Elder Law Prof Blog

Happiness and the Oldest-Old

2017 has  been a bit of a wild ride, and I thought it would be good  to end the year on a happy news item. So, check out this article in the New York Times.

Want to Be Happy? Think Like an Old Person. is an update on a series that follows six New York elders who at the time of the first article were " over the age of 85, one of the fastest-growing age groups in America. The series of articles began the way most stories about older people do, with the fears and hardships of ...."  In this article, the author is examining happiness.  "Older people report higher levels of contentment or well-being than teenagers and young adults. The six elders put faces on this statistic. If they were not always gleeful, they were resilient and not paralyzed by the challenges that came their way. All had known loss and survived. None went to a job he did not like, coveted stuff she could not afford, brooded over a slight on the subway or lost sleep over events in the distant future. They set realistic goals. Only one said he was afraid to die."

This attitude, the article explains, has a name: "the paradox of old age: that as people’s minds and bodies decline, instead of feeling worse about their lives, they feel better. In memory tests, they recall positive images better than negative; under functional magnetic resonance imaging, their brains respond more mildly to stressful images than the brains of younger people."

Two of the six have died, and the updates on the remaining four show some ups, downs, adjustments, and changes.

So ends another year for four members of New York’s oldest old: not with a whimper, but with small joys to ease their aches. Each lost a little and moved a year closer to death, as we all did. But each welcomed another morning, the start of another year to come. All had beaten the odds just to get this far.

 Resilience and perseverance matters. 

Happy New Year 

Dementia Therapy in German Nursing Home

A German nursing home is turning back the hands of time in an effort to better treat residents with dementia. The Washington Post story, A German nursing home tries a novel form of dementia therapy: re-creating a vanished era for its patients, explains how rather than trying to help residents remember, the facility takes them back to a specific period of time when they were younger.  For example one "nursing home ...  is trying to trigger [resident] ... memories by re-creating settings from [a prior] era as a form of therapy. While other nursing homes are also trying to help their residents remember details of their lives, what is going on here could well be the only concerted effort to re-create for its residents an entire historical era." This includes providing residents with tools they used in their jobs-but this only works if they liked their jobs, according to the article. Items are placed in "a memory room" for residents to visit.  The staff had to become knowledgeable about the time period in order to appear as an authentic residents of the era. So far the facility focuses on two decades with plans to expand to encompass a third decade.

Thanks to my colleague, Professor Mark Bauer, for alerting me to the article.

Elder Caregiving and Women Not in the Workforce

For regular readers of this blog, it's no surprise that we have written on several occasions about family caregivers and the upcoming shortage of caregivers as the boomers age.  Professor Naomi Cahn called this New York Times article to our attention (thanks Naomi),  How Care for Elders, Not Children, Denies Women a Paycheck looks at why more women aren't in the workforce. "[T]he consensus is incomplete. It misses perhaps the most significant impediment to women’s continued engagement in the labor market, one that is getting tougher with each passing year: aging. Focused laserlike on child care, we haven’t noticed that the United States is walking into an elder-care crisis." The article offers sobering statistics and as we know, in many instances the family caregiver is the female.

About a quarter of women 45 to 64 years old and one in seven of those 35 to 44 are caring for an older relative, according to the American Time Use Survey. ... It takes a toll. Ten percent of caregivers have to cut back on their hours at work; 6 percent leave their jobs entirely, according to a report last year by the National Association of Insurance Commissioners.... A 2015 survey by the insurer Genworth Financial found that caregivers spend about 20 hours a week providing care — about half what a full-time worker would spend at work. Almost four in five said they had missed work, and about one in 10 lost a job. One in six reported losing around one-third of income because of caring responsibilities.

Thinking ahead to another generation, the Millennials face an even greater task.

Unlike the boomers now taking care of their parents, their millennial children will not have as many siblings to help care for their parents. Higher divorce rates imply that many aging boomers will have no spouse to care for them, putting additional demands on their children. And the elderly of the future are going to live longer, which suggests there will be a lot of caregivers well into their 50s juggling work with care for their children and their parents.

How this issue will be solved, or resolved, will likely fall to the states. "And if prime-age women start leaving the work force in even higher numbers to care for their aging parents, this will also be a problem for the American economy."

