On Death and Dying Well

This is going to be a tough post. I’m going to talk about death and dying. I’m going to tell you some stories of clients and friends who have died recently and what it was like.

In the course of my work, I spend most of my time counseling older folks and their adult children about their options. How to manage their stuff when their health fails. Who will make and what healthcare decisions need to be made.  How will they distribute what’s left of their stuff when they die?

Those discussions often begin when a elderly parent has a medical emergency or takes a precipitous decline. Sometimes the parent or adult child has had the foresight to engage me or another professional before a serious health issue occurs.

One such client, I’ll  call her Lucy, died last week.

Lucy called me up last year and engaged my service a year or so ago. At that time she seemed pretty healthy although she was growing older and frailer. Lucy was an artist. As is sometimes the case, I connected with Lucy in ways I don’t always do with my clients. Some of them I grow quite close to.  I liked and admired Lucy –  I think we were  both immediately comfortable and at ease with each other sitting around her kitchen table in her comfortable old farmhouse surrounded by much of Lucy’s collected treasures.  Lucy has several adult children. She agonized over whom to name as Executor over her relatively modest estate, whom to name as Power of Attorney and whom to make her Healthcare Agent.  We settled all that and a week or so later she dutifully signed, had witnessed and notarized all her documents. That was that!

I ran into Lucy a couple of time over the last year. At an art show. At the SeniorCenter. She had divorced her first husband eons ago and never remarried. She did have a “companion” – he too was growing older and quite frail.  But she took him everywhere and they seemed quite content in their circle of family, friends and community.

A while back – maybe 6 weeks ago or more – a mutual friend of informed me that all was not well. Lucy was sick. They feared it might be cancer. They were doing tests and would know more soon.

In my line of work, this kind of news is pretty common. When you work with older people, they are forever dying on you. It comes with the territory.  So I was not surprised by this news though I was saddened and concerned for Lucy, her friend (who needed her to help with his daily needs) and all of her adult children, grandchildren and even great grandchildren.

I didn’t hear anymore until last week, when one of the sons, one called me to tell me that Lucy was in the hospital. In fact, she was in ICU. And that it “didn’t look good.”  He wanted my help to sort out Power of Attorney issues and might I be available. I told him I could come by the hospital right away and to look for me within the next ½ hour.

ICU Death
This is what dying in ICU might look like

By the time I reached the hospital ICU unit, the representative from Hospice was already there. Lucy and her sons were making plans to transfer her to Hospice House. She would be discharged there the next morning provided all arrangements could be made.

Lucy did not look good. Her breathing was very labored and she was panting a little even. She was on oxygen of course; though she was always a slight little thing, she seemed emaciated and sunken to me. Her skin color and tone was bad.  Her eyes were darting rapidly from side to side and she was clearly very anxious.

The most I could do was reach out and take her hand and say hello. I said, “well, I guess I don’t have to ask you how you are…?”  — that got a wry smile out of her.

The hospice person excused herself and looking at Lucy I could tell she was overwrought and tired. They had come in early that morning by ambulance into  the E.R. and it was now after 5 p.m. After asking her permission to speak to her sons (which she gave) I suggested perhaps she was tired and needed some rest to which she promptly agreed. I asked her if she minded if we went down the hall  –  just the boys and I – to talk for a few minutes. She nodded with relief. Her eyes were drooping already (I presume she was already getting large doses of pain medication).

When I tucked Lucy up in her bed, I noticed she had ink marks on her chest. The kind they use when they do radiation treatments.  She was cold so I pulled the blanket up further and touched her cheek by way of goodbye. I was pretty sure I would not see her again.

I walked with the boys to the “consult” room. They told me that they had been told just today that Lucy had stage 4 lung cancer.  Then they told her there was nothing more they could do.  I told her sons that now was not the time to worry about banks, or bills, or Powers of Attorney or any of that stuff. Now was the time to spend with their mother and each other. And then I left inviting them to let me know how things progressed and to call me if there was anyway I could be of assistance.

Lucy never made it to hospice. She never even made it out of the hospital. She was transferred off the ICU and died a few hours later in a “regular” hospital bed.

For six weeks (at least) Lucy had undergone tests and treatments of all kinds – she had struggled to breathe, had radiation, and all kinds of drugs and chemo for six weeks. Surely the medical community had already diagnosed her with stage 4 lung cancer. Worse, they had to know the treatments and poisons they were pumping into her were all for naught and indeed made what remained of her life more difficult than it had to be. Just organizing alternative care for her companion and getting to and from the dozens of appointments she must have had would have been a serious challenge.

This is not the first case I’ve seen like this. Nor the last.

Earlier this spring, I was called to see a man in UVa Medical Center. He was suffering from advanced  liver cancer. He had been treated, radiated, chemotherapied and was preparing to be discharged home into the care of hospice. He wanted my assistance to write his burial instructions and Will. He was on heavy doses of narcotics. He could not tell me what time of day it was or even if it was night or day (there was a window right behind me. He was in pain. He was bloated and discolored and he could not hold his hand steady enough to write. He died the next day at home before he could finalize any arrangements and before Hospice could even sign him on.

Last year I was called by the administrator of a local Assisted Living to write a Will for a gentleman who was already completely debilitated and near death – blinded from the effects of diabetes and macular degeneration, he was in great pain and suffering from several serious medical conditions. The next day he was transported to Martha Jefferson Hospital where he lapsed into a coma and died of uremia and kidney failure without ever regaining conciousness much less executing a Will.

Three years ago, a dear friend – not a client – at age 80 developed a very aggressive form of lung cancer. When I told my partner, who is an R.N. and hospice case manager, about my friend and told her was called a “Pankose” tumor, she shook her head knowingly said, “six weeks.”  My friend proceeded to deteriorate quickly. Yet the radiologists and oncologists continued to urge her to undergo radiation and if possible, chemo to check the tumor’s growth and “make her more comfortable”. The tumor was inoperable. It was so large and so entwined in the brachial nerves that there was no chance surgeons could safely get at it.  After a few weeks, my friend developed a blood clot in the arm on the same side the tumor was growing. Her arm swelled to the size of an overripe melon. She was in agonizing pain yet the doctors insisted she continue to get up, dressed, climb in the hot car (it was June), travel to Mosby Radiation clinic, undress, climb on the table and lie flat and still on her back for 30 minutes or more. Weeks before she had already developed difficulty lying down at all – even laying propped on a wedge pillow in her own bed caused her pain and made breathing (not to mention sleep) difficult. Lying on a cold metal table staring at a radiation tube for ½ an hour was sheer agony.

I went with her on several of these trips to various doctors and clinics (she had accompanied me months before to MY appointments at UVa’s Cancer Center and visited ME in the hospital following surgery).

