Wednesday, March 5, 2014
The American Geriatrics Society and the American Board of Internal Medicine Foundation have joined in a venture called "Choosing Wisely," and recently issued "Five Things Physicians and Patients Should Question."
The items are intended to stimulate more thoughtful decision making, especially in dementia care, and address diet, restraints, and use of screening tests. Two items that hit home include:
- Don't prescribe cholinesterase inhibitors for dementia without periodic assessment for perceived cognitive benefits and adverse gastrointestinal effects.
- Don't prescribe any medication without conducting a drug regimen review.
This "Five Things" list was actually the second set of "Choosing Wisely" recommendations. Here's a link to the important first list, which includes the concern about off-label prescriptions of antipsychotic medications to treat symptoms in dementia, a topic that has also been the subject of major whistleblower cases and settlements involving the pharmaceutical industry.
Tuesday, February 25, 2014
One of my frequent travel routes is to drive between Carlisle and Baltimore, in order to take direct flights from BWI to Phoenix, where my parents live. Usually these drives are in the middle of the night, as I try to avoid traffic by scheduling very early or late flights. One positive aspect of this travel is the time to discover interesting radio programs; there is something about listening to radio in the dark that allows one to hear more clearly. Last week, I lingered in the car after reaching the long-term airport parking, to listen to the end of an especially effective interview.
On Point with Tom Ashbrook, was hosting Kimberly Williams-Paisley who spoke movingly about her family as they coped with her mother's early onset of a form of dementia, diagnosed at age 61. For those of you who enjoy either movies or music, you might recognize Kimberly as an actress from Father of the Bride (she was the daughter driving Steve Martin to wit's end) and Nashville, or as the wife of country music star Brad Paisley. Also featured on the program was a clinical social worker, Darby Morhardt, who is an associate professor at the Cognitive Neurology and Alzheimer’s Disease Center at Northwestern University’s Feinberg School of Medicine.
The program was very thoughtful and emotional, but for me the most compelling words came from Kimberly's father, Gurney Williams.
This is a man deeply in love with his wife and also deeply affected by her condition. At first he tried to hide her diagnosis, but over time, this became more and more difficult. Mr. Williams describes how he finally came to terms with the need for help -- and the need for more than family help -- when his children staged a bit of an intervention. They asked him to recognize that his wife's condition, which in her case included confusion, mood swings, anger and -- at times -- violence, was more than they could cope with in the home. They were worried about their mother, but even more devastated by "losing" their father as he struggled to care for her. With the family's help, he finally made the difficult decision to place his wife in a formal care setting.
And it was during his description of the journey, that I heard the words I've also heard many times from friends, family, students and clients. "I promised my loved one I would never put her in one of those places." I have come to recognize this promise as completely well-intentioned, but also potentially dangerous for all involved.
Listening to Mr. Williams and Kimberly, you could tell formal care was the right decision and they were able to find the right kind of care facility for their loved one. And it was a decision that allowed all of them to find a new way to express their love and devotion to her, while also providing her with a supportive, safe environment. Kimberly talks about how she stopped talking about her mother in the past tense, rediscovered her and how they created a new, valuable relationship. Their story has a happy evolution, which, of course, is different than a happy ending.
One of the reasons I was so affected by listening to Mr. William's words, was that I was on my way to the airport to visit my father -- to see him for the first time -- after his transfer to a dementia-care community. All of my fears and hopes were bound up in my listening. On arriving in the airport I went directly to a shop and bought a copy of the March issue of Redbook Magazine, which carried the story by Kimberly Williams-Paisley that led to the invitation for her and her father to be guests on the On Point program. I read and re-read "How I Faced My Mother's Dementia" on the plane -- and shared her words with my mother when I arrived.
I suspect I might write more about my own evolution with my father. Right now it is easier for me to recommend the article, and to say the podcast of the On Point show is even better than the article.
Wednesday, February 12, 2014
Peter Strauss, Co-Director of the Elder Law Clinic at New York Law School, leads off his school's recent Law Review symposium by reminding us of a powerful early piece published in 1983 by Marion Roach. She recounted the first moments when she realized her mother her mother "might be going mad." She went on to explore her mother's Alzheimer's and the family's struggle in her well-regarded memoir, Another Name for Madness.
