Chapter 13
Personality Disorders
Personality Disorders
Characteristics that all people bring to social relationships, for example: shyness, rigidity, obsessiveness, manipulation, suspiciousness, or passive-aggressive
What are personality traits?
pg. 174
Individuals with this type of eating disorder tend to have intense irrational beliefs about their shape and weight. They may engage in self-starvation, express intense fear of gaining weight, and have a disturbance in self-evaluation of weight and its importance.
What is anorexia nervosa? pgs. 191-192
Anorexia can compromise muscle wasting, heart and brain damage, and multiorgan failure
Anorexia has the highest mortality rates of any psychiatric DO
Two subtypes
Individual restricts intake of food
Individual restrict foods but also has periods of binge eating and purging
This neurocognitive disorder is always secondary to another condition: Medications, substance use (either intoxication or withdrawal) or toxin exposure. The elderly are at greatest risk.
What is delirium? pgs. 287-289
Delirium is a transitory condition and is reversed when interventions are timely
If the underlying etiologies are not addressed, dementia, even death may occur
Delirium is one of the most commonly encountered medical conditions seen in medical practice, with the elderly at greatest risk
Often overlooked and misdiagnosed
Associated with increased mortality, falls, functional and cognitive decline, and significant health care costs
3 different types: hyperactive, hypoactive and mixed
Common S/S: Autonomic hyperactivity (increased vital signs),Hypervigilance (constantly alert or scanning room) Labile mood swings, Agitation/anger
This term describes the shifting of a person or population from one institution to another, such as from state hospital to jails, prisons, nursing homes or even the street.
What is Transinstitutionalization? pg. 434
Deinstitutionalization
Moving persons from inpatient psychiatric care, such as a state hospital to the community
Intended to provide care in less restrictive settings and reduce costs for state hospitals
In many cases the new setting is actually more restrictive, and the costs have simply been transferred to another provider
Stressors unique to the older population?
What are pg. 451-452
a decline in physical functioning
Face many losses of friends and loved ones
When facing physical health conditions, it places the person at risk for depression
Patients with Personality disoerders experience neurobiological abnormalities in these areas of the brain.
What are the frontal, temporal and parietal lobes?
pg. 175
May be caused by perinatal injury, encephalitis, trauma, or genetics; unknown if theses are the cause or effect
This eating disorder has multiple related complications related to weight loss, purging/vomiting, laxative misuse, and appetite suppressant abuse which can compromise every organ system of the body.
What is bulima nervosa? pg. 191-192
Untreated bulimia can lead to serious GI problems, electrolyte imbalances and cardiovascular diseases
Individuals with bulimia nervosa engage in repeated episodes of binge eating (consuming large amounts of calories) followed by inappropriate compensatory behaviors such as self-induced vomiting, misuse of laxatives, diuretics, other medications or excessive exercise
Name the memory tool used to screen for risk factors associated with delirium.
What is MINDSPACES? pg. 287
M-Medications
I-Infection
N- number of co-occurring disorders
D-disorders of substance abuse or ETOH use
S-surgery or invasive procedure
P-pain (uncontrolled)
A- Age, young children and older age at most risk, may occur at any age
C- Cognitive impairment- dementia
E- emotional or mental illness (depression, anxiety)
S- Sleep disturbances and altered patterns of sleep
This evidence-based treatment team is an approach to improve symptom management and quality of life while reducing hospitalization for those living with a serious mental illnees (SMI).
What is Assertive Community Treatment (ACT)?
pg. 435
Patients work with an established team of professionals who provide comprehensive services and 24/7 access to a team member
Institute for Healthcare Improvement recommends identifying these the “4 Ms” when caring for elderly.
What are:
Identify what Matters
Consider Mentation and provide appropriate supports
Encourage Mobility within the individual’s limitations
Medication should be optimized to reduce polypharmacy and over-medication
Disturbances in the levels of this neurotransmitter have been linked with irritability, impulsivity, and hypersensitivity.
What is serotonin?
pg. 175
A faulty reward-processing system seems to be an important feature of bulimia and anorexia. As a result, this neurotransmitter appears to be an altered in both disorders.
