Health Care Proxy Dilemma/Question

MunoRN, RN · Dec 22, 2012

These laws vary by state, but in my state, at least from what you describe, "activating" a proxy wouldn't be appropriate in this situation. To defer to an agent that a proxy designates, or designated through a legal process, the patient would have to be found incompetent to make their own healthcare decisions. An unconscious patient would obviously fall into this category, others aren't so clear. An A&O patient would have to be declared incompetent based on their inability to understand the purpose of treatment and the risks to refusing treatment, or if they are deemed a danger to themselves or others. Danger to oneself however does not necessarily include refusing recommended treatments, even if refusal might result in death. In my state, even someone found incompetent is still has the legal right to know what they are being given, even if they can't refuse.

Guest219794 · Dec 23, 2012

Hello all! I'm a long-time lurker and haven't posted in a while but I have an issue that's really been bothering me. So let me give you a background..
Pt has Parkinson's disease, AAO to person place and time, occasionally forgetful (but who isn't?). Presenting lately with slight paranoia and ?depressive symptoms- feeling staff does not want to care for him, hiding his call bell, doesn't want him around, "no one likes me". Investigated- found that call bell not being hidden but pt very demanding so it wouldn't surprise me if staff was a bit short with him at times. We decided to have psych see him to see if perhaps they could increase his scheduled anti-depressant. Psych saw him, recommended a new anti-psychotic TID. Pt very hesitant to start medication, and was his own proxy, decided to talk it over with dtr and get back to us after the weekend. I was off for a week, and came back.
Fast forward to today. I come in and his health care proxy was activated (not per his request to my knowledge). Pt is baseline- AAO to person place and time. Still understands his condition, health status and medications. I am told by two nurses that since his HCP has been activated he has started on the anti-psychotic. However, if he asks, we are not to tell him that he's taking it ("because his HCP is activated, he doesn't need to know").
Two things sound very strange about this scenario, first of all, if a man can tell me his name, the town and state he is in, and what year it is, down to who the president is and what the score of last nights football game; how can his HCP be activated? Is occasional forgetfulness in the criteria?
Secondly, does not telling him what meds he is getting sound appropriate? Even if his HCP were appropriately activated- if he asks, doesn't he have a right to know?
I do plan to speak to the social worker, as well as my unit manager, but I was wondering if anyone had any insight? Or similar situations they could share?
Thank you for taking the time to read this, I'm thoroughly exhausted, so I apologize in advance for any incoherent wording!

I am pretty sure that having a health care proxy involved does not make it OK to lie to a pt.

The fact that this is a lie of ommision, rather than an overt lie is irrelevant.

Unfortunately, it is likely that this anti-psychotic he unknowingly takes helps with his symptoms.

tyvin, BSN, RN · Dec 24, 2012

Who is the agent of the proxy. The health care proxy is just like a health care power of attorney. These documents can be drafted to be very specific. It's when the person can no longer make health care decisions for themselves is when the proxy is activated. What are they telling this man he's taking 3 times a day?

You need to find out who the agent is and then you'll be able to figure out why they activated it when he's still able to make health care decisions...or is he? It could also be if he went to psych that the psych doc recommended the action of activating the proxy in order to have him take the medication for his own good. Has his behavior improved, gotten worse, stayed the same?

I think in this case you may need to understand the dynamics of mental health and how some things are necessary for the patient's well being.

sapphire18 · Dec 24, 2012

It is never ok to lie to a pt about what they are taking.

nurseprnRN, BSN, RN · Dec 24, 2012

Let's also be very clear that declaring a patient incompetent is not a decision made by physician or family. It is a legal decision by a court of law. If that wasn't done, then in my state that HCP could not have been activated. People are entitled to refuse medications even if we don't think they should.

There's a very famous case in the law and medicine arena. Mrs. Candura in NJ was an elderly diabetic with a gangrenous leg. She refused surgery. She completely understood that if she didn't have it off she would die from it, and said she was ready to die. Her physicians agreed not to amputate because that was her wish. After a time she began to fail (die), and was not longer alert and oriented. At that time her daughter went to court to compel her mother's physician to amputate the leg to save her mother's life. The court refused to so order, saying, in effect, it would be unconscionable to know what her wishes were and then wait until she could no longer defend herself against unwanted medical intervention, in this case, amputation.

Is there an ethics committee in your facility, or within your facility's corporate structure? That's the next step.

One Flew Over · Dec 28, 2012

I haven't really had a patient of this nature; it's always been easy to define whether they are competent or not. I guess that's why I was asking. I definitely see why he was seen in the first place, but I feel that other interventions such as counseling with our in house psychiatrist could have been at least tried first. His behavior has been at his baseline with no improvements. I also fear that with his already gait due to Parkinson's and desire to maintain independence he will be at higher risk for falls taking this medication.

After further investigating I found that his PCP activated the HCP, however, he rarely comes in to see the patient and knows little about him. His reasoning was increasing forgetfulness.. the pt has a history of depression, though, so it could be related to that. I guess I just thought that occasional periods of forgetfulness in an otherwise AAO patient was not enough to activate a HCP but like I said, I'm not too fuzzy on the criteria.

He takes his meds whole in pudding due to swallowing difficulties, so as far as I know, he didn't notice the addition of the medication. He has since learned that he is taking the med (through his daughter- HCP) and was a bit put off at first but OK now. But that still hasn't eliminated my feelings about the situation and how it was handled.

Tea: We don't have an ethics committee unfortunately, however, I do plan to discuss things further with the social worker and charge nurse once things at my building settle down.

tyvin, BSN, RN · Dec 30, 2012

I haven't really had a patient of this nature; it's always been easy to define whether they are competent or not. I guess that's why I was asking. I definitely see why he was seen in the first place, but I feel that other interventions such as counseling with our in house psychiatrist could have been at least tried first. His behavior has been at his baseline with no improvements. I also fear that with his already gait due to Parkinson's and desire to maintain independence he will be at higher risk for falls taking this medication.
After further investigating I found that his PCP activated the HCP, however, he rarely comes in to see the patient and knows little about him. His reasoning was increasing forgetfulness.. the pt has a history of depression, though, so it could be related to that. I guess I just thought that occasional periods of forgetfulness in an otherwise AAO patient was not enough to activate a HCP but like I said, I'm not too fuzzy on the criteria.
He takes his meds whole in pudding due to swallowing difficulties, so as far as I know, he didn't notice the addition of the medication. He has since learned that he is taking the med (through his daughter- HCP) and was a bit put off at first but OK now. But that still hasn't eliminated my feelings about the situation and how it was handled.
Tea: We don't have an ethics committee unfortunately, however, I do plan to discuss things further with the social worker and charge nurse once things at my building settle down.

What state are you in?

One Flew Over · Dec 31, 2012

I'm in Massachusetts