About three weeks in, she had just about given up and was asking the doctors about alternatives. Not yet ready to say “hospice” the discussion turned to “palliative” care. That is, treatment to make the patient more comfortable, relieve pain and reduce symptoms. A week later, my friend had just about decided to give up “traditional” cancer treatment (which was having no positive effect in any event) when the radiologist said to her, “Oh I’ve seen patients with this kind of Pankose tumor live for 5 years!”  So my friend struggled back up on the table for her radiation treatment again.

A week later, we were in the hospital with her again. The clot was so painful and the swelling so bad that something else needed to be done. They were giving her difficult to manage injected blood thinners to try to help break-up the clot and prevent any new ones from forming. This treatment seemed to have no beneficial effect.

My friend was discharged home with the plan that radiation would continue along with blood thinners and a pile of other difficult to manage medications  –  the radiation was to help reduce the tumor and hopefully allow the clot to dissolve “over time.”

That week, freak windstorms – micro-bursts-  took out electricity through large swaths of Charlottesville. My friend’s house was one of those without power for over a week in the sweltering heat. She could not be easily moved. By now, she was also on an oxygen tank which thankfully had battery backup power. She was, by now, pretty much confined to bed and couldn’t stay awake long enough to read or watch television anyway so she didn’t care about lights or power. We used damp cloths to keep her cool and pushed water to keep her hydrated and she seemed to be fine with the heat – she was old school and wasn’t crazy about air conditioning she said. She wanted to be in her own home.  Soon, she would need so much pain medication – Oxycodone and Roxynol in combination – that it was difficult to get her bowels to move and she had become impacted, another very uncomfortable situation. She could barely get out of the bed to get on the bedside commode to urinate and then, because she was so unstead,  only with the assistance of two of us. Even with the narcotics she was in excruciating pain and robbed of all dignity. Her hands shook so badly she could not administer her own meds so if no one was there to help, she went without her doses of painkillers. Or spilled most of it on her nightgown and sheets.

Still, the doctors wanted her to continue radiation. Finally, my friend said enough. She agreed to a “Do Not Rescuscitate” order and had the medical team refer her to hospice.

I stayed with her the day the nurse came to admit her to Hospice; she took her medical history and vital signs and explained what could be expected in the days to come.

At the end of that afternoon my friend was exhausted. Physically and emotionally, completely spent. As she sat back she asked me to rub her back which I did. She finally lay down and said, “I can rest now, can’t I?”  I stroked her head and assured her she could.

Corrine died two days later. Almost exactly 6 weeks after my partner predicted she would.

One last story, I’ll cut it short:

A friend from law school developed cancer on his tongue. A young man, with a new wife and young child. He had a growing law practice when his life was cut short. I won’t go into all the details but he tried valiantly to fight it. He lost.  Toward the end, as in the stories above, the oncologists and other traditional medical staff threw every mighty poison and potion they could at the cancer they were fighting.  That’s what we do in America. We fight heroically.  He also went down in immense pain and suffering —half his tongue cut away at first then the remainder of his tongue removed. More surgeries, chemo, radiation. Finally, he died after the excruciating pain as his bones cracked from the metastasizing cancer that grew in them. This is traumatic for friends and family to watch someone they love die this way feeling there is nothing they can do to alleviate their suffering.

We do not allow our dogs and cats to suffer this long and to die this badly.

Am I advocating euthanasia? Not at all. My point is that we have allowed “traditional” medicine to make decisions that do not serve their patients well. In fact, in some cases we have allowed them to conduct torture under license from the Board of Medicine.

Many, maybe most, patients don’t know that they can ask their doctors about alternative treatment plans. Palliative or comfort care. Holistic or natural treatments. Or that they can refuse treatments altogether. Hospice care, which, by the way, doesn’t mean you are actively dying. Hospice can come in  six months in advance. And if you don’t die in six months? Your doctor certifies you for another six months.  Many patients actually IMPROVE on hospice care and a few are actually discharged.

Most patients, by the time they are diagnosed with a fatal illness, are not in any position to absorb most of the very technical jargon and obtuse information that is thrown at them by medical professionals. Many of us simply are in a daze. We nod and go along with the treatment plan they set forth without our really grasping and understanding what the choices are. If any are even discussed.

As a cancer patient myself, I can tell you that ones ability to absorb any kind of information past the word “cancer” is greatly diminished.  I’m sure that the same holds true for those receiving treatment for heart disease, kidney failure, Lou Gehrigs disease or any of the many other things that are ultimately become our “cause of death”. (N.B. I have been cancer free for 3.5 years)

Medical professionals are trained to “cure” – to cut, to prescribe medication or chemo, to radiate, do physical or other therapies – even when it is clear that such treatmenst are without benefit or that their value is outweighed by the suffering and pain they cause. Medical professionals – yes, doctors – as well as pharmacies, ancillary treatment facilities and hospitals – are also billing hundreds of thousands of dollars for every test, image, treatment, lab test, consult, prescription and every follow up visit that goes along with them.

There is much broken with the healthcare system in the United States. But one thing that I see that is consistently broken and badly managed is the way that we die. And those astronomical medical bills? They don’t die with the patient. They go to his or her estate.

Polls consistently show that most people wish to die naturally in their own homes. Yet the vast majority of people in this country end up dying in an Emergency Room. or ICU or CCU with a nurse or resident pounding on their chest and another shoving a respirator tube down their throat, along the way breaking some of their frail and delicate teeth and ribs.  Many of the older people that die this way arrive by ambulance from the nursing home or assisted living where they believed they could pass quietly but that facility does not wish to have another “statistic” on their watch.

This kind of violent, tortuous death is not what I want. Most of the people I counsel do not want that kind of death.

As a patient you have rights. Residents in Assisted Livings and Nursing Facilities have rights. How do you protect them? You can help protect your healthcare decisions and see that your care plan goes as you want it to go only by making sure others know what your wishes are;  that can only be done effectively in writing. Get an Advanced Medical Directive – and if appropriate – have your lawyer include appropriate language to consent to a Do Not Resuscitate order (DNR).  Have a serious, open discussion with the person you appoint as your Healthcare Agent (Medical Power of Attorney). Ask questions of your physician or other providers, get an advocate if you can’t advocate for yourself (and most frail elderly and sick people are not able to do that for themselves)

Talk to your loved ones now – do not wait until a medical emergency is upon you!  You can “die well” – comfortable, free of pain, and with dignity and you can do so in your home, in a nursing facility, in a hospice house or if you prefer, in a hospital.

Don’t wait until you get sick to do this. Do it NOW!

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“Choosing” a Nursing facility- troisième partie

It’s been more than a week, I know. Things got a bit busy and since I am chief cook, bottle washer and everything else around this office, I have to set some priorities. Blogging is way down the list when clients are demanding my attention. Would you want it any other way if you were my client?

Well, let’s return and see how Mom has fared in the nursing home shall we? When I left off in my last post, Mom had just been “de-certified” from Medicare and moved to “unskilled” nursing bed.  She is no longer receiving intensive therapy.