Professor Strauss' Introduction opens the symposium issue on the theme of Freedom of Choice at the End of Life: Patients' Rights in a Shifting Legal and Political Landscape. Videos of the presentations are available here.
Sunday, February 9, 2014
Recently an individual contacted me with a fact pattern to present on our Blog, a variation on what we've written about in the past. Here are the basics. I've assigned some gender roles to make the fact pattern easier to follow:
The daughter of an older parent wants to know whether she has a legal "duty" to interfere with her brother's role in the life of their parent, where it appears the brother is failing to either apply for Medicaid or otherwise pay the parent's rehabilitation facility. The parent is not unhappy with the son's actions (or rather, inaction), and in fact declined to give power of attorney to the daughter, even when told of a likely "eviction" for nonpayment of the bill. The parent has mostly recovered from the medical crisis that triggered the need for care -- and just wants to go home. Parent has made it clear to daughter that her help is "unnecessary."
The complication is the size of the unpaid bill, more than $100,000. Apparently the care facility, approved to receive Medicare and Medicaid, is now demanding that the daughter pay the bill. Apparently no one applied for Medicaid and it is unclear whether Medicare ever paid. Daughter doesn't know much about her parent's income, but assumes it is limited and probably the only asset is a house, where the widowed parent lives when not in a hospital or in a care facility, and where the brother also resides.
The rehab facility is in Pennsylvania, home to "filial support" laws that have been enforced against adult children, with or without evidence of fault on the part of the child who is sued. Under Pennsylvania's law, those with statutory standing to pursue a support claim include a "person" who has provided care or maintenance, and that has been interpreted to include residential care facilities. We've discussed tough filial support decisions before on this Blog, including Health Care & Retirement Corp. of America, v. Pittas, (Pa. Super. Ct. 2012).
Thus, a lawyer is probably going to have to break the bad news to the daughter that the facility arguably has a potentially viable claim under 23 Pa.C.S.A. Section 4603. Daughter would appear to have some equitable defenses, including laches, but nothing that is expressly provided in the Pennsylvania statute. But who can afford to defend such a case? The facility appears to be using the child's potential liability under filial support laws to insist the daughter take action, either to obtain a guardianship or other order that would permit her (force her?) to apply for Medicaid -- and the threat may work. The longer she waits, the tougher it will be to get sufficient retroactive coverage. But in this instance, it is not clear whether the parent's capacity is impaired, or whether the parent is simply following a long pattern, even if unwise, of preferring one child's "help" over the other.
The moral question of "Am I my brother's keeper," becomes a Family Keeper's Dilemma, when you add in the third part of the triangle, a parent in need of care or protection, against their will. And the moral question becomes a legal liability question, when a filial support law that permits third-party suits is involved.
For another Family Keeper's Dilemma, see the Washington Court of Appeals' January 14 decision, "published in part," in the case of In re Knight, addressing the level of proof required for one son to obtain a Vulnerable Adult Protection Order, to prevent his brother, with a mental health history and a criminal record, from continuing to live with or near their 83-year-old mother. The mother opposed the protection order.
Thursday, February 6, 2014
Via NBC News:
Every Saturday at Casa Maravilla, a housing development for seniors in Chicago, dozens of older Latinos gather to dance and, they hope, help preserve their memory. At twice-weekly practices, they step in sync in promenade-like moves to danzón, the slow and elegant musical genre that’s popular in Mexico. Or, they swish their hips and twist through each others’ arms to more energetic salsa. The dancers are part of the Latino Alzheimer’s & Memory Disorders Alliance, or LAMDA, which started “Bailando por la Salud” (Dancing for Health) to inspire Latinos who are uncomfortable with other forms of exercise to get fit and healthier -- which in turn may help stave off Alzheimer’s and other memory loss conditions.
Read more at NBC News.
