Bitcoin Healthcare Directive Access
Healthcare Directives and Bitcoin Access Gaps
This memo is published by CustodyStress, an independent Bitcoin custody stress test that produces reference documents for individuals, families, and professionals.
What Healthcare Directives Do
Healthcare directives address medical decisions during incapacity. Holders who have completed healthcare planning may assume their bitcoin is covered during incapacity, but bitcoin healthcare directive access does not work the way some expect. Healthcare directives typically grant authority over medical treatment, not financial assets. The gap between healthcare planning and asset management leaves bitcoin unaddressed by documents focused on medical decisions.
Incapacity affects both medical needs and financial affairs. Different documents address different domains. Confusing what each document covers creates planning gaps that become apparent only when incapacity occurs—exactly when clarification is impossible.
What Healthcare Directives Do
Healthcare directives—sometimes called living wills, advance directives, or medical powers of attorney—specify preferences for medical treatment and designate who can make healthcare decisions if the person cannot make them themselves.
Treatment preferences address medical interventions. Do you want life support? Under what circumstances? What procedures do you consent to or refuse? These preferences guide medical providers when the patient cannot communicate directly.
Healthcare agents receive authority to make medical decisions. The designated agent can consent to or refuse treatment, access medical records, and communicate with healthcare providers on behalf of the incapacitated person. This authority is specific to healthcare matters.
Facility and provider recognition follows from the document's healthcare focus. Hospitals and doctors recognize healthcare directives because they address the hospital's domain—medical treatment. The document speaks to decisions these institutions need to make.
What Healthcare Directives Do Not Do
Healthcare directives do not grant authority over financial matters. Managing bank accounts, accessing investments, paying bills, or handling cryptocurrency falls outside the scope of documents designed for medical decisions.
The healthcare agent has no authority over assets by virtue of that role alone. Being empowered to make medical decisions does not empower the same person to make financial decisions. These are separate grants of authority requiring separate documents.
Bitcoin sits entirely outside healthcare directive scope. No provision of a standard healthcare directive addresses cryptocurrency. Even broadly drafted directives that cover "all healthcare decisions" do not cover asset management—because asset management is not a healthcare decision.
Assuming coverage creates dangerous gaps. Someone who believes their healthcare directive handles incapacity generally may not realize they need separate financial planning. This assumption leaves bitcoin unmanaged during incapacity because no one has authority to manage it.
The Incapacity Gap
When someone becomes incapacitated, their bitcoin needs may not pause. Bills may need paying. Security may need maintaining. Market conditions may warrant action. But without proper authority, no one can act—regardless of how urgent the need.
Healthcare directives activate for medical decisions. Someone in a coma has a healthcare agent making treatment decisions. That same person's bitcoin sits untouched because the healthcare agent has no authority over it. Medical needs receive attention while financial needs do not.
Duration compounds the problem. Brief incapacity may not create urgent financial needs. Extended incapacity—lasting months or years—leaves bitcoin unmanaged for the entire period. Security practices lapse. Opportunities pass. Problems accumulate. The gap persists as long as incapacity persists.
Recovery does not undo the gap's effects. When the person recovers, they may find their bitcoin situation has deteriorated. Neglected security, missed actions, or accumulated problems during incapacity may have caused damage that recovery cannot reverse.
Documents That Do Address Financial Incapacity
Financial powers of attorney grant authority over assets during incapacity. Unlike healthcare directives, financial POAs address money, investments, and property. A properly drafted financial POA may cover bitcoin—though coverage depends on the document's language.
Durable provisions ensure the POA survives incapacity. A non-durable POA terminates when the principal becomes incapacitated—exactly when it is most needed. Durable POAs explicitly continue despite incapacity, providing the continuity that incapacity planning requires.
Digital asset provisions may clarify cryptocurrency coverage. Standard financial POA language may or may not clearly include bitcoin. Specific provisions addressing digital assets or cryptocurrency remove ambiguity about whether the agent can manage bitcoin.
Trusts with incapacity provisions offer another mechanism. A revocable trust that names successor trustees upon incapacity can provide continuous bitcoin management without court involvement. The trustee manages trust assets—including bitcoin—when the grantor cannot.
