Tuesday, November 13, 2018

Famous Faces of Dementia

Soon after Justice O'Connor's announcement, the New York Times ran an article, Dementia Is Getting Some Very Public Faces.

Focusing on the issue of stigma that accompanies the disease, the article notes the impact of Justice O'Connor going public about her condition.  Dementia and specifically Alzheimer's can strike any one, regardless of fame or fortune. As the article notes

Justice O’Connor had joined a growing but still tiny group: public figures who choose to share a dementia diagnosis. ...  The breakthrough came in 1994, when Ronald and Nancy Reagan released a handwritten letter disclosing his Alzheimer’s disease.

“In opening our hearts, we hope this might promote greater awareness of this condition,” the former president wrote. “Perhaps it will encourage a clearer understanding of the individuals and families who are affected by it.”

Musician Glen Campbell and his family reached a similar decision in 2011, announcing his Alzheimer’s diagnosis, and several farewell concerts, in a magazine interview. The concerts became a 15-month tour and an intimate, unflinching documentary.

The famous folks also include Pat Summit and Gene Wilder.  So what is the value of famous folks going public with their diagnosis? We already know that a large number of folks are diagnosed with dementia and that Alzheimer's disease in particular is horrible disease in my opinion.

It’s hardly an obscure condition. About 5.7 million Americans have Alzheimer’s disease, the Alzheimer’s Association estimates. That represents just 60 to 80 percent of people with dementia, which takes multiple forms.

Though dementia rate seems to be declining, possibly because of rising education levels and better treatment for conditions like hypertension, both of which seem to help prevent dementia. But the number of Americans affected will continue to grow as the population grows and ages.

Already, Alzheimer’s has become the fifth leading cause of death for those aged 65 and older — and the only one for which medicine can’t yet offer prevention or treatment.

The article explains the value of famous folks going public with their diagnosis lessens the stigma others may feel from that diagnosis. Plus it may lead to earlier diagnosis for others and although there is no cure, it gives the patient and families more time to plan.

November 13, 2018 in Advance Directives/End-of-Life, Cognitive Impairment, Consumer Information, Current Affairs, Dementia/Alzheimer’s, Health Care/Long Term Care | Permalink | Comments (0)

Sunday, November 11, 2018

Living Life at the End of LIfe

Kaiser Health News ran a story recently on living with a terminal diagnosis. At Death’s Door, Shedding Light On How To Live explores the impact of such diagnosis on how one person decided to live the rest of her life and how she is coping with the diagnosis. The article lists the things she no longer does  (regular exercise) or finds concerning: "[N]o more worrying, even for a minute, what anyone thinks of her. As [she] wrote in a recent blog post, 'All kinds of things … fall away at just about the exact moment the doctor says, ‘There is no treatment.'"  She blogs about her situation and has found positive responses from readers yet the article notes others may not prefer to share their lives with strangers: "Other people may have very different perspectives as they take stock of their lives upon learning they have a terminal illness. Some may not want to share their innermost thoughts and feelings; others may do so willingly or if they feel other people really want to listen."

November 11, 2018 in Advance Directives/End-of-Life, Consumer Information, Current Affairs, Health Care/Long Term Care | Permalink | Comments (0)

Sunday, November 4, 2018

10 Commandments of Capacity

The ABA Commission on Law & Aging published its September-October newsletter, BIOFOCAL. The lead article is on  The Ten Commandments of Mental "Capacity" and the Law.

Recognizing the evolving state on the issue of capacity, the article explains 

[R]ecent changes have called the legal term “capacity” into question. The U.N. Convention on the Rights of Persons with Disabilities in Article 12 recognizes that “persons with disabilities enjoy legal capacity on an equal basis with others in all aspects of life” and that governments must take measures to assist individuals in exercising their capacity. The emerging principle of supported decision-making focuses on providing the needed support to help people make decisions. Finally, the 2017 Uniform Guardianship, Conservatorship and Other Protective Arrangements Act (UGCOPAA), approved by the Uniform Law Commission for adoption by state legislatures, does not use the term “capacity” – rather, it guides courts in determining whether there is a “basis” for the appointment of a guardian, taking into account needed supports and supported decision-making.

