Medical-Surgical Nursing 8th Edition by Donna Ignatavicius , Linda Workman

Exercise 2

A 77-year-old female with stage IV heart failure has had two hospitalizations for congestive heart failure (CHF) exacerbations in the past month. The patient lives alone and has no durable power of attorney for health care or living will. She tells you she does not need an advance directive because she "can just come back to the hospital and they will take care of me."
What types of referral might you make for her? How would you do this?