Durable power of attorney vs. Living will

[iA-MD2013]

If they contradict each other, which one wins on the USMLE?

Kaplan said that durable power of attorney overrides everything else. Uworld says "Medical professionals must respect decisions of the next of kin unless there are contradictory written wishes of the patient."

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[tco]

If they contradict each other, which one wins on the USMLE?

Kaplan said that durable power of attorney overrides everything else. Uworld says "Medical professionals must respect decisions of the next of kin unless there are contradictory written wishes of the patient."

It depends on the situation. If the next of kin talked to the patient last night about the subject, and the will was written before that, the kin wins. However, if the kin is just basing it on whatever they believe, the living will wins.

There's so much ambiguity in ethics...I guess that's why they're called ethical dilemmas.

 

[SirGecko]

If they contradict each other, which one wins on the USMLE?

Kaplan said that durable power of attorney overrides everything else. Uworld says "Medical professionals must respect decisions of the next of kin unless there are contradictory written wishes of the patient."

So somewhere along the line there is some confusion here as durable power of attorney and next of kin are not the same thing. You next of kin can be given power of attorney but the patient has to specifically designate who is making decisions on their behalf. (I don't know if I am reading your post wrong or if you are actually making this connection or if kaplan did)

As to which wins? Seems like a silly question since I don't know why a patient would have both and not have them agree. I would assume that whoever has the power of attorney would also have the living will and would have talked to the patient about this ahead of time. If the person with the power of attorney where trying to contradict something in the living will I would hope this was based on a conversation that they had with the patient since the writing of the living will. If they changed their mind since the will was written then go with the changing of the mind. So unless the patient told you what they wanted and didn't tell the holder of the power of attorney I would go with what they say. (as always this is situation specific so without knowing the actual question stem all we can really say is to always try to do what the patient wanted)

 

[donysious]

In Kaplans notes it states that in end of life circumstances when the power to attorney directly contradicts a living will then follow the living will.
In USMLE Rx QID:1563 it states that power of attorney supersedes a living will.

So both the sources contradict each other. Which would any of you suggest I go with ?

 

[glykon]

In Kaplans notes it states that in end of life circumstances when the power to attorney directly contradicts a living will then follow the living will.
In USMLE Rx QID:1563 it states that power of attorney supersedes a living will.

So both the sources contradict each other. Which would any of you suggest I go with ?

I'd go with the one that helps the patient and respects his/her most recent wishes/beliefs.

 

[Phloston]

Durable power of attorney DOES override everything else.

This is extremely high-yield.

When you become someone's durable power of attorney, it is essentially him or her saying he or she gives you full trust to make the most important decisions regarding his or her life.

If you're 65 years-old, for instance, and you appoint your best friend from kindergarten as your DPA, that does override your wife.

The DPA also overrides the living will. It overrides everything except the patient him or herself (obviously).

You've gotta watch out for the "durable." There are many different types of "power of attorneys" apparently, each which can operate at different times/circumstances, but the durable is the peak of it all.

On the USMLE, you might get some bloated/long vignette about a patient's adult children, wife, living will, DPA, etc. all combined into one. Once you see that DPA's thoughts: done.

 

[Jamiu22]

Durable power of attorney DOES override everything else.

This is extremely high-yield.

When you become someone's durable power of attorney, it is essentially him or her saying he or she gives you full trust to make the most important decisions regarding his or her life.

If you're 65 years-old, for instance, and you appoint your best friend from kindergarten as your DPA, that does override your wife.

The DPA also overrides the living will. It overrides everything except the patient him or herself (obviously).

You've gotta watch out for the "durable." There are many different types of "power of attorneys" apparently, each which can operate at different times/circumstances, but the durable is the peak of it all.

On the USMLE, you might get some bloated/long vignette about a patient's adult children, wife, living will, DPA, etc. all combined into one. Once you see that DPA's thoughts: done.

Bump!!! Good question... an RX question that stumped me!

 

[MLT2MT2DO]

Durable power of attorney DOES override everything else.

This is extremely high-yield.

When you become someone's durable power of attorney, it is essentially him or her saying he or she gives you full trust to make the most important decisions regarding his or her life.

If you're 65 years-old, for instance, and you appoint your best friend from kindergarten as your DPA, that does override your wife.

The DPA also overrides the living will. It overrides everything except the patient him or herself (obviously).