The article goes on to offer Ten Commandments:

1. presume capacity, 2. talk alone to the client, 3. make efforts to increase the client's abilities, 4. recognize there is no one "universal standard for assessing capacity", 5. lawyers shouldn't administer the mini-mental status exam, 6. remember it's capacity to do a specific task, 7. remember to examine the big picture, 8. keep the client's wishes, goals, etc. in the forefront, 9. remember client confidentiality and autonomy, and 10. remember the importance of advance planning.

 

 

 

 

November 4, 2018 in Advance Directives/End-of-Life, Cognitive Impairment, Consumer Information, Current Affairs, Dementia/Alzheimer’s | Permalink | Comments (1)

Sunday, October 28, 2018

Good Life in Later Years

The latest issue of the  Hastings Center Report is devoted to examining what gives a good life to someone in later life.  Volume 48, Issue S3 is titled What Makes a Good Life in Late Life? Citizenship and Justice in Aging Societies. All 15 of the articles are available for free. The topics run the gamut from social policies to age-friendly initiatives to housing to communities to advance directives for people with dementia, to name a few. Be sure to read the introduction before reading any of the individual articles, so you have the context of the volume. Here's the abstract for the introduction

The ethical dimensions of an aging society are larger than the experience of chronic illness, the moral concerns of health care professionals, or the allocation of health care resources. What, then, is the role of bioethics in an aging society, beyond calling attention to these problems? Once we’ve agreed that aging is morally important and that population‐level aging across wealthy nations raises ethical concerns that cannot be fixed through transhumanism or other appeals to transcend aging and mortality through technology, what is our field’s contribution? We argue that it is time for bioethics to turn toward social justice and problems of injustice and that part of doing so is articulating a concept of good citizenship in an aging society that goes beyond health care relationships.

Good stuff!

October 28, 2018 in Advance Directives/End-of-Life, Cognitive Impairment, Consumer Information, Current Affairs, Dementia/Alzheimer’s, Health Care/Long Term Care, Housing, Science | Permalink | Comments (0)

Thursday, October 11, 2018

California Vets Sue for Right to Aid in Dying

Bloomberg Law News ran a recent story about litigation in California. California Veterans Sue for Right to Die in State Home reports on a suit recently filed concerned vets living in a state veterans home.

Terminally ill California veterans wishing to use the state’s assisted dying law must be evicted or leave the state veterans’ home, a lawsuit challenging a regulation prohibiting the use said.

California is among a handful of states that permit assisted suicide. The California Department of Veterans Affairs (CalVet) argues the regulation banning assisted suicide was necessary to avoid violating the 1997 federal Assisted Suicide Funding Restriction Act, the lawsuit said. Veterans contend the agency’s argument is unsupported by law or fact and, in fact, harms terminally ill residents.

The suit was filed the first week of October in trial court in Alameda County.  The plaintiffs include 2 veterans groups,  a vet from Vietnam, and a non-veteran spouse. Defendants include the California Department of Veterans Affairs and the California Veterans Board.

October 11, 2018 in Advance Directives/End-of-Life, Consumer Information, Current Affairs, Ethical Issues, Federal Statutes/Regulations, Health Care/Long Term Care, State Statutes/Regulations | Permalink

Sunday, September 9, 2018

ECHO MOLST

i was reading about ECHO MOLST the other day. ECHO MOLST is part of Project ECHO

a lifelong learning and guided practice model that revolutionizes medical education and exponentially increases workforce capacity to provide best-practice specialty care and reduce health disparities. The heart of the ECHO model™ is its hub-and-spoke knowledge-sharing networks, led by expert teams who use multi-point videoconferencing to conduct virtual clinics with community providers. In this way, primary care doctors, nurses, and other clinicians learn to provide excellent specialty care to patients in their own communities using an all-teach all-learn model.

Project ECHO links expert specialist teams at a “hub” with primary care clinicians and other professionals in local communities. Primary care clinicians, the “spokes” in the ECHO model, become part of a learning community, where they receive mentoring and feedback from specialists. Together, they manage patient cases so that patients get the care they need. Although the ECHO model makes use of telecommunications technology, it is different from telemedicine.