Common Assumption Errors
Several assumptions lead people to believe their healthcare directive covers bitcoin when it does not. These errors stem from reasonable but incorrect inferences about how legal documents work.
Assuming "incapacity planning" is a single thing leads to confusion. People who have "done their incapacity planning" by completing a healthcare directive may believe they have addressed incapacity comprehensively. Healthcare and financial incapacity are separate planning domains that require separate documents.
Assuming the healthcare agent handles everything follows naturally from naming that person for medical decisions. If they make medical decisions, why not financial ones too? Because the document that grants medical authority does not grant financial authority. The same person could hold both roles—but only if appointed separately in both documents.
Assuming family can step in without documents reflects a belief that family automatically has authority. In reality, family members have no legal authority over an incapacitated person's assets without court appointment or prior delegation. Being a spouse or child grants no automatic access to the incapacitated person's bitcoin.
The Self-Custody Complication
Self-custody bitcoin has no institution to approach for access. Even with proper financial authority, acting on that authority requires practical access to keys. The gap between healthcare and financial planning combines with the gap between legal authority and technical access.
Banks respond to proper documentation. Present a financial POA to a bank, and the bank can verify it and grant account access. Self-custody bitcoin has no bank to verify documents. The POA grants authority; it does not grant access. These are separate problems.
Healthcare crisis scenarios may destroy access. If the holder is suddenly incapacitated—accident, stroke, medical emergency—they cannot communicate custody information. The seed phrase location, the PIN, the passphrase—this information may exist only in the holder's now-inaccessible mind.
Combining access gaps with authority gaps creates compounded vulnerability. The person at the hospital bedside may lack authority to manage bitcoin (no financial POA), practical access to bitcoin (no custody information), and any way to remedy either gap (the holder cannot help). Every layer fails simultaneously.
Healthcare Directive as Trigger
Although healthcare directives do not grant financial authority, incapacity determinations made in healthcare contexts may trigger other documents. The connection is indirect but relevant.
Springing financial POAs activate upon incapacity. The trigger event may be defined as a medical determination—physician certification that the person lacks capacity. The healthcare determination enables the financial document, even though the healthcare directive itself grants no financial authority.
Trust incapacity provisions may use similar triggers. When the grantor becomes incapacitated as determined medically, the successor trustee takes over. The medical finding enables the transition, but the trust—not the healthcare directive—grants the management authority.
Coordination between documents matters. Healthcare determinations that trigger financial documents require those financial documents to exist. The healthcare directive can be perfectly executed; without corresponding financial documents, no financial authority exists to trigger.
Planning Integration
Comprehensive incapacity planning integrates healthcare and financial documents. Each addresses its domain; together they cover the full scope of incapacity needs. For bitcoin holders, integration must also include technical access provisions.
Naming the same person for both roles simplifies coordination. The healthcare agent and financial agent can be the same person, receiving both medical and financial authority. This avoids conflicts between different agents and simplifies communication during crisis.
Different people for different roles may serve specific purposes. Someone trusted for medical decisions may not be trusted for financial decisions, or vice versa. Separating roles allows matching people to their areas of trust and competence. But separation requires coordination between agents during incapacity.
Technical access documentation complements legal documents. Neither healthcare directive nor financial POA provides custody information. Separate documentation—seed phrase locations, recovery instructions, access procedures—must exist alongside legal documents to enable actual bitcoin management.
Summary
Bitcoin healthcare directive access represents a gap that many holders do not realize exists. Healthcare directives address medical decisions, not financial matters. Having completed healthcare planning does not mean bitcoin is covered during incapacity. The healthcare agent has authority over treatment, not assets.
Financial powers of attorney and trusts address asset management during incapacity. These separate documents—not healthcare directives—provide the authority needed for bitcoin management. Even with proper financial authority, self-custody bitcoin requires separate technical access arrangements.
Comprehensive planning integrates healthcare and financial documents while also addressing practical custody access. Assuming healthcare planning covers bitcoin creates a gap that surfaces during incapacity—exactly when the holder cannot clarify or correct the assumption.
System Context
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