Medical Care at the End-of-Life

Medical Care Immediately Prior to Death

In the first half of the 20th century, most people who died had an accident or contracted a disease or they had physical disorders that inevitably lead to death. Life-saving medical interventions such as sophisticated resuscitation, complicated surgeries, life-saving treatments, ventilators, feeding tubes and other life-support were rarely used or even available. Nowadays there is great emphasis on curing medical problems sometimes to the exclusion of recognizing that death might be a more welcome outcome.

Surveys indicate that older people are often more afraid of death than younger people. But for all Americans — young and old — there is a great fear of death.  Oftentimes, the families of those near death will go to great lengths to try interventions that may be ineffective in prolonging life. Estimates are that about 30% of Medicare reimbursements are spent on people in the last year of their life. It is a fact that much of this medical care did little to prevent death and prolong life.

According to the Dartmouth Atlas study on death:

“The quality of medical intervention is often more a matter of the quality of caring than the quality of curing, and never more so than when life nears its end. Yet medicine’s focus is disproportionately on curing, or at least on the ability to keep patients alive with life-support systems and other medical interventions. This ability to intervene at the end of life has raised a host of medical and ethical issues for patients, physicians, and policy makers.”

The Dartmouth Atlas project uncovered some startling differences in what happens to Americans during their last six months of life. The level of hospitalization during those months varies greatly from one region to the next.

The Atlas researchers asked why this was so.  Why is someone living in Miami so much more likely to receive a great deal of high-tech, expensive medical services, while someone with the same condition who lives in Minneapolis receives so much less? The answer appears to have very little to do with religious or spiritual beliefs or personal preferences.  Rather, the answer appears to be that the capacity of the local health care system – the per-capita supply of hospital beds, doctors, and other forms of medical resources – is the dominating influence. Those who live in areas like Miami, where there are very high per capita supplies of hospital beds, specialists, and other resources, have one kind of end of life experience. Those who live in areas like Minneapolis or San Francisco, where acute care hospital resources are much scarcer, have very different kinds of deaths.

The question, then, is which is better? From the dying person’s perspective, more is not necessarily a good thing.  That is, more visits to doctors for someone who is very sick can be stressful and exhausting. For many people a hospitalized death is something to be avoided if at all possible. From the perspective of the health care system, much of the care being given is futile, and accomplishes little. People who live in areas with very high utilization of hospital resources do not live longer than people who die in areas where utilization is lower – and if extension of life is not the goal of intervention, what is?

Deciding How and When to Stop Curing and Start Caring

Some people are content to leave decisions regarding their death in the hands of others. By doing so, they may expose themselves to unnecessary and futile treatments as outlined above. They may experience numerous visits to the emergency room in the last stages of their life. And their dependency on others often results in great stress to family members when loved ones at the end-of-life lose their capacity and didn’t make their last wishes known. Families are often forced to make decisions about life-support and treatment without knowing whether their loved one would have wanted these interventions.

Advance Directives

These, are the minimum documents you need to make sure your wishes for health and medical care and end of life decisions are honored.

• Durable Power of Attorney for Health Care
• Living Will
• POST (Physician Orders for Scope of Treatment)
• HIPAA Release

A patient or his or her spouse or a family member will typically call 911 in the event of a life-threatening emergency. Very seldom will the advanced directives end up with anyone in the emergency room. Therefore, medical decisions are generally made by family members who show up at the hospital. The actual health treatment wishes of the patient may be at home in the desk drawer. It is therefore extremely important to remember to take these documents to the emergency room whenever a crisis arises. It is also critical that family members be made aware of your wishes and the existence of your advance medical directives as well as where they can be found.

When it comes to these very difficult questions timing is everything. In order to maintain control as long as possible and have an effect on your own end of life decisions you must choose to act now. Your decisions need to be made known and documented correctly. Good planning is no accident!

Call us today and let us help.

Idaho Estate Planning

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4 Steps of Long Term Care Planning Part II

Step 1-Knowledge & Preparation are the Keys to Success

This step requires an understanding of the variety living arrangements and different settings under which care is provided. In addition, understanding the provisions and limitations of government programs is essential because the public generally has a misconception that the government will step in and provide care when the time is needed.

Take time to investigate the options for short and long term care in your area. Knowledge of the choices available to you and the annual costs involved will make the steps that follow easier.

Government programs are limited and according to research by the National Care Planning Council, only 16% of all long term care services are provided by government programs. The other 84% is provided free of charge by family members, friends, charity, church groups or volunteers or paid for by private funds.