What makes this training unique?  According to the website, "Project ECHO’s innovative approach will support the current and future needs of our clinicians and system leaders. ECHO MOLST will provide long term, sustainable MOLST education that will improve the competency and capacity of clinicians and improve adherence to patient preferences at end-of-life." The video conference 8 week training is set to start on September 13, 2018 .

September 9, 2018 in Advance Directives/End-of-Life, Consumer Information, Current Affairs, Health Care/Long Term Care, Programs/CLEs, State Statutes/Regulations, Webinars | Permalink

Thursday, September 6, 2018

Is There Such a Thing As Rational Suicide?

The New York Times ran an article,  A Debate Over ‘Rational Suicide’.    What is a rational suicide? And how is it different than physician-aided dying?  

Is suicide by older adults ever a rational choice? It’s a topic many older people discuss among themselves, quietly or loudly — and one that physicians increasingly encounter, too. Yet most have scant training or experience in how to respond, said Dr. Meera Balasubramaniam, a geriatric psychiatrist at the New York University School of Medicine.

She has written on the topic with a colleague, in an attempt "to generate more medical discussion,... in a 2017 anthology, “Rational Suicide in the Elderly,” and she revisited it recently in an article in the Journal of the American Geriatrics Society." The Hastings Center has also weighed in on the issue with the current Hastings Center Report with "a debate over “voluntary death” to forestall dementia."

The article acknowledges that suicide is an important public health issue that also includes older adults. The article explains the issues on both sides of this debate. For example, 

Failing to take action to prevent suicide, some ethicists and clinicians argue, reflects an ageist assumption — one older people themselves aren’t immune to — that the lives of old or disabled people lack value.

A tolerant approach also overlooks the fact that people often change their minds, declaring certain conditions unendurable in the abstract but choosing to live if when the worst actually happens. 

Slippery-slope arguments factor into the debate, too. “We worry that we could shift from a right to die to a duty to die if we make suicide seem desirable or justifiable,” Dr. Balasubramaniam said.

The article explores some of the research regarding suicide and features some quotes from individuals in addition to experts.

September 6, 2018 in Advance Directives/End-of-Life, Consumer Information, Current Affairs, Ethical Issues, Health Care/Long Term Care | Permalink

Wednesday, September 5, 2018

Rituals for the Death of Residents in LTC Facilities

When a resident of a long term care facility dies, should that person's passing be marked in some way?  According to a recent article in Kaiser Health News, Creating Rituals To Honor The Dead At Long-Term-Care Facilities one expert says the answer to that question is yes. This expert 

wants to see bereavement openly acknowledged at facilities throughout Georgia to end what she calls “the silence surrounding loss and death in long-term care.” Following in-depth discussions with more than 70 staffers, residents and family members at nine facilities in central Georgia, she has created two handbooks on “best practices in bereavement care” and is gearing up to offer educational seminars and staff training in dozens of nursing homes and assisted living residences across the state.

As the article explains, "[f]raught reactions to loss and death are common among nursing assistants and other staff in long-term-care facilities, research shows. When feelings aren’t acknowledged, grief can go underground and lead to a host of physical and psychological symptoms, including depression, distancing and burnout." The article offers several stories as well as some best practices. Some of those "best practices include offering support to grieving residents and relatives of the deceased, recognizing residents’ bereavement needs in care plans, and having a protocol to prepare bodies for final viewing." Others develop unique acknowledgements of a resident's death, including the use of candles, balloon releases and other activities..

September 5, 2018 in Advance Directives/End-of-Life, Consumer Information, Current Affairs, Health Care/Long Term Care, Other | Permalink

Tuesday, August 28, 2018

When Family Members Disagree about Care Arrangements....

While courts are most often called upon to appoint guardians or conservators in the absence of an authorized agent, another way in which courts may be required to act is when family members disagree about the course of care under private arrangements.  High profile examples of how this can arise often involve celebrities.  The latest example seems to involve comedian Tim Conway, where his wife and daughter are reportedly at "odds over his medical treatment."  From People magazine's online site comes this sad report:  

The 84-year-old Carol Burnett Show star’s daughter Kelly is asking to be appointed conservator of her father and be in charge of his medical treatments, according to court documents obtained by PEOPLE and first reported by The Blast.

