Thursday, November 1, 2018
The National Consumer Law Center sent out an email listing resources for attorneys and others helping elders recover from natural disasters. The email described the situation:
Older adults living in communities hit by natural disasters disproportionately suffer emotional trauma and financial hardship after the event. Age-related changes, including decreases in mobility and cognitive abilities make it harder for older adults to navigate the recovery process and access resources to repair or rebuild their homes. Once the immediate danger has passed, older adults will need assistance from insurance, government, and nonprofit organizations or other aid agencies to rebuild their home and community support system. In the days and weeks after the disaster older adults are forced to deal with a wide variety of issues, including home repair, reconnecting utilities, and making payments, including mortgage, credit cards, and student loans. Unlike many others affected by disasters, older adults may have fewer private assets to aid in recovery making the process to rebuild financially more difficult. Here are some resources the National Consumer Law Center (NCLC) has compiled to help guide advocates in advising older adults.
Issue Brief: Assisting Homeowners with Reverse Mortgages after a Natural Disaster: A Guide for Advocates, October 2018
Webinar: Assisting Older Homeowners after a Natural Disaster (National Center on Law and Elder Rights), June 20, 2018:
Free Webcast: Assisting Older Homeowners After a Natural Disaster, June 2018
Issue Brief: Helping Older Homeowners Recover from Natural Disasters, June 2018
Wednesday, October 31, 2018
Periodically as elder law profs, we have shared ideas for videos that we might use in our classes. It seems to me that it's been a while since we have done that, so I thought I'd share that I used the movie UP by Pixar recently in discussing property concepts regarding people who are older. I thought the first 15-20 minutes were good illustrations of aging in place, new urbanism, ageism, ADLs, crimes, stereotyping and even land use principles. Particularly the sequence that shows the husband and wife aging together is very compelling as the entire segment has no dialogue, yet the students completely know what was going on.
Any of you elder law profs have movies you use in your classes?
Tuesday, October 23, 2018
Consider enrolling in Medicare Part A, to cover hospitalization expenses....
Double up on checkups....Starting at age 65, [doctor] visits should last longer than the standard 20 minutes — so older patients have time to discuss what’s on their minds. Older patients who do this regularly tend to require “minor tweaks” instead of major repairs ....
Schedule annual visits to the dermatologist, ophthalmologist — and visits every five years to the gastroenterologist.
Take the leap and sign up for long-term health insurance....
Stick to a vaccine regimen. Vaccines are important again....
Evaluate your diet....
Bone up on Social Security....
Challenge your financial plan.....
Serve your community [by volunteering]....
Look to the future....
Get your paperwork in order....
Wednesday, October 17, 2018
EAGLE is the new guide on elder abuse for law enforcement is a joint effort from the U.S. Department of Justice along with USC's Keck School of Medicine (host of the National Center on Elder Abuse (NCEA)) as well as the USC Keck School of Medicine Department of Family Medicine & Geriatrics, the USC-Irvine Center of Excellence on Elder Abuse & Neglect & USC-Davis School of Gerontology. EAGLE includes a first responder checklists, a checklist for gathering evidence, information about state statutes, a section on interviewing victims and photography tips, to highlight a few. This is a significant tool and you need to take a look at it. Make sure your local law enforcement folks know about this website.
Thursday, October 11, 2018
Previously we have blogged about the need for caregivers and how that role typically falls to family members. What about those "elder orphans" or "solo agers" who don't have kids or family to fill that role? Kaiser Health News addressed that issue in the article, Without Safety Net Of Kids Or Spouse, ‘Elder Orphans’ Need Fearless Fallback Plan. “[E]lder orphans” (older people without a spouse or children on whom they can depend) and “solo agers” (older adults without children, living alone), [are expected] to move through later life without the safety net of a spouse, a son or a daughter who will step up to provide practical, physical and emotional support over time [and almost]22 percent of older adults in the U.S. fall into this category or are at risk of doing so in the future, according to a 2016 study." Not only are there a fair amount of folks in this category according to the survey, "70 percent of survey respondents said they hadn’t identified a caregiver who would help if they became ill or disabled, while 35 percent said they didn’t have “friends or family to help them cope with life’s challenges.” This means these folks are not prepared for aging, according to one expert quoted in the article. The article discusses the survey results and provides so suggestions for experts on how these elder orphans or solo agers can prepare.
But the key here is to be proactive-there is no magic wand here folks.
