Not having a healthcare proxy form completed, especially for older individuals, can significantly complicate medical decision-making. A healthcare proxy is a legal document that designates an individual to make medical decisions on behalf of someone else if they cannot do so themselves.
Before reading further, ask yourself: Do I have a healthcare proxy in place? What about my parents or grandparents?
This form is crucial when an individual becomes incapacitated and cannot make decisions for themselves—a scenario frequently encountered in critical care settings.
In the absence of a healthcare proxy, the medical team is faced with the task of identifying and contacting next of kin to make decisions. For instance, consider an 80-year-old widowed man with five children. Despite their differing relationships with their father—ranging from close involvement to years of no contact—all five children have equal say in his medical care. This situation can exacerbate social tensions and complicate consensus, especially under stressful circumstances. You can also read my previous Insights on a similar topic regarding family members not being aware of their loved ones’ wishes at the end of life.
Ideally, healthcare proxy forms should be completed in outpatient settings facilitated by a primary care physician. However, these discussions are often neglected. The limited time physicians spend discussing mortality and the discomfort patients feel contribute to this critical oversight. Confronting this reality is essential, as it affects everyone at some point.
After my time in the ICU, I made sure my parents had healthcare proxy forms filled out. You can find NY HCP form here. Just search for your state form on Google.
Insights
Root Cause Analysis: 5 Whys
The 5 Whys process in root cause analysis involves repeatedly asking "Why?" five times to drill down into the root cause of a problem by exploring the cause-and-effect relationships underlying the issue.
The problem: Seldom are healthcare proxy forms filled out.
Why?: Physicians have limited time during appointments, and patients are often uncomfortable discussing topics related to incapacity or death.
Why?: The healthcare system often emphasizes quantity over quality, leading to shorter appointment times to accommodate more patients.
Why?: Reimbursement models and healthcare policies typically prioritize high patient throughput as a measure of efficiency, which can detract from the quality of care and the thoroughness of patient-physician interactions.
Why?: Many health insurance and provider payment structures are designed around service volume rather than patient outcomes, influencing how healthcare providers structure their practice to align with financial incentives.
Why (root cause)?: Historically, healthcare financing has been set up to incentivize procedures and visits rather than outcomes, a model that has been slow to evolve towards more patient-centered care that rewards preventive measures and outcomes.
Impact Analysis
Impact analysis is the assessment of the potential consequences and effects that changes in one part of a system may have on other parts of the system or the whole.
Patient: the absence of a designated decision-maker can lead to delays in receiving necessary medical care during critical times and may result in decisions that are not aligned with their preferences or values. This situation can also cause emotional stress for family members who are thrust into making urgent health decisions without clear guidance.
Clinician or Provider: physicians need to spend time identifying and communicating with potential decision-makers rather than focusing solely on patient care. This can lead to increased stress and frustration among healthcare providers, especially in acute or emergency situations where decisions need to be made quickly.
System: the lack of healthcare proxies can lead to inefficient use of medical resources and increased healthcare costs. When medical teams have to engage in lengthy discussions to reach a consensus among family members, it can delay treatment and extend hospital stays unnecessarily. Furthermore, the healthcare system as a whole suffers when the focus shifts from patient-centered care to managing avoidable administrative and interpersonal complexities. This inefficiency can also strain relationships between healthcare providers and patients' families, ultimately impacting overall patient satisfaction and trust in the healthcare system.
Potential Solutions
Monetary Incentives for Patients: Offer a monetary incentive to patients who complete their healthcare proxy forms. This could be a direct financial reward or a reduction in insurance premiums, encouraging patients to prioritize this critical aspect of healthcare planning. The incentive would overcome reluctance to discuss uncomfortable topics by providing a tangible benefit.
Implement Systematic Education and Awareness Programs: Healthcare systems could introduce regular education and awareness programs that inform patients about the importance of completing a healthcare proxy form. These programs could be integrated into routine healthcare visits and supported with materials that are easy to understand, addressing common concerns and the implications of not having a proxy. For example, patients could be given the form while they wait for their physician. They can fill it out, so all the physician has to do is witness it. One thing I try to do in the inpatient setting is bring an HCP form with me when I see a new patient and their family to have them designate someone from the get-go.
Streamline the Process with Digital Tools: Develop and integrate digital tools that simplify the process of completing a healthcare proxy form. These tools could be accessible via patient portals online and designed to guide patients step-by-step through the process, making it less daunting. Additionally, reminders could be set up through these platforms to prompt patients and physicians to discuss and update the forms regularly.