Kelly, 56, filed the documents in Los Angeles on Friday, claiming Conway’s wife Charlene is “planning to move him out of the excellent skilled nursing facility he is currently at” and place him in one that won’t give him access to “registered nurses at all times and his 24-hour caregiver and speech therapist (to help with swallowing).”

Charlene is Conway’s second wife. He was previously married to Kelly’s mother Mary Anne Dalton from 1961-78. (In addition to Kelly, they share daughter Jackie and sons Jaime, Tim Jr., Pat, Corey and Shawn.)

Kelly also states that Conway cannot “properly provide for his personal needs for physical health, food, and clothing” and is “almost entirely unresponsive.”

Second marriages, where the families did not blend well, often seem to be a factor, especially if money becomes an issue.   My thanks to my Dickinson Law colleague Laurel Terry for sharing this item for our Blog. 

August 28, 2018 in Advance Directives/End-of-Life, Cognitive Impairment, Consumer Information, Current Affairs, Dementia/Alzheimer’s, Elder Abuse/Guardianship/Conservatorship, Estates and Trusts, Ethical Issues, Health Care/Long Term Care, State Cases | Permalink | Comments (0)

Friday, August 10, 2018

Learning Early You Have Alzheimer's?

Kaiser Health News ran a story How Soon Is Soon Enough To Learn You Have Alzheimer’s?  Do you want to know, or instead think just it's age-related memory loss?

The prospect of having Alzheimer’s can be so scary, and the current treatment options so few, that many people dismiss memory problems or other symptoms rather than investigate them, say Alzheimer’s specialists; it’s estimated that as many as half of all cases aren’t diagnosed.

But that may soon change. Researchers are making progress in measuring beta-amyloid and other Alzheimer’s biomarkers in blood that might eventually be able to reliably, inexpensively and non-invasively identify the disease years before cognitive symptoms develop.

Despite the scariness of the diagnosis, the article notes good reasons for early diagnosis, including discovering the underlying cause is a treatable condition, saving money "in terms of  health costs and long-term care costs over the course of their lifetime," the time to plan for incapacity and "[r]esearchers hope that by getting more Alzheimer’s patients diagnosed early on, more people with the disease will, like Jose, be able to make the best of the health they have."

August 10, 2018 in Advance Directives/End-of-Life, Cognitive Impairment, Consumer Information, Current Affairs, Dementia/Alzheimer’s, Health Care/Long Term Care | Permalink

Tuesday, August 7, 2018

The Role of Palliative Care At End of Life

We have had a number of posts of late regarding medical aid-in-dying, so I was interested in this article in the Washington Post, Assisted suicide is controversial, but palliative sedation is legal and offers peace. The article opens relating one individual's experiences and explains that "[u]nder palliative sedation, a doctor gives a terminally ill patient enough sedatives to induce unconsciousness. The goal is to reduce or eliminate suffering, but in many cases the patient dies without regaining consciousness." The article makes a stark contrast between physician aid-in-dying, which is authorized in a handful of states, compared to "[p]alliative sedation [which] has been administered since the hospice care movement began in the 1960s and is legal everywhere." The article notes that palliative care is not without concerns, mainly moral lconcerns on the part of health care providers, with variations in policies throughout hospitals.

Where is the line between terminal sedation and euthanasia, ponders the article, with positions offered on both sides.

[M]any doctors who use palliative sedation say the bright line that distinguishes palliative sedation from euthanasia is intent. ... "There are people who believe they are the same. I am not one of them,” said Thomas Strouse, a psychiatrist and specialist in palliative-care medicine at the UCLA Medical Center. “The goal of aid-in-dying is to be dead; that is the patient’s goal. The goal in palliative sedation is to manage intractable symptoms, maybe through reduction of consciousness or complete  unconsciousness.”