Tuesday, October 9, 2018
As Hurricane Michael is bearing down on the Florida panhandle, it bears mentioning that we are still in hurricane season down here in the Gulf coast and that natural disasters can occur anywhere at any time. So this article in the Tampa Bay Times giving an update about the SNFs in Florida complying with the generator law was timely. As hurricane nears, most long-term care facilities haven’t finished backup power plans notes that even as Hurricane Michael has the Florida panhandle in its path, "[m[ore than half of the 412 assisted-living facilities and nursing homes have yet to implement their emergency power plans, after receiving extensions from the state to comply."
A review of data maintained by the Agency for Health Care Administration shows that, in 33 counties encompassing the western half of the state south to Hernando County and east to Putnam County, more than half of the 412 assisted-living facilities and nursing homes have yet to implement their emergency power plans. Nearly all of those facilities have been granted extensions, many through the end of the year, citing regulatory delays and equipment and contractor shortages.
What are these non-compliant facilities likely to do, especially with landfall imminent? The article notes that "those facilities are turning to temporary generators, portable coolers and sometimes evacuations to keep residents safe — just as they have in years past before the rules were approved." The area projected for Hurricane Michael has a number of facilities that have received exemptions or are still in the process of complying with the rule. The article discusses what the state and regulators are doing and how facilities are preparing.
We have to hope for the best at this point. I think everyone is well served by asking long term care facilities about their disaster plans. The rest of us in Florida are keeping an eye on Michael's path and thinking about those in it.
Thursday, October 4, 2018
The call to action explains that "Medicare as we know it is under attack. Current efforts and proposals will privatize Medicare and increase costs. Against the wishes of most Americans, some lawmakers want to cut Medicare benefits, driving up costs to you, and making health care and prescription drugs even less affordable." (emphasis in the original). The website covers "why now", stories, facts, "take action" and has a link to donate. The "take action" page includes questions to ask Congressional candidates and an action kit, among other tools. Test your Medicare IQ on the facts page. And if you want to feel the urgency, look at the countdown clock to the midterm elections on the home page.
Tuesday, October 2, 2018
Sunday's Washington Post ran this article with an eye-catching title: Self-proclaimed ‘Old Coots’ offer life advice at farmers market. Their slogan: ‘It’s Probably Bad Advice, But It’s Free.’ Here's how this all came about:
The group of retired friends who meet every Saturday morning at a Salt Lake City deli were growing tired of the same conversation each week.
Sure, they were solving the world’s problems. But they wanted more excitement in their Saturday morning. They wanted to share their wisdom beyond their friend group of seven. As a lark, they set up a card table at the nearby Salt Lake City’s farmers market and told people they were dispensing free advice.
And guess what happened? "[T]o their surprise, people started showing up and sharing their problems. A lot of them." They realized they were filling an important need and they took this duty seriously. How popular are they? According to the article, "[e]ach Saturday since the summer, the “Old Coots” have taken on the issues of about 30 to 40 people who come by seeking their advice. It’s a way for a person to get an outside opinion from somebody who has nothing to gain...." Among the most common questions? Meeting someone and keeping romance in a relationship. They do get some unique questions, such as what to do about ghosts in the house of one person who stopped by for advice. What's out of bounds for topics? Politics and religion but they do have forms for folks who want to register to vote.
They don't give advice to each other-- they only give advice to strangers, because, as one of them quipped about giving advice to each other, “Who would listen?”
The end of the farmer's market season also marks the end of their advice giving at the market. They "will fold up their banner and card table when the farmers market ends for the season later this fall, but they hope to return next year, coffee cups in hand, advice at the ready. As one of them so insight fully noted, “To be truthful, I’m not sure that any of us can claim to have much wisdom, said [one of the old coots], but it sure has been a lot of fun. Maybe all of us coots really do have more to offer than we thought.”
Thursday, September 20, 2018
Florence has moved on, the California wildfires are under containment, and there is still that volcano in Hawaii... so it's only a matter of time until the next natural disaster. So the National Center on Law & Elder Rights recent issue brief from Fay Gordon at Justice in Aging, Legal Services and Disaster Assistance, is so timely. As the issue brief notes, "Legal aid organizations are quickly mobilizing to help older adults impacted by recent hurricanes,
wildfires, and volcanoes. Older adults are at increased risk of disease and death during disasters due to a higher prevalence of chronic conditions, physical disability, cognitive impairment, and other functional limitations.1 Potential limitations in mobility, access to transportation or limitations can further exacerbate the challenges older adults face during emergencies." (citations omitted) The brief offers resources from several agencies, offers a quick summary of the toolkit for state Medicaid agencies and consumer protection advice. This is all very useful information for us, regardless of where we live. Bookmark this issue brief!