Wednesday, February 5, 2014
An important new book, Sexuality and Dementia: Compassionate & Practical Strategies for Dealing with Unexpected or Inappropriate Behaviors, published in December 2013, offers a physician's candid assessment of a topic often discussed, if at all, only in hushed tones.
Reading the first chapter called to mind a colleague in aging studies, a nurse, who related to me how a tearful woman once asked her how to hire a prostitute, as her husband was in the mid-stages of dementia and constantly wanted sex. The wife as the home caregiver was, in a word, exhausted. This book recognizes that a wide range of sexual behaviors often accompany dementia. Sexual agression is sometimes even a sign that something has changed in the individual's cognitive functioning, only later recognized as an early step in the process of dementia.
The author, Geriatric Neuropsychiatrist Douglas Wornell, is quite critical of the medical profession's approach -- or rather a frequent failure to even discuss -- the topic. Dr. Wornell observes that "to date, patients and their partners have been virtually abandoned by an entire medical system that has provided little to help them with sexuality as it relates to dementia. Considering the numbers of people affected -- tens of thousands of people in my practice alone -- that abandonment is nothing more than shocking."
The book is written in plain terms, covering everything from the "neurobiology of sex and dementia" to the potential for medication to stimulate -- or alleviate -- the condition, while also discussing the impact of the behaviors in the home and in more formal care settings.
Tuesday, January 21, 2014
Recently, a Pennsylvania friend was describing her aging father's situation in one of the sunshine states. When her father, a widower, began to show signs of diminishing capacity, the adult children discussed options, including moving Dad closer to one of them. But, he liked his retirement spot in the sunshine, had friends, and, in fact, there were more care options where he was living.
Eventually, my friend hired a local geriatric care manager in the sunshine state, with the cost shared by her and two siblings. In our most recent conversation, my friend described that decision as perhaps the best move the family made. She said that at first she had a hard time getting her father's facility to accept the fact that they should call the care manager first. But having an informed person -- an experienced advocate for her father -- in the community has often been essential, as questions arose over insurance, level of care, medications, transfers between facilities, nutrition and whether to hospitalize. My friend still makes regular trips to visit her father, but the local manager meant there were fewer emergency trips.
Geriatric care managers, sometimes called care coordinators, elder care coordinators, or professional care managers, could -- and perhaps should -- be an increasingly important part of planning. One of the questions about this emerging profession is credentials. At least two national trade groups exist, including the National Association for Professional Geriatric Care Managers (NAPGCM) and the National Academy of Certified Care Managers (NACCM).
In addition, law firms specializing in elder law frequently offer care management services, often employing non-lawyer professionals as part of the team.
Geriatric care management may be very important to "elder boomers," both as they become seniors caring for their even-more-senior-aged parents, and as future care-needing individuals themselves. Unfortunately, a big question may be cost. Medicare and Medicaid -- and most insurance -- does not cover the cost of care management. As reported by the New York Times a few years ago in "Care Coordination: Too Expensive for Medicare?," attempts to secure public funding for care managers has been stymied by studies that show care management does not necessarily reduce the costs of care.
Nonetheless, such coordination may be particularly important in a nation where family members often live far apart. In my friend's situation, she expected the need to last for a couple of years, but in fact, her father is approaching age 98, and the "healthy" relationship between the children, their father and his care coordinator has lasted for more than 10 years.
January 21, 2014 in Cognitive Impairment, Consumer Information, Dementia/Alzheimer’s, Ethical Issues, Health Care/Long Term Care, Legal Practice/Practice Management, Medicare | Permalink | Comments (0) | TrackBack (0)
Monday, January 20, 2014
I've been catching up on reading of practitioners' blogs. I quickly came across interesting discussions of potentially cutting edge decisions in recent law and aging cases. Here's a selection:
- From Tucson, Arizona, Robert Fleming's Legal Issues Newsletter reports on the background of the Arizona Court of Appeals decision on January 2, 2014 in Savittieri v. Williams, affirming the post-death annulment of a woman's marriage for lack of capacity.
