When a patient is unable to make sound decisions about her own care, what is the physician practice to do? It could be an elderly patient whose cognitive abilities are declining, or a college student who is over 18 but has never dealt with medical care on his own before, or a seriously ill patient who is planning for the future. It is important for the practice to have someone to communicate with about such patients without fear of violating HIPAA or state laws.
Authorization for medical decision making is something that patients need to consider both at the beginning of adulthood and in the later years of life. Although young adult patients may not need the same level of thought regarding end-of-life planning, it is important to educate them about HIPAA privacy and security rules. Young adults often incorrectly assume that their parents or significant others will have automatic access to their information and can and will make decisions on their behalf in case of emergencies, so it is important to ask them specifically and proactively about who is allowed to communicate with members of the care team if and when needed. This can easily be accomplished by including one or more forms along with new-patient paperwork.
For older patients, or patients with serious or terminal conditions, it is even more important to address what they want and who is authorized to make decisions on their behalf. Clinicians may conduct (and bill Medicare for) advance care planning as needed (typically at the time of a health status change or other significant life change, such as marriage, divorce, or event that might affect whom a patient may wish to educate or designate).
Practices can be prepared for these scenarios with a little planning. Clinicians and staff should know about several documents. The living will or advance directive provides general guidance about what treatment a patient would or would not want, but it is not a medical order, so clinicians cannot use it to guide treatment decisions. The power of attorney (sometimes called a medical power of attorney, medical proxy, or health care agent, depending on the state) designates a specific individual to make decisions for a person when and if he is unable to make his own decisions. The physician orders for life-sustaining treatment (or physician orders for scope of treatment) form is generally used to detail treatment wishes of patients who are nearing the end of life. This last document would be used together with the other documents when a patient cannot make treatment decisions. For older patients, advance care planning is an important discussion to have at least once and to likely revisit as things change.
The practice should establish a policy that staff and clinicians can follow regarding when and how to discuss advance care planning. You can start by contacting your malpractice carrier to see if they have any examples you can use. Because rules can vary by state, your state or local medical society may have policies that provide state-specific information. ACP's Advance Care Planning Toolkit provides resources to explain and bill for advance care planning and to access forms that you might need to provide your patients. The HIPAA Privacy Manual includes authorization forms that patients can use to authorize specific individuals to have access to their information. The Patient Education and Caring: End of Life (PEACE) Series also provides guidance.