What is dopamine? pg. 192
Bulimia
weaker than normal response to the dopamine reward system
May report less pleasure when eating “usual” amounts, which may explain the desire to binge eat
Anorexia
Release of dopamine triggers anxiety rather than pleasure
Report that sitting down to a meal makes the feel worried
May be R/T the release of dopamine in the dorsal striatum that triggers anxiety rather than pleasure
The two main brain lesions invloved with dementia.
What are senile plaques and neurofibrillary tangles?
Pg. 294
The main underlying neurobiological mechanisms in AD include amyloid or senile plaque formation, development of intracellular neurofibrillary tangles, synaptic deterioration and neural cell death
The pathogenesis is complex, involves multiple theories of causation and no single theory clarifies the pathology of the disease
This impulse control disorder is characterized by recurrent, unpremeditated episodes of marked verbal or behavioral aggression or rage. The acts are severe enough to hurt people or destroy significant property and occur in otherwise normal individuals.
What is Intermittent explosive disorder?
pg. 437, Table 27.2
The acts are disproportionate to the perceived provocation and can occur in response to ordinarily minor events such as traffic delays. The individual may feel depressed or remorseful afterward and may face recrimination, arrest, civil actions, and loss of relationships and employment as a result of the acts. "Road rage" is sometimes a manifestation of this disorder.
A term that refers to refers to the unnecessary use of simple, childlike phrases, slow speech, high volume, and collective pronouns when communicating with older adults
What is Elderspeak? pg. 453
Refrain from using Elderspeak. The intention behind is to create a sense of caring, however, it can be implied as the older adult is incompetent. Studies have shown that these interactions can be perceived as insults, whether intentional or not, and contribute to poorer health outcomes
Refrain from dismissing the presence of older adults in the room; speak directly to them.
This common defense mechanism is seen with borderline and other personality disorders. Characteristics are a division of beliefs, thoughts and feelings into good/bad or black/white thinking.
What is splitting?
pg. 176
This formal assessment tool can be used to help identify those at risk for developing anorexia nervosa and other eating disorders.
What is the Scoff questionnaire? pg. 193
a standardized screening tool to assess for eating d/os
Answering 2 or more questions may indicate an eating d/o
Sick: Do you make yourself sick or vomit after a meal because you feel uncomfortably full
Control: Do you fear loss of control over what you eat
One stone:Has the patient lost 14lb in a 3-month period? (a stone is a unit of weight in Great Britain)
Fat: Do you believe you are fat even when others tell you that you are too thin
Food: Does food dominate your life?
This theory of dementia involves several different alterations in cholinergic neural transmission that are looked to as the cause of cognitive impairment. Current drug treatments are based upon this hypothesis.
What is cholinergic hypothesis? pg. 294
Beta-amyloid is one of the factors that alters the functioning of cholinergic receptors
Deficits in the expression of nicotinic (nick o tin ic) and muscarinic (mus car in ic) are also implicated in the neurodegeneration and cell death associated with Dementia
This paraphilic disorder derives sexual gratification from having pain and/or humiliation inflicted upon oneself or creating psychological and physical pain in others.
What is sexual masochism and sexual sadism disorders? Pg. 440, Table 27.4
Derives sexual gratification from having pain and/or humiliation inflicted upon oneself (masochism) or creating psychological and physical pain in others (sadism). Masochism can include bondage, verbal abuse, electrical shocks, whipping, being urinated on, or being forced to humiliate oneself. Sadism includes inflicting such acts on a (usually masochistic) partner and often involves dominating one's partner physically and psychologically. The partner may be consenting or nonconsenting.
Pharmacokinetics of any drug change as we age. Due to this, explain how this is dangerous in older adults.
What is as metabolism slows, drugs last longer in the body and thus drug levels build up in the body? Pg. 453
Older people frequently do not drink adequate fluids or move as much
50% of accidental drug-related deaths occur in the adult population.
Factors contributing to medication nonadherence include: complicated small print, hearing and visual impairments, cognitive and memory deficits, child-resistant packaging, and inability to pay for medication
Previous studies have found that anticholinergic activity, which is a side effect of many commonly used drugs, has been linked with reduced brain function, and early death in elderly
Individuals with this Cluster A disorder most closely resemble people with the diagnosis of schizophrenia. They are perceived by others as having strikingly odd thinking and beliefs.Their speech is peculiar.
What is Schizotypal Personality Disorder?
pg. 176
This physical sign associated with low body weight is suggestive of anorexia nervosa. It appears as fine, downy hair on the face and back.