Five Part Webinar on Abuse in Later Life

DOJ's office on Violence vs. Women (OVW) is offering a 5-part webinar series on Abuse in Later Life. The webinar series is free. The series will be presented jointly by the National Clearinghouse on Abuse in Later Life (NCALL) and The ABA Commission on Domestic and Sexual Violence.  The 5 parts will cover

• January 25, 2018  Abuse in Later Life Overview
• February 8, 2018   Forming the Relationship with your Client
• February 22, 2018  Client Goal-setting and Non-litigation Responses
• March 8, 2018    Legal Resolutions and Remedies
• March 22, 2018  Bringing the Case-Trial Skills

All the webinars are offered at 1:30 est. To register click here

Mark Your Calendars-Webinar on Elder Abuse Hotlines

The DOJ Elder Justice Initiative is holding a free webinar on January 12, 2018 at 2 est on What Hotline Workers Need To Know About Elder Abuse. To register, click here.  Here's the info about the webinar

Julie Childs, J.D., Consultant to the U.S. Department of Justice Elder Justice Initiative, hosts a discussion with Maria Shumar, Victim Specialist Consultant to the U.S. Department of Justice Elder Justice Initiative, and Keeley Frank, Senior Service Specialist from the National Center for Victims of Crime, on assessing and responding appropriately to calls from older adults who may have experienced elder abuse. We’ll discuss case examples to provide hotline workers tips on how to assist these callers and direct them to relevant resources and services.

Florida WINGS Project-Florida Guardianship Law

For those of you from Florida, The Florida Supreme Court’s Guardianship Workgroup and Florida’s Working Interdisciplinary Networks of Guardianship Stakeholders (WINGS) will be holding a public hearing on Thursday, February 1, 2018 at the Orange County Courthouse from 4-7 p.m.  The courthouse address is 425 North Orange Avenue, and the hearing will take place in  Suite 180.  According to the announcement

Members of the public will be able to share their concerns about guardianship and to identify possible solutions for those concerns. This event will help the Guardianship Workgroup and Florida’s WINGS advance guardianship reforms and increase the effectiveness of Florida’s guardianship systems.... Speakers are asked to address one of two questions: [1] If you could make one change in Florida’s guardianship system, what would it be? OR ... [2]  How can courts improve their processes to better ensure protection of the person, property, and rights of individuals who are under guardianship or who need assistance making decisions? Comments should be succinct. A time limit will be imposed.

There are other ways to make your voice heard. Another public input event will take place in February in Central Florida. Comments may also be submitted through the WINGS website: https://flwings.flcourts.org/.

The website also has a link to a 29 question survey about Florida guardianship law.  Folks can also submit comments online from the link here.

 

 

 

Filial Friday: Can Americans be Compelled by Germany to Contribute to Costs for a Parent's Care in Germany?

It has been awhile since I've written a "Filial Friday" post. Perhaps any question about legal obligations for family members to pay for care of another is an unfair topic during the holiday season.  A bit too downbeat, yes?  But, in fairness it is a topic that has reemerged in my "inbox," as I've recently received two communications from American adult children of biological parents in Germany.  In each instance, the reason is that Germany authorities are writing to American citizens to notify them that an aging German parent is or may be in need of "social welfare benefits" in Germany.  As one demand letter puts it:

"The above person is your mother.  According to [the Germany Civil Code] you have a basic obligation to pay maintenance for your mother.  According to Section 94 of the [Social Security Code] the maintenance obligations of a person eligible for benefits are passed on to [the Germany regional authorities] up to the amount of the expenses we incur in so far as this is not excluded for legal reasons."

In other words, it appears the German social service agency is saying that if it is called upon to incur expenses for welfare of a Germany citizen, it has the legal authority to seek contribution or reimbursement from the family members identified in German statutory law as having a maintenance obligation, including any children living in other countries.

As readers of this Blog know, I have a long-standing interest in such filial support claims, in large part because I live and work in Pennsylvania, the U.S. state that most frequently enforces a colonial-era law, permitting third-party providers of care in certain instances to compel adult children to pay reimbursement for costs of care, usually nursing home care.  The 2012 Pennsylvania Superior Court decision in Health Care & Retirement Corporation of America v. Pittas, where an adult son was found to be liable for more than $90,000 for his mother's nursing home care, is one of the most dramatic modern example of domestic enforcement in the U.S.   

