Legal issues become the hospice social worker’s business when they cause stress to your hospice patients and their families. When family members disagree on how to care for a patient, it is important for them and the hospice team to know who the decision-maker is.
You serve the patient, family and your team by clarifying this question for each patient soon after a start of care. Laws are different in every state, so take it upon yourself to research them or ask fellow social workers near you.
I’m not a lawyer, so don’t take legal advice from me. But like you, I advocate for the well-being and self-determination of patients. Below are some of the guidelines relating to medical proxy I follow in Texas:
Patients are competent to make their own decisions–until they’re not.
Patients can have psychiatric diagnoses like bipolar or dementia, and still decide for themselves. If they can tell you their name, where they are and what the date is, then they are still the boss and the MPOA is not. They can decide for themselves if they want a DNR or if they want to change their MPOA. Their wishes should be honored as long as they can discuss them meaningfully. It requires a decision from a judge or a psychiatric/psychological evaluation to deny them that prerogative.
A nurse once expressed doubt about the validity of a DNR because a patient had a history of depression. “If she’s depressed, should she really be allowed to deny life-saving treatment?” I say the prospect of staying alive through CPR and artificial means is depressing.
MPOA goes into effect when patient is no longer able to communicate wishes
Patients don’t give away their own decision-making rights by appointing a proxy. The Texas MPOA form clearly says that the decision-making power goes to the proxy beginning when a doctor says the patient is no longer capable:
“This Medical Power of Attorney takes effect if I become unable to make my own health care decisions and my physician certifies this fact in writing.”
Medical Power of Attorney trumps marriage for medical decisions
At least it does in Texas. In my previous article, I told the story of Suzi, whose husband decided that he was in charge, regardless of what she said she wanted. She completed a DNR, but the first moment her physical condition prevented her from communicating her wishes, he demanded that the DNR be destroyed. If she had appointed an MPOA , the MPOA would be able to advocate for the patient’s wishes despite the husband’s assertions.
What if there’s no MPOA, and the patient is no longer competent?
A patient who is no longer decisional won’t be appointing a proxy. If there is no MPOA paperwork, the decision-making rights automatically fall to them. In Texas, the spouse automatically make decisions if there is no MPOA. If there’s no spouse, the patient’s adult children assume the responsibility. In the absence of adult children, it falls to the parents. None of the above available? It goes to the nearest living relative.
If there are no near living relatives available or willing to take command, then a court appoints a guardian. In my region, Family Eldercare runs a guardianship program that manages decisions for people who have no one else.
The hospice social worker’s job in all this
Your job as hospice social worker is to advocate for the well-being and wishes of the patient and family members. After clarifying what the patient’s wishes are, you can represent them to the team. In some cases, you might even clarify them for family members. And when you can clarify for family members who is the decision-maker, you reduce the chances of disagreements getting out of control. Terminally ill patients often don’t enjoy being in the middle of family arguments.
I hope the information in this article helps you to do this.
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