Others, including the National Hospice and Palliative Care Organization, recommend that providers use as little medication as needed to achieve “the minimum level of consciousness reduction necessary” to make symptoms tolerable.

The question often posed is whether terminal sedation will hasten death, and in some cases, no antibiotics, nutrition or hydration are provided and whether death occurs sooner depends in large part on the person's condition. As one expert noted, "in all cases the goal isn’t death but relief from suffering."

When is the use of terminal sedation appropriate? The article discusses its use to relieve "existential suffering" which is defined by "the hospice and palliative-care group ... as 'suffering that arises from a loss or interruption of meaning, purpose, or hope in life.'" In comparing it to aid-in-dying, it may provide an option for those who are not eligible for aid-in-dying assistance.  "Whether palliative sedation truly ends suffering is not knowable, although doctors perceive indications that it does."

 

August 7, 2018 in Advance Directives/End-of-Life, Current Affairs, Health Care/Long Term Care, State Cases, State Statutes/Regulations | Permalink

Thursday, July 19, 2018

What is the Best Way to Measure Appropriate Use of POLST Forms?

During a session at the first day of the  21st Annual Pennsylvania Elder Law Institute, we had an interesting dialogue about how best to utilize Physician Orders of Life-Sustaining Treatment (POLST) forms.  One attorney described how clients sometimes arrive at her law firm for advice on various estate planning matters, including a blank POLST form that was given to them in the hospital.  The client asks, in essence,"what should I do with this?"  One attorney said she walks through the form with clients, but always emphasizes that the most important part of the process is the conversation with the client's physician about her choices that should be happening before completing the document.  

Along that line, there is a timely post on the Health Affairs Blog today, with the headline "Counting POLST Form Completion Can Hinder Quality."   The authors, two physicians in Oregon, describe an incident in which a patient reported feeling pressured at a hospital to complete a POLST form, and they raise the potential for the pressure being a side effect of that patient's health plan keeping track of frequency of completion of POLSTs or other advance directives for all patients 65 or older, marking a high rate of completion as success.  They observe:

Many stakeholders have been concerned about how best to measure the quality of advance care planning and use of the POLST form. Some health plans and payers measure the frequency of POLST form completion without a clearly delineated eligible denominator population. Use of such a metric erodes the quality of the POLST program as the following case illustrates. . . . 

 

 When health care professionals encourage patients who are “too healthy” to complete a POLST form (instead of an advance directive), even when orders are for “CPR/Full Treatment,” they may cause harm. If the patient later loses decision-making capacity and clinically deteriorates to a condition in which he or she would have desired a comfort-oriented approach, the presence of the inappropriate POLST may increase the decision-making burden on the family. Another concern is that some healthy patients have been denied life insurance because their medical record inappropriately includes a POLST form; the company incorrectly believing the patient has a limited life expectancy.

The authors argue persuasively that:

Accordingly, we do not believe that POLST forms should be mandated or counted as a quality measure. Instead, POLST quality measures should count conversations about patients’ goals for care as they near the end of their lives.

I recommend the full article, linked above, including review of their "seven imperatives to preserve POLST quality." 

July 19, 2018 in Advance Directives/End-of-Life, Consumer Information, Current Affairs, Ethical Issues, Health Care/Long Term Care, Programs/CLEs, State Statutes/Regulations, Weblogs | Permalink | Comments (0)

Friday, July 13, 2018

More on California's Aid-in-Dying Law

We have blogged a couple of times at least about California's Aid-in-Dying law, most recently about the judge declaring the law unconstitutional. While the constitutionality issue makes its way through the court system, California in late June released statistics to show how many folks had previously availed themselves of the law. The New York Times reported that Nearly 400 People Used California Assisted Death Law in 2017.

Here are some statistics from the article:

374 terminally ill people took drugs to end their lives in 2017, the first full year after a law made the option legal....

577 people received aid-in-dying drugs last year, but not everyone used them....

Of the 374 who died, about 90 percent were more than 60 years old, about 95 percent were insured and about 83 percent were receiving hospice or similar care. The median age was 74....

Most of the recipients were college educated and receiving hospice or similar care....

The 374 people who died include 11 people who were prescribed drugs in 2016 but died last year.

