What should be discussed with a patient's medical power of attorney (MPOA) regarding advanced care planning for a patient with fluctuating capacity?

Advanced Care Planning Discussion with Medical Power of Attorney for Patient with Fluctuating Capacity

When speaking with the brother who holds medical power of attorney for a patient with fluctuating capacity, you must first confirm his legal authority as surrogate decision maker, then explore the patient's previously expressed values and goals during periods of capacity, and establish clear documentation of preferences for specific medical interventions before the patient loses decision-making ability permanently. 1

Essential Elements to Address with the MPOA

Confirm Legal Authority and Role

• Verify that the brother is formally designated as the medical power of attorney and understands his role as surrogate decision maker 1
• Explain that his responsibility is to make decisions based on the patient's known values, goals, and preferences—not what he personally would want 1
• Clarify that he should have received explanation from the patient about why they were chosen and what the patient's wishes are 1
• Document this verification in the medical record 1, 2

Capture the Patient's Values and Goals During Lucid Periods

• Explore what the patient has expressed about their personal values, beliefs, and what makes life meaningful to them during periods when they have capacity 1
• Ask the MPOA what the patient has communicated about their priorities: What is most important to them? What are they hoping for? What do they fear? 1, 3
• Discuss the patient's understanding of their medical situation and prognosis as expressed during lucid intervals 1
• Address how the patient's culture, religion, or spiritual belief system affects their end-of-life decision making 1

Establish Specific Treatment Preferences

Document clear preferences for specific interventions before capacity is permanently lost: 1, 2

• Cardiopulmonary resuscitation (CPR): Determine if the patient wants CPR attempted if their heart stops 1, 2
• Mechanical ventilation and intubation: Clarify preferences about being placed on a breathing machine 1, 2
• Vasopressors and intensive care: Discuss whether the patient would want medications to support blood pressure or ICU-level care 2
• Artificial nutrition and hydration: Address preferences about feeding tubes or IV fluids for nutrition 1
• Dialysis: If relevant to the patient's condition 1
• Antibiotics for infections: Clarify under what circumstances these would align with goals 4

Provide Medical Information Appropriate to Decision-Making

• Share diagnosis and prognosis information in small amounts, using language appropriate to the MPOA's health literacy, and check understanding frequently 1
• Explain what to expect as the disease progresses, particularly regarding the fluctuating capacity 1, 4
• Clarify which goals and preferences for future treatment are realistic given the medical situation 1
• Ask permission before sharing difficult news or significant changes in the treatment plan 1

Address Preferred Location of Care

• Determine where the patient would want to receive care and where they would prefer to die (home, hospital, hospice facility) 1
• Explain that dying in a hospital ICU is associated with higher physical and emotional distress for patients and prolonged grief for caregivers compared to home or hospice 1
• Discuss palliative care and hospice options explicitly 1

Establish Documentation and Communication Plan

• Complete formal advance directive documentation, including POLST/MOLST forms if appropriate, and ensure copies are available across all care settings 1, 2
• The documentation must include: 2
  • Patient's capacity status at time of decision-making
  • Date of implementation
  • Specific interventions to be withheld
  • Interventions still permitted
  • Signatures of patient (if capable during lucid period), MPOA, and witnesses
• Ensure the MPOA and all family members have copies of the advance directive 1
• Document that the MPOA has been encouraged to share these preferences with other family members 1

Plan for Regular Review and Updates

• Establish that preferences should be reviewed regularly, particularly when the patient's condition changes or during periods of capacity 1, 2
• Explain that values and preferences may change over time in response to disease progression and physical/emotional changes 1
• Set up a system for the MPOA to contact the care team with questions or concerns 4

Critical Communication Strategies

Tailor the Conversation Appropriately

• Use open-ended questions to explore the MPOA's understanding: "What has your brother told you about what matters most to him?" 1
• Avoid medical jargon that might confuse or overwhelm 4
• Acknowledge and address emotions throughout the conversation 1, 4
• Allow time for questions and emotional processing—don't rush 4

Address Family Dynamics

• Ask if all appropriate family members are aware of the patient's goals and the MPOA's authority 1
• Explore potential conflicts between what the patient wants and what family members may expect 1, 4
• Offer palliative care consultation to assist with conflict resolution if the MPOA, other family members, and medical team do not agree 1

Provide Reassurance About Ongoing Care

• Emphasize that advance care planning does not mean abandoning the patient or that "nothing more can be done" 4
• Clarify that DNR/DNE orders do not affect other treatments unless specifically noted—comfort measures, symptom management, and appropriate medical care continue 5, 2, 4
• Explain that the care team will continue to monitor closely and adjust treatments as needed for comfort 4

Common Pitfalls to Avoid

• Do not assume the MPOA knows the patient's wishes without explicitly asking 1
• Do not wait until a crisis to have these conversations—the fluctuating capacity makes early discussion during lucid periods essential 1
• Do not use vague language like "do everything" or "comfort care only"—be specific about individual interventions 1, 2
• Do not make the MPOA feel guilty about difficult decisions—validate that this is challenging and comes from concern for the patient 4
• Do not introduce palliative care as only about dying—frame it as comprehensive symptom management and support 4
• Do not assume cultural or religious preferences based on stereotypes—ask open-ended questions about how these factors influence decision-making 1

Documentation Requirements

Document the following in the medical record: 1, 2

• The MPOA's legal authority and relationship to patient
• Patient's values, goals, and preferences as reported by MPOA and expressed during periods of capacity
• Specific treatment preferences for each intervention discussed
• Rationale for decisions made
• Cultural, religious, or spiritual factors influencing decisions
• Plan for review and updating preferences
• All conversations with dates and participants present