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?