Monday, September 10, 2018
The Washington Post recently published an interesting article considering the implications of retirement of business owners on employees. What a ‘silver tsunami’ of retiring Baby Boomer business owners could mean for their workers focuses on the implication of "the wave of retiring Boomers who own closely held private businesses. They will need to sell their companies, transition them to a new generation of owners -- or risk shutting them down, cutting jobs in the process."
The article looks at "a little noticed measure in the recently signed defense spending bill aims to address the widening wealth divide between workers and the owners or top executives who manage them. The measure, co-sponsored by Sen. Kirsten Gillibrand (D-N.Y.), is intended to expand financing options and raise awareness for programs that can help employees become partial owners of the companies where they work" which "make[s] it possible for firms to use Small Business Administration loans to finance what’s known as employee stock ownership plans, or ESOPs, an arrangement that can help transfer ownership of the company to employees rather than have to find a suitable buyer or rely on family members who may be ill-suited or unprepared to keep the lights on."
According to one expert, this change is a big deal, although the "immediate impact is probably limited to small companies: The SBA loans that can be used are capped at $5 million, though they can be combined with other financing."
Wednesday, September 5, 2018
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
Wednesday, August 29, 2018
Women still tend to work fewer years and earn less than men, which leads to less income in retirement. One reason is that women are often still the main family caregiver. Traditionally, Social Security has recognized this role by providing spousal and widow benefits for married women. Today, however, many women are not eligible for these benefits because they never married or they divorced prior to the 10-year threshold needed to qualify. Even those who are married are less likely to receive a spousal benefit, as their worker benefit is larger. Thus, many mothers receive little to no support to offset lost earnings due to childrearing.
The 10 page brief looks at how the topic is handled in other countries and discusses two avenues for resolution in the U.S.: (1) "[i]ncrease the number of work years that are excluded from benefit calculations ... [and] (2) [p]rovide earnings credits to parents with a child under age six for up to five years." The article concludes in part
It is easy to understand the appeal of crediting Social Security records to reflect lost earnings due to caring for a child. In the past, this activity was usually compensated for by the spousal benefit, but changes in women’s work and marriage patterns have left fewer eligible for it. A credit is also more appealing than a spousal benefit if the goal is to compensate for the
costs of childrearing, independent of marital status.
Tuesday, August 28, 2018
On several occasions I've written about the issues of caregivers (the shortage of family caregivers, the financial impact on care giving) so i was interested in this article by Kaiser Health News, A Late-Life Surprise: Taking Care Of Frail, Aging Parents notes the failure of adult children to plan for their roles of caregivers-a role that may last a number of years and even cause the adult child to stop working. The KHN story focuses the profile of a "typical family caregiver, "“When we think of an adult child caring for a parent, what comes to mind is a woman in her late 40s or early 50s,” said Lynn Friss Feinberg, senior strategic policy adviser for AARP’s Public Policy Institute. “But it’s now common for people 20 years older than that to be caring for a parent in their 90s or older.” The story cites a new study from "the Center for Retirement Research at Boston College [which] is the first to document how often this happens. It found that 10 percent of adults ages 60 to 69 whose parents are alive serve as caregivers, as do 12 percent of adults age 70 and older."
The study shows that "about 17 percent of adult children care for their parents at some point in their lives, and the likelihood of doing so rises with age ... because parents who’ve reached their 80s, 90s or higher are more likely to have chronic illnesses and related disabilities and to require assistance, said Alice Zulkarnain, co-author of the study."
So consider the implications, some of which I mentioned in the above parenthetical in the opening sentence. The article lists the physical wear and tear "on older [caregiver] bodies, which are more vulnerable and less able to recover from physical strain" the potential for psychological stressors which can exacerbate any health issues the older caregiver may have, and social isolation of caregivers. There's also the financial toll that may come, with "hard-earned savings at risk with no possibility of replacing them by re-entering the workforce."
Monday, August 27, 2018
The title is somewhat tongue in cheek (I use the phrase in my class to be provocative) but it was only a matter of time until the potential of a micro-chip for elders was becoming a reality. This firm already microchips employees. Could your ailing relative be next? in the Washington Post, explains that a firm that already microchips employees is looking to develop "a more sophisticated microchip that is powered by human body heat and includes GPS tracking capabilities and voice activation [and]... [they] acknowledge that the chips will offer a convenient way to track people — especially those suffering from Alzheimer’s and dementia." The chip the company has in mind will do more than just track whereabouts, according to the article. It will have a medical component that will track the wearer's vitals and notify the wearer's doctor if something is amiss. These "medical microchips" have proponents as well as detractors as the article explains.
