From the Guidelines
A healthcare proxy becomes crucial when a patient loses decision-making capacity, and it generally takes precedence over an advance directive because it designates a living person who can interpret the patient's wishes in real-time and respond to unforeseen circumstances. The healthcare proxy, also known as a durable power of attorney for healthcare, is more powerful than an advance directive for real-life clinical purposes because it allows for flexibility and adaptation to new situations that may not be covered by the advance directive 1. An advance directive (living will) only provides written instructions for specific scenarios and cannot adapt to new situations, making it less effective in ensuring that a patient's wishes are honored in all circumstances.
When no healthcare proxy exists, decision-making typically falls to next of kin in a specific hierarchy: spouse, adult children, parents, adult siblings, and then extended family. However, this hierarchy may vary by state law. It is essential to note that a properly designated healthcare proxy supersedes family members' wishes, even if they are next of kin, as it is a direct expression of the patient's autonomy and preferences 1. The proxy should make decisions based on substituted judgment (what the patient would want) rather than their own preferences. Physicians should verify that a proxy exists before defaulting to next of kin and should document capacity assessments when activating proxy decision-making authority.
Some key points to consider in the context of healthcare proxies and advance directives include:
- Advance care planning is an essential process that should begin at the time of diagnosis, if not already initiated, to ensure that all patient and family rights are preserved 1.
- Patient-centered goals for care and expectations should be elicited at first assessment and reassessed frequently as conditions change 1.
- Physician Orders for Life-Sustaining Treatment (POLST) and similar medical order forms provide explicit direction about resuscitation status and additional interventions the patient may or may not want, and can be more effective than traditional advance directives alone in conveying end-of-life preferences 1.
- Provider training in advance care planning and end-of-life discussion is associated with increased ease and comfort in initiating these discussions, and can help healthcare professionals communicate effectively and compassionately with patients and their families 1.
From the Research
Importance of Healthcare Proxy
A healthcare proxy is important in situations where a patient is unable to make medical decisions for themselves, such as in cases of severe illness, sedation, or anesthesia 2. It allows the patient to designate a person to make decisions on their behalf, ensuring that their wishes are respected.
Advance Directives vs Healthcare Proxy
Advance directives and healthcare proxies are both used to promote patient autonomy and ensure that their wishes are respected in end-of-life care. However, they serve different purposes:
- Advance directives provide written documentation of a patient's wishes for future care 3, 4.
- Healthcare proxies designate a person to make decisions on behalf of the patient when they are unable to do so themselves 2, 5.
Precedence of Advance Directives and Healthcare Proxies
In general, a healthcare proxy takes precedence over an advance directive if the two conflict. This is because a healthcare proxy is a person who can make decisions based on the patient's current situation, whereas an advance directive is a written document that may not account for all possible scenarios 5. However, if a patient has a valid advance directive, it should be respected, and the healthcare proxy should make decisions in accordance with the patient's wishes as outlined in the advance directive.
Key Considerations
Some key considerations when it comes to healthcare proxies and advance directives include:
- Patients should be encouraged to designate a healthcare proxy and complete an advance directive to ensure that their wishes are respected 3, 2.
- Healthcare providers should discuss end-of-life care options with patients and respect their wishes as outlined in their advance directive or as expressed by their healthcare proxy 4, 6.
- Family disagreements over end-of-life care can be challenging, and healthcare providers should be aware of the ethical issues involved and seek guidance from ethics consultations or palliative care consultations when necessary 6, 5.