In this issue:
September 22, 2010
"Health Care Decisions" In An Assisted Living Community
Part Six of Susan's Nine Part Series
If you have an urgent question, or just wish to speak to Susan directly, you can email or call, susan@mymomnpop.com or (310) 897-7434.
If you have missed any part of Susan's extremely insightful series on Assisted Living, just "click here" and email us. Be sure to be specific about what "Parts" of the series you missed and we will send them to you right away.
Counting My Octobers (Dedicated to The Magnificent Mrs. MB)
This is a MUST Read from Susan's latest blog. It will inspire you. Guaranteed.
"Raising UP Your Parents," the Graceful Aging Seminar and Expo
Do you know anyone in Orange County of the San Fernando Valley who is dealing with elder care issues? Tell them about Susan's California Seminar Tour. Just go to the bottom of this email and click on the blue wording,Forward Email.
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"Health Care Decisions"
Part Six of Nine on Assisted Living
Anyone
who knows me or who has
attended one of my lectures know that I am a huge proponent of advanced
planning. For anyone who is over the age of 18, an advanced health care
directive is a must. Most people have this done as part of their estate
plan, whether they have a will or a trust.
If you do not have an estate
plan and you have 
assets or children to protect call me, please.
Please
don't mistake this as a shameless plug for
business. I have
an estate plan and picking who
the appropriate person would be to act
as guardian for my children should something happen to me and my husband
was agonizing. Moreover, having a complete stranger make medical
decisions for me should I become incapacitated was a horrifying
prospect.
Many of my clients had their estate
plans done some time ago and the individuals chosen are no longer appropriate.
One such client had a friend who was no longer alive and daughters who
subsequently moved out of the country. If you have an estate plan, please
check your documents to make sure that they are still in line with your
wishes or practical.
If you have been getting the last
5 parts of this series (there are only 3 left), you have gotten the
idea that assisted living is not unlike living in your own apartment
or condo. Hence, it goes without saying that an assisted living resident
has the right to make her own health care decisions as long as she has
the capacity to do so.
If, however, a resident becomes mentally incapacitated
(due to a stroke, coma, dementia, or other disease or accident), the
resident legally can receive health care only if a legal representative
for the resident authorizes the health care, or if the resident previously
had issued health care instructions in the format required by law.
(Remember, if you do not wish to read the entire newsletter, but would like to ask me any questions, call me at 1 (888) 422-6070 or email me, susan@mymomnpop.com )
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May a resident authorize or refuse medical treatment?
Yes. An assisted living resident has the same 
rights as other adults to receive
or reject
medical care. This brings up the issue of a do
not resuscitate (DNR)
form, a living will and a
POLST (physician orders for life sustaining
treatment).
Mostly what I encounter is that people do not understand the
difference between these documents and their interrelationship.
Here
are some basic definitions:
A DNR (Do Not Resuscitate) Form (actual title: "Emergency Medical Services
Prehospital Do Not Resuscitate (DNR) Form) is an official State document
developed by the California EMS Authority and the California Medical
Association which, when completed correctly, allows a patient with a life
threatening illness or injury to forgo specific resuscitative measures that may
keep them alive.
These measures include: chest compressions (CPR), assisted
ventilation (breathing), endotracheal intubation, defibrillation, and
cardiotonic drugs (drugs which stimulate the heart). The form does not affect
the provision of other emergency medical care, including treatment for pain
(also known as "comfort measures"), difficulty breathing, major
bleeding, or other medical conditions.
Many patients make their DNR wishes
officially known because they do not want to be placed on life-assisting
equipment in the event that their heart or breathing ceases.
The best way to ensure that your wishes are honored is to complete the official
State Prehospital DNR form and have it signed by your physician and readily
accessible when EMS help arrives. If you are concerned about the form being available at
all times, you would be well-advised to obtain and wear a MedicAlert bracelet
or neck medallion engraved with your DNR requirements.
I spoke to a number of assisted living facility personnel and they almost
uniformly stated that they will still call the paramedics if a DNR is in place,
but they will then show them the document upon arrival. I suspect that this is
a liability issue.
Many times families do not know or understand that a loved
one did not want intervention and might challenge the facility. Also, if the
individual can speak, they may override their own written order. If that
happens, the most recent communication of one's intentions will prevail.
If a resident is on hospice however, EMS will not be called. The facility will call the police who then calls
the coroner.
Physician Orders for Life-Sustaining Treatment 
(POLST), a standardized medical
order form
printed on brightly colored paper, indicates
which types of
life-sustaining treatment a
seriously ill patient wants or doesn't want if his
or her condition worsens.
On August 4, 2008 California
Governor Arnold Schwarzenegger signed Assembly Bill (A.B.) 3000 into law. This
bill amends the California Probate Code to add a recognition of Physician
Orders for Life-Sustaining Treatment (POLST) forms to the current recognition
of "do not resuscitate" (DNR) forms. It does not require the use of a
POLST form, but describes the requirements if one is used. It also changes the
phraseology describing POLST and DNR forms from a "request to forgo
resuscitative measures" to a "request regarding resuscitative
measures." This reflects the fact that POLST forms may be used by a
patient to request interventions as well as to refuse them.
Too often, necessary conversations about end-of-life medical interventions and
intensity of care don't occur. The POLST form, signed by both the physician and
the patient, becomes a tool to capture these discussions and make them part of
the patient's medical record. The form moves with the patient and must be
honored across all settings of care.
