Adult-Gerontology Primary Care NP (AGPCNP) |
| Updated | October 2026 |
Free sample paper for NR 579 Week 4
Advance Care Planning Note for a 66-Year-Old With ALS: The Health Care Agent, Instructions Written in Substituted Judgment and Preferences Tied to the Circumstances They Govern
Student Name
College of Nursing, Chamberlain University
NR 579: Palliative Care in Adult-Gerontology Across the Spectrum
Instructor Name
Month Day, Year
Advance Care Planning Note for a 66-Year-Old With ALS: The Health Care Agent, Instructions Written in Substituted Judgment and Preferences Tied to the Circumstances They Govern
Who Was Present
The patient, who typed answers on a tablet and had decision-making capacity, assessed by the palliative care nurse practitioner at the start. The spouse of 41 years, Linda, the named health care agent, present throughout. The patient's son, Michael, not present; told afterward by the patient and spouse by video the same evening, with the patient's agreement. The palliative care nurse practitioner, who led. Me, as student, recording.
The Agent
Linda, the patient's spouse, was named health care agent in a signed health care power of attorney three years ago, before the diagnosis. The patient confirmed today that Linda remains the choice. Asked what would guide a decision made on the patient's behalf, Linda said: "What we talked about. Not what I'd want." The patient typed that Michael should be told about decisions but should not make them.
The Standard Being Used
Decisions on the patient's behalf, if the patient cannot make them, are to be made by substituted judgment: what this patient would have chosen, based on what the patient has said and done, rather than what the agent or anyone else would prefer (Sulmasy & Snyder, 2010). This note records the evidence for those choices so the agent has something to stand on.
Instructions, With the Circumstances They Govern
If breathing fails despite the mask: no tracheostomy and no intubation. The evidence: the patient typed this twice, at the goals of care conversation and today, and explained it by an uncle's two years on a tracheostomy in a nursing home.
If pneumonia develops: antibiotics, by mouth at home if possible; hospital admission is acceptable if treatment can be given without a breathing tube. The evidence: "I'll go in for antibiotics. Not for a tube."
If swallowing fails: a feeding tube is acceptable if placed while it can still be done safely. The patient typed today that the answer is now yes, after the family meeting last week. The neurology practice parameter recommends considering a feeding tube before vital capacity falls below 50% (Miller et al., 2009a); the patient's is 38%, so timing is urgent.
If the heart stops: no resuscitation.
If the patient can no longer communicate by voice or tablet: comfort care only, at home, with hospice. The evidence: the patient's statement in week 3 that losing both voice and typing would mark the end of a life worth living.
Documents Completed and Where They Are
A portable medical order for life-sustaining treatment was completed and signed today: do not resuscitate; selective treatment, no intubation; no tracheostomy. Original at home on the refrigerator; copies in the ALS clinic record, the primary care record and the shared health information exchange. The durable power of attorney is scanned into the record. A copy of this note goes to the home health agency.
What the Instructions Do Not Cover
The instructions do not cover a choice between hospice at home and a hospice facility, because the patient has said home and nothing has tested it yet. They do not cover what happens if the feeding tube placement fails; the gastroenterology team will discuss that before the procedure. And they do not cover medical research participation, which the patient said to raise again at a later visit.
The Son
Michael was told by video. The spouse reported Michael's reply: "I'm not ready for this," and asked whether the tracheostomy decision could change. The patient typed in reply, during the call, "It won't." The disagreement is noted here because it may surface in an emergency; the agent's role is to state the patient's choice.
How Capacity Was Assessed
The palliative care nurse practitioner asked the patient, by tablet, to explain the choices in their own words. The patient described what a tracheostomy would involve, why it was being declined, what a feeding tube would do and what would happen if the heart stopped. The patient could compare the options and gave reasons that matched earlier conversations. Capacity was judged present for these decisions. Capacity is specific to each decision and may need to be checked again, by the same method, if the patient's communication or thinking changes.
Who Has Copies and Who Was Told
The spouse has the original order. Every service involved, from the neurology team to the family doctor, the visiting nurses and the regional ambulance service, can open the order in the shared record, and the paramedics were told it exists. Sarah, the daughter, was emailed a summary at the patient's request. The son was told by video, as above. The patient asked, too, that the grandchildren not be told about the specific decisions, and the spouse will decide with the patient what to say to them and when, with the clinic social worker available to help.
Review
At every ALS clinic visit, and sooner if the patient's ability to communicate changes. A Delphi panel defined advance care planning as something that continues over time, with values and preferences shared and revisited as illness changes (Sudore et al., 2017).