- From Dearborn Michigan and Pittsburgh, Pennsylvania, John Payne's Off the Top O' My Head, comments on recent decisions within the Third Circuit that address the use of spousal annuities or trusts in Medicaid planning. For example, he discusses the January 14, 2014 ruling in the United States District Court, Western District of Pennsylvania in Zahner v. Mackereth, that makes fact-specific rulings in three consolidated cases involving annuities and which also, surprising, revisits the dormant "Granny's Lawyer Goes to Jail" provision of federal Medicaid law. Fortunately for attorneys, the court agrees with former Attorney General Janet Reno that application of the law to legal advice is unconstitutional. Nonethless, I think it is safe to say that the Pennsylvania Department of Public Welfare's attempt to push the law is an indication of the battle lines being drawn over use of annuities.
- From Fairview, Oregon, Orrin R. Onkin's Oregon Elder Law, reports on an array of elder abuse cases, including a 2013 decision by the Oregon Court of Appeals affirming an award of treble damages under the state's elder abuse statute against an ambulence company, in Herring v American Medical Response Northwest, Inc.
Tuesday, January 14, 2014
NBC News had an interesting piece on a self-test for mental acuity, reportedly developed by Ohio State University in response to the growing number of Elder Boomers who apparently are concerned about distinguishing between "ordinary" forgetfulness or changes in brain function. (Really? Is that what aging boomers are worrying about?)
In any event, NBC's medical expert, Nancy Snyderman, reminds us that OSU's "Sage Test" (good name, consumer friendly!) is just one tool to assist in early identification of potential problems -- and is not an ultimate diagnosis.
Monday, January 13, 2014
A few years ago, one of the more perplexing cases handled by Penn State's Elder Protection Clinic involved the sale of deferred annuities (specifically, an annuity that would not fully mature for 20 years) to a senior, a widow in her early 80s.
The individual was a ripe target for a manipulative sales pitch, having recently been diagnosed with early stages of dementia, even though at the moment of sale she was still living independently in her home. She was able to talk and communicate; arguably she did not seem impaired. She was told the product would save on taxes -- a pitch alluring to the frugal woman -- except for the fact that she really didn't need to save on taxes.
If one lives long enough or has looming care needs even at an earlier age, an individual's post-death estate planning goals can conflict with pre-death care needs. In the clinic client's case, the woman's annual income was modest, and her total estate was not large enough to trigger other major taxes. The assets used to fund the annuity were virtually her entire savings. Several months later, her daughter learned of the purchase, while exploring care options for her mother. Her mother was facing ineligibility for Medicaid, as the purchase of the deferred annuity would be treated as transfer, while the alternative was a large penalty if she cashed in the annuity "early."
How often does this -- or worse -- happen?
In "Still No Free Lunch: Recent Regulatory Initiatives to Protect Seniors From Fraud in the Sale of Investment Products," 41 Securities Regulation Law Journal 397 (Winter 2013) (paywall protected; available on Westlaw as 41 No 4 SECRLJ Art 2), attorneys Ivan B. Knauer and Michele C. Zarychta address recent efforts to prevent or address fraudulent practices by an array of regulatory bodies. The 2013 piece updates their 2008 article (available at 36 No 4 SECRLJ Art 3). They outline several types of fraud and various financial products often marketed specifically to elders. For example, they observe:
"One of the most pressing concerns of the regulatory entities is the improper -- or at least confusing-- use of 'senior' designations by professionals, implying that a professional has expertise or training in senior-specific issues. FINRA [the Financial Industry Regulatory Authority] 'Rule of Conduct 2210 prohibits brokerage firms and brokers registered with FINRA from referencing nonexistent or self-conferred degrees or designations or referencing legitimate degrees or designations in a misleading manner.' Misleading use of such designations may also violate federal securities laws or state laws."
The authors, who are experienced in representation of investment and financial service companies, recognize that business lawyers can help clients recognize the need to "take measures to ensure that their own policies and procedures protect seniors." "Still No Free Lunch" is a reminder that attorneys who are advisers to companies can and should be a larger part of the solution, rather than be viewed as part of the problem.
