advance directives, family stress, terminal illness



  1. Davis, Barbara A. PhD, RN
  2. Burns, Jennifer BSN, RN
  3. Rezac, Debra BSN, RN, CCRN, CNRN
  4. Dillard, Barbara BSN, RN
  5. Kieffner, Erin BSN, RN, OCN
  6. Gargus, Jessica BSN, RN, ACNP-S
  7. Tiberi, Antonio S. BSN, RN
  8. Waters, Jennifer BSN, RN


The purpose of this descriptive, comparative study was to compare stress levels of families of terminally ill patients who have advance directives with stress levels of families of terminally ill patients without advance directives. A convenience sample of 105 family members or healthcare surrogates completed the Horowitz Impact of Event Scale. Significant differences were found between the two groups on the total scale (t = -3.44, df = 100, P = .001) and the two subscales of intrusion (t = -3.35, df = 101, P = .001) and avoidance (t = -2.12, df = 100, P = .036). Families of patients with advance directives reported less stress than families of patients without advance directives. Nurses need to provide opportunities and guidance to terminally ill patients and their families regarding the need to discuss end-of-life issues and development of advance directives.