Another 86 people were prescribed the lethal drugs but died without taking them, while the fate of the remaining 128 people wasn't reported.

July 13, 2018 in Advance Directives/End-of-Life, Consumer Information, Current Affairs, Health Care/Long Term Care, State Statutes/Regulations, Statistics | Permalink | Comments (0)

Tuesday, July 10, 2018

More on Using Trusts As Planning Devices for Firearms

I've written in the past about the use of "gun trusts" as a legal device to handle passage of guns to others, while avoiding some laws related to registration by gun owners.  

There's another way to think about trust documents with guns, to provide a safeguarding process within families.  As one article suggests, 

Talk to your loved one about how to safely transfer ownership of their guns if they should become incapacitated. Consider writing a “gun trust,” a legal document outlining that process.

For more, read the Kaiser Health News's piece, Worried About Grandpa's Guns? Here's What You Can Do.  Thanks, Matt Lawrence, for sharing this story.

July 10, 2018 in Advance Directives/End-of-Life, Cognitive Impairment, Dementia/Alzheimer’s, Ethical Issues, Property Management | Permalink | Comments (1)

Tuesday, June 26, 2018

More on End of Life

Two more items to add to your resources and reading on end of life in the U.S.

First: The New York Times ran an op-ed earlier in the month, Let Dying People End Their Suffering.Written by Diane Rehm, the  focus of this piece is on California's aid-in-dying law. She writes about a friend with terminal cancer who expressed relief about the law that allowed her to seek aid-in-dying.  As readers of this blog know, the law was overturned, so Ms. Rehm writes about the turmoil the decision has caused for those with terminal illnesses and their families. She writes about her husband, in Maryland, without the option of aid-in-dying, who instead opted for voluntarily refusing food and fluids.

Ms. Rehm makes a heartfelt argument in support of the aid-in-dying law, concluding her article this way

Let me be clear: I understand that many people believe that only God should determine the time of their death, and I support them 100 percent. Others want every additional minute of life that medical science can give them, and I support those people 100 percent. But the end of life is an extremely personal experience. If, when my time comes, I see only unbearable suffering ahead of me, then I want my preference to have access to medical aid in dying to be supported 100 percent, as well.

As Archbishop Desmond Tutu has written, “Regardless of what you might choose for yourself, why should you deny others the right to make this choice?”

Second:

Back in May, the president of the Hastings Center  wrote  a piece, Hastings Center President Calls for “Moral Leadership” to Improve End-of-Life Care.

The president made two lectures, "the 23rd annual Joseph N. Muschel Medical House Staff Award Lecture at Medicine Grand Rounds at Columbia University on May 16 and the Annual Wilhelm S. Albrink Lecture in Bioethics at West Virginia University on May 18... [where she] called on clinicians, hospital leaders, and bioethicists to broaden the usual ethical framework beyond “thin” notions of autonomy to a more robust relational ethics, that would build new systems, better capable of ensuring that frail older Americans and their caregivers get the support they need."

In her talk, when she turned to the topic of end of life "and population aging, she told the audiences: 'Redesigning our systems of health care delivery is one of the most important challenges of our time and will take significant moral leadership. But even that is not enough: beyond changes within care delivery settings, we also need to redesign our communities – so that housing, transportation and social supports are there for the increasing number of Americans living longer with frailty and dementia.'"

I'm sure these two pieces will not be the last on end of life care, so, stay tuned.

June 26, 2018 in Advance Directives/End-of-Life, Consumer Information, Current Affairs, Health Care/Long Term Care, State Cases, State Statutes/Regulations | Permalink | Comments (0)

Tuesday, June 19, 2018

Interpreting a Living Will in the ER Setting

Maybe it's just me, but does it seem to you that there are a lot of articles of late about advance directives and end of life issues?  Here's a recent one published by Kaiser Health News.   That ‘Living Will’ You Signed? At The ER, It Could Be Open To Interpretation.

opens with an ER nurse saying DNR because the patient had a living will, but reading the document showed the language to be just the opposite, "'[d]o everything possible,' it read, with a check approving cardiopulmonary resuscitation."  The point is to illustrate the mistake that the existence of a living will automatically means no resuscitation. "Unfortunately, misunderstandings involving documents meant to guide end-of-life decision-making are “surprisingly common,” said [the] medical director of advance-care planning and end-of-life education for Huntsville Hospital Health System in Alabama."

