Do you really want a clinical ethicist to be your medical power of attorney?

This is the story of how I became my aunt’s medical power of attorney. It was almost 10 p.m. on a Tuesday, and my phone chimed with a new text message. The messages were from my aunt, Gerry. At 79 years old, Gerry has been an enthusiastic convert to the joys of texting. For the past few weeks, Gerry had been keeping me updated on strange new dizzy spells.

Her usually active days were interrupted by episodes of feeling lightheaded and faint that forced her to lay down for hours at a time. As her only family member nearby, I had been joining her doctor’s appointments by phone and acting as a second set of ears.

Despite multiple rounds of lab work and physical exams, the only thing that came back was slightly elevated blood pressure. Her doctor assured us that, at her age, this was not too concerning. As I opened her text, a second message came through. 

I googled troponin and it indicates a heart issue.

Last week I left a message with the Doctor’s office asking if they had checked for troponin on my lab work and I haven’t heard anything back yet.

I quickly called her back. I learned that an hour before she had another dizzy spell but had experienced a new symptom. This time, she said, her chest felt heavy, like someone was sitting on her, and her hands were numb and tingly. “It only lasted a few minutes. I feel better now,” she said.

My heart started beating quickly. I was scared for her and angry that she had not called me earlier. My fear heightened because symptoms of a heart attack manifest differently in women than men, and women often dismiss and fail to identify their symptoms as signs of a heart attack.  Gerry’s new symptoms paired with her recent dizzy spells and high blood pressure seemed like signs of a heart attack. I told her I would be right there. We were going to the emergency room.

As a clinical ethics fellow, I am familiar with the medical power of attorney (MPOA) paperwork and their legal powers in the state of Texas, as well as with the ethical theories that define the role of an MPOA in surrogate decision making.

Ethically speaking, a surrogate is supposed to make medical decisions based on substituted judgment and the best interest standards. Specifically, the surrogate ought to evaluate the patient’s medical information from the patient’s perspective. To do this the surrogate is supposed to set aside their own values and, instead, the surrogate should rely on their knowledge of the patient’s preferences, values and interests.

In my role as a clinical ethicist, I have worked with surrogate decision makers as they have tried to put these ethical standards into practice. I have seen how it is sometimes hard for surrogates to interpret an advanced directive or to reflect on previous conversations with the patient. Often surrogates are asking questions that only the patient could definitively answer. Is this really what she meant? Did she imagine herself in this situation? Would she choose this treatment under all conditions or only under certain circumstances?

Gerry and I had talked before about me becoming her medical power of attorney. Despite decades of vacations, dinners and deep conversations, I still wanted to know more details. I wanted to know about her values and what she cares about. Not wanting to be caught without these details, I had given her homework. I had asked her to identify the parts of her life she finds most meaningful and joyous and to reflect on what it is about those things that she most values. Knowing these sorts of preferences can help an MPOA reason about treatment options.

For example, if someone enjoys having a glass of wine, knowing whether they most enjoy the flavor of the wine, the buzz or the company could inform treatment goals. For instance, knowing the patient would prioritize the flavor of the wine might entail a goal of working with speech/language pathologists to work up to a point for sponging wine on the tongue for pleasure tasting if the patient required tube feeds. Despite this homework, we never got around to talking through all the details I had asked for, and like so many other families, we thought we had more time.

After a night in the ED and inconclusive test results, Gerry was transferred to the hospital for observation. It was now clear that in case anything should happen, it was time for her to formally appoint me as MPOA. I told Gerry that she could have the nurse page the hospital chaplain to help her complete the form and ensure it was appropriately witnessed, per Texas law.

Over the next two days, test results slowly came in fleshing out the diagnostic picture, ultimately revealing nothing was amiss and she could go home. When she was discharged, I was relieved that she was ok, and it also meant I again had time to learn the details that I hope will enable me to make decisions in her place as her medical power of attorney.

To learn more about medical power of attorney and fill out the form, click here; provided by the Texas Medical Association

-By Dr. Eleanor Gilmore-Szott, Clinical Ethics Fellow, Center for Medical Ethics and Health Policy, Baylor College of Medicine

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