Medical Decision Making

[cshelly12]

I am a hospice admissions nurse, and frequently run in to the problem of patients unable to make decisions for themselves, and either don't have an MPOA, the MPOA is not present for the visit, and/or those who would be considered first in line to make decisions are not there. I live in Texas, and understand the order of who is first, second, third, etc. in line to make medical decisions. Does anyone have any insight on what to do if the MPOA or first in line to make decisions is not at the visit, and they cannot be contacted. To give an example, I had a patient who was still legally married, but was not in contact with the spouse. Her adult child was at the visit, and the only option was to have her sign the admission papers. Any advice on these situations would be greatly appreciated.

[RiskManager]

I have risk management oversight for our home health and hospice service lines, amongst others. This is a common problem. It is not unusual to have hospice patients who are incompetent and have no living relatives whatsoever or none that are reasonably available. I always took the philosophy that we would not deny services to someone based only on the inability to have someone sign the consent and registration paperwork. If the patient does have someone acting as the caregiver, I would ask that person to sign. We would document the chart up the wazoo explaining the circumstances as to why there was no patient or surrogate signature or why a non-relative was signing. It was not a realistic option to have a guardian appointed; in my jurisdiction, that would take weeks or months and cost several thousand dollars which the patient could not afford. I would have the staff write on the forms a statement like this: 'patient is in need of clinical services, is incompetent to sign and no legal surrogate is available'. If you have a risk manager, be sure to ask that person about this as well.