There's a new report from Pennsylvania, Empowering Patients and Agents to Help Prevent Errors with Living Wills, DNRs, and POLSTs

In 2016, acute healthcare facilities in the Commonwealth reported through the Pennsylvania Patient Safety Reporting System (PA-PSRS) nearly 100 events involving the code status or treatment level of patients. Twenty-nine patients were resuscitated against their wishes. Two patients were not treated when their wishes indicated they should have been. The remaining cases represent near misses that could have affected the patient, but were resolved before harm occurred.

The Pennsylvania Patient Safety Authority is unable to verify whether the do not resuscitate (DNR) orders or physician orders for life-sustaining treatment (POLST) were appropriate, correctly created, or verified prior to these patient safety events occurring in real time.

The Kaiser Health News article details communication missteps and offers that

The problem, Hoffman explained, is that doctors and nurses receive little, if any, training in understanding and interpreting living wills, DNR orders and Physician Orders for Life-Sustaining Treatment (POLST) forms, either on the job or in medical or nursing school.

Communication breakdowns and a pressure-cooker environment in emergency departments, where life-or-death decisions often have to be made within minutes, also contribute to misunderstandings, other experts said.

One expert interviewed for the article suggests these missteps are more common explaining his use of hypotheticals where "he has asked medical providers how they would respond to hypothetical situations involving patients with critical and terminal illnesses."  He goes on to explain

He described a 46-year-old woman brought to the ER with a heart attack and suddenly goes into cardiac arrest. Although she’s otherwise healthy, she has a living will refusing all potentially lifesaving medical interventions. What would you do, he asked more than 700 physicians in an internet survey?

Only 43 percent of those doctors said they would intervene to save her life — a troubling figure...Since this patient didn’t have a terminal condition, her living will didn’t apply to the situation at hand and every physician should have been willing to offer aggressive treatment, he explained.

The article offers some suggestions from one expert to avoid these situations: "[m]ake sure you have ongoing discussions about your end-of-life preferences with your physician, surrogate decision-maker, if you have one, and family, especially when your health status changes...  Without these conversations, documents can be difficult to interpret."

June 19, 2018 in Advance Directives/End-of-Life, Consumer Information, Current Affairs, Health Care/Long Term Care, Other | Permalink | Comments (0)

Monday, June 18, 2018

Case Study Using Substitute Decision-Making

The New England Journal of Medicine published recently Substitute Decision Making in End-of-Life Care. The article uses a case study of a hypothetical patient in a very serious condition in ICU who has no advance directive. The case study asks whether to enter a DNR or continue treatment and offers short essays by experts to use as resources in making the decision.  The article then gives the reader a chance to answer DNR or continue treatment and the ability to compare the choice to other readers'.  This is an interesting way to educate on an issue and could be easily adaptable to our elder law classes.

 

June 18, 2018 in Advance Directives/End-of-Life, Consumer Information, Current Affairs, Health Care/Long Term Care | Permalink | Comments (0)

Friday, June 8, 2018

Guardianships According to John Oliver

John Oliver, the star of Last Week Tonight focused on guardianship on the June 3, 2018 show.  The segment focused quite a bit on some of the abuses that have been reported recently in the press. But, to Mr. Oliver's credit, he notes that sometimes, despite a person's efforts, a guardianship is needed. He provides suggestions for improving the system and for individuals on planning to minimize the chances of a guardianship going wrong. There is some good info in the segment, and he makes several important points, but in a comedic and satirical format.

The link to the segment is here.  Be sure to watch through to the end, to see cameos from several celebrities offering advice on planning for incapacity (although they do get off track quite a bit) including health care powers of attorney and DPOAs. And who wouldn't want Tom Hanks to be their health care agent! (You have to watch the last bit to get that reference). Caveat: there is some "salty" language used throughout the segment.

