Where is the line?

I’m going to throw this question out there while setting aside the legalese and differences between the individual states. It’s a very general question, and I hope I can adequately paint the picture that I’m trying to get across. I’d like to know what you think, if you’d so kindly humor me.

Sometimes, an elderly patient who is no longer able to make competent decisions has a Durable Power of Attorney for Health Care that was drawn up at some point in the past, usually naming their adult child(ren) as Attorney(s)-in-Fact, or in some cases, even a Conservator appointed to handle their affairs, including health care decisions. Most of the time, the people making the decisions on the patient’s behalf clearly are interested in making decisions in the best interests of the patient and look to us for guidance regarding treatment and transport decisions. There is usually no problem at all.

However, once in a while, such agents don’t make decisions that are in the best interests of the patient, and they refuse treatment and/or transport on the patient’s behalf, which they are legally authorized to do as the Attorney(s)-in-Fact or Conservator(s), even when it is plainly obvious that treatment and/or transport is/are necessary.

(Let’s leave issues regarding resuscitations out of this post for the sake of this discussion.)

Now, there are mechanisms in place to challenge the decision-making abilities of an Attorney-in-Fact or a Conservator, but these are typically after the decision in question has already been made, long after the call is over.

So, what do we do on the scene of the dispute?

And, more importantly – this is the main point of this post – when does poor decision-making cross that line and become neglect and/or abuse? For example, should an agent be allowed to refuse transport, unchallenged, on behalf of a demented patient with an apparent ongoing infection with no obvious evidence of any prior treatment or even a Plan B?

9 thoughts on “Where is the line?”

  1. I suppose your only recourse is to radio Medical Control, in front of the Conservator/ Attorney-in-Fact (important to use the radio if you’re a 911 entity as it’s recorded) and tell the Doc what you have and that they’re refusing transport against your advice. Then at least it’s recorded.

  2. I’ve had the POA (daughter) refuse transport on her elderly mother that met all criteria for a Stroke, & we called & alert & prepared to load & go when she stopped us at the doorway. She’s an out-of-state physician that stated we were not transporting. We tried to call med control & were told that they can’t do anything about it. POA’s reason: pt has terminal brain cancer of which they refused to tell her. And she ordered her sister (who called us) to administer 324mg of ASA.

    Our docs are now stating they don’t want us calling unless weve exhausted our guidelines in an arrest or something else…no more refusals, etc.

  3. Only once have I had a POA make a decision clearly against the best wishes of the patient, by any reasonable standard. We clearly stated the problem, what needed to happen, and the risks of refusal. When that did not work, we turned to the officers on scene and asked if this was considered neglect. This apparently helped to put light on the risks to the patient we felt they were unfairly taking. I hope never to be in that situation again.

  4. Laws vary widely from state to state, but I’d say in general we are bound by what the patient or their proxy decide to do. We don’t have to like it, but we do have to respect it.

    1. thank you for the responses so far. i hope to hear from more of you.

      since i’m primarily talking about patients who are unable to make health care decisions anymore, therein lies my question – when does it begin to be neglect and/or abuse? and at what point do we stop respecting the decisions of the proxy and start seriously considering the welfare of the patient who is potentially being neglected and/or abused?

      at the heart of it, the patient doesn’t have a lot of means to report that neglect and/or abuse, and the proxy potentially has a lot of power and incentive to hide it, aided by this powerful legal tool that can easily be misused. even if the reasons are legitimate and reasonable, the question still becomes, in my mind, why is the proxy refusing treatment/transport?

      i realize there are no definitive answers, and each case has its unique circumstances; rather, i’m wondering if we as a profession have given this subject enough attention in general.

      at some point, it appears that we’re choosing between what is easy and what is right.

      1. I think your question could be worded in another way, “at what point should we consider an inappropriate refusal from a POA like an invalid order from medical control?”

        1. i can see the parallel, except that even within an invalid order from medical control, i wouldn’t really expect any ill intentions, unless the voice on the end of the line identified him/herself as “dr. evil,” followed by “mwahahahaha.”

  5. This is no different from a parent (or guardian) making decisions for a child. If we believe that the decision will jeopardize the health or life of the patient, we can always call Medical Control, who can in many states order the patient be taken in against their will, the police, who could decide it’s an elder abuse situation or a company supervisor. My thought is to get others involved in the decision, not only to have more brains mull the situation but also spread the liability if anything were to go wrong.
    I’d like to say that we can’t go wrong by treating and dealing with the consequences later,but we all know this isn’t true…

  6. I see this all the time because I work for a retirement community. The POA has a lot of power when it comes down to these things and there’s little we can do about it, while we’re on scene.
    If something bothers a provider that much, they can contact the state and ask them to investigate. (Your local hospital and/or police should have these numbers or the website on file.)
    I have seen people lose their right to be someone’s POA because they made bad decisions regarding a loved one’s care. It can happen, but it won’t happen while you’re on scene talking to the POA.

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