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Friday, November 19, 2010

Who should be your medical care "proxy" with durable power of attorney?

When you visit a good estate attorney, he or she will usually instruct you to fill out an advance medical directive if you don't have one already. The link in the previous sentence is a sample document provided by the State of California, although the directive does not have to be in this specific format. This document allows you to leave some specific instructions, but most important, allows you to designate whom you want to represent you for medical decisions if you are unconscious or cannot make your own decisions.

Many people designate a trusted loved one, such as a child or a spouse for this role, if they have one. However, some people do not have such a person. Such people should hire a primary agent to whom to give durable power of medical attorney in case they are incapacitated. My new business, Your Health Care Advocate, provides this service. Although I don't have a website specifically for this arm of my business, you can find contact information at http://www.myadvicedr.com. Please note that if I am serving as your agent, I cannot provide any other medical services to you as this would be a conflict of interest. Conversely, if you have consulted me for medical advice, I can become your agent as long as you realize that once the agency takes effect (you become unconscious or unable to make your own decisions), I will not be able to provide other medical services or advice to you, but rather would follow your wishes or attempt to figure out what your wishes would be in making decisions or providing input for medical decisions.

One of the reasons for appointing an agent who works for you is that doctors are unlikely to follow patients' wishes about life sustaining care, as demonstrated by the SUPPORT study . In my own experience, this goes in both directions, where doctors keep patients on life support that they wouldn't have wanted, or discontinue life support earlier than patients might have liked. In a recent case, doctors were ready to discontinue a man from life support on the same day as a cardiac arrest, before they had even assessed that his brain function was gone, despite the wishes of his medical proxy, his wife, that he wished every intervention to be done to attempt to save his life. In another case of a man with congestive heart failure who had dementia from several strokes, who had expressed his wishes to his family that he did not want to be put on a ventilator except for acute pneumonia, young doctors on call came in to the intensive care unit prepared to to intubate him (put him on a ventilator) when he stopped breathing during another massive stroke, despite very poor brain and heart function before the event happened. Had an agent not been present, he would have been put on life support, as his wife was not confident enough to question the doctors. From many religious perspectives, withdrawing life support is more problematic than not using it in the first place when it is not indicated. And, of course, failing to provide it when indicated and desired is even more concerning.

Thus, while it may superficially seem to be the most prudent avenue to appoint a family member to this role, there are some significant drawbacks to this choice.

1. If it is a child, they may not live where you do. Critical medical decisions in an emergency require very quick answers or the doctors are left to their own choices instead of getting input from anyone you instructed or anyone you trust. Telephone conversations are not that great for helping people understand critical medical situations. In this case, you may wish to designate a local alternate agent as well as the child who serves as primary agent. Consider hiring a medical agent or advocate to play this role if you do not have any friends with extensive medical knowledge.

2. If it is a spouse, he or she may already be frail and have health problems or may be emotionally fragile, or may lack self-confidence interacting with doctors. These are likely to be exacerbated by your being critically ill. This will make it difficult for them to have any meaningful input into the process. They are likely to feel overwhelmed and simply trust the doctors to carry out your wishes. Therefore, you may wish to designate or hire an alternate agent with a medical background in case your spouse feels too overwhelmed to carry out this responsibility effectively and wishes to delegate it.

3. The trusted person you designate may have little or no medical knowledge. Therefore it may be hard for them to understand the implications of the choices doctors are asking them for input on. You may wish to hire someone with a good medical background.

4. Conflict among family members often revolves around these decisions. It creates significant conflict among family members when one has decision-making authority and the others do not, and input from the others is ignored or devalued. Children also have conflicts of interest. In the worst cases, issues of inheritance and property may drive a child who has not been close with you to argue in favor of discontinuing life support, or, if you have children who live in your house, are very emotionally attached to you, or will benefit more by your survival in some way, they may militate for interventions you do not wish to have. A spouse may be somewhat narcissistic, and feel angry with you for abandoning him/her, and ignore your wishes not to intervene in certain situations.

A great alternative is to hire a medical agent who works for you to carry out your wishes and has no vested interest one way or the other.

[Of course, you may have little or no medical knowledge too, which is why I recommend that for important medical decisions, you consult a skilled doctor as a health care advocate (like me! http://www.myadvicedr.com)]

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