Step 2-Funding the Cost of Long Term Care

Much emphasis is being placed on purchasing long term care insurance or arranging for reverse mortgages in order to fund the cost of care. These can be useful tools for providing funding but in reality, this approach for planning is not working that well.

After 30 years of being touted as the ultimate solution, less than 2% of the American public and only 9% of seniors own long-term care insurance policies and using reverse mortgages may be a good strategy but in practice, few seniors are using them to pay for care.

Financial planning is an important part of being prepared for long term care if and when it becomes necessary. The scope of investment tools available to Americans has dramatically increased over the last few decades. Consult with an experienced professional to determine the best course of action.

Step 3-Using Long Term Care Professionals

Long term care services are complicated and provider contacts are fragmented throughout the community. For the majority of Americans, eldercare becomes a frustrating do-it-yourself process. This approach is unnecessary. Using care professionals is the most cost effective and efficient way to provide help for a loved one.

Those people who need help with long term care and use the services of professionals often find they save money over doing it themselves. They also reduce their stress and they free up a considerable amount of their personal time. Another benefit with using professional help, such as a care manager, elder law attorney or mediator, is to help you alleviate or avoid family conflicts that often arise as a result of caregiving.

Hiring professional advisers or providers to help with long term care is no different than using professionals to help with other complex issues such as investing, car repairs, dealing with taxes or legal problems. With their education and training, long term care professionals also bring experience that only comes from dealing with countless hands-on, caregiving challenges.

Step 4-A Written Plan that is Accepted by All Involved

The first three steps in the planning process are designed to give you a wealth of information about long term care. It is important for you to have an understanding of care systems and the resources you can turn to when the need arises. However, knowledge of long term care systems is not enough. You must take some tangible action now to prepare for the day when you will need to deal with eldercare for your loved ones or for yourself.

The final fourth step in the planning process is making a care plan. You need to prepare a written plan for you or a loved one. The challenge of dealing with long term care will unfold for you in a more manageable manner if you make a plan and put it in writing. You will experience less stress, have fewer costs, require less time committed and have fewer family conflicts.

At Idaho Estate Planning we have all the resources you need to put a plan together. We have the experience and expertise to help you maintain your options and protect yourself as well as your loved ones now and into the future. The best time to plan is always now!

Recognizing Symptoms of Dementia

The Brown family reunion has always been an event everyone looks forward to. Family visits, games, stories and everyone’s favorite foods are always on the agenda. On the top of the menu is Grandmas Lemon Coconut Cake. Grandma always makes the traditional cake from her old family recipe. This year, however, the cake tasted a little on the salty side, perhaps a half cup full of salty.
Though the family was disappointed over the cake, of more concern was Grandma’s confusion with the recipe and her similar confusion about the loved ones around her. Could something be wrong with grandma’s mental state?
One might say that for an elder person a little forgetfulness or confusion is normal, but when do you know if there is a serious problem, such as dementia?
An online article from FamilyDoctor.org outlines some common symptoms in recognizing dementia.
“Dementia causes many problems for the person who has it and for the person’s family. Many of the problems are caused by memory loss. Some common symptoms of dementia are listed below. Not everyone who has dementia will experience all of these symptoms.

• Recent memory loss. All of us forget things for a while and then remember them later. People who have dementia often forget things, but they never remember them. They might ask you the same question over and over, each time forgetting that you’ve already given them the answer. They won’t even remember that they already asked the question.
• Difficulty performing familiar tasks. People who have dementia might cook a meal but forget to serve it. They might even forget that they cooked it.
• Problems with language. People who have dementia may forget simple words or use the wrong words. This makes it hard to understand what they want.
• Time and place disorientation. People who have dementia may get lost on their own street. They may forget how they got to a certain place and how to get back home.
• Poor judgment. Even a person who doesn’t have dementia might get distracted. But people who have dementia can forget simple things, like forgetting to put on a coat before going out in cold weather.
• Problems with abstract thinking. Anybody might have trouble balancing a checkbook, but people who have dementia may forget what the numbers are and what has to be done with them.
• Misplacing things. People who have dementia may put things in the wrong places. They might put an iron in the freezer or a wristwatch in the sugar bowl. Then they can’t find these things later.
• Changes in mood. Everyone is moody at times, but people who have dementia may have fast mood swings, going from calm to tears to anger in a few minutes.
• Personality changes. People who have dementia may have drastic changes in personality. They might become irritable, suspicious or fearful.
• Loss of initiative. People who have dementia may become passive. They might not want to go places or see other people.”