The letters from Germany undoubtedly surprise, and perhaps frighten, the American children who have probably never heard of such a claim coming from public authorities.  (In the U.S., in the modern era the occasional claim usually comes from a nursing home that isn't being paid for long-term care by private or public means, and the claims are not coming from public agencies.)

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Social Media Job Ads Targeted to Specific Age Groups-Discriminatory Based on Age?

The New York Times ran an interesting article that was co-researched and co-written with ProPublica,   Facebook Job Ads Raise Concerns About Age Discrimination   Target marketing is nothing new. I'm sure you all have the experience of having ads for things you might "like" pop up all over webpages you are browsing. So what about target marketing for job applicants? The article notes that a number of large corporations have "placed recruitment ads limited to particular age groups ... The ability of advertisers to deliver their message to the precise audience most likely to respond is the cornerstone of Facebook’s business model. But using the system to expose job opportunities only to certain age groups has raised concerns about fairness to older workers." This then raised the question-whether such advertising would be considered discriminatory. Facebook's response "[u]sed responsibly, age-based targeting for employment purposes is an accepted industry practice and for good reason: it helps employers recruit and people of all ages find work,” said Rob Goldman,  a Facebook vice president."

The article explains how this story came about in doing research for another story regarding political ad placement. Now litigation has started, according to the story. "[A]  class-action complaint alleging age discrimination was filed in federal court in San Francisco on behalf of the Communications Workers of America and its members — as well as all Facebook users 40 or older who may have been denied the chance to learn about job openings. The plaintiffs’ lawyers said the complaint was based on ads for dozens of companies that they had discovered on Facebook."

There are a number of social media sites used to advertise jobs, and the article notes for example  that they may require advertisers to certify compliance with non-discrimination laws. The article discusses a number of legal issues, including what, if any,  liability the social media companies may have.  It's a fascinating article that presents arguments on both sides of the issue. Check it out!

Hawaii Starts Long-Term Care Program

The New York Times The Daily 360 series did a story about the long-term care program in Hawaii. You know the old saying-a picture is worth a 1000 words? A video must be worth many more words.  So, click here and watch the video!

Getting to Know More about the National Center for Law and Elder Rights

Are you familiar with the National Center on Law and Elder Rights? If you are an academic teaching courses about any aspect of elder law, disability law, Medicare or Medicaid, you will want to know more about this resource.  If you are working in a legal services organization that represents older clients or disabled adult clients, you will want to now about this resource.  If you are a young lawyer and just handling your first case involving home-based or facility-based care for older persons who are can't afford private pay options,  you will definitely want to know about this resource.  In fact, if you are a long-time lawyer representing families who are struggling to find their way through an "elder care" scenario,  you too might benefit from an educational "tune up" on available benefits.  And the very good news?  This is a free resource. 

The National Center on Law and Elder Rights (NCLER) was established in 2016 by the federal Administration for Community Living. The new entity is, in essence, a partnership project, with the goal of providing a "one-stop resource for law and aging network professionals" who serve older adults who need economic and social care assistance. Justice in Aging (formerly the National Senior Citizens Law Center) which has primary offices on the east and west coast is a key partner, working with the American Bar Association's Commission on Law and Aging, the National Consumer Law Center (NCLC), and the Center for Social Gerontology (TCSG). Attorneys at these four NCLER partners provide substantive expertise, including preparation of materials available in a variety of formats, such as free webinars on a host of hot topics.  The Directing Attorney is Jennifer Goldberg from Justice in Aging and the Project Manager is attorney Fay Gordon.  

It strikes me that a very unique way in which NCLER will be a valuable resource is through what the offer as "case consultations" for attorneys and other professionals.  Think about that -- you may have long-experience with one branch of "elder law" such as Medicaid applications,  but you have never before handled an elder abuse case with a bankruptcy problem. Here is the way to potentially get experienced guidance! 

The web platform for NCLER offers a deep menu of resources, including recordings of very recent webinars and information on future events. I recently signed up for a January 2018 webinar program on elder financial exploitation and even though it is a "basics" session I can tell I'll hear about a new tools and possible remedies, as the presenters are Charlie Sabatino and David Godfrey.  I just watched a recording of another recent webinar and it was very clear and packed with useful information.  There is a regular schedule for training sessions -- with "basics" on the second Tuesday of every month and more advanced training sessions on the third Wednesday every month. 