References
Miller, R. G., Jackson, C. E., Kasarskis, E. J., England, J. D., Forshew, D., Johnston, W., Kalra, S., Katz, J. S., Mitsumoto, H., Rosenfeld, J., Shoesmith, C., Strong, M. J., & Woolley, S. C. (2009a). Practice parameter update: The care of the patient with amyotrophic lateral sclerosis: Drug, nutritional, and respiratory therapies (an evidence-based review): Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology, 73(15), 1218-1226. https://doi.org/10.1212/WNL.0b013e3181bc0141
Sudore, R. L., Lum, H. D., You, J. J., Hanson, L. C., Meier, D. E., Pantilat, S. Z., Matlock, D. D., Rietjens, J. A., Korfage, I. J., Ritchie, C. S., Kutner, J. S., Teno, J. M., Thomas, J., McMahan, R. D., & Heyland, D. K. (2017). Defining advance care planning for adults: A consensus definition from a multidisciplinary Delphi panel. Journal of Pain and Symptom Management, 53(5), 821-832. https://doi.org/10.1016/j.jpainsymman.2016.12.331
Sulmasy, D. P., & Snyder, L. (2010). Substituted interests and best judgments: An integrated model of surrogate decision making. JAMA, 304(17), 1946-1947. https://doi.org/10.1001/jama.2010.1595
The Chamberlain NR 579 Week 4 instructions
The Week 4 note is partly administrative, and that is part of the genre. It records a conversation and a set of documents together. The appointed person appears by name and relationship, with a line on whether they were present or told afterward and what they said when asked. Instructions should be written in the language of substituted judgment: what this patient would have chosen, with the evidence. Preferences need circumstances attached, since almost nobody refuses everything in every situation. Most rubrics also want the completed forms listed with where each copy is kept. Expect to show how capacity was judged for these decisions.
Inside the NR 579 Week 4 example
The note opens with everyone present and their roles, including the son told afterward by video. The agent's section gives the spouse's name, when the power of attorney was signed and the spouse's own words about how to decide. A section states the substituted judgment standard with a source. Five instructions follow, each tied to a circumstance and to the patient's own evidence, from failing breathing to loss of communication. The completed order and where every copy sits are listed. Capacity is described as judged for these decisions. Sections record what the instructions do not cover, the son's reaction and the review plan.
NR 579 Week 4 rubric: what full points look like
Nothing loses more than a note that asks the family what they want, because substituted judgment and best interest are different standards and this course is built on whose values decide. This note records what the patient would choose, with evidence. Preferences without circumstances lose the next row, since they cannot be acted on; each instruction here begins with an if. Forms completed but not located lose a row, and every copy is listed. A capacity description tied to these decisions earns the legal criterion. Recording a disagreeing relative prepares future clinicians and earns credit for completeness. Naming what the instructions do not cover also helps the next clinician know where the record stops.
NR 579 Week 4 help: mistakes that cost points
The most common NR 579 Week 4 error is asking the agent what they would want, instead of what the patient would want. Another is writing preferences such as no heroic measures with no situation attached. Many notes say forms were completed without saying where they are. Capacity is often assumed rather than described. Some notes leave out family members who disagree, which surfaces in an emergency. If your patient's wishes differ, send what the patient has said and to whom; a note can be written with instructions tied to circumstances and the evidence for each. Write every instruction as if, then what, then the evidence in the patient's words, and list every copy of every form with where it is kept.
Get a NR 579 Week 4 example written to your instructions
Send the assignment, the rubric, and the state form your classroom uses if there is one, and a custom advance care planning note written to it returns inside 24-48h, the first free. Say whether the section wants the note by itself or the note together with a completed sample form.
More NR 579 papers and AGPCNP samples
- NR 579 Week 1: Palliative Timing Discussion Post
- NR 579 Week 2: Symptom Management Plan
- NR 579 Week 3: Goals of Care Write-Up
- NR 579 Week 5: Family Meeting Summary
- NR 579 Week 6: Pain Management Case Analysis
- NR 579 Week 7: Ethical Dilemma Write-up
- NR 579 Week 8: Narrative Reflection
- NR 578 Week 4: Transition of Care Plan
- NR 568 Week 4: Allopurinol in CKD Case Analysis
- NR 577 Week 4: Chronic Disease Visit Note
- NR 576 Week 4: Clinical Reasoning Write-Up
NR 579 Week 4 questions, answered
Is this the same as a living will?
Not quite, and the example keeps the distinction visible. A living will records the patient's own instructions; appointing a health care proxy records who interprets them. Most assignments want both addressed, along with the fact that one covers situations the other never anticipated. Terminology varies by state, so use whatever your classroom's form calls it.
What if the patient does not want to discuss it?
Record that, because it is a decision with consequences and it belongs in the note. Say what was offered, how the offer was made, what he said, and what was agreed about coming back to it. A man who declines the conversation still needs somebody named, and the note can show that this part remains open.
Do I need to fill in an actual form?
Only where the assignment supplies one, and then the note usually accompanies it rather than replaces it. The graded object in most sections is documentation of the process: who was asked, what was decided, which standard was set for the proxy, and where everything ended up. The form is the artifact; the note is the evidence.
Where can I find a free NR 579 Week 4 sample paper?
The full advance care planning note, with the agent, five instructions and where every document is kept, is published here.
What standard does the NR 579 Week 4 note use for future decisions?
Substituted judgment: what the patient would have chosen, based on the patient's own statements, rather than what the agent or other family members would prefer.