As the days and weeks go by, Mom becomes more depressed and hopeless. She seems dull and lifeless. Even her hair is limp and lifeless. When you visit she is often still in bed even though it’s the middle of the day. She’s not had a bath or brushed her teeth even.  When you visit she is both irritable and angry, or cries and begs you to take her home. Visits become something you dread.  More and more your visits are shorter and farther between.

One night, you get a phone call from the nursing home. Mom has taken a fall and hit her head. They think she’s okay, but it’s the nursing home’s policy that anytime someone falls and no one sees it happen they must automatically transport them to the E.R. to have them checked out.  At the time of the accident, your mother was in pain, confused and panicked. As the EMT’s arrived and tried to put her on a stretcher and into the ambulance, she started to shout and became combatative. In order to safely transport her, the  EMT’s needed to calm her down to prevent her from hurting herself (or them) so she is given a powerful tranquilizer and immobilized onto a stretcher.

Before you are able to arrive at the hospital, Mom is taken for an MRI. She is placed on a moving table and strapped down, then she is  slid into a large cylindrical machine for 45 minutes. The machine makes all manner of very loud clanking, buzzing and ringing sounds while disembodied voices tell her to lie perfectly still. She comes out dazed, completely disoriented and not sure where she is or what is happening.  It’s now 3 a.m. and the doctor decides to keep her “for observation.”  They give her a drug that is meant to help her regain herself, an antipsychotic called Seroquel.  It also acts as a sedative and knocks her out for the night.negative effects antipsychotics

The next morning she awakes and you are at her bedside. She has little or no recollection of what happened or why she is there. The doctor says she may have a concussion and wants to keep her for another day. She complains of pain in her hip and has severe bruising on her face.  The last thing she remembers is at the nursing facility. She recalls ringing the call bell repeatedly for assistance to go to the bathroom. She says that no one ever came and her need became so urgent that she decided to get up herself rather than wet the bed. She thinks she may have had an accident on the floor and may have slipped on the wet floor. She must have fallen then. She recalls nothing else.

Meanwhile, back at the nursing home, the business office tells you that if your mother doesn’t pay for her bed, that is, put  a “bed hold” on it,  they will discharge her. With mother in the hospital again, your boss complaining that you’re taking too much time off, and the kids needing picked up from school,  you can’t worry about this and set that aside so you concentrate on the urgent needs like the kids and mom in the hospital.

As it turns out, Mom has only bruised her hip and does have a concussion but its mild.  However, the neurologist who treated her after the MRI of her head has also diagnosed her with vascular dementia (brought on by mini-strokes) which, while relatively mild now, will get worse over time. She ends up staying one more night in the hospital under observation.

The discharge planner comes around the next morning and starts discussing plans about where to send mom now. Come to find out that her bed at the nursing facility is now gone. Her belongings have been packed up and stored. She was “discharged” from the nursing facility to the hospital.  However, the hospital never “admitted” Mom as an inpatient. She was only there on observation.

While this may seem to be mere bureaucratic technicalities,  they have very significant consequences.

To discharge your mother to a nursing facility now means that she will NOT be eligible for Medicare for any rehab because she did not have the requisite 3 night inpatient stay  she was merely there on observation..  Mother’s resources are nearly tapped out for privately paying for long term care. She has no long term care insurance. No Veterans or other benefits. That leaves very few options. In such cases, the only choice may be to find a “Medicaid” bed.

Medicaid rates (the rate at which Medicaid reimburses a nursing home) are substantially lower than the private pay rates. If a person comes into a nursing facility while eligible for Medicare treatment, the reimbursement rates are higher.  But if a person has fewer resources and will be quickly dependent on Medicaid – public assistance – most nursing homes are reluctant to take them.

Nursing homes typically want to bill every penny they can to Medicare or other 3rd party source (supplemental, long term care insurance etc.) and/or if they can, they want the person to privately pay (out of their own pocket).   These sources are usually quickly depleted by the monthly rates which average about $7,000 a month.

In your mother’s case, she used Medicare in her initial admission following the stroke, thereafter, she paid from her own funds but now that money is almost gone.  Had she stayed where she was, she would simply have depleted her resources and an application for Medicaid would have been filed and she would have stayed right where she was.  But that didn’t happen – instead she was discharged from that nursing facility.

The hospital’s discharge planner begins seeking a facility that will accept a Medicaid resident from the outset – no private pay, no Medicare billing. Almost all nursing homes are “dually certified” – that is, they accept Medicare and Medicaid patients. However, many of them limit the number of beds available to Medicaid patients. There is a therefore a shortage of certified Medicaid beds and the need is great.

But the discharge planner manages to find a bed for your mother after you indicate you can pay their private pay rate for two more months. So off mother goes to a new nursing facility. She is discharged from the hospital (to which she was never actually admitted!)  and transported to the new facility.

Along with the little ditty bag of stuff from the hospital she carries is a discharge order and a list of medications. The med list now includes some things that were not on her regular regimen before. Among them are the antipsychotic medication, Seroquel.  You notice that mom is much more agreeable, calmer and sleeps a lot more.  That seems helpful to you.  What no one notices is that Seroquel – and most of the other medications of this sort – carries a specific “black box” warnings about use in older adults.  The warning reads something like this:

Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. Seroquel is not approved for the treatment of patients with dementia-related psychosis

There are many potential negative side effects listed as well. Among them, are the increased risk for falls.

However, in a nursing home, the drugs are not administered in the same form we get them from retail pharmacies. Nurses never see the box or bottle the drugs come in, or the sheaf of fliers that come with them. Nursing facilities get “bubbled paks” for each patient from their own pharmacy or contracted pharmacy. So they never see the warnings.

The new nursing home is older, the carpet worn and dingy, the furniture nicked and upholstery faded. The walls are painted a dull blue and stained and marked up.  It’s noisy, smelly and the only activity that is available on a regular basis is a big tv blaring very old movies and bingo every afternoon. The hot food is served on ice cold dishes and the cold food —  iceberg lettuce masquerading as salad, jello, sherbet, cottage cheese and the like —  is served on steaming hot dishes. Everything is stewed or looks like its stewed. All of the food is either over-salted or completely tasteless.

Mom is very complacent though. She sleeps a lot but doesn’t complain much. She has a lot pain so whenever she asks for it, they give her a narcotic painkiller for which her attending physician has written a PRN order or “as needed.” She is also labeled “high risk for fall” so she is no longer allowed to stand or try to walk and is restricted to a wheel chair and completely dependant on nurses aids to transfer her from bed to chair or chair to toilet.  Her lack of activity and complacency about the food means she as begun to put on weight. She eats and snacks on sweets at every opportunity. To please her, you bring in more such treats when you visit.