What is Lanuago? pg. 194
Healthcare providers believe lanugo grows when a person doesn't have enough body fat to keep them warm.
Name specific sypmtoms that may occur in the moderate to severe and late alzheimer's disease
What are... pg. 296
Stage 3: Moderate to severe Alzheimer's Disease
The individual is often unable to identify familiar objects or people (severe agnosia)
Repeated instructions and directions are needed, even for the simplest of tasks (advanced apraxia)
Agraphia (inability to read or write) is evident
Stage 4: Late Alzheimer’s Disease
Hyperorality- the need to taste, chew, and put everything in one’s mouth
Blunting of emotions,
Visual agnosia- the loss of ability familiar objects
Hypermetamorphosis- manifested by touching everything in sight
Sexual acts or fantasies that involve deviation from conventional, socially acceptable sexual behavior.
What is paraphilias? pg. 439
They are not DOs; they are on a continuum with normal sexual interests and practices and unless a person experiences distress about the sexual differences, they typically do not merit a need for tx
Difficult to measure due to stigma, potential for embarrassment, and other concerns that cause reluctance to disclose this information
Divergent religious and cultural beliefs have created conflict without society about how to define appropriate sexual behavior (age, to begin sexual relations, whom one should be able to choose as a sexual partner)
Conflict stemming from these beliefs can result in ostracism, hostility and even aggression.
Education, counseling and support are helpful for persons who come to perceive themselves as “perverted” or abnormal as a result of negative societal views and for family members who are hurt or confused
When choosing a drug to treat depression in the older adult, the primary emphasis is placed on the avoidance of side effects rather than on efficacy. Explain the side effects unique to the elderly population.
What are...? pg. 455
Lower doses are initiated, often half of a usual adult dosage, then the medication is advanced gradually “start low, go slow” for the young and the elderly
Pts and caregivers must be aware of the potential side effects of the onset or an increase in suicidal thoughts
The choice of which class of antidepressants for older adults is complex
SSRIs have traditionally been the 1st-line antidepressants for older adults because of their more benign side effects and their lack of toxicity when taken in overdose. SSRIs may also cause an increased risk of fractures as well as increased bleeding
Some studies rate the risk of morbidity with SSRIs as higher than with TCAs, Fractures are twice as common using SSRIs through falls or even minor activity such as walking
TCAs have more cardiac and anticholinergic S/E, as well as interactions with other meds
The risk and benefits, medical profile, and medication list must be assessed carefully in choosing the best antidepressant for a particular pt
Discontinuation symptoms may occur when stopping a medication, may lead to an increase in symptoms such as depressed mood or anxiety, or make a person feel physically ill. Should decrease medication slowly to limit symptoms
An indiviudal with this Cluster B personality disorder has a sense of entitlement and feels little sense of responsiblity for their actions. A diagnosis can only be made in people 18 years of age or older. Often there is an evidence of conduct disorder with an onset before the age of 15 years.
What is Antisocial Personality Disorder?
Pg. 177
This potential deadly complication may develop when the anorexic patient resumes the eating process.
What is the refeeding syndrome? pg. 196
Occurs when starved patients begin to eat and metabolize calories
The body shifts from a catabolic state (a state of breaking down tissues for nutrients) to an anabolic state (a state of rebuilding tissues/growth), causing a shift in fluids and electrolytes
Associated complications of this shift can include heart failure, arrhythmias, respiratory failure, muscle breakdown, and death
Close monitoring while caloric intake is gradually tends to prevent the development of refeeding syndrome
These are the 4 defense behaviors the nurse might notice during a dementia assessment.
What are: Denial, confabulation, preseveration and avoidance of questions. Pg. 298
Hiding symptoms is actually a form of denial, an unconscious protective defense against the terrifying reality of losing one’s place in the world
Family members may also deny that anything is wrong as a defense against the painful awareness that a loved one is deteriorating
This diagnosis inhibits academic achievement at all ages, it is believed to reduce work productivity and increases criminal justice system costs significantly.
