Case Presentation: The patient is a 74 year old woman with past medical history of dementia and an aggressive right upper lobe cavitary mass who presented with post-obstructive pneumonia. The lung mass was diagnosed two years prior, however the patient refused further workup. The patient named her two daughters to be dual healthcare powers of attorney (HCPOA). During her admission, the patient was intubated. Ethics consult was placed on hospital day (HD) 23 as the two daughters refused a tracheostomy, PEG, and LTAC; simultaneously, they refused to change the code status or pursue comfort care. The dual HCPOAs would not entertain options other than extubation and going home at the patient’s previous baseline. The ethics committee determined that the family’s failure to make a decision was, in fact, making a decision to impose undue suffering. One daughter eventually was agreeable to comfort care. Legal processes were initiated to appoint a new HCPOA as the intensivist believed that one of the HCPOAs was unwilling to act in the patient’s best interest. Eventually, the patient was deemed by a psychologist to be competent. The patient expressed understanding and desire to made comfort care and have a terminal extubation. On HD 38, the patient was extubated and passed.
Discussion: The HCPOA is used to minimize confusion when the patient cannot make medical decisions. While most people choose one person to serve as their HCPOA, multiple people can be chosen, which can be problematic. This case highlights the perils of multiple HCPOAs. As physicians, we aim to act in the best interest of the patient and rely on HCPOAs to advocate and act in accordance to their loved one’s wishes. With increasing emphasis on earlier palliative care involvement, it is important to continue underscoring the Internist’s role in guiding their patients and having goals of care conversations earlier.
Conclusions: Clear lines of communication between the two HCPOAs clouded the management of this patient, however, the unique decision to have two powers of attorney introduced a distinct predicament. The literature does not describe prior cases of multiple HCPOA that do not agree on a course of action. As such, there was no legal precedent to navigate this difficult situation. All attempts were made to act in the best interest of the patient. Eventually, the patient’s autonomy took precedence over the word of the HCPOAs.