Healthcare Proxies in Nursing Homes

A healthcare proxy is someone you legally authorize to make medical decisions for you if you become unable to communicate your wishes. This might happen due to unconsciousness, advanced dementia, stroke, or any condition that affects your decision-making capacity.

A healthcare proxy differs from a power of attorney in a critical way. Power of attorney gives someone authority over financial and legal matters—managing bank accounts, paying bills, signing contracts. A healthcare proxy deals exclusively with medical decisions: which treatments to pursue, which to refuse, whether to try surgery, when to transition to comfort care.

Think of them as two separate roles for two different domains. You might name your spouse as financial power of attorney and your adult daughter as healthcare proxy, or you might choose the same person for both roles. The important thing is understanding that healthcare proxy authority stops at the hospital or nursing home room door—it does not extend to your finances or legal affairs.

Most states allow you to name virtually any competent adult as your healthcare proxy. This could be a family member, a close friend, a clergy member, or anyone you trust to understand your values and advocate for your wishes.

However, there are limits. In many states, you cannot name your doctor, a nurse, or staff member of the facility where you receive care as your proxy—this prevents conflicts of interest. Some states also prohibit naming an owner or administrator of a nursing home or assisted living facility.

Many people name a spouse or adult child. Others choose a sibling they are particularly close to. Some name a trusted friend, especially if family relationships are strained or geographically distant. The key question is: Who knows me well enough to make decisions aligned with my values, even in situations I never specifically discussed?

The process varies by state, but most states use a standard healthcare proxy form or health care power of attorney document. You can typically find these forms through your state's health department, the National Hospice and Palliative Care Organization, or your doctor's office.

The general steps are straightforward:

• Complete the form clearly, naming your chosen proxy and usually one or two alternate proxies in case your first choice is unavailable
• Sign the document, usually in front of witnesses (typically two adult witnesses who are not relatives and not named as proxies)
• Some states require notarization; others do not
• Keep copies at home, give one to your healthcare proxy, give one to your doctor, and bring one to the nursing home when you admit

Do not just fill out a form and store it in a drawer. The document only works if people know it exists. Tell your healthcare proxy they have been named—do not surprise them with the responsibility. Give your doctor a copy so it appears in your medical record. When you enter a nursing home, specifically mention during intake that you have a healthcare proxy and provide a copy.

Your healthcare proxy can make virtually any medical decision you could make yourself, provided you lack decision-making capacity. This includes:

• Consenting to surgery, medications, or treatment
• Refusing treatment or stopping treatment
• Making decisions about life support, breathing machines, feeding tubes
• Choosing hospice or palliative care
• Making decisions about organ donation
• Accessing your medical records
• Signing medical documents on your behalf

The proxy's authority is limited by your expressed wishes. If you have an advance directive stating you do not want a feeding tube under any circumstances, your proxy cannot override that. If you have a Do Not Resuscitate (DNR) order, your proxy must respect it.

Proxy authority typically activates only when you lack decision-making capacity—when a doctor determines you cannot understand the medical situation, retain information, reason about it, and communicate your choice. While you are alert and able to make decisions, you remain in control. Your proxy's role is to step in when you cannot.

While healthcare proxies have broad authority, important limits exist. They cannot:

• Override your clearly expressed wishes if you documented them
• Make decisions that contradict your known values and preferences
• Authorize research participation not related to treatment
• In most states, make decisions about psychiatric hospitalization or certain mental health treatments without additional documentation

Facilities also cannot require your proxy to make decisions that violate facility policy regarding futile care. For example, a nursing home cannot demand that your proxy authorize treatment the medical team believes is not medically appropriate. However, if the proxy and medical team genuinely disagree about what is in your best interest, mechanisms exist—sometimes ethics committees—to address the disagreement.

The proxy should also understand they are bound by your values, not their own preferences. If you said, "I never want to be on a ventilator," your proxy must refuse ventilation even if they personally believe you should have a chance. This fiduciary duty—acting as a faithful representative of your values—is central to the proxy role.

Family conflict around healthcare proxy decisions is remarkably common in nursing homes. Your proxy decides to pursue comfort care only, but a sibling wants aggressive treatment. Your proxy authorizes stopping dialysis, but another child disagrees. How does the facility handle this?

First, the nursing home respects the documented proxy, not the disagreeing family members. The proxy has legal authority; other family members do not, regardless of how much they object. The facility should not allow a vocal disagreeing relative to override documented proxy authority.

That said, good practice involves trying to address disagreement before it becomes a crisis. The social worker or care team might convene a family meeting to explain the medical situation and help family members understand why the proxy is making a particular decision. Sometimes information resolves disagreement. Sometimes it does not.

If genuine conflict persists and the proxy's decision seems inconsistent with your documented wishes, a family member can request an ethics committee review or pursue guardianship through the court—but this is time-consuming and emotionally draining. This is why clear advance planning and open family conversation before a crisis occurs prevents much conflict.

If you do not formally appoint a healthcare proxy, most states have a legal "surrogate hierarchy"—a predetermined order of who can make decisions for you. This hierarchy typically looks like this:

• Your spouse (if you have one and are not separated)
• Your adult children
• Your parents
• Your adult siblings
• Your grandchildren
• Your adult nieces or nephews
• Others with a close relationship

The first person in this hierarchy who is available, willing, and able to make decisions becomes your surrogate decision-maker. However, relying on the surrogate hierarchy is risky in a nursing home context. Facilities must spend time identifying the correct person, disputes might arise about who qualifies as "available and willing," and the person assuming the role may not truly understand your values.

Naming a specific healthcare proxy in advance is far clearer. You eliminate confusion and ensure the right person—the person who truly knows you—makes decisions.

If circumstances change—your first choice proxy becomes unreliable, you move to a different state, your relationship with your named proxy deteriorates—you can revoke the old proxy document and create a new one.

Revocation typically requires:

• Signing and dating a written statement that you revoke the prior healthcare proxy
• Notifying relevant parties: your former proxy, your doctor, the nursing home, anyone who has a copy
• Creating a new healthcare proxy document
• Distributing copies of the new document to key places

Do not simply tell people verbally that you changed your mind. Put it in writing and document it. In the nursing home, notify the facility immediately and ensure the new document appears in your medical record.

You can also modify the proxy arrangement by creating a more detailed advance directive that specifies certain limitations or preferences for your proxy to follow—for instance, "My proxy may authorize comfort care only, not aggressive intervention" or "My proxy should prioritize my wish to die at home if possible."

Your healthcare proxy automatically receives certain access under HIPAA (the Health Insurance Portability and Accountability Act) once you lack decision-making capacity. However, some medical teams interpret HIPAA narrowly.

To avoid delays or disputes over whether your proxy can access information, you can execute a separate HIPAA authorization form naming your proxy and granting them access to all your medical information. Many nursing home intake packets include a HIPAA authorization form—fill it out and name your proxy explicitly.

Additionally, some facilities allow you to name emergency contacts who can receive information about your condition (but not make decisions). You might list multiple family members as emergency contacts so everyone stays informed, while your healthcare proxy holds sole decision-making authority. This structure reduces family conflict because people feel informed, even if they do not have authority.