In reading the article, which emphasizes regulators' programs to "educate" the public, I am struck by the likelihood that a key tipping point occurs when a senior's susceptibility to a manipulative pitch is outweighed by his or her weakened ability to recognize risk, regardless of any fraud-prevention education. That was true, for example, with our clinic's client. Her life-time frugal nature was still intact; however, her judgment about whether she needed to "save" money on taxes was diminished. More education was not the solution for her, as she had probably lost the ability to appreciate its application. Indeed, a common marketing practice to seniors -- free lunches or dinners disguised as "educational seminars" -- trades upon that very fact, thus giving rise to the "no free lunch" theme in both articles by authors Knauer and Zarychta.
The authors detail stepped up enforcement efforts, including recent measures by the Consumer Financial Protection Bureau, established in 2010.
Hat tip to Penn State Dickinson Law Professor Lance Cole, who shared this interesting article.
January 13, 2014 in Advance Directives/End-of-Life, Cognitive Impairment, Consumer Information, Crimes, Ethical Issues, Federal Statutes/Regulations, Property Management, State Statutes/Regulations | Permalink | Comments (0) | TrackBack (0)
Friday, January 10, 2014
The earliest signs of dementia are often subtle. It can be tempting and easy to brush them off as merely the signs of fatigue or being overwhelmed. Ironically, at the other end of the spectrum, advanced dementia, it may also be easy to jump to conclusions, believing one diagnosis fits all forms of dementia. The modern assumption is probably most often Alzheimer's, while in earlier decades the label might have been simply "senility."
I often ask a medical or gerontology professional with expertise in the various forms of dementia, including Lewy-Body Disease, Frontotemporal Dementia (FTD), Parkinson's related dementia, vascular dementia, as well as Alzheimer's, to speak to my elder law classes. The lectures are fascinating (okay, also a little frightening). But often, near the near the end of a class discussion, a student will ask, "if there is no cure for dementia, does diagnosis of the source really matter?"
A family's search for answers suggests there are may be very good reasons to pursue a definitive diagnosis, even if the ultimate answer is possible only after the death of a loved one impacted by disease. The Ruhrig Family in central Pennsylvania was perplexed by the symptoms and rapid progress of confusion for the patriarch of their family. Sixty-six year old Weston Ruhrig passed away less than a year after the family first began seeing signs of confusion:
"The 6-2, 210-pounder was up by 7 a.m. daily ... seemed always on the move. In June , he conducted a charity auction for United Cerebral Palsy of Central Pennsylvania, just as he had since 1987. He seemed normal.
But his family began noticing odd behavior. Ruhrig became withdrawn. He continually locked doors, sometimes locking out his wife after she had gone to the yard or garage during daylight. Ruhrig was known for harping on people to turn off lights to save electricity. Now he switched on lights for no reason and left the room.
By September , his family had persuaded him to see his family doctor. The doctor found no medical problems but referred him to a neurologist. Ruhrig felt nothing was wrong. In November, the neurologist gave Ruhrig cognitive tests. Ruhrig named the president and recalled facts including his wife’s birth date. But he couldn’t correctly state her age or calculate it. Still, he joked during the visit."
As carefully detailed by Patriot News writer David Wenner, eventually doctors suggested the problem was Alzheimer's. But the family, contrasting their father's symptoms with those of others they knew with more traditional presentations of Alzheimer's related dementia, persisted in seeking a more precise diagnosis. An MRI was viewed as normal. Another test was a spinal tap. Unfortunately, Mr. Ruhrig died suddenly in December 2013, after a fall that led to a rapid decline.
The diagnosis occurred after his death, based on the results of the spinal fluid analysis: Creutzfeldt-Jakob Disease, a very rare variation of the family of diseases associated with "Mad Cow" and "chronic wasting" in deer, but a form that is not considered to be caused by eating or handling contaminated meat. Deterioration associated with the condition is rapid, usually leading to death within a year, and the cause of the disease is currently unknown, and there are no cures.
But the courage of the family in pursuing and talking about the diagnosis could help others, as better understanding of the various forms and causes of dementia should help the larger community of physicians, epidemiologists and other experts chart the frontiers of dementia. Heredity, life-style, diet, viruses, environmental impacts -- with the help of families, all of these factors and others might better be understood in the search for causes and solutions for the different forms of dementia.
