Would a durable power of attorney ever NOT override a living will?

[knuckles]

From what I've read, regardless of date, the durable power of attorney always holds more steam than the living will, even if they contradict one another.

Is this really the case in the real world, or just USMLE ethics questions.

I mean, if a patient has a living will demanding they would not want mechanical ventilation to be kept alive, and then the durable power of attorney decides they want to keep mechanical ventilation, wouldn't it be obvious they are going against the patients wishes, even though legally they speak (as messenger) for the patient?

In that case, how could you possibly not follow the living will, when it's obviously being contradicted and the durable power of attorney is clearly making decisions contrary to the patients wishes.

If anyone can clarify this, it would be much appreciated. Thanks.

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[PokerDoc]

From what I've read, regardless of date, the durable power of attorney always holds more steam than the living will, even if they contradict one another.

Is this really the case in the real world, or just USMLE ethics questions.

I mean, if a patient has a living will demanding they would not want mechanical ventilation to be kept alive, and then the durable power of attorney decides they want to keep mechanical ventilation, wouldn't it be obvious they are going against the patients wishes, even though legally they speak (as messenger) for the patient?

In that case, how could you possibly not follow the living will, when it's obviously being contradicted and the durable power of attorney is clearly making decisions contrary to the patients wishes.

If anyone can clarify this, it would be much appreciated. Thanks.

I could have sworn that I got into a discussion with a physician about this once that if there is proof that a durable power of attorney is making decisions against the patients wishes, the physician can go through the court system to get a judges permission to carry out the living will.

For our exam this is way too complex an issue to really worry about but its an interesting debate for later. There is actually a vocabulary word for this, its on the tip of my tongue, I cant think of it, but when the wife for example makes a decision clearly opposing what the patient would want. I know thats not exactly the same as DPoA but its a similar idea.

 

[bergwood]

I'm pretty sure a living will (well documented, official) always overrides a durable power of attorney on the specific issues it covers. The living will is representative of what the patient wants, whereas a power of attorney is what someone else thinks the patient would want. Living will should be considered first, and if the living will doesn't address the decision, then the power of attorney grants the rights to decide for the patient. Alternatively, a power of attorney with specific directives can also be issued.

 

[knuckles]

A few qbanks have questions where the two directly contradict each other (eg living will says patient doesn't want mechanical ventilation, and power of attorney wants to keep patient alive), and the answers all have been to keep the patient ventilated.

 

[IMGUSMLEStep1]

First off, consider this...written consent can be revoked orally. For example, if a patient's will says that he is DNR, and he then changes his mind and tells you clearly that he does want to be resuscitated if the need were to arise, you would obviously take the patien't oral advance directive over any written directive issued at a previous date.

Kaplan's USMLE Medical Ethics says a durable power of attorney:

"overrules all other decision makers."

"is not there to give his personal opinion as to what he thinks should be done for the patient. The proxy is there to communicate the patient's original wishes in order to ensure that they are carried out."

So in most cases, you would do what the health proxy says because it is the most current directive and holds the most weight.

knuckles, in the case you mentioned above, the health care proxy completely contradicts the living will, so like pokerdoc said, it would be best to let a court decide whether the living will or the health proxy best represents the patient's current desires.

In the Kaplan Lecture notes it says:
"Consider going to court only if you perceive a serious onflict of interest between surrogate and patient's interests"

P.S. I don't work for Kaplan, lol

 

[PokerDoc]

I could have sworn that I got into a discussion with a physician about this once that if there is proof that a durable power of attorney is making decisions against the patients wishes, the physician can go through the court system to get a judges permission to carry out the living will.

For our exam this is way too complex an issue to really worry about but its an interesting debate for later. There is actually a vocabulary word for this, its on the tip of my tongue, I cant think of it, but when the wife for example makes a decision clearly opposing what the patient would want. I know thats not exactly the same as DPoA but its a similar idea.

Just remembered what I was trying to think of:

substituted judgement: whenever the durable power of attorney makes a decision knowing its against what the patient would want because its what [durable power of attorney] would want. If the doctor suspects this, I believe they can appeal to the courts to fight the decision.

 

[knuckles]

But of course you would never choose the courts or ethics committee on a step 1 question, hence go with DPofA as your answer.

Another random ethics fact,

if you have the typical mormon family and the father comes in with his severely injured wife and child, and refuses that the two of them receive blood products,
you can only legally give blood to the child, while the wife dies.

I think that's f'd up.

 

[PokerDoc]

haha yeah this is not really a step I issue i just thought it was interesting because its relevant down the line.. who knows how soon in our careers these issues are going to come up.. at first I hated it, but now I actually like that step I sort of forces you to learn the more common ethical dilemmas before you get out there for 3rd year.. we might have these situations come up sooner than we think... certainly more important than knowing the rate limiting enzyme of pyrimidine synthesis

 

[Raryn]

But of course you would never choose the courts or ethics committee on a step 1 question, hence go with DPofA as your answer.

Another random ethics fact,

if you have the typical mormon family and the father comes in with his severely injured wife and child, and refuses that the two of them receive blood products,
you can only legally give blood to the child, while the wife dies.

