Guidelines vary when surrogates with power of attorney disagree with advance directives
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Key takeaways:
- The surrogate of an unresponsive patient asked to continue care.
- The providers consulted with their system’s ethics and legal departments.
- Guidelines vary from state to state, if states have them at all.
BOSTON — Inconsistent guidelines can lead to conflicts when surrogates with powers of attorney disagree with what may be described in a patient’s advance directive, according to a poster presented at the CHEST Annual Meeting.
“We need a lot of work, as far as policies and law, for guidance for physicians,” Hamza Saifuddin, DO, MA, a second-year internal medicine resident with Corewell Health Lakeland Hospitals, told Healio.
Saifuddin created the poster with Katie Fitton, DO, a pulmonologist at Spectrum Health Lakeland in the metropolitan Detroit area.
The authors of the poster described a female patient, aged 74 years, on anticoagulation for atrial fibrillation who was found unresponsive and brought to the ED. The patient had experienced extensive embolic strokes in the cerebellum, midbrain and occipital lobes with bacterial endocarditis.
The patient was then intubated and placed on ventilator support. Except for positive corneal, cough and gag reflexes, she remained unresponsive. Providers recommended tracheostomy and percutaneous gastronomy tube placement.
“We knew that the patient’s advanced directive stated that they would not want to be on life support, but their power of attorney wanted to proceed,” Saifuddin said.
However, he added, the care team did not have access to the patient’s advance directive.
“It’s a difficult decision to make,” Saifuddin said. “Legally, what are we supposed to do? Because there’s a lot of fear about legal repercussions, but also ethically, what’s the right decision?”
Although advanced directives are legally recognized, he said, providers do not have to adhere to them.
“They are a very fluid process for patients,” Saifuddin said. “Advanced directives can change based on the time, the situation and what the medical treatment options are going to be like.”
Some states prioritize the advance directive when it conflicts with the durable power of attorney (DPOA), and other states prioritize the power of attorney’s decision, he said.
“Most states in the United States don’t provide any guidance,” Saifuddin said.
The authors noted a previous survey indicating that slightly more than half of the 300 participants polled said the preference of the person holding the power of attorney should take precedence when it conflicts with the advance directive.
The authors also cited a 2016 paper outlining principles and a framework that consider medical appropriateness, corroboration, discretion and purpose in determining when it may be appropriate to override an advance directive.
Yet more guidance is needed, Saifuddin said.
“Getting more work in place, not only focusing on the ethics of such a conflict, but also legally representing and providing guidance for physicians, would be very, very helpful,” he said.
Saifuddin said that his health system’s ethics and legal teams guided the care team through treatment.
“We had access to the DPOA framework, but we didn’t have access to the advanced directive,” he said. “So, legally, we go with the document that we have stating that the DPOA makes the decision.”
Despite the availability of support for making these decisions, the authors said that it is important to discuss potential conflicts when patients are planning advance care.
Saifuddin also said legislation may be helpful.
“This process would have been easier, both for family, patient, and for the health care workers, had there been a more appropriate law in place,” he said, although he was not optimistic that it would happen on the federal level. “Is something like that ever going to happen? I think that’s a different question.”
Fitton said that there is a great opportunity for the palliative care groups of professional societies to investigate frameworks and guidelines for supporting care teams in these situations.
“The problem is there just aren’t any,” she told Healio. “Nobody wants to say, ‘Do this. Do that,’ because every situation is different.”
Saifuddin is a member of his health system’s ethics committee, which meets to discuss patient cases.
“We have a few cases like this that happen from time to time,” he said. “There definitely needs to be more work and procedures and policies in place for situations like this.”
References:
- Bruce CR, et al. CHEST. 2016; doi:10.1378/chest.15-2209.
- Terry PB, et al. J Clin Ethics. 1999;10(4):286-293.
For more information:
Hamza Saifuddin, DO, MA, can be reached at hamzasaif95@gmail.com.