The nursing facility is trying to turn a profit. They are limited by the fact that so many of their residents are Medicaid payors only. So, even more than any other nursing facility, such nursing homes attempt to make money by reducing expenses. The biggest expense is staff. They keep staffing levels so low that only the barest of care is able to be provided.

Lately, your mom has been having “accidents.” You mom is not incontinent. She can control her bladder fine but, because she must wait for aids to assist her to get to the toilet on time, she is wetting herself and the bed. Soon she is labeled “incontinent.”   Rather than get her on the toilet on a regular interval, and unwilling to regularly change her and the bed, the aids now put her in an adult diaper day and night. Your Mom has become very docile and complacent on the drugs therefore they have no sense of urgency to see to her, she rarely rings the call bell anymore and never yells as she used to – she sometimes lays in a wet diaper for hours.

A year has come and gone since Mom first had her stroke. Mother’s Day is coming. You decide it would be a good idea to take Mom out for an outing, have a change of scenery, get some fresh springtime air.  When the appointed Sunday arrives, you stop for some flowers at the grocery store and go to the nursing home early to help get Mom up and dressed.  The aid has arrived to get her out of her diaper while you choose something nice to dress her in. Together, you and the aid turn her to sit her up and put her clothes on and to your horror you see large, gaping, raw sore on her tailbone.  It is the size of coffee coaster, red and angry looking, seeping fluid.

Thanks to the lack of repositioning or movement, the constant weight on her backside, the skin breakdown from the urine and lack of cleaning or moisturizing of the skin, your mother has a giant bedsore.

This is completely preventable. Bedsores,(also called “pressure ulcers”) except in very limited circumstances, can be avoided by good skin care, repositioning and constant attention and inspection. Mom obviously has received none of this.

You race down to the nurses’ station and demand to speak to the unit manager. You raise holy hell. The Unit Manager, while sympathetic, is distracted by 3 phones ringing and several call bells going off, nods, says they’ll look into it and blows you off.

Monday morning, you call the director of nursing for an explanation. You leave three messages; all go unanswered.  You call Mom’s attending physician’s office. They tell you they will send out the nurse practitioner to have a look and will call you back.

What are you to do now?

 

Tune in for Part IV!  In which we explore the resources available to help you advocate for Mom.

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“Choosing” a Nursing Facility Part Le Deux: They tried to make me go to rehab but I said ‘no, no, no’

Patient wearing respirator
How we left mom at the nursing home last week….

Last week, I wrote about how it is that we really have very little to say in the matter when the decisions are made about taking our aging loved one to a nursing or rehabilitation center when they have a serious health issue arise.

In fact, there’s plenty we can say and do, it’s really about knowing in advance that you have plenty of choices, that you could and should ask many questions and offer input into the healthcare decisions of your loved one. Unfortunately for most of us, these decisions are made when both our loved one and we, as caregivers and family members, are completely depleted – physically, mentally and emotionally.

At the conclusion of the last segment, we had arrived at the “Health & RehabilitationCenter” and Mom had been admitted.  Let’s revisit the “Rehab” and see how Mom’s getting along shall we?

So let’s say, a week has passed. In that time, the staff of the nursing home – nurses, social workers, recreation/activities, physical, occupation and speech/language therapists, (pt, ot, slt) nutritionist or dietary and so on – have all had a chance to do their part on a “baseline” assessment which is done for each and every patient who goes to a Medicare/Medicaid qualified nursing facility (that would be most, not all, there are a very few exceptions). This is called the “MDS” assessment or “Minimum Data Set.”  Medicare and Medicaid keep careful track of every patient and it is from these assessments that

a)      Billing is done for Medicaid

b)      “Quality Measures” are assessed by Medicare.

The first is pretty obvious – Medicaid pays for certain things at certain rates and MDS codes tell them what to reimburse.

The second might seem a bit more mysterious until you understand that nursing home staff are required to continuously update their assessments so that changes are documented for every resident at regular intervals. For instance, if a patient arrives and on their initial MDS assessment, they report no pressure ulcers (bed sores) and 90 days later, the same resident now has bed sores, there has been an decline in the quality of care.  If patients report chronic pain and classify it as a “number 2” on a scale of 1-10, but it gets worse, say the patient later takes a stronger painkiller and self-reports his pain is now a “5” – that too is reported. Things like Urinary Tract Infections (UTI), occurrences of Depression and other things are also carefully monitored. This set of statistics forms a picture of the “quality” of the care patients are receiving at any given facility.

This information is also readily available, to the public, online – for free! You can access it by using the 5-Star Quality Rating System provided by the Center for Medicare/caid Services (CMS).  There’s a very readable set of documentation available on what it is and how best to use the system (click on the link). You can search for data on a particular facility or compare several facilities at the Five Star Rating System. (click on the link). You can also see reports on staffing levels and recent inspection reports (“surveys” in nursing care parlance) including the actual reports of problems as cited by the surveyors.

So your Mom has now been “MDS” assessed and from that a “Care Plan” has been designed in conjunction with her care team.  First up at bat are likely to be the PT/OT/ST team who will try to get Mom into as much therapy as possible. She will have been assessed and orders written by her physician to try to get Mom to the “least restrictive alternative” for her care – that means discharged home, discharged to another facility such as an Assisted Living or to a “unskilled” nursing facility.

Lets say Mom has had a stroke and is “hemispherically” (one side, lets say left) impaired. She has trouble walking, talking, seeing, swallowing and doing most everything that engages her motor system on the left side. She also suffers from some “aphasia”  – that’s a condition where, due to the damage caused by a stroke (in this case) the person  may make mistakes in the words they use, or perhaps using the wrong sounds in a word, choosing the wrong word altogether, or putting words together incorrectly. Its a problem not of motor skill, but of the brain’s ability to handle language and communication. Your mom’s case is not bad and the SLT thinks they can correct it with some intensive therapy.

So your mother’s days are full up with intensive therapy to help her physically – to strengthen the weakened and impaired left side, and to work on balance; in Occupational Therapy – to help her figure out new ways to do tasks that she used to do without a thought: putting on her socks & shoes, getting things down from the pantry shelf, dressing, bathing and getting on and off the toilet by herself. Then hours of very intensive therapy to improve her swallowing and language. At the end of each day she is exhausted and discouraged. When you come to visit at dinner time she is depressed and irritable. She hates the semi-liquid food she’s given because of her impared with swallowing. Her roommate (she can’t afford the upcharges for a private room) watches TV all day and all night at full volume and with the lights on. When she finally does fall asleep, she is awakened by the constant noise from the nurses station down the hall or someone coming to draw blood or check on her roommate. You try to cheer her up by reminding her “its only temporary Mom, you’ll be going home soon.”

Nursing home mom
Mom’s a bit irritable, hopeless and depessed now.

Won’t she?

