Invoking The Healthcare Proxy

Two questions I get asked regularly is, who can invoke the healthcare proxy and when should it occur?  I get these questions most frequently from adult children of elderly parents.  The question is asked because they have noticed a parent is having cognitive changes or increased confusion about medications or safety issues in the home.

A healthcare proxy is a legal document that designates  the person/persons who can make medical decisions when named person is no longer able.   The healthcare proxy in order to be actualized needs to be invoked.  There are three ways it can be invoked.

1. The primary care doctor invokes the proxy by writing in the chart “ The Healthcare Proxy is invoked.”

2. If hospitalized, the medical team can invoke the proxy in the same way, ONLY if the patient is unconscious or clearly has dementia.  Hospitals are hesitant to act on the healthcare proxy and often will refer back to the PCP unless it is very obvious.

3. The courts can invoke a healthcare proxy.

The most common method is the  primary care doctor.  However, it is not easy to convince a primary care doctor to invoke the proxy.     I have found PCPs are reluctant to take the step especially with the elderly.  Problems may be ocurring at home with medications, being forgetful, not managing well with activities of daily living and  safety issues int he home, but PCPs are hesitant because these changes are not seen in the office.

I recently had a client’s parent who was over dosing on medications or not taking the medications at all.  At night there were significant cognitive, personality and memory changes.  The adult sons were very concerned because there had been multiple ER visits from wrong medication use  and several falls.  They felt their parent was not making good decisions.  They wanted the healthcare proxy invoked to protect and keep their loved in the home and safe.

I made an appointment with the PCP with one son, myself and the parent.  I had let the PCP know the issues and what the sons were thinking. The sons wanted the PCP to evaluate the situation and help keep the parent safe.  They wanted the healthcare proxy invoked so they could make medical decisions.

I had told the PCP ahead of time that  all the homecare medical clinicians  had checked the medications and found none were being taken correctly, if at all.  Bathing was not happening unless an aide came and eating was haphazard. When the PCP asked about the medications, the parent responded with a resonable explanation of how the dosing and times were kept track of.  Those of us who went into the home knew differently.

The PCP told me after the visit, she felt the parent verbalized adequately the method for taking medications.  It seemed reasonable.  I pointed out it sounded good but it wasn’t happening that way.  Two clinicians had noted the pill count was way off.  When either of the clinicians asked the parent, they were told it was the pharmacy’s fault or the parent was catching up from being in the ER.

The PCP was not convinced, as the parent responded correctly and seemed to have good recall.  She felt it was not a matter of invoking the healthcare proxy but a family issue.  I asked her what she meant by that.  She said the sons had to speak with the parent and come up with a solution.  I reminded her that no matter what the sons suggested, the parent still could ignore it and make all medical decisions.

It is my experience that medical professionals have difficulty invoking the healthcare proxy.  I understand there is reluctance to take away someone’s independence.  The invoking of the healthcare proxy should not be invoked without real data.  But how can a medical professional only make a decision in a 15 minute office visit?  If a family member asks a medical professional to evaluate, it would be prudent to do a home visit;   assess how the medications are taken; ask the patient to explain when to take medications; observe the safety in the home and speak with other professionals and clinicians involved.

I have had this experience with other clients and their families and even my mother-in-law.  With my mother-in-law, her gerontologist kept saying, maybe next time she would discuss it.  She never accepted the cognitive changes because my mother-in-law was good at her thirty minute appointment, able to read from her script, tell the doctor what she thought needed to be said.  The decision was taken out of the gerontologist hands when my mother-in-law fell in her home, was unconscious for two days before she was found.

I support keeping the elderly in their home.  The healthcare proxy being invoked does not mean they need to go to a nursing home.  It only means someone is going to make decisions that keep them safe in their home.