The Financial Power of Attorney and the Refused Session
An 84-year-old woman in a New Jersey skilled nursing facility is two weeks post-hip fracture. She has moderate dementia and sometimes refuses morning OT, saying, "I'm tired; leave me alone." Her daughter visits daily and presents a durable power of attorney for finances. The daughter demands that you "make her do therapy" and asks for a complete copy of the record, including nursing notes and a prior psychiatric evaluation. The patient has no health care proxy and no court-appointed guardian. This morning the patient is alert enough to state, "No therapy today." You need to decide who can consent or refuse, whether to override her refusal, and whether to release records to the daughter.
1. Who has authority to consent to or refuse OT for this patient, and does the financial POA change that?
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A durable power of attorney for finances gives the daughter authority over money and property, not health care decisions. It does not make her the patient's health care representative. The patient retains the right to consent to or refuse treatment if she has decision-making capacity for that decision. Capacity is decision-specific: she may be unable to manage finances but still able to understand that OT is for mobility and that she can say no today. If she lacks capacity for the therapy decision, the facility must follow New Jersey law and its policy to identify an authorized surrogate or seek guardianship; a financial POA alone is not enough. You should not treat the daughter's demand as legally controlling. Ask the facility social worker or administrator to clarify the surrogate process, document the patient's statements, and assess her understanding and voluntariness before concluding that refusal is binding.
2. Should you treat the patient over her refusal? What steps and documentation are appropriate?
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You should not physically compel or threaten the patient to force therapy. If she has capacity and refuses, honor the refusal for that session. If her capacity is uncertain, perform a brief bedside assessment: can she state the reason for therapy, the consequences of refusing, and an alternative? Try negotiation, pain management, rest, a later time, or a shorter session. If a lawful surrogate is identified and consents, you still should consider the patient's expressed wishes and minimize distress. Document the refusal, the patient's exact words, your capacity observations, attempts to persuade, notification of the nurse or surrogate, and any safety follow-up such as positioning or fall precautions. If refusal continues and the patient lacks capacity, request an ethics or care-team meeting. The key reasoning is that consent is ongoing and revocable; a signed admission form does not authorize forced treatment.
3. Must you release the complete record to the daughter? What limits apply?
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Not automatically. The daughter's financial POA does not make her the patient's personal representative for all health information. If the patient has capacity, she must authorize the release. If she lacks capacity and the daughter is recognized as the personal representative under applicable law, HIPAA may permit release, but state law and facility policy can impose additional limits, especially for psychiatric or mental-health records. The facility should verify the daughter's legal authority and the scope of the request. A complete record request including a prior psychiatric evaluation should be reviewed by the privacy officer or legal counsel. Release only the records authorized, use the facility's authorization form where required, and document the basis for disclosure. Do not release information simply because the daughter is family or because she is paying the bills. If the request is denied, explain the process for obtaining authority or a court order.