Dementia is caused by change or destruction of brain cells. Often this change is a result of small strokes or blockage of blood cells, severe hypothyroidism or Alzheimer’s disease. There is a continuous decline in ability to perform normal daily activities. Personal care including dressing, bathing, preparing meals and even eating a meal eventually becomes impossible.
The Alzheimer’s Organization reports that 5.3 million Americans suffer from Alzheimer’s disease, the most common cause of dementia. They also report that there are 10.9 million unpaid caregivers helping those afflicted by the disease. In 2000, there were an estimated 411,000 new (incident) cases of Alzheimer’s disease. For 2010, that number is projected to be 454,000 new cases; by 2030, 615,000; and by 2050, 959,000. To read the full report, visit www.alz.org.
In the beginning, family members find part time caregivers for their loved one. At first, loved ones need only a little help with remembering to do daily activities or prepare meals. As dementia progresses, caregiving demands often progress to 24 hour care. Night and day become confused and normal routines of sleeping, eating and functioning become more difficult for the patient. The demented person feels frustrated and may lash out in anger or fear. It is not uncommon for a child or spouse giving the care to quickly become overwhelmed and discouraged.
Now is the time to address concerns you may have for yourself or a loved one. At Idaho Estate Planning we have the experience and the resources you need.

IDAHO ESTATE PLANNING – THE LEGACY EXPERTS
We are your best source for legacy planning and the only source for the Life Plan™ in Idaho.
Estate Planning – Living Wills – Advance Directives – Veterans Planning – Medicare Planning

Maintaining Control of Your Health Care Options

Being In Control
Perhaps the most important goal of any estate plan is to allow the client to maintain control. Most of our clients here at Idaho Estate Planning are very intent on “being in control” as long as possible. They want to make their own decisions about whether to go into a “facility” or stay in their house. (Usually the choice is to stay at home as long as possible.) However, the ability to be in control and stay at home is challenged constantly.

Some of the challenges to being in control consist of those disabilities we all fear:  Alzheimer’s disease, dementia, other mental challenges and numerous physical disabilities. The biggest question becomes, “How do I maintain control if I suffer one of these disabilities?” While these situations are varied (and extremely difficult), there are some basics that will allow you to exercise control, that is, allow you to voice your opinion is such a situation.

Durable Power of Attorney for Health Care
First and foremost, you need to execute a Durable Power of Attorney for Health Care. This is a legal document that allows you to personally choose who will make decisions or give instructions if you are not able to, whether from mental or physical disability. This is an extremely important document to have in your estate plan. It is, therefore, extremely important to carefully consider who you want giving instructions to health care providers on your behalf. Typically, this is a spouse.

But, if the spouse is unable to fulfill this responsibility, who will take over? This requires great thought and consideration. Who has the skill set to take on this responsibility? Who understands what you want to have happen? These are not easy decisions and should not be undertaken lightly.

Living Will
A Living Will is a form created by statute that allows you to express a preference if it is determined by two doctors that you are in a terminal state and being kept alive by artificial life support measures. The Living Will also applies if you are determined to be in a persistent vegetative state (some call this being “brain dead”). The Living Will allows you three basic choices: 1) to forego all life preserving efforts being applied whether artificial or natural; 2) to forego any life preserving efforts applied; or 3) only natural efforts applied including food or water or both. In reality, while these situations do occur, they are rare.

The POST
The Physician Orders for Scope of Treatment or “POST” is a more detailed legal document that allows you be very specific in how treatment, whether artificial or natural is applied to you. You can choose to forego intravenous feeding or the use of a feeding tube. You can choose to forego intubation to keep you breathing. You can choose to forego “aggressive methods” to preserve your life. Each of these is an option that you choose.

HIPAA
If your Living Will or POST is needed, it is your Health Care Agent as established in your Power of Attorney for Health Care who gives the instructions to the health care professionals. These documents, then, work together to help you maintain control of your own situation. One more document that makes all the others work better is the HIPAA release. This is an informational release in which you give the health care professionals permission to provide your health information to your Health Care Agent or other family members. In essence, the Power of Attorney allows your Health Care Agent to talk to the doctor. The HIPAA release allows your doctor to talk to your Health Care Agent.

These, then, are the minimum documents you need to make sure your wishes for health and medical care and end of life decisions are honored. Now is the time to address these concerns and plan for the most difficult of times. Once it starts raining (or hailing as it did yesterday), it’s a little late to start fixing the roof. Once you are incapacitated, it’s too late to do this planning.

IDAHO ESTATE PLANNING – THE LEGACY EXPERTS
We are your best source for legacy planning and the only source for the Life Plan™ in Idaho.
Estate Planning – Living Wills – Advance Directives – Veterans Planning – Medicare Planning