You've gotta watch out for the "durable." There are many different types of "power of attorneys" apparently, each which can operate at different times/circumstances, but the durable is the peak of it all.

On the USMLE, you might get some bloated/long vignette about a patient's adult children, wife, living will, DPA, etc. all combined into one. Once you see that DPA's thoughts: done.

Going to bump this and ask another question to anyone who may know.

What exactly is a "Health Care by Proxy" then? Wiki says it is used synonymous with Durable Power of Attorney, but the question bank I just got the question incorrect from says an advanced directive overrides health care by proxy.

 

[medpack87]

Durable power of attorney DOES override everything else.

This is extremely high-yield.

When you become someone's durable power of attorney, it is essentially him or her saying he or she gives you full trust to make the most important decisions regarding his or her life.

If you're 65 years-old, for instance, and you appoint your best friend from kindergarten as your DPA, that does override your wife.

The DPA also overrides the living will. It overrides everything except the patient him or herself (obviously).

You've gotta watch out for the "durable." There are many different types of "power of attorneys" apparently, each which can operate at different times/circumstances, but the durable is the peak of it all.

On the USMLE, you might get some bloated/long vignette about a patient's adult children, wife, living will, DPA, etc. all combined into one. Once you see that DPA's thoughts: done.

Thank you very much, I also had this problem unresolved until now.

 

[Goober11]

Going to bump this and ask another question to anyone who may know.

What exactly is a "Health Care by Proxy" then? Wiki says it is used synonymous with Durable Power of Attorney, but the question bank I just got the question incorrect from says an advanced directive overrides health care by proxy.

It is my understanding that a PROXY/surrogate isn't necessarily someone the patient designates as their health care decision maker. The responsibility can fall on a family member if the patient is incapacitated and hasn't previously given someone DPoA. Whereas a DPoA, is Grampa Fred telling his old war buddy/some family member/favorite call girl to make his healthcare decisions. The hierarchy goes in the following order for PROXY/surrogate: spouse > adult children > siblings > other family members (grandchildren usually) > friend (http://www.amda.com/governance/whitepapers/surrogate/decisionmaking_hierarchy.cfm).

 

[sharklasers]

Durable power of attorney DOES override everything else.

This is extremely high-yield.

When you become someone's durable power of attorney, it is essentially him or her saying he or she gives you full trust to make the most important decisions regarding his or her life.

If you're 65 years-old, for instance, and you appoint your best friend from kindergarten as your DPA, that does override your wife.

The DPA also overrides the living will. It overrides everything except the patient him or herself (obviously).

You've gotta watch out for the "durable." There are many different types of "power of attorneys" apparently, each which can operate at different times/circumstances, but the durable is the peak of it all.

On the USMLE, you might get some bloated/long vignette about a patient's adult children, wife, living will, DPA, etc. all combined into one. Once you see that DPA's thoughts: done.

Wouldn't DPA only come into play if the living will doesn't include the particular situation in question?

Because I figure a living will does represent the patients words, so in what situation would a durable power of attorney take precedence over a living will?

 

[calvnandhobbs68]

Wouldn't DPA only come into play if the living will doesn't include the particular situation in question?

Because I figure a living will does represent the patients words, so in what situation would a durable power of attorney take precedence over a living will?

If I remember correctly, DPA even overrides specifications in the living will (I think we discussed it in ethics).

 

[ChessMaster3000]

Saw this post because I got stumped on the relevant Rx question. However, it brought up another point--I know now that durable power of attorney overrides everything else, but what about "other" types of powers of attorney? If Step 1 simply labels the person as "power of attorney" or "health power of attorney", then in that case does the living will override him/her?

 

[notbobtrustme]

Treat a Durable PoA as the patient in all cases except when the patient disagrees with the Attorney.

I recall something from ethics class on the USMLE that power of attorney = durable power of attorney for the purpose of the test unless otherwise stated. I haven't verified that with anyone and I also may be remembering it wrong, but just putting that out there in case anyone knows better.

 

[ChessMaster3000]

Treat a Durable PoA as the patient in all cases except when the patient disagrees with the Attorney.

I recall something from ethics class on the USMLE that power of attorney = durable power of attorney for the purpose of the test unless otherwise stated. I haven't verified that with anyone and I also may be remembering it wrong, but just putting that out there in case anyone knows better.

