Designating Power of Attorney Can Be the First Step Toward Planning End-of-Life Care

Surrogate decision-maker ensures care follows patients' wishes

Only about one-third of American adults have an advance directives (AD), which are helpful if they become seriously ill or unable to make healthcare decisions. Cleveland Clinic wants to change that statistic and recently made increasing the number of its patients with an AD a key performance indicator for the organization in 2018.

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To reach that goal, Cleveland Clinic is encouraging its staff members to start by asking patients if they have a healthcare power of attorney, a document that designates a surrogate decision-maker if the patient cannot make decisions about their healthcare — without such a proxy, state law dictates who makes those determinations.

“Everyone has a right to make their own decisions about the kind of care they want and if they can’t, because they are incapacitated, the power of attorney allows someone of their choosing to speak for them,” says anesthesiologist-intensivist Silvia Perez Protto, MD, MS, who serves as Medical Director of Cleveland Clinic’s End of Life Center.

First step

Stressing the need for a healthcare power of attorney with Cleveland Clinic caregivers is just the first step, Dr. Perez Protto says.  “As we continue forward, this will lay the foundation for us to have a meaningful discussion around goals of care for seriously ill patients and at the end of life.”

“We are using the identification of a surrogate decision maker as a starting point for people to motivate them to think about having an end-of-life conversations with their loved ones about what matters the most for them,” Dr. Perez Protto says.

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Leading by example

Talking to patients about end-of-life care in general is difficult for physicians, Dr. Perez Protto says. “As physicians, we very rarely talk about death and dying. It is common for physicians to feel death as a failure. We always want to save lives.” Physicians also worry that they don’t have time to undertake such a sensitive conversation or that they will increase their patients anxiety about upcoming treatments/diagnoses.

She and her staff are encouraging Cleveland Clinic doctors and other staff to create their own ADs to make the conversation easier and to show their commitment. Only about 7.5 percent of Cleveland Clinic caregivers had ADs in their medical record in 2017.

“We as caregivers need to lead by example, so we are recommending that not only all of our patients have ADs in the medical record, but that all of our caregivers do as well,” Dr. Perez Protto says, “not just so they have the document for if and when they need it, but also so they have a better understanding of how to communicate that recommendation to patients.”

Easing guilt

When family members do not know patients’ end-of-life wishes, they can become unduly burdened by stress and guilt. Dr. Perez Protto recalls that when her own father became ill with cancer, she, her mother and her siblings struggled over whether or not to send him to the hospital one night. Not longer after, he died in the ICU.

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“I was always thinking my father was going to recover so I didn’t have this conversation with him, and he ended up in the ICU and he died in the ICU,” she says. “It would have been better if he had died at home with all of us around him in a less stressful environment. I wish we would have had the conversation with some guidance and known what he wanted.”


To help Cleveland Clinic staff with the AD goal, the End of Life Care Center has compiled a number of resources, in addition to those available by national and state organizations:

  • The Conversation Project, a national website with a goal of making it easier to initiate conversations about dying, and to encourage people to talk now and as often as necessary so that their wishes are known when the time comes.
  • The National Hospice and Palliative Care Organization, provides resources to help people make decisions about end-of-life care and services before a crisis.
  • Ohio Hospice and Palliative Care Organization, Provides information about end-of-life care. Its online Find a Provider search allows the consumer to locate member hospice and palliative care programs for individuals who have advanced illness or have been considered terminally ill by a physician.