Does durable power of attorney cover medical decisions

What does it do?

A durable power of attorney is one that either takes effect upon or lasts after the principal's incapacitation. This is different from a general power of attorney, which would terminate at this point.

According to Section 751.00201 of the Texas Estates Code, a person is considered to be "incapacitated" for the purposes of a durable power of attorney if a doctor's examination finds that they are not able to manage their own finances. The doctor must provide a written statement certifying this finding of incapacity.

Texas's statutory form of durable power of attorney is found in Section 752.051 of the Texas Estates Code. It is a financial durable power of attorney - this means that it only allows the agent to handle financial matters. It does not permit the agent to make decisions about the principal's health care.

How long does it last?

Section 751.131 of the Texas Estates Code states that a durable power of attorney lasts until:

1. The principal dies;
2. The principal revokes the power of attorney;
3. The conditions of termination specified in the power of attorney have been fulfilled;
4. The agent's authority has been terminated under Texas Estates Code 751.132 and the power of attorney does not provide for a replacement; or
5. A guardian is appointed for the principal.

If a spouse was appointed as the agent and the couple divorces or the marriage is annulled or declared void, Section 751.132 of the Texas Estates Code states that their authority as agent terminates.

Why would I need one?

A durable power of attorney is generally used to make plans for the care of your finances, property, and investments in the event that you can no longer handle your financial affairs yourself.

• The Durable Power of Attorney: Health Care and Finances

  This article from legal publisher Nolo explains the advantages of durable powers of attorney.

Texas Law:

• Texas Estates Code, Chapter 751

  Discusses durable powers of attorney, which may serve as an alternative to a guardianship arrangement.

Forms and more:

• Statutory Durable Power of Attorney

  This statutory durable power of attorney form is available from the Texas Department of Health and Human Services in English and in Spanish.

• eFileTexas Guided Interview: Estate Planning

  eFileTexas's self-help section contains this interactive interview that will help you create completed forms for a durable power of attorney, medical power of attorney, an advance directive to physicians, a HIPAA medical records release, or all of the above.

• Durable Powers Of Attorneys — Not Just Forms

  This article, written by an experienced elder law attorney, examines durable powers of attorney in great detail. He explains the importance of and potential problems with durable powers of attorneys and how to address them.

• End of Life Documents [PDF]

  The Texas A&M Real Estate Center has written this article that discusses durable powers of attorney, medical powers of attorney, and other advance directives. The article links to forms throughout.

As I explained in a related article: it’s not always dementia but often it is. And unless an older person has done a good job planning ahead, it can be very hard and messy for others to intervene as needed.

But hopefully, that’s not yet your situation.

In which case, you might be wondering: Given that it’s so common for aging adults to eventually start slipping mentally — or to be suddenly disabled due to an accident or serious health crisis — what kind of planning should older adults and families do to avoid this kind of situation?

I’ve done some research on this question, and here’s what I found out.

One of the simplest — and often less expensive — smart planning approaches is for an older adult to complete a general durable power of attorney (POA) document.

Especially if the powers granted are broad — which they often are — a POA can enable the designated person (known as the “agent”) to step in and assist with finances, housing, safety, and anything else covered by the POA .

A durable POA allows an agent to take action once the older person is “incapacitated.” In California, such POAs can be used to move a person with dementia to a different living arrangement.

Now, the durable power of attorney approach isn’t perfect. Over the years, I’ve noticed that two broad categories of problems come up:

• Concerns as to whether the agent might be using the POA to financially exploit the situation
• Issues related to determining incapacity and whether the older person should be overridden.

In truth, I have occasionally encountered situations in which different doctors had different opinions on whether an older person was incapacitated. This troubles me, because agents should really only be stepping in and overriding older adults if we’re all sure they’ve lost capacity and are making decisions that don’t serve their overall goals, or are hazardous to others.

Still, a general durable POA is an excellent approach to consider. But I would recommend you pay special attention to how the document is drafted, in order to reduce the risk of financial exploitation and to avoid pitfalls related to determining incapacity.