In my experience, he POLST form is used for people who have serious chronic
medical issues. It covers much more than a DNR. POLST forms are designed to be
a physician's order that addresses a patient's wishes about a particular set of
medical issues, including cardiopulmonary resuscitation (CPR), antibiotic use,
artificial nutrition, and degree of medical intervention desired by a patient
when he or she is not in cardiac arrest, such as intubation, or artificial
ventilation.
In a hospital, nursing home, or assisted living facility, the form will be in
your medical record or file. It may be used in addition to -- or instead of --
a Do Not Resuscitate (DNR) order.
The POLST form helps medical providers understand your wishes at a glance, but
again, it is not a substitute for a properly prepared Advance Directive. An
Advance Directive provides more information than a POLST form, including
details about your health care agent, more complete health care wishes, and
your preference for organ donation.
The bottom line: If you have a POLST form, you do not need a DNR order, but you
should still complete an Advance Directive to provide a full set of wishes
about your care. The POLST form provides for an expression of a patient's
wishes to a health care provider for certain specific issues related to
end-of-life care by the patient or a surrogate, rather than the broad deference
to an agent to carry out the patient's health care and post-death wishes in an
advance directive. Further, an advance directive contains much more information
than a POLST form, such as the name of an agent, wishes about pain relief,
preference for or against autopsy, and preferences regarding organ donation.
A Living Will is part of your advance health care directive. It will not be by
the followed by the EMS. It is like a POLST in that it specifies what medical interventions
you would like should you suffer a terminal illness or medical crises where the
prognosis is not good but for extreme measures.
For example, if you suffer a
heart attack, but otherwise do not have any terminal illness and are not
permanently unconscious, a living will does not have any effect. You would
still be resuscitated, even if you had a living will indicating that you don't
want life prolonging procedures. A living will is only used when your ultimate
recovery is hopeless.
*****IT IS IMPORTANT FOR YOU TO UNDERSTAND THIS:
If you executed a Durable Power of Attorney for Health Care (DPAHC) before
1992, it has expired. If you have executed a DPAHC before 2000, when the
California Health Care Decisions Law consolidated previous directives into the
AHCD, you should check to see that the forms have not expired and still reflect
your wishes.
Why should a resident appoint another person to
make health care decisions for her?
Most facility residents have the capacity to make health care decisions for
themselves. Any resident, however, may become mentally incapacitated in the
future. Consequently, a resident should prepare now to assure that she receives
appropriate health care if she ever becomes mentally incapacitated.
If a resident has no legal representative when the resident becomes mentally
incapacitated, the resident may not be able to receive needed medical
treatment. Similarly, a mentally incapacitated resident without a legal
representative may not be able to refuse medical treatment which will only
prolong her pain, even if the resident has no real prospect of recovery.
On the other hand, if a person has been appointed to make health care decisions
for a mentally incapacitated resident, those decisions can be made in a way
most consistent with the resident's expressed desires.
The previous discussion applies to everyone, not just to assisted living
residents. Persons of all ages and health conditions can benefit by appointing
a family member or friend now to make health care decisions if and when the
appointing person becomes mentally incapacitated.
One last item, if you have not noticed, my seminars in Orange County are
coming up on October 9 and 23 at the Huntington Beach Hotel and Irvine Hilton
respectively.
Aside from me, there will be many speakers who are experts in their fields. A
Registered nurse from Silverado Senior Living who is in
the trenches with
dementia and Alzheimer's residents will discuss the role of social stimulation
and behavioral modification as opposed to medical interventions.
As
discussed in my last newsletter there are some assisted living facilities that
are designed to exclusively serve that population, Silverado Senior Living's
communities hold a unique place in the assisted living industry.
A representative of The Covington will also be there. The Covington is
a non-profit continuing care retirement community in OrangeCounty
that provides the full continuum of care from independent living, assisted
living, dementia care, and skilled nursing. He will be able to clarify what the
role of a CCRC is on the continuum of aging.
Also speaking will be Monica Bush from ResCare. ResCare is a 24 hour Home Care
agency that also provides Geriatric Care Management and Telehealth and their
Rest Assured program. They are a CAHSAH certified agency. Ms. Bush is a MSW and
CMC.
Oxford Home Health will discuss under what circumstances home health will be
covered by Medicare and what services constitute home health care. I have
worked with them for years and have yet to be disappointed.
Also present will be a representative from CapTel The telephone that displays
written, word-for-word captions of everything the caller says. It is remarkable
technology for the hearing impaired.
Many more experts will be there to answer questions such as Florie Leddel who
is the penultimate expert in long term care insurance and the one person I
trust the most with my clients LTC insurance needs as well as Kathryn Humphres
from MRS (Medi-Cal Regulations Specialists).
Like Ms. Leddel, Kathryn is an
expert in her field. In fact, Ms. Humphres worked for the Department of Health
services as a Medi-Cal eligibility worker for six years before starting her
company. Kathryn has been responsible for over a thousand Medi-Cal eligibility
approvals during her 13 years of privately advocating for families.
"Raising UP Your Parents" The Graceful Aging Tour for adult children, their elderly parents, and caretakers
As a Gerontologist,
elder law attorney, and a former elder law professor, I have put
together a seminar that can help prepare you for what lies ahead for you
or someone you are caring for.
Coming to Huntington Beach, Irvine and Woodland Hills, October and November, 2010.
You can forward this newsletter to your friends and loved ones by clicking on the link at the bottom of this newsletter.
"Click Here" to be taken to my web page for the seminar and you can register for free.
Remember, if you have an urgent question, or just wish to speak to me directly, you can email or call, susan@mymomnpop.com or (310) 897-7434.
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