What is Adult ADHD? pg. 441
ADHD is believed to be a neurodevelopmental DO with multiple contributing factors, including smaller brain volume, white and gray matter alterations, and alterations in the neurotransmitter, dopamine
During assessment, nurses should observe for disorganization, distractibility, irritability, lability, impulsive comments or actions, difficulty processing information or following instructions, difficulty achieving at the expected level in social, educational and vocational settings and hyperactivity
Substance use can mimic ADHD and should be R/O
Ther most common, most debilitating and most treatable psychiatric disorder in the older adult. Frequently misinterpreted as normal aging,especially if the older adult is experiencing dementia or other physical illnesses
What is depression? Pg. 455
Creates pain, suffering, poor quality of life and spiritual anguish
Can be dangerous due to chronic illness, loneliness and losses
Biggest risk factor for suicide
Frequently misinterpreted as normal aging,especially if the older adult is experiencing dementia or other physical illnesses
Symptoms of depression: such as memory loss, intellectual impairment, asocial behavior, or agitation, may be misinterpreted as dementia or other cognitive DOs
As a result, the older adult may miss out on tx that would improve quality of life
Individuals with this Cluster C personality disorder are inhibited, fearful or reluctant to express disagreement for fear of rejection and loss of support. They have an excessive need to be taken care of shown by clinging or being excessively submissive.
What is dependent personality disorder? pg. 180
High levels of anxiety intensify an inability to complete anything on their own
Risk for anxiety and mood D/Os
Co-occurs with borderline, avoidant and histrionic PDs
Seen in individuals who have a disability that requires them to be dependent on others
Research findings on anorexia nervosa and the nurse patient relationship show patient motivation to treatment adherence is increased by using these communication techniques.
What are when the nursing approach is person centered and when nurses’ attitudes were characterized by presence, genuine commitment and motivation? pg. 197
The effective nurse can be viewed as a companion in the recovery process of the patient
Explain the Four A’s of Cognitive Impairment.
What are... pg. 298
Amnesia or memory impairment: initially the person has difficulty remembering recent events, then gradually, deterioration progresses to include both recent and remote memory
Aphasia or loss of language ability which progresses with the disease. Initially, the person has difficulty finding the correct word, then is reduced to a few words, and finally in the late stages is reduced to babbling or mutism
Apraxia or loss of purposeful movement in the absence of motor or sensory impairment. The person is unable to perform once-familiar and purposeful tasks. Apraxia of gait: the person loses the ability to walk. In apraxia of dressing: the person is unable to put on clothes properly, (may put arms in trousers, or put a jacket on upside down)
Agnosia or the loss of sensory ability to recognize objects. The person may lose the ability to recognize familiar sounds (auditory agnosia) such as the ring of the telephone, a car horn, or the doorbell. Loss of this ability extends to the inability to recognize familiar objects (visual or tactile agnosia) such as a glass, magazine, pencil or toothbrush. Eventually, people are unable to recognize loved ones or even parts of their own bodies.
Name the class of medications that are an established psychopharmacological treatment for ADHD.
What are stimulants? pg. 443
Stimulants are the most widely used medication for ADHD, show a higher degree of efficacy, with 75-90% of patients reporting improvement
Methylphenidate (Concerta, Metadate, Ritalin)
Dextroamphetamine (Dexedrine)
Dextroamphetamine amphetamine (Adderall XR)
Lisdexamfetamine (Vyvanse)
These are high-risk factors that potentially contribute to suicide in the older adult.
What are...? Pg. 458
Widowhood, acute illnessess and intractable pain, status change, chronic illness, family hx of suicide, chronic sleep problems, alcholism, depression and other losses
Losses may be personal , economic, social, or functional. Multiple losses accompany the aging process, increasing stress at a time when the older adult may be the most vulnerable and least able to cope with stress, thus precipitating a depressive state
According to Erik Erikson’s stages of development, the elderly must find meaningful activities in their lives to replace the jobs and success they have lost in order to successfully transition to a fulfilling older life (ego integrity vrs. despair)
An essential element for maintaining a theraputic milieu for patients with personality disorders?
What is for the entire treatment team to act in a consistent and congruent manner? pg. 183
This starts by maintaining effective communication and collaboration with the entire team
What are the 4 broad goals of health teaching and psychoeducation with eating disorders?
What are: Information, Emotional discharge, Support treatment adherence and teach the use of self-help strategies? pg. 197, Table 14.2
What is the single most effective tool in caring for individuals with dementia?
Wht is the nurse’s attitude of unconditional positive regard? pg. 299
Facilitates cooperation with care, reduces catastrophic reactions, and increases family member’s satisfaction with care.