Well she has 100 day right? That’s what the hospital caseworker said, “Medicare will pay for Rehab for up to 100 days.”  Yes, that’s what they said. Note that it is “up to” 100 days. And she didn’t say that Medicare would pay for ALL the charges. Indeed, right around day 20 you will start hearing the Administration of the facility start making noises about “discharge planning.”  What?  Mom is ready to come home?  Well, not exactly. They don’t necessarily mean discharging Mom home. They mean discharge from therapy, or more accurately, discharge from “Skilled Nursing.”  Again you say, “what?!”

There’s a fly in the Medicare ointment. And it has little to do with your mom.  It has to do with Medicare’s reimbursement schedule. What they actually pay – at 100% reimbursement – is the first 20 days  of rehab. After days 1-20, you pay a co-pay (depending on whether you have traditional Medicare, or an Advantage plan – all of these are moving targets, but basically it comes out in the end).  On days 21-100 you’ll pay $144.50 “co-pay” each day and Medicare picks up the rest.

(By the way, if you find yourself in the hospital in advance of such a situation, one critical question to ask is if you’ve been “admitted” to the hospital as an inpatient. Well of course you were admitted! You were there for 4 days!  Except, today, hospitals routinely bring patients in on “observation” and in fact, unbeknownst to most,  they are not admitted as inpatients.  To go from a hospital to a skilled nursing, or rehab facility and have Medicare pay for it, you must have been admitted for a three inpatient day stay, not including the day you leave. What if you were on ‘observation’ on day one, stayed two more days as an inpatient and left on the fourth? No, Medicare won’t pay for your rehab because you only had a two day inpatient hospital stay. Sneaky huh?)

Most nursing facilities know perfectly well that most of us can’t afford to self pay from our own pockets for rehab. So, ready or not, they’ll begin making noises about “de-certifying” Mom from rehab because they don’t believe she can pay. Will they ask you about it? No. If there’s no second payor insurance (e.g. a private or supplemental policy that picks up where Medicare leaves off) they will start making noises such as, “your mom is no longer getting better” or “your mom doesn’t seem to be motivated in her therapy anymore” and the next thing you know you’re either frantically making plans to put mom elsewhere – your house, an assisted living, home with a home health agency coming in – or heaving a huge sigh of relief when the social worker at the “Health and Rehab” Facility offers you the option of simply moving mom to an “unskilled bed.”  There she’ll be taken care just as she has been all along (for better or worse!) but without all the pressures to participate in therapy to get her back on her feet. Indeed – she might be very hard pressed to get any therapy at all. Often we hear about “restorative therapy” that is meant to keep residents from losing whatever physical gains they’ve made. (notice they are now “residents,” no longer “patients”). Generally, that will consist of a Certified Nursing Assistant (CNA) walking with a resident and perhaps doing some mobility work with them (manipulating arms in legs in bed or shower).

Mom has now gone from a temporary “Health and Rehabilitation” patient, to a full-time, long term care resident.  And if you think she was unhappy before, wait until you see what starts happening next!

Tune in next week, same time, same place….. for Part III – “Choosing” a Nursing Home

 

 

 

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Cash Assistance for Veterans – Help Offset the Cost of Long Term Care

Lately there’s lots of “advisors” out there talking about Veterans Benefits. Many are also hawking annuities and “planning services” (creating trusts etc.) to make Veterans Eligible for these benefits. Meh!

Veteran
This guy deserves some long term care from the country he served!

The VA Enhanced Pension – often erroneously referred to as “Aid & Attendance Benefits” is meant for certain Wartime Vets who are in need of cash assistance. It is not meant for people wanting to leave all of their accumulated wealth to the next generation. In that way, it is like Medicaid — a program designed for citizens in need of assistance as they age.Unfortunately, many of the “planners” (largely insurance salespeople, financial advisors, and yes, lawyers) don’t really have any idea what they are doing with regard to these vulnerable elders and their need for assistance in paying for Long Term Care (whether at home, in nursing facilities or assisted living).  Or maybe they do and just don’t care? By “planning” for VA benefits (divesting the senior of assets to make them eligible for benefits) they inadvertently may cause the Vet or his widow to become ineligible for other benefits – particularly Medicaid.

If you, or someone you know is a Vet (our surviving spouse of a Vet!) and you believe s/he might be qualified for Pension and Enhanced Pension benefits, you might want to talk to a qualified advisor. And to be honest, it is difficult to tell who actually is qualified. (I am certified to practice before the VA and any lawyer that is offering to do VA Benefits work that is not, probably is not a good choice – I can’t speak for the other professions) The Dept. of Veterans’ Affairs allows you to search their list of qualified representives here: http://www.va.gov/ogc/apps/accreditation/index.asp – but you do not need to have a lawyer or representative to apply. But I will warn you that it can be a long and complicated process.

If you’re a Vet and have no idea what I’m talking about, but want to know more, see if you can fit into the guidelines below then give me a call. I can help.

General Guidelines to Qualifications for Veterans Affairs Enhanced Pension

 SERVICE ELIGIBILITY REQUIREMENTS

Served at least ninety (90) days active duty

At least one day served during a qualified wartime period:

  • WW2 12/7/41 through      12/31/46
  • Korea 6/27-1950 through 1/31/1955
  • Vietnam: if served inside Republic      of Vietnam,      2/28/1961 through 5/7/1975, if elsewhere then 8/5/1964 through 5/7/1975
  • Gulf War: 8/2/1990      through some future date TBD.

Any discharge not categorized as dishonorable;

 FINANCIAL ELIGIBILITY REQUIREMENTS

Assets owned by claimant must be limited. Amount claimant may hold depends on age and health of claimant. No “hard & fast” rule on maximum assets although generally if they exceed $50,000 readjustment of claimants holdings may be necessary. WARNING: do not give away or divest of assets without consulting a professional planner familiar with both VA Benefits and Medicaid. Planning for one set of benefits may result in disqualifying claimant for the other!

Assets that are NOT counted: Primary residence, car, personal effects.

Income: gross income evaluated after reduction by total out-of-pocket annual medical expenses (including pharmacy, Medicare/insurance premiums and typically, the entire cost of Assisted Living is deemed “medical expense”)

 THE VA PAYMENT RATES:

Basic Pension for those over 65 and meet above criteria –  pays the difference between countable family income and the yearly income limit (see chart below). This difference is generally paid in 12 equal monthly payments rounded down to the nearest dollar.

 Example:

Tom is single and has no dependents. He has an annual income of $5,000 from his union pension. His annual income limit is $12,465. To determine Tom’s V.A. Pension subtract his annual income of $5000 from the $12,465 income limit . This comes to an annual V.A. pension rate of $7465. This translates into a monthly VA pension check of approximately $622.

If the claimant is housebound, the amount increases as does the income allowed. Likewise if the claimant requires “aid & attendance” (with activities of daily living such as dressing, bathing, eating, toileting) – the amounts increase. In the case of Aid & Attendance, a doctor’s statement will be required.

