Post 101: Three Cautionary Patient Stories for Completing a Medical Power of Attorney

“If tomorrow you woke up delirious from a bad infection or were unconscious from a stroke or accident, whom would you trust to speak with the doctors and make medical-related decisions for you until your mind cleared?”

Most people have a ready answer (and often several backup answers) to this question.  However, it is not enough to know in your heart and in your mind whom you would trust to advocate for you when you are at your most vulnerable.  You need to have those names documented on paper. 

The most easily recognizable paper would be the Medical Power of Attorney (MPOA)/ Medical Durable Power of Attorney (MDPOA)/ Healthcare Power of Attorney (HCPOA)/ Durable Power of Attorney for Health Care (DPOA-HC) document for your state [read Post 4: Eleven Common Myths About the Medical Power of Attorney (MPOA)]. 

Though this document serves the same function in each state, each state calls this document by slightly different titles and the format looks different from state to state.  For the sake of simplicity, I will refer to all of these documents as Medical Power of Attorney (MPOA).

“Why should I fill one out?  Wouldn’t the doctors know what to do?”

As a palliative care physician (read Post 1: What Exactly Does a Palliative Care Specialist Do?), one of my roles is to explain the potential benefits (and I have yet to think of a potential risk!) of completing an MPOA document.  This may entail explaining the many potential “risks” of not completing an MPOA [read Post 14: A Medical Emergency with No Medical Power of Attorney (MPOA)! - Two Everyday Scenarios].

The following examples of how and when an MPOA could be helpful are based on real patient cases (details changed to protect patient privacy), divided into three main categories:

When one is conscious, but thinking is off (such as due to lack of focus, lack of attention, lack of energy, intense physical discomfort, intense emotional discomfort)

Just prior to the pandemic, I was asked to do a routine home visit for a patient with advanced lung disease.  I was covering for a colleague, so this was my first time seeing this patient.

When I spoke with him – we can call him Mr. S. – he answered sluggishly.   His housemate (also his sister) anxiously commented, “I called the paramedics last night, but they wouldn’t take him to the hospital!  They said it’s because he didn’t want to go, and they had to go by what he said.”

My medical assistant took his vital signs.  His oxygen saturation levels were in the 60s!  Normally, we would want oxygen saturation levels in the 90s.  We called 911, and the paramedics came.  The paramedics also found extremely low oxygen readings, so they quickly placed an oxygen mask on Mr. S.'s face and told him they were taking him to the hospital.

“Noooooo!” Mr. S. moaned, “I don’t want to go to the hospital!”

“Ok, then, answer me three questions,” one of the paramedics replied, “What’s your name?”

“S.”

“Who’s the president?”

“Trump.”

“What state do you live in?”

“Texas.”

“Ok, you’re oriented times three, and you don’t want to go to the hospital.  We can’t force you,” the paramedic said matter-of-factly, and he then indicated for his teammates to remove the breathing mask from Mr. S.’s face.

“Wait!” I exclaimed, “He needs that oxygen!  He needs to go to the hospital!  His oxygen level is in the 60s!”

“Ma’am, we understand.  However, there have been too many people who have accused us and other agencies like us of taking them to the hospital against their will.  They’re especially angry if they get an ambulance bill.  So it’s now our strict policy that if someone’s oriented times three, we have to do what they say.”

“But orientation is not the same as mental capacity,” I tried to explain, “This man cannot make life or death decisions by himself with his brain cells suffocating from lack of oxygen!” (Read Post 10: Four Simple Questions to Determine if a Person is of Sound Mind.)

“He’s oriented times three.  That’s our policy,” the paramedic responded.

 Using my body to block the doorway, I said, “But I’ll have to call 911 again.”

“Do what you have to do.  We’ll come back.”

I wracked my brain for any argument that could be considered valid.  “You know, his oxygen levels could fall further tonight, and he could die.”

The paramedic hesitated and then slowly replied, “He’s oriented on all three questions, and we can’t force him against his will.  We were here last night, and the same thing happened.  You know, some people have accused other ambulance agencies of kidnapping, that’s how serious these accusations have become.”

“Ok,” I said, “How about if he has a documented medical power of attorney?  Can we go by what his medical power of attorney says?”

“Uh, sure, yeah, we can take that.  If the MPOA assumes all responsibility.”

“I will! Please take him to the hospital!” Mr. S.'s sister called out from behind me.

“Here’s his MPOA,” my medical assistant said as she pulled up on her laptop a copy that had been scanned into our medical records just the month prior. 

“That’ll work!” the paramedic said, relieved to get the situation resolved, and his teammate set down his supplies bag to place the oxygen equipment back on Mr. S.’s face.

