HLTH 4303 Module 4 Health Care Power of Attorney Analysis Example

The Daughter Holds the Document, the Son Wants the Tube: Creating, Executing and Honoring a Health Care Power of Attorney When a Resident With Advanced Dementia Can No Longer Swallow

Student Name

American College of Education

HLTH4303: Legal and Ethical Issues in Healthcare Administration

Module 4 Assignment

Instructor Name

October 26, 2026

The Situation

Mrs. H., an 86-year-old resident of our composite skilled nursing facility, has advanced Alzheimer's disease. She no longer speaks in sentences, needs help with all care and, over the past month, has begun to cough and choke when eating. After a hospital stay for aspiration pneumonia, the hospital team raised the option of a feeding tube. Mrs. H.'s daughter holds her health care power of attorney and has told the facility that her mother would not want a tube. Her son, who lives out of state, insists that a tube be placed and has said he will contact a lawyer if it is not.

As assistant administrator, I must make sure the facility acts lawfully and respects Mrs. H.'s wishes. That requires answering three questions: whether the power of attorney is valid and in effect, what the agent's authority and obligations are, and how the facility should handle the family conflict.

Creating and Executing a Health Care Power of Attorney

A health care power of attorney, known in some states as a health care proxy, is a written document in which a person, the principal, names another person, the agent, to make health care decisions if the principal loses the capacity to make them. It differs from a living will, which states the principal's own treatment wishes, although many states combine the two in one advance directive form. It also differs from a financial power of attorney, which gives the agent no authority over medical decisions.

State law governs how the document is created and executed. The principal must have capacity when signing. Most states require the signature to be witnessed, often by two adults, and some accept notarization instead of or in addition to witnesses; many exclude certain people from serving as witnesses, such as the named agent or the principal's health care providers. Sabatino (2010), reviewing the history of advance planning law, describes how these statutes developed state by state from the 1970s onward, producing a disjointed patchwork of state rules with some points of convergence, and a gradual shift from a legal transactional approach toward one centered on communication, including portable medical orders such as POLST.

In Mrs. H.'s case, the facility's social worker reviewed the document on admission two years ago. It was signed by Mrs. H. before her diagnosis, witnessed by two adults who were not family members or care providers, and included a living will section declining artificial nutrition if she had an advanced, irreversible condition and could not eat by mouth. The document appears valid under our state's law. The agent's authority began when Mrs. H.'s physician documented that she lacked capacity to make health care decisions, which is in the record.

The Agent's Authority and Duties

An agent under a health care power of attorney does not decide according to her own preferences. Most state laws direct the agent to decide as the principal would have decided, using the principal's known wishes, a standard often called substituted judgment, and only where the wishes are unknown to decide in the principal's best interest. Here, Mrs. H.'s wishes are written down: she declined artificial nutrition in exactly the circumstances she now faces. The daughter's decision to decline the tube follows those wishes, and it is the decision the law directs her to make.

Clinical evidence supports the same conclusion. The American Geriatrics Society (2014) recommends against feeding tubes for older adults with advanced dementia, explaining that careful hand feeding produces outcomes at least as good as tube feeding for survival, pneumonia, function and comfort, while tubes bring agitation, more restraint use, tube complications and new pressure ulcers. The Society also states that tube feeding is a medical therapy that a surrogate can decline in accordance with advance directives or previously stated wishes. The law, the resident's own words and the clinical evidence all point the same way; what remains is a family in pain.

Handling the Family Conflict

The son has no legal authority to override the agent, since the power of attorney names only his sister. But the facility should not treat the conflict as a matter of who holds the paper. The son may be acting from grief, guilt at living far away or a belief that declining the tube means letting his mother starve. The facility should arrange a care conference, in person or by video, with both children, the attending physician, the director of nursing, the social worker and a speech-language pathologist. The team should explain what careful hand feeding involves, why a tube would not prevent aspiration or prolong comfortable life, and what their mother wrote. The son should be given a copy of the relevant section of her advance directive, with his sister's permission.

If the son continues to object, the facility should offer a review by its ethics committee, or by the ethics resource it shares with the local hospital. If he consults a lawyer, the facility should refer the matter to its own counsel and continue to follow the agent's decisions unless a court orders otherwise. Throughout, staff should document the conversations and the basis for the plan of care.

Why Understanding the Prognosis Matters

The son's objection is common, and research suggests how to respond to it. In a prospective study that followed 323 nursing home residents with advanced dementia and their health care proxies for 18 months, Mitchell et al. (2009) found that eating problems developed in most residents, that pneumonia and febrile episodes were frequent, and that more than half of the residents died during the study. The finding most relevant to Mrs. H.'s family concerned the proxies. Residents whose proxies understood the poor prognosis and the complications expected in advanced dementia were much less likely to undergo burdensome interventions, such as hospitalization or tube feeding, in the last three months of life than residents whose proxies lacked that understanding.

The study was about proxies, but its lesson applies to every family member involved in a decision. The son's demand may come from a belief that a tube will restore his mother's health, and no legal explanation of his sister's authority will change that belief. A clear, honest explanation of what advanced dementia is and what a tube can and cannot do is more likely to help him accept a decision he cannot legally override, and to spare the family a conflict that outlasts their mother's life.

What the Facility Should Change

The case exposes gaps that the facility can close. Advance directives are reviewed on admission but not again unless a family raises them, so many residents' documents are years old and families may not know what they say. The facility should review every resident's advance directive and power of attorney at each quarterly care conference, confirm that the agent's contact information is current and ask whether the resident, if able, wants to update it. It should offer POLST discussions for residents with serious illness, since a portable medical order is more likely to be followed across settings than a directive in a file. And it should train staff on the difference between a health care agent and other family members, so that front-line staff do not take instructions from whoever is present. Sabatino's account of the shift toward communication-based planning supports this approach: the document matters, but the conversations around it decide whether wishes are honored.

References

American Geriatrics Society Ethics Committee and Clinical Practice and Models of Care Committee. (2014). American Geriatrics Society feeding tubes in advanced dementia position statement. Journal of the American Geriatrics Society, 62(8), 1590-1593. https://doi.org/10.1111/jgs.12924

Mitchell, S. L., Teno, J. M., Kiely, D. K., Shaffer, M. L., Jones, R. N., Prigerson, H. G., Volicer, L., Givens, J. L., & Hamel, M. B. (2009). The clinical course of advanced dementia. New England Journal of Medicine, 361(16), 1529-1538. https://doi.org/10.1056/NEJMoa0902234

Sabatino, C. P. (2010). The evolution of health care advance planning law and policy. The Milbank Quarterly, 88(2), 211-239. https://doi.org/10.1111/j.1468-0009.2010.00596.x