Healthcare staff need to be proactive in minimizing the stressful effects of caregiving by teaching and providing guidelines to caregivers and loved ones
Have a realistic understanding of the disease so that expectations for the individual are realistic
Establish realistic outcomes for the person and recognize when they are achieved. Small achievements can be significant for the impaired individual
Maintain good self-care is critical for nurses and other caregivers
A sleep disorder perceived as excess sleep, either at night and/or falling asleep during the day.
What is hypersomnolence diorder? pg. 444, Table 27.7
Not to be confused with:
Narcolepsy
Sudden, irresistible urges to sleep. One may suddenly fall asleep under any circumstance; some continue autonomic behavior as if in a mental fog. Episodes are not recalled after awakening.
The interaction of drugs and alcohol in the older adult can have these serious consequences.
What are: pg. 459
May prolong, potentiate or accelerate the metabolism of various drugs.
Benzodiazepines or opiate pain medications, in combination with alcohol can be lethal or contribute to suicidal thoughts and completion
Older individuals can expect to reach higher BALs than younger people with an equivalent intake of ETOH. This is due to a decline in lean muscle mass and an increase in fatty tissue that can contribute to increased blood alcohol levels.
Extreme care is required when treating the older alcoholic with medication
Central nervous system toxicity from psychiatric drugs increases with aging
Ingestion of antidepressants or tranquilizers can be particularly harmful because their effect is further potentiated by ETOH, and the hep
A form of psychotherapy that is an evidenced-based type of cognitive behavior therapy. This therapy helps to change the self-destructive behaviors associated with a diagnosis of boderline personality disorder.
What is dialectical behavior therapy (DBT)?
pg. 184
What is the name of the SSRI has been used to treat anorexia nervosa, and FDA approved for bulimia nervosa and binge-eating disorder.
What is fluoxetine (prozac)? pg. 199, 201, and 202.
Pharmacological Tx
Binge-eating Disorder: pg. 202
Medications should not be offered as the sole tx for binge eating D/O
SSRIs may help reduce the symptoms of binge eating and can improve mood in pts who have binge eating D/O who are also struggling with depression or anxiety
Fluoxetine is FDA approved for this d/o
Dexamfetamine (Vyvanse) FDA stimulant approved for moderate to severe binge eating D/O in adults
Topiramate (Topamax) used to treat obsessive and compulsive behaviors associated with d/o
Dasotraline (dopamine and norepinephrine reuptake inhibitor) shows promising tx
Bulimia Nervosa pg. 201
Fluoxetine (Prozac) is FDA approved for the tx of Bulimia Nervosa
Binge-eating and purging behaviors are noted to be significantly decreased with this medication
SSRIs have an increase risk for suicide
Other antidepressants may be helpful
Mood-stabilizing drugs like, topiramate may help people with BN to suppress the urge to binge and reduce the preoccupation with eating and weight
Medication in conjunction with therapy tends to be the most successful strategy
Anorexia: pg. 199
Fluoxetine (Prozac) (SSRI)
Sometimes prescribed for Anorexia Nervosa when weight has been stabilized to treat depression and obsessive-compulsive symptoms
Little evidence that it treats symptoms of Anorexia Nervosa directly however it helps with associated symptoms or comorbid mental health issues
SSRIs increase the risk of suicide
Olanzapine (Zyprexa), atypical antipsychotic
Found to be helpful with weight gain and to change obsessive thinking
There are safety concerns with this class of drugs R/T cardiac complications
Explain appropriate communication strategies for those patients with dementia having difficulty expressing themselves.
What are validation therapy, reality orientation and reminiscense therapy. pgs. 299-300
Appropriate communication helps to maintain a person’s self-esteem and ability to participate in care
People with dementia often find it difficult to express themselves: have difficulty finding the right words, use words repeatedly, invent new words (neologisms), lose their train of thought, rely on nonverbal gestures, to be able to communicate basic needs in an understandable way
Validation therapy is a type of therapeutic communication that places more emphasis on emotional aspects and less on factual content. This imparts respect to the individual and their feelings and beliefs. It can be used by family and nurses
Reality Orientation focuses on concrete facts: such as the date, and using the person’s name frequently, however it is not useful to remind the person of sad events
Reminiscence Therapy involves the discussion of past activities, events and experiences with another person or group of people. Although research indicates little or no effect on cognition, it may have some small effect on quality of life and possibly mood
The structure(s) in the brain believed to be the primary regulator of sleep cycles, affecting sleep cycles by stimulating the pineal gland to release melatonin
What are the suprachiasmatic nucleus in the hypothalamus? pg. 444
The suprachiasmatic nucleus in the hypothalamus is believed to be the primary regulator of sleep cycles, affecting sleep cycles by stimulating the pineal gland to release melatonin
The neurotransmitters, serotonin and norepinephrine play a role in promoting sleep, whereas dopamine affects wakefulness
Among the most important of many legal and ethical issues for practicing nurses to be familiar with.
