Disturbing POA's

[MommaRN86]

Being new assisted living facility, I have many questions regarding liability and also difficult POA situations. I am the only RN on staff in the PM at my facility and am the "go-to-girl" for residents living in independent and assisted living quarters. I have had two situations now where the POA did not agree with my emergency treatment decisions.

One situation was regarding a res with C/P, pain to the Left arm, abnormal vitals, and EKG changes. I of course wanted to send her to ER and called 911...POA refused.

Second case regarding dementia res. with severe flank pain, POA refusing eval.

Other than contacting MD or DON what else can be done? Would it be better to call for emergency help first and then get POA permission after?

That has been the case (in regards to C/p sit) but I am wondering if I am somehow liable if I hear back from POA (as I am not always able to reach them stat) that they don't want treatment.

Isn't it always better to err on the side of providing care than denying it?

I trust my nursing judgement but some of these decisions POA's are making seem unethical, esp. since in these examples res want treatment. I feel so helpless in providing my residents care in these situations!!!

I feel especially helpless in providing care for my resident that I care for with dementia.

How is it ethical for POA to refuse any sort of work up for res. with extreme pain. Very frustrating. I also feel that being in Assisted Living your hands are tied sometimes.

I feel like I am always balancing on doing too much or not enough. The residents in AL/IL are all somewhat independent and have the right to make informed health care decisions but I cannot help to feel sometimes though that to not take an action is somehow neglectful. Anyone working in this field have any ideas or help? Thanks!!

[LaughingRN]

without being an expert on POA's and laws....

I fail to see how a POA can deny acute emergency care.

Hell, my short experience with hospice care taught me DNR and palliative care does not mean you let people suffer with acute issues that arise....you still treated them for comfort reason

I'm a parent, and I would hope that school would call 911 first instead of trying to find me by phone and say that "your son fell in gym and the bone in his leg is sticking out of his skin, can we send him to the hospital?"

Being my son's "POA" doesn't make me his personal god.

Next time send to ER, notify POA after.

[heron, ASN, RN]

It would be best to check with your facility's lawyer, I think.

The only point I have to offer is to remind you that the POA has the power to refuse treatment only if the resident is legally incompetent to make his/her own decisions. A POA cannot override the choices of a competent resident.

[Laurie52]

LaughingRN said:

without being an expert on POA's and laws....

I fail to see how a POA can deny acute emergency care.

Hell, my short experience with hospice care taught me DNR and palliative care does not mean you let people suffer with acute issues that arise....you still treated them for comfort reason

I'm a parent, and I would hope that school would call 911 first instead of trying to find me by phone and say that "your son fell in gym and the bone in his leg is sticking out of his skin, can we send him to the hospital?"

Being my son's "POA" doesn't make me his personal god.

Next time send to ER, notify POA after.

A power of attorney for health care can only be activated when a person is deemed non decisional by neuro-psych. I have a POA but I am still the one who makes decisions about my care. So the first question is, Is the POA activated?

If the POA is activated, then the POA can refuse emergency care. I was my aunt's POA and when she had a GI bleed, I allowed an IV to be placed for pain medication but refused to have her admitted to a hospital and have the bleeding worked up. I was speaking for her when she was no longer able to speak for herself and those were her wishes.

Legally, you are not your son's POA. In the situation you described your son would be given emergency treatment but anything else would require consent. When I watch my friend's or sister's children and they are out of town (not readily available), I make sure that they sign a note saying I can consent for any needed treatment for the children. I'm greatful that I have never had to use the notes, but I'm glad that they are there.

[nerdtonurse?, BSN, RN]

Why did the POA not want treatment? Is this a resident (like one of my aunts, god help us all) who has "chest pain" every time she doesn't get her way? Or is this a cardiac fragile person who the POA worried that just the stress of transport could kill them? In either case, I'd have administration talk with the POA and have them make the person a DNR or tell them if they are complaining of anything serious, they will be taken to the ER or the POA needs to find another facility. I think if she said "don't transport" and you didn't and then the patient died, she'd turn around and say, "I never said that, and I'm going to SUE."

