docB

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Interesting situation regarding a medical power of attorney (POA) recently.

60 yo patient came in after having a respiratory arrest and being intubated in the field. Patient is completely unresponsive. Patient is accompanied to the ED by a friend who is travelling with her. The friend provides EMS and then ED staff with a medical POA form which names the patient's daughter back home as the POA. The POA form appears to be in order. The friend provides the daughter's phone number and the daughter is contacted by ED staff for input about the patient's care.

A question was raised by the admitting team. Can the voice on the phone identified by the friend as the patient's daughter and POA be trusted? Are we obligated to try to verify this person's identity? Is a POA from another state valid?
 

kungfufishing

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Never thought about it before, but I think at some point you have to trust in the humanity of others. I mean, if the person on the phone seems to know mrs. jones and what her wishes were and suggests she didn't want to have all of this done and says that she is in fact the POA holder we were attempting to contact, I'll believe it. Naive, perhaps.
 

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Never thought about it before, but I think at some point you have to trust in the humanity of others. I mean, if the person on the phone seems to know mrs. jones and what her wishes were and suggests she didn't want to have all of this done and says that she is in fact the POA holder we were attempting to contact, I'll believe it. Naive, perhaps.
Agree. I don't know of any prior instances of someone faking this. What would be the motive? Kill grandma and get the inheritance? Your alternative is to ask the person who pulled out the POA letter what she wants you to do. If she wanted to control the situation, wouldn't she just keep the POA letter tucked away?
 

Apollyon

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To my reading, this is no different than the person calling who wants an update on someone's condition, and we can't give it to them.

If a live person has a POA with their own name on it, and we have reason enough to request ID, that is kosher. However, how do we know that the person on the other end of the line is not complicit, and our "unresponsive patient" isn't worth millions dead?

We err on the side of life; we can't (yet) undo dead. If someone is pressing to pull the plug, that is suspect, and that bears further investigation (including getting risk management and hospital attorneys involved). What is more likely to provide you heartburn: that you pulled the plug on grandma, or you kept her alive while she was a veg?

It's variation on a theme - "if it's too good to be true, it probably is". If the simplest thing is a disembodied voice saying "pull the tube! Let her expire peacefully!", then maybe we shouldn't.

(And maybe I'm not naïve.)

As an aside, although I've never heard of it, either, I am not going to stand on that (the "fallacy of anecdote" - "I've never heard of that, so it's not true"). As to whether another state's POA being valid or not, there's two sides to that (and why I say there is nothing prudential about jurisprudence): first, I believe that it is the "full faith and credit" clause of the US Constitution (Article IV, section 1) that applies ("Full Faith and Credit shall be given in each State to the public Acts, Records, and judicial Proceedings of every other State. And the Congress may by general Laws prescribe the Manner in which such Acts, Records and Proceedings shall be proved, and the Effect thereof."), and that means that one state's POA, if not in actual contravention of another state's laws, will be accepted at face value in that other state as if it had been drawn up there. However (and I can't believe I'm mentioning this), there was a plot point on "SVU" (which tends to hew rather closely to actual law) about a rape kit from another state, which is disallowed because the NY judge can't confirm that the chain of evidence was unbroken, because it was from another state. I have looked for evidence on this, but have been unable to find it.

So, as to the point, I would want more proof, but that's me. I, unfortunately, do not trust our fellow man more, the more that is on the line or at risk.
 

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To my reading, this is no different than the person calling who wants an update on someone's condition, and we can't give it to them.

If a live person has a POA with their own name on it, and we have reason enough to request ID, that is kosher. However, how do we know that the person on the other end of the line is not complicit, and our "unresponsive patient" isn't worth millions dead?

We err on the side of life; we can't (yet) undo dead. If someone is pressing to pull the plug, that is suspect, and that bears further investigation (including getting risk management and hospital attorneys involved). What is more likely to provide you heartburn: that you pulled the plug on grandma, or you kept her alive while she was a veg?



It's variation on a theme - "if it's too good to be true, it probably is". If the simplest thing is a disembodied voice saying "pull the tube! Let her expire peacefully!", then maybe we shouldn't.

(And maybe I'm not naïve.)