In this post, I will share:

• What I’ve learned about general durable power of attorney documents
• Why determining incapacitation is often problematic in the real world
• Tips on avoiding a common POA weakness
• What to know about including third-party accounting and other strategies recommended by the American Bar Association, to reduce the risk of financial exploitation by an agent
• Useful resources I’ve found online for more information

Note that POAs are governed by state laws, so the details can vary from state to state. But the general principles are likely to be similar throughout the country. In this post, I’ll focus on California, since this is where I live and practice. If you — or your older relative — don’t live in California, you’ll need to look for specifics for your own state.

The Basics on General Durable Powers of Attorney 

A power of attorney document essentially allows a person (known as “the principal”) to give someone else (“the agent”, also known as “attorney-in-fact”) the ability to act on the person’s behalf. The principal needs to be of “sound mind” when signing the form.

A power of attorney generally specifies:

• What kinds of activities and decisions the agent can take on behalf of the principal,
• Whether the agent’s power is effective immediately, or only once the principal is incapacitated,
• Whether the agent’s powers remain effective even if the principal becomes disabled or incapacitated.

A durable power of attorney remains in effect even if the principal is incapacitated, so older adults should always use durable POAs when planning ahead for the future. (Remember: hope for the best, plan for the likely & quite possible.)

In California and in many other states, there are POA forms specific to healthcare, and medical decisions are excluded from the general durable POAs. This means you can designate one person to be your agent for health decisions, and another for financial or legal decisions.

Now, experts often advise older adults to complete both a durable financial POA and a healthcare POA. However, when I looked into this further, I discovered that in California, financial powers are usually included within a general durable power of attorney form.

Here is one commonly used version of the California General Durable Power of Attorney form. A person using this form can give the agent all the powers listed, or can just specify a few of them.

But it’s important to realize that as long as the form complies with the relevant California probate code, the general DPOA form can be written to include more specifics about the agent having the power to move the principal to a new residence and to make personal care decisions.

You’ll also want to consider including additional language recommended by the American Bar Association’s Commission on Law & Aging, which can reduce the risk of financial exploitation.  You can learn more about the five safeguards they recommend here: Drafting Advance Planning Documents to Reduce the Risk of Abuse or Exploitation. (I also will summarize these in a section below.)

How are older adults deemed incapacitated?

A durable power of attorney document allows the agent to make decisions either right away, or when the principal is “incapacitated.” In the documents I’ve reviewed, the principal usually has to specify whether the agent has authority immediately, or whether the authority should “spring” into action upon incapacity.

But who determines incapacity, and how? Obviously, this should be a crucial issue for those “springing” POA documents that only allow the agent to take over if the older person is incapacitated.

But even for a POA that gives immediate authority to the agent, the question of defining incapacity can be important. That’s because if the principal and agent ever disagree, the principal gets to override the agent — unless the principal is incapacitated.

So it seems clear to me that defining incapacity is important. However, this seems to be a serious weak point in many POA documents. Having reviewed several of them in the course of my years practicing geriatrics, here’s what I’ve seen regarding the criteria for determining that the principal is incapacitated:

• Some POA forms say nothing about how to determine the principal is incapacitated.
• Some POA forms say something like this: “[incapacity] may be evidenced by a written statement of my regularly attending physician or two other qualified physicians or by court order.”
• One POA form said: “I shall be determined to be incapacitated, as determined solely by my attending physician and in writing delivered to my Agent.”

(Learn more about how capacity should be evaluated in this article: Incompetence & Losing Capacity: Answers to 7 FAQs.)

The Pitfalls of Incapacity Determination

A few years ago, I consulted on an older woman who had been diagnosed with “severe dementia” based on a neuropsychological evaluation conducted during a hospital stay. Based on this, the agent took over and moved the older woman to a facility.

The problem was that when I met the older person three months later, her mental state actually seemed quite good. Now, she did make several errors on the MOCA test I administered, and likely would struggle to manage finances correctly.

But she certainly was much better than described. Which is not surprising actually, because we know that many aging adults get mentally much worse in the hospital, due to delirium. And we know that it can take months for delirium to resolve; I once had a patient slowly get better over a whole year.

Sadly, this older lady was pretty unhappy about having been moved to a facility. But since she’d been determined to be “incapacitated,” her agent was now the one making the decisions.

(Now, technically if an older person recovers mental capacity and then disagrees with her agent, the agent cannot overrule her. But in practical terms, once a person has been labeled as “lacking capacity,” it can be hard for her to challenge her agent’s authority without pursuing a court process.)