I confess that somehow NCLER wasn't on my radar screen until recently (probably because my sabbatical last year put me about a year behind on emails -- seriously!) but I'm excited to know about it now.  

Polypharmacy: an ongoing problem

There's been a lot of attention of late regarding the very serious opiod crisis. But I think it's important to keep in mind the issue of polypharmacy and elders. The Washington Post ran this article, The other big drug problem: Older people taking too many pills, which opens with this "[c]onsider it America’s other prescription drug epidemic." The article offers sobering statistics

Researchers estimate that 25 percent of people ages 65 to 69 take at least five prescription drugs to treat chronic conditions, a figure that jumps to nearly 46 percent for those between 70 and 79. Doctors say it is not uncommon to encounter patients taking more than 20 drugs to treat acid reflux, heart disease, depression or insomnia or other disorders.

In fact, some elders have health issues from polypharmacy, some which are preventable,  according to the article. The polypharmacy problems can create a vicious cycle for some folks for whom  "the side effects of drugs are frequently misinterpreted as a new problem, triggering more prescriptions, a process known as a prescribing cascade." Often, a hospitalization and new meds on top of the existing ones contribute to the problem.  Evidently the problem of polypharmacy, although not new, is increasing.  The article explains that some doctors are engaging in what is referred to as "deprescribing" which is explained as "systematically discontinuing medicines that are inappropriate, duplicative or unnecessary." The article explains a number of hurdles to this goal, including lack of research, time constraints, advertising and just changing the status quo.

This is a really interesting article and worth the read!

Good Friends-More Important than You Think.

I recall a children's song I learned about the importance of keeping your old friends while making new friends.  So the Kaiser Health News story about friends caught my eye. Good Friends Might Be Your Best Brain Booster As You Age reports on a new study from Northwestern regarding the connection between "brain health and positive relationships." The Northwestern Study, Psychological well-being in elderly adults with extraordinary episodic memory is an open source article available as well as a pdf.  Here is the abstract from the study

The Northwestern University SuperAging Program studies a rare cohort of individuals over age 80 with episodic memory ability at least as good as middle-age adults to determine what factors contribute to their elite memory performance. As psychological well-being is positively correlated with cognitive performance in older adults, the present study examined whether aspects of psychological well-being distinguish cognitive SuperAgers from their cognitively average-for-age, same-age peers.

Want to live longer and happier, then be nice to your good friends (maybe call them up now and tell them hi!). The article's concluding summary offers this

SuperAgers endorse higher levels of Positive Relations with Others compared to their cognitively healthy but average-for-age same-age peers suggesting that this aspect of psychological well-being may be an important factor for exceptional cognitive aging. Investigation of the longitudinal effects of psychological well-being on subsequent cognitive performance and investigation of the conceivable relationship between psychological well-being and von Economo neurons in SuperAgers represent intriguing future directions.

 

"Nursing Home Compare" Subject to Errors through Self-Reporting "Inflation"

In a new article published by Xu Han (Florida Atlantic), Niam Yaraghi (University of Connecticut) and Ram Gopal (University of Connecticut), their analysis of data used over a 4 year period for nursing home ratings  in CMS' "Nursing Home Compare" system reveals key concerns.  From the abstract:

We argue that the rating system is prone to inflation in self-reported measures, which leads to biased and misleading ratings. We use the CMS rating data over 2009–2013 and the corresponding financial data reported by Office of Statewide Health Planning and Development and patients’ complaints data reported by California Department of Public Health for 1219 nursing homes in California to empirically examine the key factors affecting the star rating of a nursing home.

 

We find a significant association between the changes in a nursing home's star rating and its profits, which points to a financial incentive for nursing homes to improve the ratings. We then demonstrate that this association does not always lead to legitimate efforts to improve service quality, but instead can induce inflation in self-reporting in the rating procedure. A prediction model is then developed to evaluate the extensiveness of inflation among the suspect population based on which 6% to 8.5% of the nursing homes are identified as likely inflators. We also summarize the key characteristics of likely inflators, which can be useful for future audit.