Yeah, @Phloston mentioned earlier in this post that there are other types, it may be the case that they are not relevant for testing purposes

 

[Transposony]

Here is an interesting discussion about Ethics and the dilemma:

Keeping a Brain-Dead Body Alive so a Fetus Can Grow?
http://www.medscape.com/viewarticle/819314?src=wnl_edit_bom_weekly

 

[ChessMaster3000]

I have had some conflicting information come up on whether or not a parent has a right to withhold treatment that can save a child's life. In a non-emergency setting, when everyone has had time to think, can parents STILL make the decision to withhold treatment if it's in the "best interests of the child" even if the physician does not feel it is in the patient's best interest and would result in the patient's death? Of all the ethics questions we could get, this one I fear the most because I literally have no idea either way.

 

[Transposony]

I have had some conflicting information come up on whether or not a parent has a right to withhold treatment that can save a child's life. In a non-emergency setting, when everyone has had time to think, can parents STILL make the decision to withhold treatment if it's in the "best interests of the child" even if the physician does not feel it is in the patient's best interest and would result in the patient's death? Of all the ethics questions we could get, this one I fear the most because I literally have no idea either way.

If the treatment involved is proven and standard (as compared to experimental) the parents does not have the right to deny it.
But always go for the choice discuss/educate blah blah blah to find out the reason behind their denial...........if it is among the choices.
I remember doing few questions on this during my CK prep.

 

[Donald Juan]

If the treatment involved is proven and standard (as compared to experimental) the parents does not have the right to deny it.
But always go for the choice discuss/educate blah blah blah to find out the reason behind their denial...........if it is among the choices.
I remember doing few questions on this during my CK prep.

The parent does have the right to deny care to their child even if it is standard. People have a variety of religious or personal reasons they might not want care that modern medicine deems normal. The doctor also has the right to call the hospital attorney who will wake a judge up at 2am to gain temporary rights for the doctor to call the shots because the parents wishes threaten the life of the child.

But discuss/educate is the right answer.

 

[Transposony]

The parent does have the right to deny care to their child even if it is standard. People have a variety of religious or personal reasons they might not want care that modern medicine deems normal. The doctor also has the right to call the hospital attorney who will wake a judge up at 2am to gain temporary rights for the doctor to call the shots because the parents wishes threaten the life of the child.

But discuss/educate is the right answer.

Correct. I should have added that unless it threatens their life/limb etc. However, calling Hospital Ethics committee/Attorney/Judge is usually not the right answer on USMLE.

For example, parent cannot deny a child being treated for leukemia. In contrast, they can withhold vaccination based on their religious/personal beliefs.

 

[ChessMaster3000]

Ok--that would have made sense to me before I started studying....EXCEPT I came across a situation in a question where a child was a jehovah's witness and the parents did have the right to deny child life-saving blood transfusion, after extensive discussions w/ parents about outcomes of situation without blood. That seems to contradict what you're saying--now, I think it was Rx, and they could definitely be wrong on their logic...

 

[Donald Juan]

Ok--that would have made sense to me before I started studying....EXCEPT I came across a situation in a question where a child was a jehovah's witness and the parents did have the right to deny child life-saving blood transfusion, after extensive discussions w/ parents about outcomes of situation without blood. That seems to contradict what you're saying--now, I think it was Rx, and they could definitely be wrong on their logic...

I've always had pediatricians at my school give the example of life-saving blood transfusions with Jehovah's witnesses as a time when you call the hospital attorney because the parents legally have the right to deny it.

Edit: that doesn't mean that you don't first try to talk the parents into consenting

 

[NeuroLAX]

Ok--that would have made sense to me before I started studying....EXCEPT I came across a situation in a question where a child was a jehovah's witness and the parents did have the right to deny child life-saving blood transfusion, after extensive discussions w/ parents about outcomes of situation without blood. That seems to contradict what you're saying--now, I think it was Rx, and they could definitely be wrong on their logic...

I had this question in a qbank. If it is live-saving, parents do not have the right to refuse blood transfusions for their child. They have the right to refuse for themselves on religious grounds, but not for their child. You give the child blood transfusions as needed.

EDIT: If it was an Rx question, then you aren't remembering it correctly. I just went back and checked it.

 

[ChessMaster3000]

I had this question in a qbank. If it is live-saving, parents do not have the right to refuse blood transfusions for their child. They have the right to refuse for themselves on religious grounds, but not for their child. You give the child blood transfusions as needed.