An added problem: prior to hospitalization, she hadn’t had a regular primary care doctor, and she didn’t have any close family. So there was very little information on how her mental state had been prior to hospitalization. Which meant it was harder to determine whether she had dementia, or how advanced it really was.

I share this story because I think it illustrates the pitfalls of incapacity determination and POA forms. These are:

• Capacity can be temporarily impaired or permanently impaired. POA forms usually don’t address this. It would be unfortunate for a person to permanently lose their rights, if later their capacity might improve.

• Most doctors are not trained to evaluate long-term capacity in older adults. But POA forms usually don’t specify what qualifications the attesting doctors should have. Nor do POA forms specify what documentation or evidence a doctor should provide; I have seen many brief statements saying “Ms. So-and-so no longer has capacity to manage her affairs.”

• Some people don’t have a primary care doctor. And an “attending physician” basically means a doctor who has completed residency; it could even be the hospital attending who just met the older person in the hospital. POA forms seem to assume the principal has a doctor who knows him or her well, but that’s a faulty assumption.

In summary, many POA forms are flawed in that the criteria for determining incapacity are either unspecified, hard to apply, or could result in an older adult permanently losing rights prematurely.

Why It’s Essential to Have a General Durable POA

Given the pitfalls of general durable POA forms, some people might conclude they are better off not giving anyone power of attorney, for fear that they’ll lose their rights inappropriately.

Furthermore, giving another person the authority to manage your finances is a big deal, because historically, POA forms have not included clauses that enable others to exercise oversight of the agent. So it is often possible for an agent to misuse or even steal an older person’s financial assets.

For these reasons, many older adults never get around to completing a durable general POA.

But frankly, this is usually a mistake. Despite the potential for a POA to be misused, things almost always go worse for aging adults when no POA has been appointed.

That because in the absence of a POA, a family may need to go to court for conservatorship in order to take over the affairs of an older loved one who has been incapacitated by an accident, a health crisis, or even developed a chronic mental condition such as Alzheimer’s or another dementia. That is a time-consuming and expensive process, plus it usually means that whoever becomes conservator will have to provide regular reports to the court.

So provided an older person still has capacity to complete legal paperwork and make major decisions, it’s better to complete paperwork to allow someone else to take over affairs without a complex court proceeding. A general durable POA can enable this.

For a Better General Durable Power of Attorney

Reminder: I am not an attorney. But given the problems I’ve seen people encounter with their POA documents, I would really recommend that any general durable POA document you — or your family member — completes address two key issues:

1. Better language specifying how incapacity is determined, and
2. Protective clauses enabling oversight of the agent’s activities, to reduce the risk of financial exploitation.

Addressing incapacity

My feeling is that the incapacity specifications should account for the possibility of delirium, and should provide for the possibility that the incapacity might get better. Alternatively, the language needs to do a better job of making physicians state that the principal has permanent and irreversible changes to the thinking abilities, as demonstrated by the problems not improving over at least 3 months, or some such.

I haven’t yet seen an actual POA that contains such language, but I did find an online legal article titled “Elder Law Incapacity Planning” and it suggested this language, which is better than most:

” [Trustee] shall be considered incapacitated if the Trustee becomes unable to manage his or her business affairs due to illness or for any other cause, and that incapacity is likely to continue.” (pg 7 of PDF)

(By the way, the sample health care directive addendum on page 5 of the PDF is impressive in its specificity and clarity about what someone might want in the event of advanced dependency; would recommend people take a look.)

Reducing the risk of financial exploitation

Historically, most power of attorney documents have allowed the agent to have a lot of power to manage the principal’s finances and affairs, while requiring virtually no oversight.

Most agents dutifully do their best on behalf of an incapacitated older person. But an unscrupulous (or financially needy) agent can easily divert or misuse funds.

To address this issue, in 2018 the American Bar Association’s Commission on Law & Aging published an issue brief, suggesting several safeguards that can be included when drafting a durable general power of attorney, to reduce the risk of financial exploitation.

I recommend making note of these, because as of today, they are NOT routinely included in most durable POA documents unless you specifically request them when getting the document drafted.