I think that's f'd up.

Jehovah's Witness, not Mormon. The LDS are generally fine with modern medicine (except for some reproductive stuff)

 

[pyaarawala]

I know I'm bringing back an old thread here, but this question here was confusing me, regarding the same issue, from USMLERx.

65 y/o cancer patient gives his best friend durable power of attorney for health care. As his condition worsens, he goes into respiratory failure and needs to be put on a ventilator. The friend is confident that the patient would have wished for life support to be withrdrawn, but a living will from 20 years ago stipulates that all measures should be taken to save his life. The patient's son believes that the patient would have wanted all measures to be taken to maintain his life, and wants extreme measures to be taken to maintain his life.

What's the appropriate action for the phyisican?

A. Advise the friend to comply with the son's wishes
B. Give the son power of attorney because he is the next of kin
C. Keep the patient on life support in accordance with the living will.
D. Poll all family members present and follow the most supported course of action.
E. Respect the judgement of the person who holds durable power of attorney and withdraw life support.

So is the general consensus that Power of attorney > living will, even if they completely CONTRADICT one another? I watched a Kaplan 2010 video where the Behavioral Sciences teacher says that you don't follow the attorney if they completely contradict, but over here, the answer was E.

 

[Transposony]

I know I'm bringing back an old thread here, but this question here was confusing me, regarding the same issue, from USMLERx.

65 y/o cancer patient gives his best friend durable power of attorney for health care. As his condition worsens, he goes into respiratory failure and needs to be put on a ventilator. The friend is confident that the patient would have wished for life support to be withrdrawn, but a living will from 20 years ago stipulates that all measures should be taken to save his life. The patient's son believes that the patient would have wanted all measures to be taken to maintain his life, and wants extreme measures to be taken to maintain his life.

What's the appropriate action for the phyisican?

A. Advise the friend to comply with the son's wishes
B. Give the son power of attorney because he is the next of kin
C. Keep the patient on life support in accordance with the living will.
D. Poll all family members present and follow the most supported course of action.
E. Respect the judgement of the person who holds durable power of attorney and withdraw life support.

So is the general consensus that Power of attorney > living will, even if they completely CONTRADICT one another? I watched a Kaplan 2010 video where the Behavioral Sciences teacher says that you don't follow the attorney if they completely contradict, but over here, the answer was E.

It's very clear in this question that the POA will prevail since the "living will is from 20 years ago".

 

[pyaarawala]

It's very clear in this question that the POA will prevail since the "living will is from 20 years ago".

I guess you're right. So the only way the living will would prevail is if it was much more recent, but a question like that shouldn't show up on the USMLE I hope. If it does, I may just have to choose to go to court...

 

[Chiverdoc]

Glad i found this post.
I just had a hell of an ethics day.

Called to assess a patient in the ED for sepsis. Patient is a nursing home resident for 3 years, long medical history of failure to thrive, multiple strokes, pulmonary embolism, functional quadriplegic, peg feeding tube, gi bleed, aphasia.

I reviewed medical records on file and those from the nursing home. Patient has a living will declaration and a POA form all signed on the same day in 2013.

Now patient is severily Ill, has no quality of life nor any hope of a return to a life of quality.

Living will states that family, primary care physician, treating physicians, Healthcare facilities and Lawyers are to use the living will as his stated wishes. Those are that should he be terminally I'll he does not want aggressive or heroic therapy.
"I do not fear death, merely the indinity associated with it" he requests that we treat medically to manage and alleviate symptoms, and to avoid therapy aimed at delaying death/prolonging life.

POA stipulates that son can make decisions should patient be incapacitated (current and persistant state)

Now in terms ofor patient management he deserves initial management of sepsis including iv fluids and antibiotics. However vasopressin therapy, intubation and resuscitation would and are deemed as "aggressive", "heroic" and "delaying death"
For those reasons we make the patient DNR and downgrade the admission to icu and continue current therapy.

I called the son. The POA. I inform him of the patients status and the living will stipulation, son asks me to override the living will. I stated that my duty is to follow the patients wishes whenever they are known and to defere to a poa who is to represent what the patients wishes would be in a situation.

Now given that it is clearly documented what the patient wanted, the POA can not legally overrule that.

I confirmed all of this with the hospital legal team.

Ethically and legally, we are to do no harm and to follow the patients wishes be that refusal of care or otherwise. POA's are designated persons whom are to represent the patient and inform the physician what the patient's wishes would be in situations when they are not known.

When or if a patients wish is clearly documented that can not be overridden.

As some of you have said above, the next thing is to appeal or discuss this with the poa at an ethical meeting. My hospital has, in the past gone to court to settle similar matters however at no instance has a POA been successful in appealing or overriding a living will.

The reality is that we all want to avoid conflict and so we go along with the POA or additional family members demands. This leads to, in my experience, continued suffering and indignitation of the patient, the very person we are meant to help.

 

[Phloston]

As far as I'm aware, durable power of attorney always supersedes the living will, which is why the person is durable. The durable power of attorney basically = the patient in power if the patient isn't there (mentally or physically). And of course a patient would always override his or her own living will.