June 8, 2018 in Advance Directives/End-of-Life, Cognitive Impairment, Consumer Information, Crimes, Current Affairs, Dementia/Alzheimer’s, Elder Abuse/Guardianship/Conservatorship, State Cases, State Statutes/Regulations, Television | Permalink | Comments (1)

Wednesday, June 6, 2018

Doctors' Conversations with Patients About Aid-in-Dying

Earlier this week I posted an update on California's aid-in-dying law.  I was interested in this article published in the New England Journal of Medicine, Beyond Legalization — Dilemmas Physicians Confront Regarding Aid in Dying.

Noting that doctors in jurisdictions where aid-in-dying is lawful are will need to have conversations with patients making the request, the author suggests

Physicians can start by clarifying what patients are asking and why. Some ways in which patients might raise the topic of PAD are listed in the box. Not every question about PAD is a request for assisted suicide. Patients might be seeking information, talking through concerns, expressing distress, or trying to ascertain the physician’s views. To clarify the patient’s motivation, physicians might say, “I’ll be glad to answer that question, but first please tell me what led you to ask.”

The author offers some examples of how patients might raise the issues with their doctors and suggests the next step for doctors is to

explore patients’ concerns and identify and address their palliative care needs, regardless of the physicians’ own views or the legal status of PAD where they practice. Discussions could cover patients’ physical symptoms; psychosocial, existential, and spiritual suffering; hopes and fears; and goals of care. All options for end-of-life care should be discussed, including palliative and hospice care and palliative sedation.

It’s also important for physicians to think through what actions they’re willing to take. Both physicians who support PAD and those who oppose it should try to relieve patients’ multidimensional concerns and distress. After comprehensive palliative care is intensified, 46% of patients who have requested PAD change their minds. (citations omitted).

The author recommends the doctors consider the parameters of when they would participate in medical-aid-in-dying, offering that "perceived loss of autonomy and dignity is now a more common reason for requesting PAD than inadequate pain control." (citation omitted). The author also discusses issues that may occur from a doctor's lack of experience in the area and potential adverse outcomes and counseling families about them. The author also offers some comments for doctors who are opposed to medical aid-in-dying  and concludes with this advice: "[r]esponding to inquiries about PAD is new territory for most physicians. To fulfill their obligations to patients and be true to their own values, physicians should think through how they will respond to the challenges raised by these conversations."

 

June 6, 2018 in Advance Directives/End-of-Life, Consumer Information, Health Care/Long Term Care, Other, State Statutes/Regulations | Permalink | Comments (0)

Monday, June 4, 2018

More on California's Aid-in-Dying Law

As we previously blogged, after a trial court judge struck the law, the California Attorney General filed an appeal.  According to a recent article in the San Francisco Chronicle, California’s right-to-die law on hold for at least a month.

California’s right-to-die law for terminally ill patients will apparently remain suspended for at least another month after a judge on Wednesday reaffirmed his ruling that the law was illegally considered and passed during a special legislative session on health care.

[The judge] ruled the law invalid May 15 and halted its enforcement last Friday. It had been in effect since June 2016, allowing doctors to prescribe life-ending medication to mentally competent adults who have less than six months to live.

On Wednesday, the nonprofit Compassion & Choices ... asked [the judge] to suspend his ruling and cited its potential impact on two terminally ill patients, one of them an 82-year-old Marin County woman who has already obtained a prescription for life-ending medication. The judge denied the request.

The state attorney general also weighed in, seeking to have the order set asid eon the grounds that "the judge improperly issued a statewide order in a local lawsuit and also should have given his office 10 days, under state law, to file objections to Friday’s order before putting it into effect."  The Judge has set a June 29 hearing.

The article offers this to describe the impact of the order. "Because of the ruling, doctors can no longer prescribe life-ending medication to dying patients, and a patient who had already been provided with the medication would be committing suicide by taking it, with implications for insurance coverage." 

Stay tuned!

June 4, 2018 in Advance Directives/End-of-Life, Consumer Information, Current Affairs, Health Care/Long Term Care, State Cases, State Statutes/Regulations | Permalink | Comments (0)