Here are the five key safeguards to consider:

1. Third-party accounting. This means the agent will have to provide records of financial transactions to someone else.
2. Second signatures for major transactions. This means the agent will have to get a designated other person to agree and sign, for certain major financial transactions (e.g. selling a home, liquidating a major investment).
3. Power to revoke. This authorizes a trusted third party to revoke the power of the agent. This could also be used to authorize Adult Protective Services or another agency to revoke agent’s authority. (Without a power to revoke specified in the document, it usually requires court intervention to remove an agent as POA.)
4. Define gifting powers. This means limiting the agent’s authority to bestow gifts, either by prohibiting gifting entirely or by clearly specifying permitted recipients and/or limits on amounts.
5. Limiting powers. This can be used to prevent the agent from changing the right of survivorship for bank accounts, or beneficiary designations for trusts, life insurance policies, or other similarly valuable assets.

Although these safeguards are especially intended to reduce the risk of financial exploitation, the increased transparency — and limits on the agent — can also help mitigate a much more common issue: family conflicts over what an agent is doing with an older person’s money.

For more details regarding these safeguards, and for sample language to consider including in a POA, I highly recommend reading the American Bar Association’s 2018 Issue Brief: Drafting Advance Planning Documents to Reduce the Risk of Abuse or Exploitation.

We also have a podcast episode featuring the attorney who authored the issue brief, David Godfrey JD, of the ABA’s Commission on Law & Aging: 091 – Interview: Reducing the Risk of Power of Attorney Abuse.

To complete a better general durable power of attorney, it’s best to work with a lawyer experienced in elder law in your state. Qualified attorneys can help you decide on many important details, such as how many agents to appoint and making provisions for a successor agent. (Some people appoint two people as agents, which means they can collaborate and also potentially keep an eye on each other.)

Summary & Useful Resources

In summary:

• A general durable power of attorney can give the agent pretty broad powers to manage an older person’s money, assets, support services, and even living situation, once the principal (meaning, the older adult) has been “incapacitated.” This means a general durable POA is a good way to plan for the possibility that an aging adult could become mentally impaired.

• Most power of attorney documents will not include safeguards to reduce the risk of financial exploitation, unless you specifically request them.

• Many power of attorney documents don’t do a good job of defining what exactly constitutes “incapacitated,” or who determines “incapacity” and what evidence they should review in doing so.

• Older adults can reduce the chance of being inappropriately deemed “incapacitated” by making sure their general durable power of attorney includes language specifying how incapacity is to be determined. I would recommend language that helps the agent distinguish between temporary and permanent incapacity. I also believe attesting physicians should have to provide some evidence for their conclusion that a senior is permanently incapacitated.

• Older adults should avoid having no general or financial durable power of attorney. Despite the possibility that a person may inappropriately be deemed incapacitated — or that the agent may not make appropriate choices — it is probably riskier overall to have no mechanism allowing others to step in.

Resources:

Here are some online resources that I’ve found are especially useful:

• “Drafting Advance Planning Documents to Reduce the Risk of Abuse or Exploitation“, from the National Center on Law and Elder Rights, in collaboration with the American Bar Association Commission on Law & Aging
• “The Durable Power of Attorney: Health Care and Finances” from Nolo.com
• “Elder Law Incapacity Planning” by Cynthia L. Barrett, Marquette Elder’s Advisor
• “Questions & Answers on Powers of Attorneys” from Columbia Legal Services & Senior Services (WA state)
• “Frequently Asked Questions About Powers of Attorney” from CTLawHelp.org
• “Guardianship or Power of Attorney: Which One Do YOU Need?” from Wake Forest University Elder Law Clinic
• “7 Decisions to Make for Your Durable Power of Attorney” from Margolis & Bloom, LLP

Now, can you recommend any resources to help aging adults create better durable powers of attorney? Please share below!

You can also learn more about capacity should be evaluated in this article: Incompetence & Losing Capacity: Answers to 7 FAQs.

Last but not least, we have some additional useful resources included in the show notes for our related podcast episode: 091 – Interview: Reducing the Risk of Power of Attorney Abuse.

How is a durable power of attorney helpful to an incapacitated patient?

Can a durable power of attorney make medical decisions in Florida?

What is a durable power of attorney in Michigan?

What is a durable power of attorney Florida?