For more, see the full article, Winning at All Costs: Analysis of Inflation in Nursing Homes' Rating System, published November 20, 2017 in the journal Production and Operations Management.

"Snake Oil," Tattoos & Why Some Hospice Doctors Prefer Medical Powers of Attorney

Are games and food supplements that promise to stave off the onset of dementia the modern day version of "snake oil?" I promised to write more about the Aging Brain Conference at Arizona State University's Sandra Day O'Connor College of Law on December 8, 2017.  Speaker Dr. Cynthia Stonnington, Mayo Clinic, offered an important look at ways in which law, ethics, medicine, and commerce can collide with her survey of a host of approaches receiving "popular" press treatment.  

She examined self-described "brain-training" programs, miracle diets, supplements and targeted exercise programs, noting that most studies that purport to demonstrate positive results from these items have serious flaws.  Thus, at best, programs that claim to provide "protection" against dementia are usually promising more than has been proven.  Dr. Stonnington, along with the morning keynote speaker, former U.S. Surgeon General Richard Carmona, reminded us that

• maintaining social engagement,
• engaging in lifelong learning,
• getting regular exercise of any type,
• having good blood pressure control,
• getting adequate sleep, and
• focusing on good nutrition (including eating plans such as the Mediterranean, DASH or MIND diets)

are  far more important than any single, magic game or exercise.

One of the most lively discussions of the day came near the end, in response to presentations by Dr. Patrica Mayer of Banner Health in Phoenix, Amy McLean of Hospice of the Valley. and Life Sciences Professor Jason Robert (ASU) speaking for himself and Susan Fitzpatrick (James S. McDonnell Foundation), about end-of-life considerations for persons with dementia or other serious illnesses.  What would be the most likely response of a physician or emergency personnel confronted with a "do not resuscitate" tattoo on the chest of an emergency patient?  Dr. Mayer stressed that she is seeking reliable methods of communicating end-of-life wishes, and for her that means a preference for a written, Medical Power of Attorney.  She wants that "live" interaction whenever possible, in order to fully explore the options for care for individuals unable to communicate for themselves.  But she also noted a frequent frustration when she contacts designated  POAs about the need to make tough decisions, only to learn they were completely unaware before that moment of having been named as the designated agent.  

I was part of a panel of court-connected speakers, including Arizona Superior Court Judge Jay Polk (Maricopa County), neuropsychologist  (and frequent expert witness) Elizabeth Leonard, and experienced Phoenix attorney Charles Arnold.  I was interested to hear about  -- and will pursue more information on -- the psychologists' use of evaluative tools for clients that use scenarios that would appear to test not just for loss of memory, but impaired judgment.  I was speaking on the unfortunate need for judicial inquiries into "improvident transactions" by persons with problematic cognition and I used litigation approaches from other locations -- Ireland (common law) and Maine (statutory) -- as examples.  The Arizona legal experts reminded me to take a closer look at Arizona's financial exploitation laws.

For more from this conference, see Learning to Say the Word "Die"  --  about a pilot program developed by Dr. Mayer while she was an advanced bioethics fellow at the Cleveland Clinic.  I also recommend Dr. Mayer's article on CPR & Hospice: Incompatible Goals, Irreconcilable Differences, 

 

When "Emergencies" Last for Months -- and the Impact on Seniors

Over the last several weeks, I've been in an ongoing conversation with a good friend who operates a court-appointed special advocate program and guardianship agency in St. Croix, Virgin Islands.  I've visited her several times over the years, and in fact, was just there in May. We talked then about whether she would evacuate in the event of any predicted hurricane strike on her island.  Her answer was "probably not," in large part because of her commitment to sharing the workload for a community already under stress from lack of jobs and other financial pressures.  

She rode out the two hurricanes that hit her part of the Caribbean in September and while her own home was spared serious damage, she could provide only sporadic reports -- when she had cell phone service and enough battery power -- about the aftermath for her clients.  When she mentioned the trauma caused by the "simple" fact that having no way to escape heat and humidity, especially at night, was one of the most exhausting parts of the post-storm struggle for all ages, I searched my local stories for battery operated fans to send (and then we had the challenge of finding a way to get them to her island).  

