Why healthcare power of attorney is critical for physicians
Key Takeaways
A healthcare power of attorney and a living will guide advanced care planning (ACP).
Although physicians recognize the importance of following a healthcare power of attorney, it can be difficult to locate the documentation or to enact power of attorney in emergency situations.
It’s important that physicians involve family members in the process of following a healthcare power of attorney.
Not everything in medicine is clear-cut. Sometimes, important ethical concerns crop up that can change the course of care.
For instance, the field of advanced care planning (ACP) focuses on making decisions for patients who can no longer make decisions for themselves.
The most important tool in ACP is the healthcare power of attorney.
Power of attorney terms defined
A general power of attorney could refer to a person or organization that has the power to act on the designee’s behalf. A healthcare power of attorney allows the designated person or party to make medical decisions on the designee’s behalf.
A durable power of attorney (ie, healthcare proxy) usually accompanies a healthcare power of attorney and protects the power of attorney if the designee loses their ability to make their own decisions.
Unlike a healthcare power of attorney, a living will refers to a document that specifies certain desires made by the person signing. It doesn’t give anyone else the power to make medical decisions.
A living will can accompany healthcare power of attorney to better guide decision-making.
Who is the designated healthcare agent?
Everyone should designate a power of attorney, but currently, only between 18% and 36% of American adults have set up ACP, according to an article published in StatPearls.[]
One or several people can be designated as having power of attorney. A backup agent should also be named. Physicians should make sure whether an agent or agents are entitled to act independently or if joint decisions are necessary.
Having multiple agents can allow for a more balanced approach, but it can also eat up time and lead to conflict.
Kaiser Permanente recommends that patients choose their healthcare agents wisely.[] The agent should be comfortable with the decision and aware of the patient’s moral and religious views. They must be committed to making all decisions—in particular, the hard ones. This agent will do what the patient wants—even if they personally disagree. The agent should ask the physician questions as needed, and be confident when making decisions with the physician and healthcare team.
Role of the physician
Physicians interested in enacting a power of attorney must determine patient competence—or lack thereof. Typically, one trusted physician is given this authority in the power of attorney. If no physician is listed to determine competence, two licensed physicians must agree on competence. The authors of the StatPearls article outline the following approach:
Communication. Patients should not only be able to voice their desires, but also the rationale underlying these choices.
Understanding. Patients must be able to remember treatment plans and understand causal relationships regarding treatment.
Appreciation. Patients need to understand the consequences of receiving or forgoing treatment.
Rationalization. It’s important to understand the pros and cons of any medical decision and come to a conclusion that reflects their interests and goals.
The physician should be aware of various stressors such as memory issues and psychiatric disorders, which can impact a patient’s competence.
"It is important to remember that capacity is not static and can change from absent to present as a patient progresses through the healing process."
— Desai, et al.
“Similarly, a patient’s non-capacity to make one decision does not necessarily deem that patient not to have the capacity to make any other decisions regarding their care," the StatPearls authors continued.
On a related note, when signing a durable power of attorney, standards of competence include:[]
Recognition of familiar objects and people
Level of consciousness
Ability to plan/organize
Ability to understand quantities
Orientation to person, place, and time
Finding power of attorney
Although 78% of ED physicians think power of attorney documentation is very helpful, only 31% claimed they felt confident in their ability to track down ACP documentation.
Electronic health records are a good place to store (and later access) ACP documents. Patient portals can also direct patients toward ACP documents.
Power of attorney in emergencies
Power of attorney can be difficult to follow in emergency situations, where denying treatment such as vasopressors or ventilators could lead to death. It’s important that physicians align with family members on the proper deployment of power of attorney. Doing so allows patients to live their last few moments with the dignity they hoped for.
Engaging family members in the process has also been shown to decrease associated costs, as well as the stress and anxiety of surviving family members. Research shows power of attorney also increases the utilization of hospice and results in fewer patient deaths.
What this means for you
Ask your patients and their families about healthcare power of attorney and involve them in this process. When enacting a power of attorney, make sure to carefully evaluate the capacity of a patient. Although it may be difficult to access and follow power of attorney and living wills in life-and-death situations, this step is a vital component of compassionate care.