The article offers that only about half of the company's employees opted for the microchip, and there are other companies using the technology with humans. One expert thinks using microchips with humans is going to be a done-deal, but not for a few decades. I'm all for the use of tech, but worry about privacy, informed consent and cyber security issues. Although it requires a chip to be inserted into the body, is it any less invasive than cameras or technology monitoring devices such as those used in a medical cottage or a gps tracker in a cane or shoes? I still hold out hope for privacy....even though it may be eroding.
Monday, August 13, 2018
A recent article, ‘Too little too late’: bankruptcy booms among older Americans published in The Business Times opens with a sobering thought: "[f]or a rapidly growing share of older Americans, traditional ideas about life in retirement are being upended by a dismal reality: bankruptcy." A new study featured in the article paints a foreboding picture for many elder Americans "'[t]he rate of people 65 and older filing for bankruptcy is three times what it was in 1991, the study found, and the same group accounts for a far greater share of all filers." What is causing this increase? According to the article, many factors, including changes in pension plans, health care out of pocket costs, declining incomes, to name a few. It notes as well that elder Americans may have more challenges in recovering from financial setbacks than others. The study is done by the Consumer Bankruptcy Project, which "is a long-running effort now led by Thorne; Lawless; Pamela Foohey, a law professor at Indiana University; and Katherine Porter, a law professor at the University of California, Irvine. The project — which is financed by their universities — collects and analyzes court records on a continuing basis and follows up with written questionnaires. ... Their latest study —which was posted online Sunday and has been submitted to an academic journal for peer review — is based on a sample of personal bankruptcy cases and questionnaires completed by 895 filers ages 19 to 92."
The paper by the study authors, Graying of U.S. Bankruptcy: Fallout from Life in a Risk Society has been placed on SSRN.
The abstract offers this
The social safety net for older Americans has been shrinking for the past couple decades. The risks associated with aging, reduced income, and increased healthcare costs, have been off-loaded onto older individuals. At the same time, older Americans are increasingly likely to file consumer bankruptcy, and their representation among those in bankruptcy has never been higher. Using data from the Consumer Bankruptcy Project, we find more than a two-fold increase in the rate at which older Americans (age 65 and over) file for bankruptcy and an almost five-fold increase in the percentage of older persons in the U.S. bankruptcy system. The magnitude of growth in older Americans in bankruptcy is so large that the broader trend of an aging U.S. population can explain only a small portion of the effect. In our data, older Americans report they are struggling with increased financial risks, namely inadequate income and unmanageable costs of healthcare, as they try to deal with reductions to their social safety net. As a result of these increased financial burdens, the median senior bankruptcy filer enters bankruptcy with negative wealth of $17,390 as compared to more than $250,000 for their non-bankrupt peers. For an increasing number of older Americans, their golden years are fraught with economic risks, the result of which is often bankruptcy.
Tuesday, July 24, 2018
We have blogged in the past on the family caregiver shortage heading our way. Some might even call it a crisis as the baby boomers relentlessly age on in large numbers. On Monday, one item in Kaiser Health News daily briefing offers this headline For Generations, Nation Has Relied On Family Caregivers. But Shifting Social Dynamics Could Leave A Vacuum.The Wall Street Journal examined this issue in America Is Running Out of Family Caregivers, Just When It Needs Them Most(subscription required). The article opens with a focus on one elder who has no children. Who will be her caregiver? "For generations, the nation has relied on family members to keep aging loved ones in their homes. Today, many Americans are growing older without family nearby, offering a glimpse of what the future may hold for the cohort of Americans who are approaching retirement."
The article pains a somewhat distressing picture of the future facing many older Americans, with low incomes, substantial debt (the article notes some of which may be from caring for their parents), and no family or nearby family to be caregivers. Currently nearly 95% of caregivers are family providing approximately "$500 billion worth of free care annually [yes you read that correctly--BILLION]—three times Medicaid’s professional long-term care spending—and help keep people out of costly institutions, according to a 2017 Merrill Lynch study." That sounds wonderful, but here is where this is all about to fall apart: "the supply of these caregivers is shrinking just as the nation needs them most. Every day, 10,000 people turn 65. In 2020, there will be 56 million people 65 and older, up from 40 million in 2010" while the number of available caregivers is shrinking, for a variety of reasons. Are there other options? Yes-private sector, but that's expensive and home health aides may be in limited supply. We already know about the limited benefits through Medicare and Medicaid. Boomers, no strangers to being part of the sandwich generation, may now find themselves in a different type of sandwich-they may be providing care for their parents and will perhaps need care for themselves or their spouses. Families are far flung, so caregiving from afar may be a new model. "Children do what they can from hundreds of miles away, checking references for an aide, managing bills, or arranging grocery deliveries. They often feel guilty for not being there to take a parent to the doctor and uncertain about how someone is really doing."
