User:Riley S. Williams/sandbox

= Healthcare proxy =

Definition and Uses
In the field of medicine, a healthcare proxy (commonly referred to as HCP) is a document (legal instrument) with which a patient (primary individual) appoints an agent to legally make healthcare decisions on behalf of the patient, when the patient is incapable of making and executing the healthcare decisions stipulated in the proxy. Once the health care proxy is effective, the primary individual continues making healthcare decisions as long as the primary individual is legally competent to decide. Moreover, in legal-administrative functions, the healthcare proxy is a legal instrument akin to a "springing" health care power of attorney. The proxy must declare the healthcare agent who will gain durable power attorney. This document also notifies of the authority given from the principal to the agent and states the limitations of this authority.

Those over the age of 18 are allowed to have a healthcare proxy, and these documents are useful in situations that render a person unable to communicate their wishes such as being in a persistent vegetative state, having a form of dementia of an illness that takes away one's ability to effectively communicate, or being under anesthesia when a decision needs to be made. Healthcare proxies are one of three ways that surrogate decision makers are enacted, the other two being court orders and laws for the automatic succession of decision makers. In contrast to a living will, healthcare proxies do not set out possible outcomes with predetermined reactions, rather they appoint someone to carry out the wishes of an individual.

Living Will
The basis of the beginning of advance healthcare planning in the United States was a "living will". This idea was proposed by the Euthanasia Society of America in 1967 and was the first advance directive method. It came about under the influence of common law which include that an individual would not have to forgo treatment without their consent. This document allowed a written record of how much treatment a patient would be willing to undertake.

This idea was officially adopted into legislation in California in 1976 with the living will statute. This allowed patients to express their future wishes and gave physicians the immunity to go ahead with treatment as long as it was not conflicting with what was officially stated in the living will.

Power of Attorney
The methods of healthcare planning and tools of advanced preparation have changed dramatically over the years. The very beginning of this concept arose in 452 B.C. with one brother allowing his other to control the money of the Temple of Sharru. In the a modern sense, the concept of durable power of attorney arose in Virginia in 1954 for the purpose of setting property matters. In this agreement, the document had to be signed in the presence of a judge and the Model Act was applied which enacted a maximum amount that this power could be applied to. This allowed for a continued existence of power of attorney following the original person losing capacity to carry out the necessary actions. This concept evolved over the years and in 1983, the President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research addressed this idea as one of great potential in the healthcare industry. This commission also stated the possibility of abuse as a noted concern going forward. In response to this commission, there was an evolution of this concept throughout the 1980's and the 1990's that eventually led to all states in America having a healthcare power of attorney statute by 1997.

Criteria for Healthcare Proxy
Some jurisdictions place limitations on the persons who can act as agents. (Some forbid the appointment of treating physicians as the healthcare proxy.) According to the state of Massachusetts, no person who is an employee or administrator of a facility can be an agent unless it is for someone who is of familial relation to them. In any event the agent is recommended to be someone close to and trusted by the primary individual. In the absence of a power of attorney, a legal guardian must be appointed.

Legal Guidelines
Healthcare proxies are permitted in forty-nine states as well as the District of Columbia. Healthcare forms may differ in structure from state to state and pre-made forms are not compulsory as long as certain guidelines are met. The common guidelines include:


 * Name and address of the agent.
 * Name and address of an alternate agent.
 * Duration of the proxy – not indicating a duration means it is valid unless stated otherwise.
 * Special instructions – these can broaden or limit the powers of the agent. If the patient doesn't want to be on feeding tubes no matter what, this can be stated here. If there are certain treatments that the patient does not want to receive like dialysis or blood transfusion, then they must be indicated. However, if the patient wants to give the agent more flexibility with some or no restriction, this must be written.
 * Name, date and signature of the primary individual.
 * Instructions on tissue or organ donation.
 * Two adult witnesses must sign the document stating that they have witnessed this agreement and that both parties appear to be sane. The witnesses must be 18 years or older. The agent and primary individual do not qualify as witnesses.
 * Presence of a lawyer - such a person may help in drafting a document tailored to the needs of the primary individual.
 * Once signed, copies of the form must be given to health care providers, the agent, spouse, and close friends. A copy should also be carried by the primary individual (in wallet or purse).

The Patient Self Determination Act (PSDA) established in 1990, is a federal law that requires patients to inform healthcare professionals if they currently have a healthcare proxy, or to be advised on how to obtain one. It requires that institutions must also inform you of your rights involving healthcare decision making. Additionally, it prohibits health institutions from discriminating based on the absence of a HCP.

In addition to the guidelines for a proxy, there must also be a consensus that the agent chosen is appropriate for the patient. The person must not be under any pressure or influence in the completion of the HCP as this could lead to exploitation of the patient. Evaluation of this can involve the clinicians seeing if there is a general consensus among family member and evaluating possible conflict of interests.

Default Surrogate Consent
This occurs when their is a lack of a healthcare proxy and allows someone to step in as an agent and make legal decisions on behalf of the patient in the result of an emergency. The automatic succession of a surrogate completely depends on the area and differs widely based on state as well. This person has not been officially appointed through the judicial system but is chosen through a surrogate hierarchical chain of command. There is no uniform ladder of consent, but it generally starts with the spouse if there is one, and then travels down to the patients parents, and siblings.

Capacity to Appoint a Proxy
There are limited legal foundation to determine the ability of someone to appoint a healthcare proxy. Although physicians are allowed to deliver life-saving treatment in emergent situations, in non-emergencies, the it is determined if the patient has the ability to then appoint a healthcare proxy. It is possible for a patient lacking the ability to make healthcare decisions, to still have the capacity to appoint an agent and have a proxy. One way of determining if someone has the capacity to appoint an HCP is the ability to understand the information of what a proxy would entail. This includes the person's knowledge of someone else making decisions about their medical situation and that this could be in life and death occurrences. The individual's capacity could also be measured through administering a Mini-Mental State exam which tests levels of cognitive impairment. A sign of extreme cognitive impairment is sometimes associated with a score of ten or less on this exam.

Another way of deciding one's ability to appoint a proxy is through their consistency in choice of a proxy. Some individuals though lacking the ability to make complex medical decisions for themselves, can be deemed consistent in their choice of a healthcare agent.

Abilities of an Agent
A healthcare proxy gives another person of the patient's choice the ability to make medical decisions on their behalf in the event that they are not able to do so. The situations that an agent can decide on the future course of action for the patient include:


 * Surgical Procedures
 * Serious injury resulting in incapacity
 * Cases where cardiopulmonary resuscitation (CPR) is needed
 * In situations related to ventilator use
 * The supply of artificial nutrition or hydration
 * Comfort care in end of life instances

Agents use the recommendation of the physicians in order to make decisions that align with the wishes of the patient. They have to ability to whether an individual will continue in life support in cases of permanent coma or persistent vegetative states. An agent can also emphasize wishes of a patient in relation to organ donation.