As an aside, although I've never heard of it, either, I am not going to stand on that (the "fallacy of anecdote" - "I've never heard of that, so it's not true"). As to whether another state's POA being valid or not, there's two sides to that (and why I say there is nothing prudential about jurisprudence): first, I believe that it is the "full faith and credit" clause of the US Constitution (Article IV, section 1) that applies ("Full Faith and Credit shall be given in each State to the public Acts, Records, and judicial Proceedings of every other State. And the Congress may by general Laws prescribe the Manner in which such Acts, Records and Proceedings shall be proved, and the Effect thereof."), and that means that one state's POA, if not in actual contravention of another state's laws, will be accepted at face value in that other state as if it had been drawn up there. However (and I can't believe I'm mentioning this), there was a plot point on "SVU" (which tends to hew rather closely to actual law) about a rape kit from another state, which is disallowed because the NY judge can't confirm that the chain of evidence was unbroken, because it was from another state. I have looked for evidence on this, but have been unable to find it.

So, as to the point, I would want more proof, but that's me. I, unfortunately, do not trust our fellow man more, the more that is on the line or at risk.
Agree completely. In my many years in the SICU (not ED) we never took instructions over the phone from an unknown proxy. We handled it 2 different ways---sometimes we just asked that two different forms of ID be copied and faxed over along with the proxy (the person named should have a copy). In end of life decisions, we called the local police where the relative was and asked them to verify identity, and no one ever refused. In terms of the form of the proxy itself---it varies by state and is not an automatic. Some states don't require it to be notarized, some do; some, like NY before this June, required the POA specifically to state that the proxy knew wishes regarding "artificial" ventilation and feeding in order to include those powers, etc. Any doubt, everything was done. We were a large Level 1 by a highway, so relatives were often far. Risk Management dealt with anyone who had a problem with this.
 

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This is nuts. If the patient is capable of making the decision, I ask them. If there is a person there with them willing to hang out in the ED with a dying grandma peeing all over herself who self-identifies as family, I ask them what they think she would want done in this situation. Then I do that. If they're not sure, they pull their cell phone out and start making calls and I intubate the patient and let them sort it out upstairs in the unit.

If the patient is already dead and all I have to decide is how long I'll push on their chest before stating the obvious, then it doesn't matter. If the patient is 95, I probably won't push very long. If they're 35, I'm going full-bore for the next hour.

If I ever go to court with Grandson Bill who says I let Aunt Bessie die because Cousin Joe said that's what she'd want when really she would have wanted to die in the ICU 2 weeks later just so Cousin Joe could get his inheritance sooner, I'll just argue I did what I felt was medically appropriate.

I mean, what do you guys do when the patient's husband is standing there? Flog his elderly wife until he produces a marriage certificate?

I mean, it's one thing if it's a suspicious situation (35 year old woman and husband is saying "She wouldn't have wanted to be intubated") but to routinely require a family member to produce documentation? Maybe appropriate in the ICU, but I'm having a hard time imagining a scenario when I would require it in the ED.
 
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docB

docB

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This is purely an academic discussion. In the actual case I did defer to the POA over the phone without any verification and everything worked out fine. Making things easier was the fact that the friend and the POA were both very appropriate and reasonable, no red flags for badness.

The discussions we had after the fact though raised some interesting possibilities. One of the most sobering was a scenario where the friend produces the POA but then purposefully misdirects us to another person because they don't trust the actual POA (even though the patient did).

Out of the initial set of questions the one I do think I definitely know the answer to is the one about the POA being valid across state lines. My understanding is that just like any other contract all the states will recognize it.
 

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ok, here's another scenario...

71 year old woman with advanced dementia, transported from nursing home. Daughter arrives, but is not POA. Son, who lives 200 miles away but travels extensively, is the POA. Daughter calls brother, (who can be a rather selfish moron at times) brother blows top because paperwork has been submitted 5 times to be filed in mother's chart. (medical poa) rants more about that than actual treatment for mom. Daughter insists mom is DNR. After 15 minute phone call, brother finally tells physician that yes, mom is DNR. By this time, the point is moot, because mom is now breathing fine on her own...

All the paperwork is at nursing home, and filed with them. A call to them confirms that yes, Mom is DNR, and yes, Son/Brother is a jerk.

The physician told me later that it was a difficult situation for him--he was worried about the whole "who is really supposed to be talking". He was relieved that we both agreed on the course of treatment, even tho it turned out not to be necessary after all.