Durable Power of Attorney and Healthcare Directives

Estate planning addresses not only what happens after death but also what happens if a person becomes unable to manage their own affairs during their lifetime. Incapacity can occur suddenly through accident or illness, or gradually through conditions such as dementia. Without proper legal documents in place, family members may need to pursue costly and time-consuming court proceedings to gain authority over financial and medical decisions.

Four primary documents address incapacity planning: durable power of attorney, healthcare proxy, living will, and HIPAA authorization. Each serves a distinct purpose, and a complete incapacity plan typically includes all four.

Durable Power of Attorney

A power of attorney (POA) is a legal document that grants one person (the agent or attorney-in-fact) the authority to act on behalf of another person (the principal) in specified matters. A "durable" power of attorney remains effective even if the principal becomes incapacitated.

Key features of a durable POA:

• Grants authority over financial and legal matters
• The word "durable" means it survives the principal's incapacity
• Can be effective immediately upon signing or "springing" (effective only upon incapacity)
• Terminates upon the principal's death
• Can be revoked at any time while the principal has mental capacity

Powers typically granted include:

• Managing bank accounts and investments
• Paying bills and managing debts
• Filing tax returns
• Buying, selling, or managing real estate
• Managing business interests
• Handling insurance matters
• Making gifts (if specifically authorized)

The scope of authority can be broad (covering all financial matters) or limited to specific transactions. Most estate planning attorneys recommend a broad durable POA to provide flexibility in unforeseen circumstances.

Springing vs. Immediate POA:

An immediate POA takes effect as soon as it is signed. A springing POA only becomes effective when a specified event occurs, typically the principal's incapacity as certified by one or two physicians.

Immediate POAs are generally preferred because they avoid potential delays in proving incapacity. The agent has no authority to act unless the principal is unavailable or incapacitated, regardless of when the document technically takes effect.

Healthcare Proxy

A healthcare proxy (also called a healthcare power of attorney or medical power of attorney) designates a person to make medical decisions on behalf of the principal if they become unable to make or communicate their own decisions.

Key features of a healthcare proxy:

• Grants authority over medical treatment decisions
• Only effective when the principal cannot make their own decisions
• The designated agent should understand the principal's values and preferences
• Can include guidance on specific treatments or conditions
• Terminates upon the principal's death or recovery of decision-making capacity

The healthcare proxy agent may be called upon to make decisions about:

• Surgical procedures
• Medication and treatment options
• Hospitalization and care facilities
• Diagnostic testing
• Life-sustaining treatments

Choosing a healthcare proxy agent requires careful consideration. The agent should be someone who will advocate for the principal's wishes even under emotional pressure, can be reached quickly in emergencies, and is willing to serve in this role.

Living Will

A living will (also called an advance directive for healthcare) documents a person's preferences regarding end-of-life medical treatment. Unlike a healthcare proxy, which designates a decision-maker, a living will provides direct instructions to healthcare providers.

A living will typically addresses:

• Artificial nutrition and hydration
• Mechanical ventilation
• Cardiopulmonary resuscitation (CPR)
• Dialysis
• Palliative care and pain management preferences

Living wills generally apply only when a person has a terminal condition or is in a persistent vegetative state with no reasonable expectation of recovery. The specific triggering conditions and available options vary by state.

Having both a healthcare proxy and a living will is advisable. The living will provides guidance to the healthcare proxy agent and directly informs medical providers of the principal's wishes.

HIPAA Authorization

The Health Insurance Portability and Accountability Act (HIPAA) restricts healthcare providers from disclosing medical information without patient authorization. A HIPAA authorization form permits designated individuals to access the patient's medical records and receive information about their condition and treatment.