The reality for seniors living day-after-day, week-after-week, and now several months in a row without a reliable source of power is part of the picture painted in a recent article in The New York Times.  

With large areas of Puerto Rico still in the dark three months after the first of the storms — according to government reports, only 60.4 percent of the pre-storm power grid load has been restored — older residents and those with chronic medical conditions are suffering in even more ways than their neighbors. Many nursing homes have no power. The failure to re-establish functioning telephone networks and transportation systems in many areas makes it difficult to get regular medical care. Fire safety systems are inoperable, posing special dangers for those who cannot easily escape.

 

A look inside the 356 units that make up Puerto Rico’s largest housing project for low-income seniors, Comunidad del Retiro, or Retirement Community, helps explain the hurricanes’ continuing impact on the vulnerable. Inside the complex, there is a man with apnea who cannot sleep at night without power to his oxygen machine. A woman with dementia who was scheduled for transfer to a nursing home before the storm. And Ms. Rodriguez de Jesus, who mistakenly drank a poison in the dark and came close to becoming another uncounted hurricane death.

There have been falls in dimly lit apartments. Special diets that could no longer be followed. Medical interventions, drugs and treatments missed or delayed.....

For more, read Lives at Risk Inside a Senior Complex in Puerto Rico With No Power. 

Legal Implications of Biomarkers for Dementia Highlight ASU's Conference on "The Aging Brain"

The "Aging Brain" Conference hosted by Arizona State University's Sandra Day O'Connor College of Law held on December 8, 2017 at the Sandra Day O'Connor United States Courthouse in Phoenix (that's a double helping of Sandra!) proved to be a fascinating, deep dive into the intersection of medicine, ethics and law with a focus on neurocognitive diseases, including Alzheimer's Disease.  The panelists and audience included academics in a wide range of fields, plus practitioners in medicine, law, social services, and more, along with both state and federal judges.  United States District Judge Roslyn Silver is a long-time supporter of law and science programming with ASU.

One of the important themes that emerged for me was the growing significance of pre-symptomatic tests that can disclose genetic markers associated with greater incidence of an eventual, active form of a degenerative brain disease.  Neurologist Richard Caselli from Mayo Clinic and Jessica Langbaum, principal scientist with Banner Alzheimer's Institute laid out the latest information on a variety of genetic testing options, including the possibly mixed results for "risk" connected to positive results for specific genetic markers.  A provocative question by a morning speaker, Law and Biosciences Professor Henry T. Greely at Stanford, captured the personal dilemma well, when he asked the audience to vote on how many would want to to know the results of a genetic test that could disclose such a connection, especially as there is, as yet, no known cure or even any clear way to prevent most neurocognitive diseases from taking hold.  

Taking that a step further, how many of us would want our employer to know about that genetic marker results?  How about our health insurers? As we discussed at the conference, some consumer information is already available through "popular" ancestry testing sites such as "23 and Me," which expressly offers testing for "genetic health risks," including "late-onset Alzheimer's Disease and Parkinson's Disease."  Arizona State Law Professor Betsy Gray, director of the Law & Neuroscience Program for ASU's Center for Law, Science and Innovation, who master-minded the conference, helped to identify a host of legal and ethical issues connected to this developing world of science and medicine. Jalayne J. Arias, a full-time researcher at University of California San Francisco's Neurology, Memory and Aging Center (and clearly a rising academic star and graduate of ASU Law) outlined the implications of pre-symptomatic testing from the perspective of long-term care insurance.  For more from Professor Arias, I recommend her 2015 paper for the Journal of Clinical Ethics on Stakeholders' Perspectives on Preclinical Testing for Alzheimer's Disease.

 I plan to write more about this conference, as many perspectives on legal, ethical and medical questions were offered.      

If You Made a List, What Would You Do Differently When You are Older?

I was reading the article, Things I’ll Do Differently When I’m Old, in the New York Times.  The author writes about a do and not do list.  What is this type of list? "It was a highly judgmental, and super secret, accounting of all the things I thought my parents were doing wrong. . .  It was all too easy to call them out, and I recognized over and over just how awful it is to become feeble, sick and increasingly absent-minded, or worse." 

