POA question

[ottermadness]

Detailed one sorry. This is regarding the health and well-being side of POA.
My grandad when filling in the form a few years ago (prior to recent significant heath deterioration) signed the form saying that he is to be consulted and included in decisions about his care. He is now almost certainly lacking capacity to make reasonable, and definitely long term, decisions about his care. Family around him are worried about repeat emergency admissions to hospital and an endless cycle of IV and oral antibiotics. He’s miserable and definitely losing his orientation to time, place and people. BUT.. am I right in thinking that because of how he has filled in the form true POA is not really in place? Or if I am wrong what are the limitations of the POA in this case, if/when a medical professional determines a lack of capacity.
The background is diagnosis of bladder & aggressive prostate cancer, one of which has metastasised and he is 95.
Thanks if you can help.

The capacity issue has to be formally determined by a psychiatrist, so health&welfare POA doesn’t kick in until that’s been done. We had to have it done last year for my dad who has dementia. Fortunately he’s made his wishes well known to us over the years and they haven’t changed.

We also have an Anticipatory Care Plan in place which lays out the ceiling of care. This was done with the GP when he did have capacity and it lays out that he doesn’t wish any hospital admissions for infections etc, and has no wish for antibiotics-if he becomes ill, he wants palliative care I.e. pain relief, only.
There is a copy of the document held in the nursing home and in his hospital and medical records, and it flashes in bold red letters on his computerised records with his GP

The Lasting power of attorney can only be used if it was registered with the office of the public guardian whilst someone had/has capacity.

If that hasn’t happened then all decisions are best interest decisions made by the relevant clinical teams in discussion with the person concerned and where they wish or where they have no capacity about that particular decision then the family are consulted.

Capacity assessment is decision specific. He has said he wishes to be consulted and that wish must be respected. Each decision is made assuming capacity unless assessed as otherwise.

People with capacity (and the default is that people have capacity) can make decisions others consider unwise. They are allowed to take risks others might consider unacceptable.

The diagnosis and age are irrelevant to capacity decisions.

Thank you for the info.
I’ll try to make my question more specific... Is signing the POA document I do not give authority (sec 5) the same as not having a POA at all when it comes to the reality of making decisions around life saving care? (Obviously only where capacity has been determined as not present).

If he signed section 5 saying he did not consent to the LPA making life sustaining decisions, then any future care decisions about whether to provide such treatment sit with the clinical team.

Which is what would have happened if he hadn’t signed the document at all?

If he lacks capacity, he lacks capacity. It doesn't need a psychiatrist, capacity is decision specific so he could lack capacity for one decision and not another. For example he might have capacity to decide he wants to take his tablets that morning but not to decide about having an operation.

Any healthcare professional making a decision about his care should be able to make a decision about whether he has capacity to make the relevant decision at that point in time.

It sounds like you need a conversation about Advance Care Planning given he has advanced cancer, advanced age and is having multiple admissions of limited benefit. Is he known to a Palliative Care Team as this is exactly what they are for?

The POA shouldn't be the main issue as I suspect most of the issue here is about making medically appropriate decisions rather than it being all down to his choices and whether or not he has capacity.

And yes, a POA without the bit about life saving treatment is a bit useless except for deciding about moving to care homes.

However the vast majority of people don't have POA and still get all these decisions made entirely smoothly as Best Interests Decisions. So don't panic.

I'd say less than1% of the patients I see have POA and I do this sort of thing all the time.

Thank you, I just needed to check my understanding. I’m a bit secondary to this and family closer to it than I are beating themselves up a bit over it (there is clearly some misunderstanding about POA there). Completely agree about medically appropriate decision making. This conversation is helping me to understand that family close to this need to stop trying to sort everything on his behalf (they can’t) and arrange for consultations about his care to take place with him there. Even if that is really very difficult to arrange.
p.s. no criticism here, it’s all very much best interest driven.

Currently GP won’t/can’t refer to palliative care as hasn’t managed to actually see him (literally missing him In the last few weeks as repeatedly admitted short term at the weekly visit to his home). It was only at an appointment made this week the POA not really being POA was actually discovered by all involved.

Perhaps that isn’t fair, they knew he had ticked the box he had ticked but didn’t have the understanding of what that meant in the reality of facing the situation now.

The referral to the specialist palliative care team doesn’t have to come from the GP. If he’s admitted it can be by the hospital clinicians - but he’d need to consent to this.

Has nobody put a DNACPR in place? This can often be a trigger for a palliative care referral and ceiling of care decisions.

The difficulty being that the hospital clinicians are less willing to make the call on capacity when he is acutely unwell, and less able to see the holistic picture of his overall heath. I think this is why it hasn’t happened yet. Another complicating factor is that because he is in a home with full nursing care he is often rushed back there (sometimes in the middle of the night) because they can look after his needs to a higher level there. He doesn’t stay long enough to see anyone senior or anyone with time to see the whole picture.

DNACPR already in place

Sorry, I don’t understand. I thougt the section 5 bit was a choice between “I give permission for my poa to make decisions for me now” and “I give permission for them to make decisions only when I lack the capacity to make them myself”.

If he doesn’t have capacity to make the decisions then they go to the person with poa. If he does have capacity then it’s his decision.

Is he in a nursing home? You really need to get the gp or whoever is the lead on end of life care involved as a priority.

Does he have a EPA or LPA? The newer LPAs (from 2007) are better defined I think when it comes to capacity.
(Not a legal expert in the slightest but been through this a couple of times!)

Sec 5 on the health POA relates to life saving care.

Sorry, life sustaining

LPA

There's consent and consent. Particularly in hospital, palliative care teams see a lot of patients who are just told a referral is being made because it's indicated, just as you would to other teams like cardiology or orthopaedics or physio without making a big song and dance over it - in some hospitals palliative care teams pick up patients on the door without referrals. Very very few people turn it down and it's much easier than making a big deal over it 'we think you need to see palliative care now'. Also patients who won't see 'palliative care' are delighted to see 'symptom control' who are exactly the same people.

With his diagnoses, GP and nursing home should be on it, making the referral anyway, and thinking about admission prevention. Often they can do this by themselves.

Thanks @AnnaMagnani I will pass on the message to ask for a visit from palliative if/when he next ends up going in. More voices can’t hurt.

Thanks all for info