Technology (and there are a lot of cool options out there) may be offered as a mode of caregiving, perhaps even a substitute for an in person caregiver, but technology is not without limits. In some areas volunteers are filling in the gaps but of course, funding and sufficient volunteers can be an issue.
So what should these "elder orphans" do? "One-third of middle-age adults are heading toward their retirement years as singles. Women, in particular, are likely to stay or become single as they age....About 14% of frail older adults, or two million people, are without children and the number is expect to double by 2040, according to the AARP Public Policy Institute. “There’s no natural caregiver for this population,” says Grace Whiting, CEO of the National Alliance for Caregiving....While they can, they need to construct a network around themselves, aging experts say."
The article concludes with 5 recommendations, including local area agencies on aging, transportation, private companies, technology and remodeling a home to make it accessible. To that list I'd add, make a plan and talk to your elder law attorney about it. This is a comprehensive article that would be a good basis for a class discussion!
Monday, July 23, 2018
Ugh, identity theft. It's just awful. Too many people have their identities stolen and the thieves use the information to file false tax returns. Is the IRS doing enough to protect taxpayers? The GAO recently released a report analyzing the actions of the IRS and making recommendations. Identity Theft: IRS Needs to Strengthen Taxpayer Authentication Efforts provides 11 recommendations from the GAO, revolving around identity authentication. Recommendations include policies for undertaking risk assessments through a variety of mediums, since taxpayers don't use the same communications method to contact the IRS, examine procedures and collect data. The full report is available here. The landing page also offers highlights as well as a podcast. And here's a bonus recommendation-whatever safeguards the IRS uses for authentication, how about making the reporting process as easy as possible for the victims? Just a thought....
Wednesday, July 11, 2018
AARP has named the top 10 cities with populations 500,000 and over that are the most "liveable." I'm not living in one of the top ten-are you? Nor am I living in one of the top 10 mid-sized (100,000-499,999) "liveable" communities. Nope, not living in one of the top 10 small (25,000-99,999) "liveable" communities either.
How does AARP determine if a community meets their liveability scale? The website explains that "AARP developed the Livability Index, a ground-breaking tool—now in its third year—that uses more than 50 national data sources and 60 indicators spread across seven categories to jump-start community conversations about livability and encourage action by consumers and policymakers alike.It turns out that many of the characteristics that make a community “livable” are the same across all ages: safety and security, affordable and appropriate housing and transportation, and the ability to live near family and friends who can be relied upon." The index looks at housing, environment, health, community engagement, employment, neighborhoods and transportation. How does your city fare?
BTW, this could be a really good exercise for students to do in their elder law course. The fall semester will be here before we know it!
Friday, June 22, 2018
CityLab recently ran a story about populations and particularly, where elders are residing. Mapping America’s Aging Population explains that "Demographers and geographers have watched as this aging cohort transformed the U.S., from young children in the 1950s and 1960s to senior citizens today. This graying of America has left a distinctive geographical fingerprint."
Want to guess where elders are living? If you started with the sunbelt you would be somewhat correct. "Unsurprisingly, popular retirement states like Florida and Arizona have high concentrations of older Americans... What may be more of a surprise is the broad swaths of elderly running through the Midwest and the Appalachians. These regions have aged significantly, as many younger residents headed toward the coasts." The demographic maps provide good pictorial representations of the locations where elders are living.
The article looks at births and deaths and relocation. Interestingly, "[p]eople are less likely to move as they age. In 1968, parents of the baby boomers were in their highly mobile, young adult years, but today boomers are older and more apt to stay where they are."
The Boomers seem to be clustering in certain geographic areas:
Baby boomers have contributed to this trend. Fifty years ago, this group was spread out evenly among the rest of the general population. By 1990, they had became more bicoastal and were concentrated in a small number of dynamic, growing metropolitan areas.
Between 1990 and 2000, a substantial number of boomers flocked from these metro areas to amenity-laden retirement and pre-retirement regions, like the Pacific Northwest, Florida, northern Wisconsin and Michigan, as well as some areas of the South, like the Ozark region and the Western Carolinas.
These areas have continued to grow, while baby boomers moved away in their greatest numbers from the southern Great Plains and the area along the Mississippi River Valley.
Thanks to my colleague and dear friend, Mark Bauer, for sending me the article.
Tuesday, June 19, 2018
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."