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A recent California appellate case, Stewart v. Superior Court (2017) 16 Cal.App.5th 87, validates the primacy of medical powers of attorney and (as they are more currently known) advance health care directives.  Medical providers who disregard the instructions of duly-appointed health care agents by providing unauthorized treatment may be liable in California for elder abuse in addition to medical malpractice.

We focus our blog on the financial aspects of California trust and estate disputes.  But, as we increasingly become involved in “parent custody” fights and other conflicts over the care of elder and dependent adults, it is important to understand the authority vested in an agent under a health directive.

What happened to Anthony Carter?

Anthony Carter, age 78, was experiencing confusion.  He was admitted to St. Mary Medical Center in 2012.  Maxine Stewart was Carter’s partner and a registered nurse.  Carter first gave Stewart authority to make medical decisions for him over ten years earlier.

There were four-second gaps in Carter’s heartbeat, leading his doctors to recommend a pacemaker.  Stewart canceled the implantation of a pacemaker, saying she thought the pauses were related to sleep apnea.  She requested a second opinion.

Although the hospital recognized the validity of the medical power of attorney in favor of Stewart, the hospital proceeded with pacemaker surgery after convening a meeting of its ethics committee.  Stewart was not given notice of, or a chance to participate in, the ethics committee proceeding.  The committee concluded that it could void Stewart’s status as agent if she failed to authorize lifesaving measures because the power of attorney stated, in essence, that all measures were to be taken to preserve Carter’s life.

Rather than notifying Stewart of the ethics committee’s conclusion, the hospital quickly proceeded with the pacemaker surgery she opposed.

Stewart alleged that the pacemaker, which was removed two days later, caused serious injury to Carter and led to his death.

How did the courts view these events?

Stewart sued the hospital, one of the treating physicians, and others.  She claimed the hospital denied Carter the right to refuse unnecessary surgery, the right to be involved in secret hospital meetings to invalidate his power of attorney, and the right to obtain a second opinion before proceeding with surgery.

A San Bernardino County Superior Court judge granted summary adjudication in favor of the hospital as to the cause of action for elder abuse on the theory that interpreting the power of attorney, then letting the surgery occur, did not meet the requirements for elder abuse claims under California’s Elder Abuse and Dependent Adult Civil Protection Act (the elder abuse statute).

Alarmed with this ruling, the Court of Appeal took the unusual procedural step of up of considering summary adjudication by writ petition and reversed the trial court, allowing the elder abuse claim to proceed to trial.  In a published opinion issued in October 2017, the court wrote: “we find it important to emphasize that elders have the right to autonomy in the medical decision-making process.”

The statute provides strong remedies against defendants who commit physical abuse or neglect against an elder or dependent adult, as those terms are defined in Welfare and Institutions Code section 15610.63 and section 15610.57.  Since Carter depended on the hospital to meet his basic needs, he had a custodial relationship with the hospital that would support a neglect claim.

The appellate court discussed the fundamental nature of the right to personal autonomy, which includes the right to determine whether or not to submit to medical treatment.  Excluding a patient from a judicial proceeding regarding a surgery to be performed over his objection denies fundamental due process.  Even if a doctor believes that an operation or other treatment is desirable or necessary, the law does not permit the doctor to substitute his or her own judgment for that of the patient by any form of deception.

It was undisputed that the hospital authorized the pacemaker surgery without the consent of Carter or Stewart, gave no notice of the ethics committee meeting to Carter or Stewart, and did not give Stewart prior notice of the surgery.  Stewart acted rationally in opposing the surgery.  Hence, the deprivation of Carter’s right to personal autonomy could amount to elder abuse, not mere professional negligence.

The hospital’s contention that it should not be punished for listening to the advice of a doctor in good standing failed to account for its decision to structure the ethics committee meeting in such a one-sided manner.

What does this mean for health care directives in California?

The Health Care Decisions Law, codified at California Probate Code sections 4600-4806, lays out the rules governing advance health care directives.  The Legislature has confirmed that “an adult has the fundamental right to control the decisions relating to his or her own health care, including the decision to have life-sustaining treatment withheld or withdraw.”  Although such proceedings are rare, interested parties, such as health care providers, family members, and friends, can ask a court to determine whether an agent’s acts or proposed acts are consistent with the patient’s desires as expressed in his or her health care directive.

Health care directives only work when medical providers accept and follow them.  Carter found in Stewart a health care advocate he trusted.  He executed the paperwork necessary to put her in charge of his care.  Unfortunately, the hospital did not trust her judgment and proceeded to install a pacemaker that apparently harmed him.

Even when a person signs a health care directive instructing an agent to approve lifesaving care, the agent named in the directive still wields broad discretion with respect to accepting or rejecting medical interventions recommended by treating physicians.  This is appropriate given the various paths that can be taken in response to a serious illness or condition.

A hospital cannot casually override the directives of an authorized agent.  Instead, hospital personnel should consider allowing the agent to participate in any ethics committee meeting to review the patient’s care and should get legal advice if they feel uncomfortable with the position taken by the agent.