EDIT: If it was an Rx question, then you aren't remembering it correctly. I just went back and checked it.

Yeah, sorry, so the question was not phrased the way I said it, but didn't the explanations propose a situation like I described?

 

[ChessMaster3000]

I've always had pediatricians at my school give the example of life-saving blood transfusions with Jehovah's witnesses as a time when you call the hospital attorney because the parents legally have the right to deny it.

Edit: that doesn't mean that you don't first try to talk the parents into consenting

If the parents legally have a right to deny it, why are you calling the attorney?

 

[NeuroLAX]

Yeah, sorry, so the question was not phrased the way I said it, but didn't the explanations propose a situation like I described?

They just say that in an emergency situation like the above child, you do what you have to do to save the child's life, even if the parents refuse. There's not enough time to call the hospital ethics committee, and it would take too long to get a court order.

 

[Donald Juan]

If the parents legally have a right to deny it, why are you calling the attorney?

So, after looking into a little more, my state says that if there is time to obtain a court order giving you the right to treat then that is what you do. My understanding in the children's hospital here it is a relatively standard practice and their is always a judge on call to get it done at any time. If it is a true emergency then you can proceed in the manner that is in the best interest of the child and the law favors protecting a child over patient autonomy.

Federal law generally says what everyone has been saying, you protect the child. Specifics on practice and neglect legalities can vary from state to state.

 

[ChessMaster3000]

They just say that in an emergency situation like the above child, you do what you have to do to save the child's life, even if the parents refuse. There's not enough time to call the hospital ethics committee, and it would take too long to get a court order.

My bad, I just came across the question I was looking for and it was a UW question, QID 783, if you have access to UW at the moment. The explanation makes it pretty clear that in NON-emergency situations (even though the question is about emergencies), parents CAN refuse lifesaving tx if it is in the best interest. So the kicker on the real deal will be how well they delineate whether or not the parents decision is in the best interest of the child. I would imagine a situation where a child has cancer and the prognosis is incredibly grim, but there is a therapy that has a small chance at survival but high morbidity--then it may be in the interests two forego treatment. Otherwise, full press!

Thanks for all of your help!!

 

[NeuroLAX]

My bad, I just came across the question I was looking for and it was a UW question, QID 783, if you have access to UW at the moment. The explanation makes it pretty clear that in NON-emergency situations (even though the question is about emergencies), parents CAN refuse lifesaving tx if it is in the best interest. So the kicker on the real deal will be how well they delineate whether or not the parents decision is in the best interest of the child. I would imagine a situation where a child has cancer and the prognosis is incredibly grim, but there is a therapy that has a small chance at survival but high morbidity--then it may be in the interests two forego treatment. Otherwise, full press!

Thanks for all of your help!!

No problem, dude. Thanks for the heads up. I bought UWorld but haven't activated it yet. I've enjoyed learning about medical ethics in my board studies so far. My school only gave a 2-hr. lecture on it so I've had to teach myself. I hope I get at least a few ethics questions on my exam. I feel like I would nail those.

 

[ChessMaster3000]

No problem, dude. Thanks for the heads up. I bought UWorld but haven't activated it yet. I've enjoyed learning about medical ethics in my board studies so far. My school only gave a 2-hr. lecture on it so I've had to teach myself. I hope I get at least a few ethics questions on my exam. I feel like I would nail those.

You say that now, but just wait. They seem like freebies until they aren't.

 

[Transposony]

My bad, I just came across the question I was looking for and it was a UW question, QID 783, if you have access to UW at the moment. The explanation makes it pretty clear that in NON-emergency situations (even though the question is about emergencies), parents CAN refuse lifesaving tx if it is in the best interest. So the kicker on the real deal will be how well they delineate whether or not the parents decision is in the best interest of the child. I would imagine a situation where a child has cancer and the prognosis is incredibly grim, but there is a therapy that has a small chance at survival but high morbidity--then it may be in the interests two forego treatment. Otherwise, full press!

Thanks for all of your help!!

You got it.

I remember doing a question somewhere in which a mother and child were involved in the accident and needed blood transfusion. Both parents refused blood transfusion based on their belief (Jehovah's witnesses). The correct answer was to proceed with blood transfusion for the child but respect the wishes of the mother and do not transfuse her.