 

FAMILY SITUATION (2013 Rates) INCOME LIMIT MAX BENEFIT (MONTHLY)
Veteran, no dependents $12,465 $1,038
Veteran, one dependent $16,324 $1,360
Veteran, no dependent & housebound $15,233 $1,268
Veteran, one dependent & housebound $19,093 $1,591
Veteran, no dependent, and Aid & Attendance $20,795 $1,732
Veteran, one dependent, and Aid & Attendance $24,652 $2,054
Each additional child $2,093 $174
Widow, no dependent $8,359 $696
Widow, no dependent and housebound $10,217 $851
Widow, no dependent and Aid & Attendance $13,362 $1,113
Surviving child $2,129 $177
Veteran married to Veteran, Both Aid &   Attendance $32,100 $2,675

 

 

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Senior Citizens and — Sex?

seniors sex
No dysfunction here!

Yep. Old people gettin’ it on.

For all the ads for Viagra or Cyalis or other drugs to help men with “Sexual Dysfunction” there seems to be no shortage of older folks have no trouble whatsoever doin’ it.

For folks that work in nursing and assisted living facilities one of the most unsettling issues they have to deal with is intimate relations between residents.

It’s true that in some older folks, either desire or function has diminished. In some cases its a health issue. In others the side effect of some drug.  But for many older folks – even VERY old folks – sexual function is still alive and well.

While some are actively engaged in sexual relations, others are just looking for a intimate connection and that often includes close physical contact.

One major problem in long term care facilities is a lack of privacy. Most nursing facilities only offer “semi-private” rooms as their standard accomodation; that means two perfect strangers of the same gender sharing a very small space and a bathroom. Its hard enough to agree when lights are on or off, how the TV volume is managed, who has how much storage space. Imagine having to hang a sock on the doorknob to advertise you’re needing some privacy with your loved one when you’re in your 70’s?

Under such conditions its impossible to have a close, personal relationship with someone which may or may not include sex.  But residents and their family’s should know that thanks to the 1987 Nursing Home Reform Act, they DO have rights, explicit rights to privacy for instance, and they should be respected.  You can read more about “Residents Rights” here

Another problem is the moral or religious values of caregivers — nurses, social workers or aides who frown on consensual sex relations between adults and actively work to prevent it.  The imposition of one’s cultural, moral or social beliefs on another is also wrong. The  freedoms and rights surrounding beliefs and mores of senior citizens are to be as respected INSIDE a nursing facility as they are in the halls of the Supreme Court.

More recently, a seemingly new social problem has arisen. In 1969 the “Stonewall Generation” kicked off the creation of a new, “out and proud” gay and lesbian community. These folks built community in our cities and countryside, they created community centers and health centers catering to the gay communities unique needs; they won protections against discrimination in housing, employment and public accomodation in many states, and more recently won battles over gaysserving legally  in the military and in some states, equal marriage rights. They came “out of the closet” in force – suddenly appearing in television programs, plays and movies, on the streets, in the bars, in your YMCA – and in your church, your schools and everywhere straight people were.  But notice that if you were a gay activist or just coming out at say, age 25 in 1969, that means today you are 68 years old today.  You may be in good health, but many others are not and “grey gays” are thinking about and talking about Long Term Care options  in greater numbers than ever before.

If you are husband and wife, you can share a room in a nursing or assisted living facility. As a same-sex couple, you are treated as perfect strangers and have no right to demand a shared room with someone who may have been your lifelong partner.

If you are a husband and wife, you also have options with regard to Social Security, Medicare and Medicaid and other retirement benefits that may help preserve assets for the couple. As a gay couple, none of this applies and both halves of a gay couple are subject to the likelihood of being completely impoverished by the high cost of Long Term Care.

Its a little uncomfortable thinking about sex among seniors in nursing homes. Imagine how uncomfortable it is for some seniors – greying gay seniors – whose relationships are completely and officially unrecognized and often unofficialyl go unremarked. The issue is not really about the sex — although just as for younger people, sex is certainly a part of our lives and finding ways to meet the needs of seniors in this regard is important as it is for younger people. More importantly, its about preserving the longtime, intimate relationships that keep us healthy, vital and happy.

Denying that older people have intimacy needs and sex lives is silly. Forcing them to deny their sexuality is unhealthy. Forcing gay seniors back into the closet in order to live in our typical Long Term Care facility seems unconscionable.

 

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New Year – New Committment to Improving Long Term Care

I long ago stopped making impossible New Year’s resolutions.  I quit smoking when I was ready to quit (I think it was in September, no New Years involved); I’ve never succeeded at dieting at any time of year. Ditto exercise though I do swim regularly in the summer – still nothing to do with New Year’s resolve.  But I am recommitting myself to something: improving the state of long term care in our community

When I was preparing to open my Elder Law practice, one of the things I did to get familiar with the issues elders face and the regulatory schemes that are associated with them, was to volunteer with our local “Ombudsman” program. In the Jefferson Planning District (5 counties: Albemarle/Charlottesville, Nelson, Fluvanna, Louisa and Greene), JABA is responsible for providing Ombudsmen in local nursing and Assisted Living facilities. You can read more about the federally mandated Ombudsman program here.

As a volunteer ombudsman, I was assigned to a local nursing home to visit with residents and talk to them about questions, concerns, problems or any issues they might have with the facility where they resided. As a neutral 3rd party we could try to help advocate and intercede on their behalf, often anonymously so that the staff could not “retaliate” against the patient or resident who “complained” about their care. In that capacity I met many residents and their family members as well as a large variety of the staff from housekeepers to executive directors. We solved problems whereever the problem lay.

But many problems were so intractable that there seemed to be no solution. Confounding and infuriating. Some residents seemed broken, miserable and unable to be helped. Many were depressed, some were suicidal.

One of those residents died earlier this year.  I’m writing this blog post to honor her.

In my practice area (elder law) I lose clients all the time. Its to be expected when when you deal with the elderly. I always grieve for their passing, but I generally take it in stride as the natural order of things.. But Anita was different. She was not old. Well, not compared to most of my clients or the other residents of the nursing home.

brain trauma
Residents of LTC facilities with traumatic brain injuries – are they properly treated?

Anita was in her late fifties, perhaps early sixties. Under normal circumstances one doesn’t find many people that young in nursing homes. But Anita was had suffered a traumatic brain injury some years earlier. After being in a coma for several months, she awoke to find herself on life support. Her condition improved and after she had undergone many rounds of reconstructive surgery, her horrific automobile accident left her alive, but unable to care for herself.By the time I met Anita, she had been in a nursing home for several years. When I first met her, she was able to wheel herself about in a wheelchair. By late spring of this year (almost two years later) she could barely move and needed to be lifted from bed to chair with a Hoyer lift (sort of a person-sized block and tackle used by nursing staff to save their backs from injury in hoisting patients who cannot transfer themselves in an out of beds, chairs, toilets etc.) Anita required the aid of two people to assist her on and off the toilet or was left in adult diapers. Her looks had been destroyed in the accident despite reconstructive surgery; almost all her teeth had had been removed as well. Her hair was either a tangle of uncombed knots, or cut so short she resembled Sinead O’Connor. She had barely a shred of dignity left and no desire to live.  Perhaps the most heart breaking aspect of Anita’s story was when I learned that before her accident, Anita had worked a registered nurse. She was extremely smart and capable. She worked in ICU and knew all about trauma victims. She knew what good nursing care was supposed to be. And she knew she was never going to get it in the situation she was in.

