Who has medical power of attorney for a patient with urosepsis secondary to a urinary stone needing surgical intervention?

Medical Power of Attorney for a Patient with Urosepsis Requiring Surgery

In the absence of a designated durable power of attorney for healthcare, the current spouse is typically the first surrogate decision-maker for a 52-year-old male with urosepsis secondary to a stone needing surgical intervention. 1

Surrogate Decision-Making Hierarchy

When a patient lacks decision-making capacity due to their medical condition (such as urosepsis):

• The primary surrogate is the person designated in the patient's durable power of attorney for healthcare document, if one exists 1
• If no durable power of attorney exists, state statutes specify the hierarchy of surrogates, typically in this order:
  • Current spouse 1
  • Adult children 1
  • Parents 1
  • Adult siblings 1
  • Other relatives or close friends 1

Assessment of Decision-Making Capacity

• Physicians determine medical decision-making capacity, while legal competence is determined by courts 1
• Patients with urosepsis may temporarily lack decision-making capacity due to:
  • Altered mental status from infection 2
  • Pain and discomfort 2
  • Effects of medications 1

Special Considerations in Urosepsis Cases

• Urgent decompression of the collecting system is required in cases of urosepsis with obstructing stones 2, 3
• The surrogate must be informed that:
  • Immediate intervention is necessary to prevent septic complications 2
  • Definitive stone treatment should be delayed until sepsis is resolved 2, 4
  • The procedure will likely involve placement of a ureteral stent or nephrostomy tube 3

Potential Challenges with Surrogate Decision-Making

• If the designated surrogate has impaired judgment capacity (incapacitated surrogate), hospital ethics committees may need to intervene 5
• When family members disagree with the surrogate's decisions, hospital ethics committees can assist in resolving conflicts 1
• If no surrogate can be identified, the hospital ethics committee or court-appointed guardian may need to make decisions 1

Documentation Requirements

• The medical record should clearly document:
  • The patient's lack of decision-making capacity 1
  • Identification of the appropriate surrogate 1
  • The surrogate's informed consent for the procedure 1
  • Any discussions regarding treatment options and risks/benefits 3

Clinical Management Considerations

• The surrogate should be informed that:
  • Antimicrobial prophylaxis must be administered prior to stone intervention 6
  • If purulent urine is encountered during the procedure, stone removal will be aborted and drainage established 6, 3
  • Once infection is controlled, definitive stone management can proceed 4
  • Stone material should be sent for analysis to guide future prevention 6