What are: pg. 459
Use of restraints
Decision making about health care
Elder abuse (a serious problem for the older adult)
End of life care
An important pharmacological consideration when treating patients with boderline personality disorders?
What is potential for self-harm, therefore medications with low toxicity are preferred for individuals with boderline personality disorders?
pg. 184
Patients diagnoised with BPD may becomes psychotic, under distress, a 2nd gen antipsychotic may be used to control high levels of anxiety
SSRI’s to tx depression (panic attacks in BPD) and SNRI, Venlafaxine (Effexor) - least toxic in the event of OD. SSRI can also help BPD patients who have co-occurring panic disorders
Carbamazepine (Tegretol) targets impulsivity, uncontrolled behaviors, and self-harm
Mood stabilizers can be helpful for mood dysregulation
Name the focus of care for all eating disorders.
What are... pg. (throughout the chapter)
Refraining from suicidal behaviors or self-harm
Stabilize acute medical symptoms
Restore the patient’s nutritional state
For anorexia nervosa this means restoring weight within normal range.
For bulimia this means ensuring a balanced metabolic state.
Modify the patient’s distorted eating behaviors.
Help change distorted and erroneous beliefs about weight and body image.
Name the class of medications approved by the FDA for Alzheimer's Disease.
What are the FDA-approved cholinesterase inhibitors: these medications demonstrate a mild positive effect on cognition, behavior, and ability to function in ADLs for people with mild to moderate AD. These medications are effective in slowing down the progression. There is no cure for AD. pg. 304-307, Table 18.11 (pg. 307)
Galantamine hydrobromide (Razadyne)
Rivastigmine tartrate (Exelon)
Donepezil hydrochloride (Aricept)
These medications are effective in slowing down the progression of AD for a limited period, 3-6 months only
Memantine hydrochloride (Namenda) works by regulating glutamate and inhibiting the toxic effects of the excess influx of calcium that causes neurodegeneration. It targets symptoms of AD during the moderate to severe stages of the DO. The benefits are time-limited and minimal.
Namzaric is composed of both donepezil and memantine. It is targeted to treat moderate to severe AD
These types drugs are used for sleeping disorders due to their quick reaction time, thus reducing awakenings, increasing total sleep time and are well tolerated.
What are sedative-hypnotic drugs? Pg 445
There are 3 benzodiazepine-like drugs that are frequently used for insomnia:
Zolpidem (Ambien)
Ezopiclone (Lunesta)
Zaleplon (Sonata)
(Suvorexant (Belsomra) a novel selective dual-orexin-receptor antagonist)
These drugs are used due to their quick reaction time, thus reducing awakenings, increasing total sleep time and are well tolerated
These medications can cause grogginess, impaired coordination and reflexes, dizziness and increased fall risk in susceptible persons
Pts should be educated to use these with caution; some are addictive, and tolerance can develop, they are encouraged to use on a short-term basis
Benzos increase the risk for dementia
A sleep aid not approved by the US Food and Drug Administration (FDA) and available OTC that may be helpful to some is melatonin
It appears safe for short-term use, however long-term safety has not been confirmed
In 1990, Congress passed this act requiring that health care facilities provide clear, written information to every patient regarding their legal right to make health care decisions, including the right to accept or refuse treatment.
What is the Self-Determination Act (PSDA)?
Pg. 460
Establishes the right of a person to provide written tx directions for clinicians in the event of a serious illness
Living Will
A personal statement of how and where one wishes to die
Can be changed at any time, by the individual
Directive to Physician
A physician is appointed by the individual to serve as a proxy
Durable Power of Attorney for Health Care
A person is appointed to act as the pt’s agent