Though this story (based on real events) is bit dramatic, variations of this scenario occur every day:

-  A patient with moderate dementia already involved in two motor vehicle accidents driving into a pole is asked to consider the potential risks and potential benefits of a heart procedure

- A patient who stares off into space and requires help turning on the hot versus cold water faucets since starting chemotherapy a year and a half ago is asked to consider trialing another chemotherapy since his cancer has not responded to the first two lines (“types”) of chemotherapy

-  A patient who is struggling to catch her breath during a flare-up of her end stage lung disease is asked to consider and quickly make a decision regarding intubation, including the potential long term dependence on the breathing machine

 When one is not conscious

The palliative care team was once consulted to see a patient in the Intensive Care Unit.  Mr. T. had had an abdominal surgery for which he unfortunately had suffered several weeks of complications and repeated surgeries.  He had been intubated for a couple weeks and was now also showing signs of liver and kidney failure. He was also not regaining enough alertness to follow commands, even when sedation was turned off, and a neurologic workup could not find a potentially reversible cause (read Post 9: How Terminal is Terminal?).

His three stepchildren, whom he had raised since they were in preschool and elementary school, met to make major medical decisions on his behalf.  Mr. T. had no other family to speak for him.  His wife and parents were deceased, and he had no siblings.

(Keep in mind that every state in the United States has a different default hierarchy of surrogate decision makers.  In Texas, the hierarchy order is spouse, followed by children, parents, then closest relative.)

It turns out that though Mr. T. had raised his stepchildren and remained an active part of their lives when they had their own families, he had never completed formal adoption papers for his stepchildren.  They could not be legally recognized as surrogate decision makers for their “dad.”

Now, if a patient receiving medical care in Texas has no completed Medical Power of Attorney document and no family as recognized by law, then major medical decision making falls on “two physicians,” one involved in the patient’s case and one not involved in the case, to make medical decisions together.

In Mr. T.’s case, the two physicians  did ultimately make medical decisions as directed by the stepchildren.  In this sense - having the people who knew him best "make" medical decisions for him - his was a fortunate case.

In addition to the right to make major medical decisions for a loved one who temporarily does not have the mental capacity to make decisions themselves - for example, a loved one involved in a major motor vehicle accident, a loved one who is unconscious after a major stroke, or a loved one who is severely delirious from a serious infection -  the MPOA document can help with practical matters such as allowing the person holding the medical power of attorney to obtain medical records on behalf of their loved one. 

We have had spouses tell us they have yet to be able to obtain medical records from certain hospitals because their loved one never completed an MPOA document naming them to hold the MPOA.

When one is conscious and of sound mind (but for various reasons, does not want to make medical decisions

Occasionally, when I introduce myself and explain to the patient and family that I will be talking big picture about how the patient is doing, potential health trajectories (read Post 67: The Difference Between "Potential" and "Likely"), prognosis if they want to discuss prognosis (read Post 70: It's Not Cowardly to Not Want to Know), and issues the doctors are worried about, the patient will say, “Are you going to discuss anything negative?  Because I don’t want to hear anything negative.”

There are multiple reasons why someone may not want to hear certain details about their health, especially potentially worrisome health news (read Post 13: Sometimes It's Denial, and Sometimes It's Just Really Bad Timing).  Perhaps they feel overwhelmed already from hearing multiple bad news.  Perhaps they just heard great news just prior to that clinic visit and are having a good day and do not want to ruin it.  Perhaps they are tired of being stuck in the hospital and this is one of the very few ways they can exert control.  Perhaps they feel that articulating the worrisome news will make the potentially worrisome events “manifest.”

In these situations, I would respond to the patient, “Okay, if you ever change your mind, let me know and I would be happy to answer any questions you have.  In the meantime, while we honor your wishes, I’ll speak to your medical power of attorney regarding what’s going on with your body, and based on that information, make plans together with them as they act on your behalf.”

After over a decade practicing palliative care, I have never seen a patient regret completing a medical power of attorney document. 

However, I do regularly see family members regretting not pursuing their loved one’s completing a medical power of attorney document (as well as a financial or durable power of attorney, which is different from a medical or healthcare power of attorney) before their loved one lost (even if just temporarily) mental capacity to do so.

I urge you to save yourself and your family from potential regret or avoidable hassle.  Print out a copy of the medical power of attorney (the exact name of which differs state to state) from your state’s health and human services website, complete one today (no attorney needed, though some states require a notary or witnesses for the signature), and provide copies to all of your designated surrogate decision makers, and I hope none of us become a cautionary story.