For more, read "Hampton Township Man Dies of Mysterious Disease Sometimes Associated with Mad Cow and Chronic Wasting." Thanks to my colleague, Professor Laurel Terry, for pointing me to this interesting local article.
Tuesday, January 7, 2014
This book review is the first of two student-authored pieces I will be posting this week. We've heard from Regan before--she attended the NAELA/NALI conference in November and wrote two posts about her experiences there. Regan is a December 2013 graduate of William Mitchell. She also has a certificate in health law compliance from Hamline. Regan will be taking the Minnesota bar in February and is looking for a position in the elder law/health law field. Contact me if you have any leads for her and I will put you in touch!
Barbara Cassidy, Deliberate Accident (BookCrafters 2013) (self-published) (available from Amazon)
Review by Regan Bovee, J.D. William Mitchell College of Law, December 2013
Deliberate Accident tells the story of author Barbara Cassidy’s fight to protect her father, Robert, from physical, financial, and verbal abuse from his second wife, Diane. After Robert’s first wife (Barbara’s mother) dies, Robert quickly begins dating and enters into several relationships with women who take advantage of his generous, trusting personality. Robert eventually meets and marries Diane, a nurse at a local nursing home who, unbeknownst to Robert, has recently married a well-to-do resident. Diane makes a living from seducing male residents and other elderly men, gaining control of their finances, and selling their possessions.
The beginning of Robert’s relationship with Diane coincides with the first signs of his dementia. It is often hard for Barbara to tell if her father’s actions are “her father being her father” or if he is losing cognitive ability. By the time it is clear that Robert has dementia, Diane is so entangled in their lives that Ms. Cassidy, her father, and their family are helpless.
The focus of the book is Diane’s reprehensible treatment of Robert, but the real value is in the very accurate depiction of how Robert’s dementia progresses over the course of ten years. Ms. Cassidy frequently quotes a psychologist who tells her that Robert’s dementia is “as good as it will ever get right now . . . In fact, it will only get worse.” This statement holds true throughout the book and is sure to have a familiar ring to those who have cared for someone with dementia. Although Ms. Cassidy, a long-term care nurse herself, continues to advocate for her father as his dementia becomes increasingly worse, there is little she can do for him.
Although Ms. Cassidy describes the book as a memoir, there are several conversations and descriptions of other’s thoughts and actions of which it would be impossible for her to have knowledge. This makes the story seem a bit less credible but enhances the dramatic quality. Further, the story line is difficult to follow in some areas. Characters are referred to interchangeably by their name or relationship (i.e. Robert or Dad) and sometimes switch mid-page, which disrupts the flow. Some of the sentences are also a bit choppy. Ms. Cassidy’s goal in writing this book, however, was to share her experience dealing with her father’s dementia and his new wife who abuses him physically, emotionally, and financially. She more than succeeds in that goal.
Note: This book is self-published.
Tuesday, December 17, 2013
Via the Telegraph:
Tens of thousands of pharmacists, bus drivers and bank staff are being trained to recognise the signs of dementia as part of a “front-line force” against the disease. Managers of some of the biggest firms have pledged to educate staff to recognise the effects of dementia. Boots, Lloyds bank and First Group have all committed to do as much as possible to help dementia sufferers after David Cameron promised to lead a national “fightback” against the illness. Jeremy Hunt, the Heath Secretary, said “every section of society” must “step up” to help tackle the illness, which affects 800,000 people in the country. “Britain’s biggest companies will build up a front-line force of thousands of people able to spot the signs of dementia and understand the needs of sufferers, helping people with the disease to live a normal life for longer,” Mr Hunt told The Daily Telegraph. The Prime Minister said this week that a cure for dementia could be found within 12 years as he announced funding for research into the disease would be doubled.
