The Slow Code - page 15

by TheCommuter Asst. Admin

I have been a nurse for only seven years; however, certain events and situations will remain embedded in my memory for the rest of my life. One of these events took place during my first year of nursing practice when I was... Read More


  1. 1
    Quote from MunoRN
    POA's don't actually have the legal right to go against the expressed wishes of the patient. They are legally obligated to ensure that the patient's expressed wishes are being followed.
    That's not my understanding (and I've worked on these topics quite a bit over the years). I've heard attorneys lecturing on this topic explain more than once that the reason you should be extremely careful about who you make your POA is because, once you are incapacitated and the POA takes effect, that individual is under no obligation to follow your wishes -- you have given that person the full legal right to make decisions (as s/he sees fit) on your behalf, using her/his best judgment (but not necessarily following your wishes).
    jadelpn likes this.
  2. 0
    POA/AD laws are state specific, but I don't know of any that don't include some form of this provision. This usually includes anything in a living will, but particularly DNR orders. Situations involving a DNR used to be pretty rare since a patient would have to come in to the hospital able to make their own decisions and lose that ability, although now with POLST forms this is fairly common that a patient comes into the hospital with an already active DNR order.

    A couple of examples specific to DNR:

    The legal scope of a POA is to make the patient's wishes known, to the best of their ability, when the patient is unable to make their wishes known. A DNR order is a Physicians order and cannot be overturned by a POA. A POA only comes into play when there are not "clearly stated" patients wishes available. In practice, this essentially means that the POA can do whatever they want, since by definition they are only referred to when the patient's wishes are not known, leaving no way of knowing if they are abiding by those wishes. Whether or not hospitals will actually enforce this is another issue; dead people don't sue, families due, creating an unfortunate situation where hospitals are more likely to bow to the family even when that might go against the wishes of the patient.

    Having a meaningful palliative care team helps. My hospital used to be very leery of making families unhappy, even when it meant violating the patient's wishes. After establishing a palliative care team that actively enforces the expectations of the POA, I've actually been surprised how well POA's take it when their some decision making gets taken away or overridden, POA's understandably have a hard time holding back when appropriate, they tend to view futile actions in terms of "at least we did everything for dad", rather than the more accurate "at least we did everything to dad". Almost always POA's are relieved to have someone else enforce the patient's wishes when they know deep down what the patient really wanted, they just can't bring themselves to act on that.
  3. 0
    Quote from elkpark
    That's not my understanding (and I've worked on these topics quite a bit over the years). I've heard attorneys lecturing on this topic explain more than once that the reason you should be extremely careful about who you make your POA is because, once you are incapacitated and the POA takes effect, that individual is under no obligation to follow your wishes -- you have given that person the full legal right to make decisions (as s/he sees fit) on your behalf, using her/his best judgment (but not necessarily following your wishes).
    This is absolutely the truth! More than once in my years, the "plan" is all well and good until at bedside, then depending on the situation, minds change and it becomes what the POA/HCP wants as opposed to the patient's wishes. So be really, really clear with who you choose for your POA, because when it comes down to it, decisions are made on understandibly emotional grounds.

    There is more than one resident of skilled care who had a lengthy, detailed "legal" document as to their wishes. Those documents become wildly subjective for some POA/HCP's when it comes down to it. It may be different in other states, but generally speaking, POA's (or HCP's) have the final word. It is not always "keeping someone alive". If one chooses to value quantity over quality (and who are we to judge that decision) there can be and is HCP/POA's who say "no way" and go against those wishes.

    This is serious stuff, and the goal in the perfect world would be comfortable and peaceful. Family gets caught up in patient's "starving" more than anything else, in my experience.

    Families need to have these talks. A POA/HCP is a difficult position to be in.


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