Informed Consent, Advance Directives, and Who Can Sign
Informed consent turns on one idea: who has the right to decide. The provider explains the procedure, its risks, benefits, alternatives, and the consequences of doing nothing and obtains the consent, while the nurse only witnesses the signature by confirming identity, that the client is signing voluntarily, and that they appear mentally able. If the client does not understand, the nurse stops and calls the provider rather than explaining it themselves.
Informed consent and advance directives: who signs, who witnesses, and what the nurse does when something is missing.
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These questions look like legal questions. They are really about one idea: who has the right to decide?
Learn that idea and these questions become easy.
Informed consent: who does what
This is the most tested point, and students get it backwards.
The provider (doctor, surgeon, or other prescriber) gets the consent.
They must explain:
- What the procedure is
- Why it is needed
- The risks
- The benefits
- Other choices
- What happens if the client does nothing
The nurse witnesses the signature.
That is the nurse’s role. You are confirming three things:
- The person signing is who they say they are
- They are signing voluntarily (no pressure)
- They appear mentally able to sign
The nurse does NOT explain the procedure. That is not your job and it is a very common wrong answer.
What to do if the client does not understand
This is the classic question.
The client says, “I’m not really sure what they’re going to do to me.” What should the nurse do?
Answer: stop and call the provider.
Not: explain it yourself. Not: have them sign anyway. Not: reassure them.
Consent is not valid if the client does not understand. The provider must come back and explain again.
The nurse’s job is to notice the problem and stop the process.
Who can give consent
Adults who are mentally able sign for themselves. This is the default.
A healthcare power of attorney (also called a healthcare proxy or agent) signs if the client cannot decide. The client chose this person in advance.
A legal guardian signs for someone a court says cannot decide.
Parents or legal guardians sign for children under 18.
Emancipated minors sign for themselves. A minor is usually emancipated if they are married, in the military, living independently by court order, or (in many states) pregnant or already a parent.
Mature minors can consent to certain care in many states without a parent — often for pregnancy care, sexually transmitted infections, substance use treatment, and mental health care. This varies a lot by state.
Emergencies
In a true emergency, when the client cannot consent and no decision-maker is available, consent is implied.
The reasoning: a reasonable person would want life-saving care.
Do not delay emergency treatment looking for a signature.
But this applies only to emergencies. Not to routine care.
What does NOT count
A spouse cannot automatically consent for an adult unless they are the named healthcare agent or legal guardian, or your state’s law makes them the default surrogate. Do not assume.
Adult children cannot automatically consent for a parent for the same reason.
A client who has had sedatives cannot sign. Consent must be obtained before sedation. If a client already got a sedative, stop and tell the provider.
A client who does not speak your language has not consented unless a qualified medical interpreter was used. A family member is not a substitute for an interpreter.
Advance directives
These say what a client wants if they cannot speak for themselves later.
Living will — written instructions about what treatments the client wants or refuses. For example, no ventilator, no feeding tube.
Healthcare power of attorney (proxy or agent) — the person the client chooses to decide for them.
DNR / DNAR order — do not attempt resuscitation. This is a medical order, written by a provider, based on the client’s wishes.
Key facts about advance directives
They only take effect when the client cannot decide. An awake, able client makes their own decisions, even if it goes against what their living will says.
Clients can change or cancel them at any time. Verbally too.
Hospitals must ask about them on admission. This comes from the Patient Self-Determination Act.
Having one is not required. Clients can refuse to make one.
A DNR does not mean “no care.” A DNR client still gets pain medication, comfort care, antibiotics, oxygen, and everything else — unless those are also refused. DNR means do not attempt resuscitation if the heart or breathing stops.
That last one is heavily tested. Wrong answers often suggest cutting back care for a DNR client.
The right to refuse
Any mentally able adult can refuse any treatment, even if it will kill them.
The nurse’s job is to:
- Make sure they understand the consequences
- Tell the provider
- Document it
- Respect the decision
Wrong answers: convincing them, calling the family to change their mind, giving it anyway.
Examples
Example 1 > The client has signed the consent form but tells the nurse, “I still don’t know why I need this surgery.” What should the nurse do?
Notify the provider. The client does not understand, so the consent is not valid.
Example 2 > A client with a DNR order stops breathing. What should the nurse do?
Do not start resuscitation. Provide comfort care. Notify the provider and the family per policy.
Example 3 > A confused older client needs surgery. The daughter is at the bedside. Who should sign?
Not automatically the daughter. Find out if there is a healthcare power of attorney or legal guardian. If the client cannot decide and no one is named, follow the facility’s process and state law.
The short version
- Provider explains. Nurse witnesses.
- Client does not understand? Stop and call the provider.
- Advance directives only apply when the client cannot decide.
- DNR means no resuscitation — not less care.
- Any able adult can refuse anything.
Consent laws, surrogate decision-maker rules, and minor consent rules vary by state. The NCLEX tests general principles; follow your own state’s law in practice.
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Frequently asked questions
Common follow-up questions on Prioritization, Delegation & Management of Care.
What is the nurse's role in informed consent?
The nurse witnesses the signature, confirming that the person signing is who they say they are, that they are signing voluntarily without pressure, and that they appear mentally able to sign. The nurse does not explain the procedure; that is the provider's job, and 'the nurse explains it' is a very common wrong answer.
What should the nurse do if the client does not understand the procedure?
Stop and notify the provider. Consent is not valid if the client does not understand, so the answer is not to explain it yourself, have them sign anyway, or simply reassure them. The provider must come back and explain again; the nurse's job is to notice the problem and stop the process.
Who can give consent when the client cannot?
A healthcare power of attorney (proxy or agent) the client chose in advance, or a legal guardian appointed by a court. A spouse or adult child cannot automatically consent for an adult unless they are the named agent, legal guardian, or the state's default surrogate. In a true emergency with no decision-maker available, consent is implied because a reasonable person would want life-saving care.
Does a DNR order mean the client gets less care?
No. A DNR (do not attempt resuscitation) client still receives pain medication, comfort care, antibiotics, oxygen, and everything else unless those are also refused. DNR means only that resuscitation is not attempted if the heart or breathing stops, and wrong answers often suggest cutting back care for a DNR client.
Can a mentally able adult refuse treatment?
Yes. Any mentally able adult can refuse any treatment, even if it will kill them. The nurse's job is to make sure they understand the consequences, tell the provider, document it, and respect the decision. Convincing them, calling the family to change their mind, or giving it anyway are wrong answers.
Sources and references
- Potter PA, Perry AG, Stockert PA, Hall AM. Fundamentals of Nursing. 10th ed. Elsevier; 2021; Chapter: Legal Implications in Nursing Practice.
- American Nurses Association. Code of Ethics for Nurses with Interpretive Statements. Silver Spring, MD: ANA; 2025.
Reviewed by the NCLEXPace team, October 2026.
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