I discovered that despite her injury, Anita’s mind was still plenty active. And she had a very sharp – if dark – wit. Regardless of the motor skill deficit and behavioral issues, she liked to read, especially science fiction. She also became an avid member of the “Science Club” which we created for another severely brain injured resident (this one by stroke) who’s scientific mind was clearly genius level (he was a nuclear engineer in a previous life). Anita kept right up with him.  Otherwise her days were a dull hum of endless bingo and relentless daytime TV as it is in most nursing homes.

Anita had many issues related to her brain injury – some of them behavioral. Many people don’t know that brain injuries – from trauma, stroke or other reasons – can cause severe emotional, psychological and behavioral changes in addition to physical impairments.

Bloomberg News service recently published a powerful expose on the care of brain injured individuals in nursing homes and it is well worth a read. The article is Brain-Injured in Nursing Homes Without Care Giffords Had. Click on the link to read it.

We tried desperately to get Anita some much needed physical, speech, and nutritional therapy. We tried wheelchair yoga and other alternatives. The staff was willing to make an effort but the universe and Medicaid were not.  The director of therapy told me plainly that they were not equipped to deal with brain trauma-injured patients who require much more specialized care than the average nursing home can accomodate.

I’m not criticizing the nursing home (although I think it and most others can do far better than they do with what they have). I understand that they really are not equipped to deal with brain injured residents’ needs in the way that they should be addressed.   This is a giant gap in our healthcare structure. And another ugly stain on our national health system.

This is not relevant only to brain injuries. I had occasion to represent a family earlier this year with a severely disabled adult son.  His disability was not a brain injury but a genetic condition with truly catostrophic symptoms that could not be managed at home.  He too was being warehoused in a facility not equipped to deal with his (admittedly) very demanding needs. Indeed, the only available solution was to spring him from a state psychiatric hospital and to admit him to a nursing home!  He is still with us and, because he is geographically closer to people who can check on him and ensure that he is getting care that is up to snuff, his quality of life has improved somewhat.

I would like to honor Anita  who died this past summer. Anita and all the other residents of long term care facilities that we lost prematurely in 2012. As I go into 2013, in her memory, I rededicate myself  to continue to fight for improved long term care. Not just for seniors, but across the spectrum of our community.

I hope you will take note of the conditions we are warehousing these people in – our brothers, sisters, mothers and fathers – and put your shoulder to the wheel too.

Happy New Year to all.

 

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You Have a Right to Make Health Provider Choices

It’s Christmas eve and I’ve just been catching up on some back reading, including our local weekly papers, The Hook and Cville Weekly.   In the latter publication, there was a reference to an article in the November 27 issue regarding hospice. I noted in the Letter to the Editor that only Hospice of the Piedmont was mentioned. The article, Long journey home: A family’s experience with hospice care, is quite lengthy. And it is perhaps one of the best articles I’ve ever read on Hospice care. *

There is no doubt that hospice does wonderful work. What concerned me about the article was that they limited themselves to people having experience with only a single hospice agency – Piedmont. They interviewed workers from Piedmont, doctors from Piedmont and families served by Piedmont. One begins to wonder if this were a paid advertisement or editorial content!

In fact there are several hospice agencies in this area that patients and their families might choose from. In addition to Piedmont, Legacy Hospice is a dedicated hospicae agency. In the Waynesboro/Staunton area, Augusta Medical offers hospice service.  Also, most home health agencies, Asera, Interim, Medi-home health and others all offer hospice care. Some nursing facilities have their own hospice care units.

My beef is not with Piedmont. Not at all. My problem is that the article perpetrates a a different problem. That is, that many patients and families do not realize that they have choices regarding care providers. More importantly, they have the RIGHT to be informed of the choices available.  So for example, if you are a patient at Augusta Medical Center, and you are preparing to be discharged home and need home health care, AMC is required to advise you that you have choices among several home health agencies – which may include AMC’s own home health care (or hospice) agency but AMC may not limit a patients’ choices by failing to inform them of the available providers.  Typically, hospitals simply provide a bewilderingly long printed  list of healthcare providers. Either overtly or covertly, discharge planners and social workers are instructed to direct patients to a particular agency – usually one affiliated with the same hospital or its corporate entity.

This is wrong.

Patients have the right to make choices in their care planning. There are costs to think of and social issues that may impact one’s choices. For example, lets say you live in Stuart’s Draft (“over the mountain”) and your father has been transported to UVa. Medical Center after a serious stroke. After the initial crisis is over, UVa begins to make plans to discharge your father to a rehab center since he has lost the ability to walk and his speech and ability to swallow are severely impaired from the stroke. The discharge planner tells you that the first available bed is at Trinity Mission in Charlottesville. Very likely, you are unfamiliar with Trinity Mission and don’t even know where it is. But you expect the discharge planner – who seems very nice and caring – to take care of things for you. No doubt they have the best of intentions.  However, Trinity Mission is a nursing home north of Charlottesville and not easily accessible to you, since you will have to drive 40 minutes each way or more to see your father.

There are plenty of nursing and rehab facilities in the Waynesboro/Staunton area that would be closer and far more accessible to you. Placement in one of those facilities means you could drive yourself and your mother to see dad on a daily basis and you could both help encourage him to do his therapy, eat, talk, visit, walk and just generally spend time with him to keep his spirits up.  However, if you don’t know that you have choices in your care providers, you will simply assume that the UVa discharge planner “knows best” and simply acquiesce.

Soon, your father is in a nursing home that you, your mother, friends and other family cannot easily get to; father is alone most of the time; gets dispirited, lonely and depressed; he begins to refuse food, only reluctantly participates in any activities including physical, occupational and speech therapy. After a time, father has deteriorated to the point where he is unlikely to ever come home since he requires 24/7 care.

The story doesn’t have to end that way. You have choices. You can insist that the discharge planner find a bed in a facility closer to home. You, your mother, church members, co-workers and others can visit your dad regularly. His spirits are buoyed by the interaction, encouragement and good wishes he receives. He works hard to go home and ultimately regains much of the ability he lost due to the stroke so that he can go home even if it means having some additional care in the home.

Again, you have choices. The hospitals and healthcare providers are required to tell you what they are. But you should also ask. Don’t rely on others to help you make informed choices.

