HELP! Nurse's Role in Medical Power of Attorney Case

[tencat]

Hi all. I did a search but didn't find what I was looking for, so I apologize if this has been introduced in another thread. I have a patient in a LTC facility, on hospice services. I wrote about him in another thread. Anyway, after a very non-productive chat with the ignorant attending physician, he remains on IV fluids and an oxygen mask that is literally cutting up his face with an order for 2 mg morphine q 6 hours PRN for pain only. Daughter is medical power of attorney (my company has a copy of it in his working file) and she finally decided enough was enough, she was going to insist they stop all fluids and place a nasal cannula on patient. LTC social worker says that they can't do that unless they have written orders from the physician, but they are unable to get hold of said ignormaous physician (no suprise there) and refuse to comply with daughter's wishes until they have written orders in hand. The facility will not accept orders from our medical director as he is not on their 'list' of physicians allowed to write orders for the facility. My question is: what does a POA mean? Does it mean that all that stuff CAN be discontinued WITHOUT a physician order since it is the POA wishes? The document specifically states that the fluids can be stopped as can oxygen. Does it have to be a physician who stops everything? OR does the document 'trump' the physician? Just wondering. Thanks.

[pink85]

I think that is a great question and I am dying to hear some responses. I had a similar situation in the hospital. All turned out Ok in the end but the trauma it put the family through was terrible.

[Jolie, BSN]

I'm no lawyer, but it seems to me that since the patient has the right to refuse these care measures regardless of physician orders, the POA does as well, unless there is evidence that the patient is capable of making his own decisions, or disagrees with the POA.

How about a hospice consult?

[mskate]

i would take it to understand that the DPOA would have the ability to make medical decisions - including refusing treatments. you cannot force treatments and the MD absolutely cannot over rule personal medical decisions.... if the hospital or the government is overly concerned about abuse, they can petition the court to assign someone else to make the medical decisions - but as it stands, dpoa = decision maker. does not mean they have to comply or agree to any treatment the md deems needed.

If it were me, I would put the pt on nc o2 and stop the ivf. i'd document it thoroughly as a "refusal" of specific care, as the pt is unable to make their own decisions - document it as the pt's decision maker's refusal. i would notify the MD, and go over his head to notify everyone of their refusal for this. they can either address it or not, but i dont force care on people who do not want it and have a solid understanding of their care and ability to make decisions.

I might also sit down with family and mention that there are many options in medical care and sometimes people choose hospice care. nothing wrong with educating people about their options - esp if they are feeling so trapped that they feel they cannot refuse care by an MD who will not even get involved!

You're the pt's advocate, not the doctors. Document, document, notify, document, but ultimately, do not push care when the decision maker or the pt is refusing it.

[kids]

The facility will not accept orders from our medical director as he is not on their 'list' of physicians allowed to write orders for the facility.

Ok, someone at your facility is out of their mind. If he's the medical director he has to be on the list to write orders. One of the responsibilities of the Med Dir is to step in and write orders if the attending can't be reached, another is to sign the monthly orders if the primary doesn't to ensure compliance with state & federal laws.

Does the O2 order specify it is to be via mask?

If your O2 orders are written to specify a mask, *technically* the patient/DPOA can refuse O2 via mask but that doesn't mean you can put a cannula on- you don't have an order for O2 via cannula.

One rather underhanded but effective methid would be to wait until after office hours to call the physician on-call for the primary for telephone orders.

Edited to add...

Wait a sec, is this patient formally on Hospice (with an outside entity)? If yes, call Hospice, they can get the orders you need.

[sirI, MSN, APRN, NP]

My question is: what does a POA mean? Does it mean that all that stuff CAN be discontinued WITHOUT a physician order since it is the POA wishes? The document specifically states that the fluids can be stopped as can oxygen. Does it have to be a physician who stops everything? OR does the document 'trump' the physician? Just wondering. Thanks.

A Power of Attorney (POA) is a legal document. If the patient (who is the "Principal") appoints someone as POA (referred to as the "attorney-in-fact"), all signatures are valid, etc., the attorney-in-fact can make decisions for the Principal. Often, Powers of Attorney will be limited as to what decisions can or cannot be made. Now, if the Principal has indeed made the POA durable (Durable Power of Attorney) then, even after the Principal becomes incapacitated, the attorney-in-fact can make medical decisions.

You did not state if the POA is durable, but let's assume it is in this situation.

Once the POA has decided that IV fluids and oxygen are to be withheld, this decision is to be honored by the physician and/or facility. Orders can be written to uphold this decision of the POA as if the patient himself was making the decision.

Your facility needs to get in touch with either the patient's physician or the physician-on-call to carry out the POA wishes. And, as stated in previous post by kids, Hospice can assist in securing these orders.

[tencat]

Thanks all! Update: Did manage to get attending physician to give verbal orders to d/c fluid and put on nasal cannula for comfort. Also got physician to agree to up the dose of morphine to every 6 hours but still PRN and still only for pain....no dice on a shorter interval or larger dose, but patient does not appear to be in too much distress. I didn't win that battle, unfortunately. Probably a good thing as the facility is pretty fast and loose with it's morphine wasting.......Had one RN tell me she was too busy to waste with me. Had another one say 'just toss it in the sink' and didn't want to watch me do it. I did insist she do as I don't trust that they won't try to say that I 'lost' some morphine. Only one nurse there is willing to give it, anyway. The others say that in their judgement he's not in pain. I've given him one of only two doses he's had since last thursday.

If it were me, I would put the pt on nc o2 and stop the ivf. i'd document it thoroughly as a "refusal" of specific care, as the pt is unable to make their own decisions - document it as the pt's decision maker's refusal. i would notify the MD, and go over his head to notify everyone of their refusal for this. they can either address it or not, but i dont force care on people who do not want it and have a solid understanding of their care and ability to make decisions.

POA and patient (before he was unresponsive) both agreed that these measures were not to be taken. So they did not want the treatments if there was no chance of getting better. It was the facility that wanted to keep pushing these treatments. The DON was not willing to contact the physician and get orders to stop the treatment, even though that is what the family wanted.

Hypothetically, let's say that there was no way to get orders from attending physician, and facility physician had been unwilling to write these orders. If a nurse decides to honor the family wishes and the POA document, orders be damned, would he/she have the authority to DO that? Or does that become practicing medicine without a license? Can a nurse be protected by a POA document?

[sirI, MSN, APRN, NP]

Hypothetically, let's say that there was no way to get orders from attending physician, and facility physician had been unwilling to write these orders. If a nurse decides to honor the family wishes and the POA document, orders be damned, would he/she have the authority to DO that? Or does that become practicing medicine without a license? Can a nurse be protected by a POA document?

Excellent question and one that a court would have to decide, I'm sure.

If the nurse practices laterally in this respect and w/o physician order, not sure how she/he would be covered. You can better advocate for your patient as you have done and protect your license. Keep on management and physicians to abide by the DPOA and write the order(s).

Good job!!