Advance directives are more than just a box to check for new hospice patients. This is especially true when it comes to medical power of attorney. It is crucial for terminally ill patients to have a legally binding decision about who they want making decisions when they no longer can. Here are three reasons why:
1. The right MPOA can ensure your wishes are followed (and the wrong one can overturn them).
If the closest family member objects to a DNR, they may revoke it when the patient stops communicating. Once a patient of mine–call her Suzi–became unresponsive and her husband ordered that the DNR be destroyed. The nursing home and hospital complied.
Planning and discussion can prevent this, clarifying which of a patient’s friends or family members is likely to support the patient’s wishes. Fortunately, Suzi regained consciousness long enough to discuss her wishes with her daughter and appoint her as MPOA.
2. An MPOA can reduce risk of exploitation.
“Denver” was a patient who was intermittently disoriented. He had a spouse, but she was completely unable to represent his wishes due to her own cognitive decline. A neighbor stepped into the decision-making role, without there being any documentation to support this. I suggested asking Denver to make her MPOA, but she didn’t want that. She called my agency instead and told them not to send me back. This became a dilemma. On the one hand, it was not up to her to make this decision. On the other, the company did not want to alienate the only person who wanted to help out in a decision-making role.
There was no clear indicator of exploitation, but this neighbor’s behavior was confusing. If financial exploitation were her intent, the risk that she’d be able to would be much lower if the patient had appointed a trustworthy proxy while he was still functioning well.
3. The right MPOA can prevent catastrophic gaps in care.
For months I visited Dorothy, a patient who lived alone seemed to have a hard time trusting people. I wanted to discuss her wishes for when she would no longer be able to live independently, but she became quite defensive every time I brought it up and demanded we change the subject. She told me that whenever that day comes I can call her MPOA, but not before. She was not convincing that her MPOA would know what to do.
Her decline quickened and soon enough, we found her on her floor, unresponsive. Her MPOA had no idea what to do to ensure adequate care from then on.
Why the horror stories?
Had I known then what I know now, I would have persisted in emphasizing the importance of planning ahead for the 1st and 3rd of these situations. The risks are great. I would have spoken more candidly with the patient about the risks, or I would have told my boss that the case was heading for disaster that was out of my hands.
Disasters happen. Our compassionate and educated intentions can only reduce their occurrence. My intended takeaway from these horror stories is this:
MPOA planning is important.
More important than other advance directive planning, because patients need an MPOA who understands their wishes in order to ensure they are carried out. Dorothy hoped to die at home, but her MPOA considered moving her to a nursing home because she didn’t know what else to do. Suzi wanted to die naturally. Without an MPOA on her side, her husband may not have allowed a natural death.
When we next convene, I’ll share some key ideas about how medical proxies work so that you can best advocate for your patients.