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*In the interest of full disclosure, I have to disclose that my partner is a Nurse-Case-Manager for another hospice agency here in town (not Piedmont). She has no ownership or profit interest however, she is a salaried employee.

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Hospice Care – And Now a Widow

For the past three years, I’ve watched my father struggle with age and debilitating disease.

henry
Henry Rosenberg Gelbman
July 31 1934 – November 29, 2012

My mother, his primary caregiver, also declined over this period, the emotional and physical strain causing her to age and struggle more than she might have otherwise.

We were blessed to have the assistance of several paid caregivers who not only took care of my parents, they loved them, sang to them, prayed for them.

In early September, my father was diagnosed with stage 5 kidney disease – e.g. kidney failure.  Because he was not a good candidate for dialysis and certainly not for a transplant, my father decided that the quality of life he was enduring was not something he wished to prolong, we arranged for hospice to come in. With his diagnosis, he finally met the criterion: a terminal diagnosis (kidney failure) and the likelihood of dying within 6 months.

Many people don’t know that hospice – a different but additional layer of care – is completely covered by Medicare & Medicaid.  (not room & board, but all the care). That meant that Dad received additional visits from and RN, a social worker, CNAs to help bath, feed, massage, dress him, change his colostomy bag and more.  All care that my mother could be relieved of on a pretty regular basis.

Another thing people don’t seem to know about hospice is that even though the certification indicates that the patient is likely to die within 6 months, they may have longer. At the end of six months, the hospice agency can simply recertify them for another 6 months.  Art Buchwald, the bestselling author and columnist was on hospice for over 2 years and was ultimately DISCHARGED from hospice because he got better.

Like Art Buchwald, my father also got better when admitted to hospice. There were no more arduous trips to doctor’s offices. They took him off many medications (many of which had deleterious side effects) and the increased hands-on personal care was terrific for his mental and physical health. Hospice paid for a hospital bed in the home. And to avoid pressure ulcers, it also paid for a special inflating mattress to alternate the pressure spots. It paid for pain medication & administration; it paid for medication to manage symptoms (like nausea, itching and others).

My father passed away after a sudden sharp decline on November 29th.  Hospice was there to pronounce him and their social workers and CNA’s were there to help us with the emotional and practical issues.

My mother is now a widow. And she has many practical and emotional hurdles to overcome.

Now, the hospice bereavement counselors are staying in touch with my mother who finds herself, after 56 years, suddenly alone. After all those years, she finds herself with no one to take care of; and not sure how to take care of herself. A host of financial, practical and life questions lay before her.

Like many adult children, and not just an elder attorney, I find myself in a position where the roles are reversed – the children are now parenting the parents.

I’m honored to take on that role (with my siblings). I’m grateful for the assistance of the professional caregivers – both private and professional – who have assisted us in these long months of transition.

Rest in Peace Dad, your wife will be well cared for.

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Prosecuting Elder Exploitation in Virginia

Sheriff's Department
We need all the tools at our disposal: Law enforcement, prosecutors, APS, private parties reporting suspicious circumstances to curb financial exploitation of our elders.

The Virginia State Crime Commission recently completed its task of reporting on efforts to enact laws to protect vulnerable elders from financial exploitation.

You can read their easy to read and understand report here

Only recently issued on November 13th it includes a really nice summary of what’s happening in OTHER states and what has been introduced in Virginia’s Legislature regarding laws to protect vulnerable adults from financial exploitation. None have successfully been enacted into law in Virginia. Yet.

My personal opinion is that it would be nice to have some criminal laws with a bit more “teeth” in them to go after perpetrators of financial exploitation against the elderly. I would sometimes like to take a baseball bat to them, but that would probably land ME in jail so that’s out.  But at a bare minimum, heightened sentencing for elder-swindling seems worth considering.  We do it for other forms of “aggravated” crimes.

Also, I thought it was interesting that they found that “An exploitation that involves a power of attorney appears to be easier to prosecute than one where there is no fiduciary duty between the parties.”    Plenty of that kind of exploitation going on around here! One of the issues might be to look at who is writing the PoA’s and who honored them – even when they suspected foul play.  I recently had a new client tell me that another attorney told her that her husband, recently admitted to a locked “memory” unit with advanced stage Alzheimer’s disease, could execute a new Power of Attorney in her favor as long as he could mark an “X” on the paper and have two witnesses sign it before a notary. Seriously. An attorney gave her that “advice.” And got paid for his trouble too.

The Commission found that, in the meantime, (that is, while we wait for better criminal laws)  it is possible to successfully prosecute under the existing theft crime laws: embezzlement, larceny, larceny by trick, and false pretenses. Perhaps there are a couple of more….  fraud, credit card fraud, check kiting. There are even a few FEDERAL crimes one might prosecute if a scheme is perpetrated by postal system, over the “wires” (includes internet) or interstate.

I reckon we oughta’ get on it.  Law Enforcement? Commonwealth’s Attorneys? Are you with me?

 

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Family Values – Includes Multi-generational families

I don’t know about you, but I’ve been hearing about the “sandwich generation” for some time now.

In my life as an advertising executive (eons ago) we identified the “sandwich generation” as a distinct demographic (or “psychographic”) — one worthy of our attention in our ever present quest to identify and nail “market segments.”

What is the Sandwich Generation? No, not PB & J. It’s adults, with small children they are responsible for AND their own aging parents for whom they are caring for as well. Get it? Adults “sandwiched” between their kids and their parents.

Back then, the idea was mostly that older parents needed assistance — with doctors visits, trips to the pharmacy, visits (at their home or nursing homes). The idea was not that they necessarily where living under the same roof with their now-adult children.

Apparently that trend, which is the HISTORIC way American families took care of their elders – is on the come back.

With the cost of long term care so incredibly high (and the quality of care so questionable!) more and more families are looking at the option of bringing Mom & Dad (or one or the other) to live with them.

This solution, while certainly cost effective, is fraught with other problems of its own.  Who pays for what?  How is mom’s Social Security income integrated into the family budget? Who pays for the babysitter and who gets babysat (kids or grandma?) If grandma takes on child care duties – does she receive a wage for it?

No one really wants to consider these questions. Or negotiate the answers. But assuming that you are all on the same page is not really an option either. Not if you plan to succeed in living together with multi-generational families all under one roof.

The Farmer’s Almanac posted a story I found very thought provoking on this very subject. You can read it here.

Another interesting and thought provoking source is a book I’ve been reading titled, Someday, All This Will Be Yours — essentially one way that financial deals between families were negotiated (or not) in the time when multi-generational families in one home were common in the U.S. (up until the mid-1950’s or so).

If you’re thinking about bringing Mom or Dad into you home, you might want to read these two sources for some insight and/or  talk to someone outside your emotional circle who can objectively help you decide if that is the right financial and practical move for you and your aging parent.  And help you negotiate the boundaries and practical arrangments between you and the other members of your family.

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