How would you handle a situation in which the family and surrogate decision maker disagree
Durable Power of Attorney for Health Care
Situation
G.V., a 64-yr-old woman, is admitted to the intensive care unit with
HF. She has many complications from a long-term history of type 1
diabetes and hypertension, including a right leg above-the-knee
amputation and blindness related to retinopathy. She severed ties
with her family 30 years ago. She has a life partner of 35 years whom
she chose as her proxy in her signed Durable Power of Attorney. She
has said many times that she would rather die than have renal
dialysis. She has been sedated and intubated for 3 days. The HCP
plans to extubate her and resuscitate her so that she can start dialysis.
Her brother shows up at the hospital and supports the HCP’s
decision. Her partner disagrees with the decision. The HCP refuses to
recognize her partner as proxy because she is not a blood relative.
Ethical/Legal Points for Consideration
The Patient Self-Determination Act (1990) requires all health care
facilities receiving Medicare and Medicaid funding to make available
advance directives allowing persons to state their preferences or
refusals of health care in the event that they are incapable of
consenting for themselves.
Durable Power of Attorney for health care is one type of advance
directive in which people, when they are competent, identify
someone else to make decisions for them, should they lose their
decision-making ability in the future (see Table 9.6).
The Living Will, another type of advance directive, permits people
to state their own preferences and refusals.
Many HCPs mistakenly think that proxies must be family members
or blood relatives. Lesbian, gay, bisexual, and transgender (LGBT)
persons often have difficulty having their partnership recognized as
valid, especially if the patient’s family disputes their rights.
Some families are deeply divided on decisions for their loved ones.
Sometimes difficulties occur when money and property are also
disputed. The passage of time may be an issue where the original
documents were executed and then changes occurred (e.g., divorce,
death or disability of the proxy, inability to contact the proxy,
inability to find a valid original of the advance directive).
Within your scope of nursing practice, you need to know the
decision-making laws and regulations in your own state and make
advance directive documents available to patients. In addition, you
need to (1) teach patients and their families about advance directives,
(2) make sure that HCPs are aware of and follow advance directives,
(3) assist the patient and family in communicating with the HCPs
when a “No Code” order is requested, and (4) assist a conflicted
family in obtaining appropriate counseling whenever needed.
Counsel LGBT patients on the importance of having a health care
proxy and a will to legally protect their end-of-life choices.
Discussion Questions
1. How would you handle a situation in which the family and
surrogate decision maker disagree?
2. How can you assess the patient and family’s understanding of
durable power of attorney and assist them in understanding
their role in decision making?
3. What should you do when an HCP orders dialysis to be started
when you know that this goes against the patient’s advance
directive?
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