No Spouse, No Kids, No Problem.
By Eleanor Tanno, M.D.
At the yearly preventative health physical exam for one of my Medicare patients, Ms. Esther, I ask whether she has an advance directive. She answers “I still need to make one of those.” I start to talk through the process with her in an attempt to make it less intimidating.
I begin by asking who would she like to make her medical decisions for her if she is not well enough to make her own? She says, “that’s just it. I don’t have anyone so that’s why I’ve avoided this process.” You see, Ms. Esther is not married and she has no children. But that does not mean she is alone!
The Perceived Dilemma
When I talk to my patients, one of the biggest perceived road blocks to creating an advance directive is for the patients who feel they do not have a “go-to” person to ask to be their medical decision maker, legally called a medical power of attorney (POA). These are often patients who were never married and have no children. Alternatively, perhaps they are widowed or divorced and have strained relationships with their kids. Another scenario is the patient who is close with their children, but their children are far away on a deployment, not mature enough to make serious decisions, or are dealing with their own personal medical conditions.
It is a logical question: whom should be your POA if you do not have a spouse or adult child in your life to make these decisions for you? For many, this is not an easy question to answer.
You are not alone!
I first reassure these patients they are not alone! Feeling like you do not have an apparent person for this role can be very isolating. However, it is quite common. It is even common among aging married people as their spouse may become too ill or may have passed away.
I encourage these patients to think of the next closest person to ask. Apparent choices are another family member, often a a sibling or a niece/nephew. The POA can be a complete non-relative such as a good friend.
I even met one woman who was asked to be the POA for an older congregant in her church. They had gotten to know each other through a book club and the idea had come to the congregant after a discussion about end-of-life care. The woman shared that she had been honored to be asked by this congregant. The pair went on to have conversations about the kinds of care the congregant would want at the end of her life. This POA woman was able to be there for the older woman at the end of her life and carried out her medical wishes. She felt very proud of her involvement at the end of the older woman’s life.
When choosing a less traditional person to be your POA, there are all the normal considerations of selecting a POA.
First, you still want to choose someone available, whether that’s in close proximity or just easy to reach by phone. You are selecting someone who may be called anytime; in the middle of the night, over the holidays, while on vacation. People get sick at inopportune times and you want a POA who is willing to be available even when it is not convenient for them.
Second, you also want to think of someone who has better health than you to increase the likelihood they will be available for years to come. It might be tempting to choose a close friend, but if that friend is also in their 80s, they may not be readily available to be at your side.
Third, you must ask this person whether they are comfortable being your POA. If they are not, they are not a good fit. Do not pressure them into this role. You want someone who is willing and ready to be available. It is a disservice to you to delegate someone who may not be present when the time comes.
Fourth, and most importantly, you must discuss your end-of-life wishes with this person. These are your medical wishes and you cannot expect your POA to know your wishes if you have not told them.
Of course, there are also a few special considerations when choosing a less traditional person to be your POA
First, you must put this person’s name in writing as your medical power of attorney. There are some variations from state to state, but if there is no legal POA named in an advance directive, there is a default legal order of succession. If the patient has no spouse or children, the order of progression states the next legal decision maker is a living parent, followed by any adult sibling. Lastly, other relatives or friends may be asked. If there is a dispute about whom it should be, the court may need to appoint a guardian to your case. Most people are, understandably, unenthusiastic about a court-appointed case worker being named to make their most critical and definitive medical decisions.
Second, you may want to be a little more specific when discussing your medical wishes with this person. Unlike a spouse or adult child who may know you very well and be better at guessing the kind of medical care you would have wanted, a more distant person may not feel as confident in their recommendations. It is up to you to have these discussions with this person so that they feel comfortable making decisions on your behalf. Additionally, talking to them may make them feel more comfortable in accepting your request to be your medical power of attorney.
Not only do you want to be more specific when discussing your medical wishes with your chosen medical POA, you may want to consider documenting a more detailed written advance directive. Remember, your discussions and documents serve as a roadmap for this person. If they are a little further emotionally from you, you want to leave them with directions they can easily follow. This will lighten the burden on them and, in turn, lighten your anxiety in asking them.
You might want to include a “face sheet” with your updated medication list, any past surgeries, and chronic medical problems for which you see your primary care physician or specialists regularly. Include a list of all physicians you see in case they need to be contacted.
You can also include anyone you want your POA to consult with about your care, such as another friend, relative, or religious figure. Sharing a heavy load always acts to remove weight from someone’s shoulders.
Take a Deep Breath
It is alright, even common, if you do have not an apparent person to ask to be your medical POA. Do not let your anxiety of choosing and asking someone prevent you from naming anyone at all. If that happens, the person making your most personal medical decisions may not be someone you would have chosen at all!
Most people would be honored to be asked to be this person for you. You can minimize your fear of being a burden to this person by discussing your medical wishes with them and documenting them in a detailed advance directive.