And even if the pt's a DNR, and DNR doesn't mean "don't treat." Unless the pt is so fragile you can't transport them (I saw a person who died just from being moved from one bed to the next as we were trying to get them into ICU -- I told them to just use our bed, they wouldn't hear of it, we moved the pt as gently as we could but it was stll enough to cause them to code....) you still treat symptoms.

However, if this was just one in a string of MIs and you knew the pt was going to die of it, if not this one then the next, then I'd go for DNR, hospice and comfort measures only, like a MS drip and Ativan.

[LaughingRN]

Laurie52 said:

A power of attorney for health care can only be activated when a person is deemed non decisional by neuro-psych. I have a POA but I am still the one who makes decisions about my care. So the first question is, Is the POA activated?

If the POA is activated, then the POA can refuse emergency care. I was my aunt's POA and when she had a GI bleed, I allowed an IV to be placed for pain medication but refused to have her admitted to a hospital and have the bleeding worked up. I was speaking for her when she was no longer able to speak for herself and those were her wishes.

Legally, you are not your son's POA. In the situation you described your son would be given emergency treatment but anything else would require consent. When I watch my friend's or sister's children and they are out of town (not readily available), I make sure that they sign a note saying I can consent for any needed treatment for the children. I'm greatful that I have never had to use the notes, but I'm glad that they are there.

I did say that I'm not an expert before I began my post.......

I also put my son's POA in "quotations" because I know that I'm not his technical "POA" But I actually do make all medical decisions for him so it was a loose comparison of having decision making powers.

My response was more of an opinion than legal expert advice.

I would hope that if I no longer am competent, that I don't have family members allow me to suffer an MI with no pain treatment and possibly cause me to suffer more during the remainder of life I have left in me.

[nurse2033, MSN, RN]

In an emergency I would call 911. And determining an emergency is up to your clinical judgment. Once the patient is at the hospital, the POA can refuse treatment. If someone is having an MI I think it would be unethical to deny them medical care, and spending time contacting family could eat up hours. Since they can't see the patient, or be properly informed of all the risks quickly on the phone, I would err on the side of patient safety. Good question.

[GGT1]

I agree with most, I would think that calling 911 would come 1st and calling POA would come later once the patient was taken care of and therefore should not have been able to refuse to have the patient transferred the the ED. But I don't work LTC so not sure what the protocol is there.

[Woodenpug, BSN]

Thank you, Momma. I have cared for so many patients who, in a nursing concept of health, would have been healthier had they stayed in long term care. Before your post, I failed to look at it from the LTC nurse's point of view.

On another note, don't you wish the TOS included legal advise along with health care advise? ?

[ErinS, BSN, RN]

Where are your POLST forms? In our state every facility pt must have this form, which is essentially a MD signed living will. If pt is unable to make decisions, the POA absolutely can refuse emergency care. I have often had pt's (granted I work in hospice) where the POA has discussed medical emergencies with, for example, the cardiologist and decided not to activate ems in case of CP, because there are no suitable interventions left. I would guess that a POA who is refusing medical care has probably had some extended discussion with either the MD or their loved one. In my experience, it is rare that a POA does not automatically want MORE treatment than what is reasonable, and if they request less treatment than is standard it is after a lot of thought and discussion. Of course, some people are just dumb and do not understand the seriousness of some medical emergencies.

[CoffeeRTC, BSN, RN]

I understand that the POA makes decisions when the resident cannot. If resident wants treatment...they get it. If there is a question then we call the POA.

What does the doc want/ say in these situations?

[MommaRN86]

Thanks for all the feed back! My biggest concern is with my memory care residents. They cannot and should not be sent out if possible without a representative/family member with them and their decision making power is of course limited. But when I contacted my resident's POA, he refused to allow transportation and she was in extreme pain. I understand not wanting advanced life sustaining treatment, but to allow one to be in so much pain is unethical. The physician told me I had to follow POA's wishes. I went to DON. Wondering if one would have to go to court to have POA changed/revoked?