Wednesday, December 11, 2013
The Royal College of Physicians of Edinbrugh is hosting a symposium on "Ethics and Care for Older People Approaching End of Life: Symptoms, Choices and Dilemmas" on April 3 in Scotland. While many of the sessions focus on medical treatment, as one might expect given the setting, the program takes an interdisciplinary approach, with sessions on:
- Pain mangement in older people
- Palliation of symptoms in advanced dementia
- Nutrition in advanced frailty
- Escalating care vs. ceiling of intervention: two sides of the same coin?
- Advanced care planning in the community: choice or chimera?
The keynote address is "Meeting the Challenge of Delivering Quality Care for Older People in the Last Days of Life."
The website explains how to identify or establish connections for live streaming of the program to venues overseas.
Wednesday, December 4, 2013
Writer Kim Severson at the New York Times reports on the death of 72-year old Ronald Westbrook, shot by Georgia homeowner Joe Hendrix after trying to gain entrance to Hendrix's home:
"In the confusion that comes from Alzheimer’s, Mr. Westbrook had taken to collecting the mail from neighbors’ mailboxes. He was doing so that night on Marbletop Road, which is a mile or so from his home. He told the deputy he lived in a nearby house, which at one time, years ago, he had. 'Better get home,' the deputy said. 'It’s cold.'
The deputy drove on, and Mr. Westbrook, in a straw hat and a jacket too light for the weather, continued walking with his dogs. Just before 4 a.m., he was nearly three miles from home in the subdivision of modest new houses where Mr. Hendrix lives, near Chattanooga."
While the NYT story focuses mostly on the fear, confusion, and potential impact of Stand Your Ground laws, as factors potentially contributing to the older man's death, I am reminded of another story I blogged about earlier, where a wandering man with early onset dementia ended up in jail, only to suffer a brutal beating at the hands of a cellmate when authorities failed to recognize the implications of the man's confusion. Ironically, that case too was in Georgia.
In both instances, it seems that public authorities arguably had a chance to shepherd their wandering citizens to a safer setting.
Tuesday, November 26, 2013
Via Yahoo News:
A man from Leeds, England has invented a dog-controlled washing machine. The "Woof to Wash" machine has a bark-activated "on" switch. A special "paw" button allows the pooch to easily open and close the machine's door. The inventor, John Middleton of U.K. laundry company JTM, intends for the "Woof to Wash" machine to make laundry an easier task for people living with disabilities by letting them delegate the trickier parts of the job to support dogs who have been trained to load and empty the machines. "We developed this machine because mainstream products with complex digital controls seldom meet the needs of the disabled user," he said. The Sheffield charity Support Dogs is training the animals to operate the new machines.
"People who are visually impaired, have manual dexterity problems, autism or learning difficulties can find the complexity of modern day washing machines too much," Middleton told Anorak. "I had been working on a single program washing machine to make things easier, and there was a lot of demand for it."
Sunday, November 24, 2013
"Do Not Hospitalize" is the latest initiative in advance care directives, driven by emerging recognition of the variety of ways that individuals may not be well served by extra-ordinary care measures, requiring specific directions. The concept may require lawyers drafting traditional living wills to think more broadly. Further, the concept highlights the importance of families working directly with physicians who are sensitive to the larger dynamic.
I have to say this one hits home in my own family. My father, after physical health problems combined with larger frailty, declared at age 86, "I would rather die on the steps of the hospital" than spend another night there. That has been hard, at times, for my family to accept.
The New York Times in Judith Graham's "A Misunderstood Directive," provides a back story for the use of DNH orders. Dr. Michael Rothberg describes what occurred after his father-in-law, with severe dementia, was transferred from a care facility to a hospital for evaluation, a move that triggered even greater disorientation and reaction by the man, leading to restraints and medication. The theory of DNH is to provide a reasoned basis not to see hospitalization as the only option for patients, especially those with dementia:
"After another difficult hospitalization, this time for pneumonia, the family decided they didn’t want this vulnerable, distressed relative transferred from the nursing home again if he took ill. They asked that a “do not hospitalize” order be communicated to staff and placed in his medical record. Several months later, the patient stopped eating and drinking and passed away."