Key features of a HIPAA authorization:

• Allows named individuals to access medical records
• Permits healthcare providers to discuss the patient's condition with authorized persons
• Can be broader than the healthcare proxy (allowing access even when the patient has capacity)
• Does not grant decision-making authority
• Should be provided to each healthcare provider

Without a HIPAA authorization, family members may be unable to obtain information about a loved one's medical condition, even in emergencies. The authorization should be separate from the healthcare proxy to ensure access to information regardless of decision-making capacity.

Worked Example: Family Needing POA for Parent with Dementia

Margaret, age 78, has been diagnosed with early-stage Alzheimer's disease. She currently lives independently and can manage most daily activities, but her children are concerned about her ability to handle financial matters as the disease progresses.

Margaret's financial situation:

• Primary residence: $400,000
• Investment accounts: $350,000
• Bank accounts: $75,000
• Monthly income: $3,200 (Social Security and pension)
• Monthly expenses: $2,800

Planning steps taken:

Margaret meets with an estate planning attorney while she still has legal capacity to execute documents. She signs:

1. Durable Power of Attorney: Margaret names her daughter Sarah as her agent with full authority over financial matters. She names her son Michael as successor agent. The POA is effective immediately but Sarah agrees not to act unless Margaret requests assistance or becomes incapacitated.

2. Healthcare Proxy: Margaret designates Michael as her healthcare agent, with Sarah as successor. She discusses her treatment preferences with both children.

3. Living Will: Margaret documents her preference to avoid artificial life support if she has no reasonable chance of recovery. She wishes to receive palliative care focused on comfort.

4. HIPAA Authorization: Margaret authorizes both Sarah and Michael to access her medical records and receive information from all healthcare providers.

Eighteen months later:

Margaret's dementia has progressed. Her physician provides a written statement that she lacks capacity to manage her financial affairs. Sarah takes the durable POA and physician's letter to Margaret's bank and brokerage firm.

Actions Sarah takes as agent:

• Consolidates Margaret's accounts for easier management
• Sets up automatic bill payments for recurring expenses
• Reviews Margaret's investment allocation and makes adjustments appropriate for her situation
• Files Margaret's tax returns
• Eventually sells Margaret's home and uses proceeds to pay for memory care facility

Costs avoided:

Without a durable POA, Sarah would have needed to petition the court for guardianship or conservatorship. This process typically requires:

• Attorney fees: $3,000-$10,000
• Court costs: $500-$1,500
• Ongoing annual reporting requirements
• Potential for family disputes in contested proceedings
• Timeline: 2-6 months before authority is granted

The durable POA allowed Sarah to begin managing her mother's affairs within days of the physician's incapacity determination, at no additional cost beyond the original document preparation.

State-Specific Requirements

Incapacity planning documents must comply with state law. Requirements vary regarding:

• Number of witnesses required
• Notarization requirements
• Specific language or forms required
• Whether statutory forms must be used
• Recognition of documents executed in other states

Many states provide statutory forms that are widely recognized by financial institutions and healthcare providers. Using these standard forms can reduce resistance when presenting documents to third parties.

Document Storage and Access

Incapacity planning documents are only useful if they can be located and presented when needed. Consider:

• Providing copies to named agents
• Informing family members of document locations
• Giving copies to primary care physicians
• Storing originals in a secure but accessible location (not a safe deposit box that requires court order to access)
• Registering healthcare directives with state registries where available

Incapacity Planning Checklist

• Execute a durable power of attorney naming a trusted agent for financial matters
• Name a successor agent in case the primary agent is unavailable
• Execute a healthcare proxy naming an agent for medical decisions
• Discuss your healthcare preferences thoroughly with your healthcare proxy agent
• Execute a living will documenting end-of-life treatment preferences
• Execute HIPAA authorizations for all individuals who may need medical information
• Use your state's statutory forms where available
• Ensure all documents are properly witnessed and notarized as required
• Provide copies of documents to named agents
• Inform your primary care physician and provide copies for your medical file
• Review and update documents every 3-5 years or after major life changes
• Store original documents in a secure, accessible location