Shirley executed a Power of Attorney (POA) for Health Care when she was 64 years old. At the time, she directed that that everything possible be done to keep her alive, regardless of her chances of recovery or costs. She kept her POA for Health Care in a file and never looked at it again, until it was resurrected 25 years later when Shirley had significant dementia and many medical problems. She was no longer able to care for herself or express her needs or desires. Had she, in consultation with her physician, agent or other trusted adviser reviewed her POA for Health Care, she may have reconsidered the level of intervention she desired. Unfortunately this did not occur.
When Shirley became gravely ill, her direction to have her “life prolonged to the greatest extent possible” resulted in 3 weeks of hospitalization in the intensive care unit, with numerous costly and invasive tests and procedures that were ultimately futile.
This sad tale provides a lesson in understanding the power of the Power of Attorney for Health Care and the importance of regular review of the document. As the health and life circumstances of an individual change, so may their wishes to continue or withhold treatment. In a health care system in which there seems always to be one more test or procedure, it is important, in creating and reviewing the Power of Attorney for Health Care to ask, “what do I want to accomplish?” through medical intervention.
The Power of Attorney for Health Care provides family and health care providers with general instructions on end-of-life care for persons who are unable to make decisions for themselves because of physical or cognitive deficits. The individual who designates the Power of Attorney for Health Care is the “principle,” while the person named to make the decisions is the “agent.”
The POA for Health Care begins with two important steps:
- Naming the “agent”: the designated individual who will make care decisions and ensure that directions regarding care are followed.
- Stipulating the person’s desired level of intervention during any period of time when the individual cannot act or speak for himself or herself.
In Illinois there are two general categories of intervention in Illinois; they range from providing “no life prolonging or sustaining treatment” to ensuring treatment to the “greatest extent possible.”
The selection of the agent should be made with care. The agent should be someone whom the principle trusts. Additionally, the agent needs to be readily available, and emotionally and intellectually capable of asking questions and of articulating and advocating the individual’s wishes in sometimes unfamiliar or overwhelming situations.
The POA for Health Care puts the onus for decision-making on the agent, who has no blueprint for all the decisions that may need to be made in real-life situations. Completing the required paperwork is one part of the process to ensure that an individual’s wishes are honored and that the agent is not unduly burdened with decisions during highly emotional times.
To be most effective and meaningful, it calls for an ongoing process of communication between the individual, the agent, family members and caregivers. To ensure that the individual’s directives are followed, the wishes of the principle must be clearly spelled out. The POA for Health Care can include very specific interventions that the individual considers “life sustaining” to give more direction or details to the agent. Does “no life prolonging” interventions include gastric feeding or antibiotic treatment? In some instances, such treatment can return a seriously ill individual to full functioning and good health, but at other times it serves only to prolong a seriously debilitated life. What is the person’s intent?
Ideally, the preparation of the POA for Health Care includes a thoughtful discussion with a trusted health care provider – the primary care physician or an experienced registered nurse who can speak to a particular diagnosis, prognosis and likely outcome of treatment. Although it is impossible to foresee every medical scenario, the physician(s) can offer an “educated opinion” not only about acute treatment outcomes but also about prognosis for and extent of recovery.
To insure that the POA for Health Care is used as intended, the agent and all successor agents should have copies of the POA for Health Care, as should the primary physician and a family member or members. A copy of the POA for Health Care should accompany the individual during any hospitalization to ensure that providers and others can be made fully aware of the individual’s wishes.
Finally, the agent should ask the physician in charge, the “attending physician,” to write an order to “contact the agent for consents for all tests and procedures” in order to ensure coordinated communication among other specialists who may be called in as consultants.
In considering interventions, the agent should consider the ultimate goals of the care. In consenting to tests, it should be clear how the information derived from the test would be used to promote the identified goals of care. It’s very easy, in this age of specialization, to treat the symptom or body “system” and lose sight of the whole person. The purpose of the agent is to ensure that all decisions regarding tests and procedures are made in the context of the individual and his or her values and wishes.
A thoughtful health care professional can speak to the myriad of possible interventions that are part of the medical arsenal when treatment “to the greatest extent possible” is the chosen option. Does the individual fully understand that in many instances treatment “to the full extent possible” does not result in meaningful recovery but merely prolongs the dying process? Likewise, many individuals who choose the option for “no extraordinary measures” are not aware that, in Illinois, a separate document is required to prevent what might be considered extraordinary – cardiac or respiratory resuscitation- from being performed.
The Power of Attorney for Health Care is much more than a legal document. It is establishes a sacred trust and demands the courage to consider the most critical life and death decisions we all ultimately face, for ourselves and for others.
Updated from an original post in 2010.