Dr. Rothberg and colleagues in Pennsylvania and Massachusetts have collaborated on a paper to describe and evaluate Do Not Hospitalize directives entered into by authorized agents (health care proxies or HCPs) for individuals with advanced dementia. They conclude:
"The potential barriers to and facilitators of HCPs initiating DNH orders identified in this study suggest that HCPs may benefit from more in-depth discussions with healthcare providers when making this decision. Interventions to address these barriers may improve the capacity of HCPs to make informed decisions about DNH orders that reflect individuals' values and wishes."
Friday, November 22, 2013
Via the Japan Times:
Humanitude, a caregiving method developed in France that emphasizes eye contact, touch and verbal communication to convey respect for the patient as a human being, is gaining attention in Japan for treating patients with dementia. Tokyo Medical Center in Meguro Ward, one of the hospitals adopting the Humanitude method, provides seminars for caregivers to expand its use. In a videotape shown at one such seminar, two nurses took a female patient with dementia to a shower. One nurse approached the woman from the front, looked at her at eye level and kept speaking to her gently while the other nurse washed her body with warm water.
The woman in her 70s, who was said to have screamed and refused to take a shower, was cooperative and remained calm, and even said that “the water temperature feels good.” The approach, with its name deriving from “human” and “attitude,” was developed about 30 years ago by Yves Gineste, who taught physical education, and his colleagues based on the philosophy of “what is humanity.”
The four basic pillars in the method are to look into the eyes of the patients, talk to, touch and help them stand upright. More specifically, particularly for elderly people with dementia, this means approaching from the front to avoid startling the patients, who tend to have a narrow range of vision; looking at them at eye level; telling them the procedures being conducted even if there is no response; avoiding gripping the patients’ wrists from above; and helping them stand upright or walk. There were remarkable scenes in the videotape that were taken in February last year when Gineste visited Tokyo Medical Center.
Wednesday, November 13, 2013
I’m at the conference on International Elder Law with Emphasis on Veterans Benefits (it is excellent, by the way). The host is Professor Jim Pietsch, Director of the U. of Hawaii Elder Law program. Jim has done a number of innovative programs throughout his tenure at the law school. One of these programs I’ve always found so clever is the “Nite of the Living Will” where the students do advance directives for elder Hawaiians on Halloween. How clever is that?
We do Wills for the Greatest Generation (a take-off on “Wills for Heroes”) where our students work with attorneys who volunteer for the Community Law Foundation (the local pro bono panel) and the St. Petersburg Bar Foundation. They provide simple wills and health care directives for veterans and spouses from World War II, Korea and Vietnam. Like the Nite of the Living Will, it gives students some great practical experience in drafting and working with clients. (Our students do not get academic credit, but can get legal pro bono hours toward Stetson’s graduation pro bono requirement). I know we are not the only schools doing something like this, so let’s hear from you. What programs are offered at your schools?
Tuesday, November 12, 2013
A new report highlighting the need for urgent action to improve residential aged care includes case studies of people being shackled, assaulted, sedated against their wishes and turned into "zombies". Australian of the Year and Alzheimer's Australia national president, Ita Buttrose, today launched the report calling for good quality residential aged care to be the norm. Quality of Residential Care: the Consumer Perspective acknowledges there are dedicated, compassionate people who work hard to provide quality care but notes there are instances of poor quality care. In 2012 there were more than 220,000 people in Australia in residential aged care in more than 2700 facilities across the nation.
"What worries me is that a minority of facilities are not providing good care, and that residents are not being respected and, in some cases, are subjected to physical or psychological abuse," Buttrose said. "Since becoming president of Alzheimer's Australia many consumers have shared disturbing stories with me of physical, psychological and sexual abuse, inappropriate use of restraint, unreported assaults and people in extreme pain at end of life not having access to palliative care. "The objective of the report developed by Alzheimer's Australia is to articulate the concerns of consumers, set out for discussion possible strategies to address them and to seek a higher priority for tackling them.
"It proposes strategies to bring providers, staff and consumers together to address the systemic issues in the aged care system that have led to breakdowns in quality care. Funding issues are important but equally so are the leadership and culture that respects the rights and dignity of older people. Common decency and respect costs nothing."
Source: Brisbane Courier Mail