The Power of Attorney Wants Full-Mouth Extractions Today
Mrs. Alvarez is 82 and has mild-to-moderate dementia. Her son, who holds her durable power of attorney for health care, brings her in requesting full-mouth extractions and immediate dentures 'today' because she has stopped eating. She has generalized severe periodontitis, several mobile teeth, and one abscessed tooth. She is alert, knows she is at a dental office, and says clearly, 'I want to keep my teeth.' She becomes tearful when her son insists. Her blood pressure is 178/96 and she takes apixaban daily for atrial fibrillation. The son says he is tired of 'being the only one who takes care of her.'
1. Does Mrs. Alvarez have capacity to make this decision? Describe how you would assess it and what you would document.
Read the worked answer
Capacity is presumed, is decision-specific, and is a clinical judgment - not a diagnosis of dementia and not a legal determination. A dementia diagnosis alone does not remove the right to consent or refuse.
Assess the four elements in plain language, with teach-back:
- Understanding - can she restate that the abscessed tooth is infected and that leaving it untreated carries risk?
- Appreciation - does she connect that risk to herself, not just recite it?
- Reasoning - can she compare extracting all teeth versus treating the abscess and keeping some teeth?
- Expression of choice - she has already stated one consistently.
Speak with her alone for part of the visit; family pressure distorts the assessment. Consider a brief cognitive screen and, if findings are borderline, a capacity consultation.
Document verbatim: her statements, the questions asked, her answers, who was present, your conclusion, and your rationale. If she understands and weighs the options, her refusal controls - the son's authority does not override a capable patient. If she cannot weigh the options, the agent decides, but under substituted judgment (what she would have wanted), not what is convenient for the caregiver.
2. If the patient's stated wish conflicts with the agent's request, whose decision governs - and can the full-mouth extractions proceed today in any event?
Read the worked answer
Whose decision: if she has capacity, hers. The agent's authority exists to carry out her wishes, not to replace them, and an agent cannot consent to treatment the capable patient refuses. If she lacks capacity, the agent decides within the standard of substituted judgment, guided by her values and any prior statements; a durable power of attorney for health care does not authorize decisions contrary to the patient's known wishes or to her best interest without justification.
Today's surgery cannot proceed regardless. Two independent constraints:
- Medical: blood pressure 178/96 and daily apixaban. Full-mouth extractions require physician coordination about anticoagulation (do not stop apixaban unilaterally) and pressure control. Same-day full-mouth surgery on a frail elder is not defensible.
- Clinical/ethical: the urgent problem is the abscess, which can be managed with a targeted plan after medical clearance. A staged, conservative plan is both safer and more consistent with her expressed wish.
Process: separate the two conversations; offer a second opinion and a geriatric or ethics consult; involve social work; document the conflict and your reasoning. If the son's pressure on a cognitively impaired patient looks coercive, consider whether a mandated elder abuse report is required - and document that analysis.
3. The son demands copies of her records and threatens to sue. How do you handle the request and what privacy issues arise?
Read the worked answer
Records: a patient, and a personal representative with authority, are entitled to copies. Confirm the scope of the power of attorney, respond promptly, charge only a reasonable copying fee, and never alter the original record - release copies and keep the originals. Log the date, recipient, authority relied on, and what was sent.
The complication: if the patient has capacity and objects to the son receiving her information, her authorization is needed despite the power of attorney. Where the dentist reasonably believes the representative may be the abuser or may endanger the patient, HIPAA permits refusing to treat that person as the personal representative. If facts develop in that direction, deny the release, state the basis in the record, and route requests through counsel or adult protective services.
The threat: a litigation threat does not change the clinical or ethical analysis. Notify your malpractice carrier per policy, do not alter records, do not discuss the case with the son beyond what the release requires, and continue to provide appropriate care and emergency coverage. Retaliation - dismissing the patient abruptly or refusing necessary treatment - creates a separate problem.