Why such a list? According to the author, it arose out of watching the impact of their poor decisions on his parents. For example, his mother continued driving past the time of her capability or his father's refusal to use an assistive mobility device.  Learning from our elders' "mistakes" is nothing new, but making a list that applies specifically to one's older age is an interesting concept. Wonder what is on the author's list?  Items include driving ability, accepting help to maintain independence,  maintaining physical appearance, not lash out at others and treat them with respect and kindness. 

The author notes that his grandmother had a similarly intended list that he found going through his dad's papers.  He concludes "I certainly hope to learn from her errors, and my parents’, and avoid making too many of my own. Mostly I hope to be able to judge when to stop adding to the list, and start following its advice."

As The Oldest Generation Ages in Japan . . .

A haunting story and visual images of growing old alone in Japan, from the New York Times, including this excerpt:

To many residents in Mrs. Ito’s complex, the deaths were the natural and frightening conclusion of Japan’s journey since the 1960s. A single-minded focus on economic growth, followed by painful economic stagnation over the past generation, had frayed families and communities, leaving them trapped in a demographic crucible of increasing age and declining births. The extreme isolation of elderly Japanese is so common that an entire industry has emerged around it, specializing in cleaning out apartments where decomposing remains are found.

For more, see A Lonely Death, by Norimitsu Onishi, published November 30, 2017.

Planning for Workshop on Physician-Aided Death

The National Academies of Science, Engineering and Medicine released information about planning for a workshop Physician-Assisted Death: Scanning the Landscape and Potential Approaches - A Workshop

The 2014 case of Brittany Maynard, a 29-year old woman suffering from terminal brain cancer who made public her desire to have an option to end her life through medication, brought to the forefront of the public eye the age-old question of whether terminally ill patients should have access to a physician's assistance to hasten death. To gain the option, Ms. Maynard relocated from California to Oregon, where a "death with dignity" law has been in effect for nearly 20 years. More recently, five jurisdictions (California, Colorado, District of Columbia, Vermont, and Washington) have legalized physician-assisted death, and physician-assisted death is also legal in one state (Montana) by virtue of a ruling of that state's Supreme Court. The question of whether and under what circumstances terminally ill patients can access life-ending medications with the aid of a physician is receiving increasing attention as a matter of public opinion and of public policy. Ethicists, clinicians, patients and their families debate whether physician-assisted death ought to be a legal option for patients. While public opinion is divided, and public policy debates include moral, ethical, and policy considerations, a demand for physician-assisted death still persists among some patients, and the inconsistent legal terrain leaves a number of questions and challenges for health care providers to navigate when presented with these patients. The Board on Health Sciences Policy of the National Academies of Sciences, Engineering, and Medicine will convene an ad hoc committee to plan a workshop that will explore current practices and challenges associated with physician-assisted death, and highlight potential approaches for addressing those challenges.

Stay tuned for more info.

When a Tattoo is an Advance Directive?

I've told my students urban myths before about a tattooed advance directive and use that story to talk about the requirements for making a valid directive. So I was interested in reading the article about the DNR tattoo. Health News Florida ran the story, Did 'Do Not Resuscitate' Tattoo Reflect Patient's True Wish?  reports the story of a patient at Jackson Memorial in Miami with a DNR tattoo.  A tattoo presents some significant ethical questions for doctors. As this story reflects, the immediate questions are "is it legal and ... is it truly the man's wishes,"  In this case the patient presented at the ER alone with no ID  and no family were reachable. Taking this to the hospital ethics committee, the committee ultimately determined this was a valid expression of the patient's directions.  In this case, the tattoo contained the patient's signature. The Atlantic also ran a story, What to Do When a Patient Has a 'Do Not Resuscitate' Tattoo which reports a split of opinions from experts regarding whether the hospital should honor the tattoo. One expert offers

It’s the discussion that matters, not the words on the form (or the tattoo), says Joan Teno from the University of Washington, who studies end-of-life wishes. And in many cases, those discussions don’t happen, or aren’t respected. In a study of bereaved family members, she found that one in 10 say that something was done in the last month of a patient’s life that went against their wishes. “The fact that someone has to resort to a tattoo to have their wishes honored is a sad indictment of our medical system,” Teno says. “We need to create systems of care where patients have the trust and confidence that their wishes will be honored. That’s the important message from this case.”

 Note to readers: republished to correct typo. Note to self-don't post with head cold.