On American Healthcare Crises

A woman suffers from peripheral artery disease. She knows something is wrong with her left foot and is checked into a hospital. By how and why she is checked into the hospital that she is, is not known. It’s discovered that the low blood flow to her feet has caused need for some digits to be amputated. As part of diagnostical prerequisite, necessity, or whatever you want to call it, a mass in her lung is also discovered. It’s malignant and has metastasized (cancer with ‘mets’ = spreading). She is 55 years old, lives alone, and has family who live out of state. For all intents and purposes the patient is alone in the city and state she currently calls home.

She has worked her entire life but was recently laid off from her job, subsequently losing her health insurance. Luckily for her she collects about $1,000 a month in unemployment benefits; this has allowed her to maintain her home and a small quality of life.

The unemployment the patient collects renders her ‘over assets’ and ineligible for the state and national medical programs (AKA: Medicaid). And, the hospital she is currently checked into is out of her county of residence. This is a big deal for a patient who has no insurance. In many major cities ‘county’ hospitals exist in order to act as a safety net for provision of medical and psychiatric needs for all of their ‘county’ residents, regardless of things like ability to pay or legal U.S. status. In other words if you are an illegal immigrant, have no insurance, are dirt poor, and live in that county…you WILL be treated to the fullest extent (this varies from state to state, etc.). There is a dignity factor that plays into this hospital philosophy. For this patient, however, a large gray line is produced by which she falls into.

The patient’s toes are amputated, at no cost to the pt. This is an issue, medically and politically, identified as an emergent need; life threatening and easily fixed in the acute setting. Unfortunately for her, her cancer is not. She is stage 4 and requires chemotherapy and possibly radiation. These treatments are expensive, and could have an indefinite timeline. They also require a lot of follow up care in an out-patient setting, such as primary care needs, specialists, tests, labs, medication, and other treatments (let’s face it, without insurance even the wealthiest cannot afford this kind of medical care). And, because ethically speaking a patient cannot be left dangling, all of this care, cost included, will be the responsibility of the hospital system that starts the care in the first place.

If only the patient had been taken to her county of residence’s hospital she may be eligible to receive the care she needs to fight her illness. But she wasn’t. Despite all efforts on the parts of the physicians and social workers currently treating this patient, her county’s hospital declines to accept a transfer of this patient. Why should they? This patient is expensive. And, currently she is being well cared for at another hospital. Regrettably, (and I cannot stress the regret enough) her current hospital cannot begin or provide the treatment needed for her cancer because this is not identified as an emergent need. “This can be treated in an out-patient setting…” The patient’s only option is to remain in the hospital until her symptoms are managed enough for her to safely return home. The current hospital is under no obligation, and is philosophically critical of, providing on-going care to out of county patients. This has nothing to do with the will or desire to care for this patient, but everything to do with the funding.

Every hospital has the opportunity to receive funds from the state to treat uninsured patients whom are unable to pay for their care. All county and most non-profit hospitals do receive these funds. Of course these funds are capitated… meaning, that there is a limit to the amount of money the state will provide the hospital, but no limit to how much treatment the hospitals are expected to give (or how many patients land on the hospitals’ door steps). The difference = millions of dollars. Ultimately, some hospitals are more willing to continue to provide care in these situations than others. So, patients come from far and wide to the locations known for providing the treatment needed, leaving some hospitals saturated with expensive patients whom they will not be paid for. When other hospitals are asked to take these patients back, there, again, is no obligation to accommodate.

Meanwhile our patient is stabilized, discharged home, and days later she is re-admitted to the same out of county hospital. Her illness is progressing and causing more symptoms. Again, the current hospital will treat the patient’s acute, or immediate needs. She will then be discharged home, again, in hopes of eventually accessing in county care. But, because this hospital cannot logistically, realistically, or feasibly keep its doors open if it takes on the responsibility of the entire state’s uninsured population, it cannot provide possible life sustaining/saving treatment to this patient. We must “share the wealth…”

In all things, it is the patient that ultimately suffers here. She will continue to get sicker and sicker. The patient WILL lose her life to cancer. Even with treatment she may only gain one extra year of life. The injustice in this is that this patient is not allowed the same fighting chance that you or I would be, OR of a wealthier, better insured person. Understandably cancer is a horribly hopeless diagnosis; but a cancer diagnosis for this patient means even less hope.

Who then takes responsibility for this patient’s life?

Sobering truth....

Post my 2011 return to the Old Lady Next Door last week, I re-read through all of my past posts. In doing so I found that a consistent sad theme throughout was obvious: death, lost love, depression, loneliness, absent families, sickness, nursing homes, etc. I thought on this awhile and resolved to include more positive and uplifting posts in the future. But that’s easier said than done. Because let’s face it, people with good retirement plans, financial security, safe homes, good health, and present and supportive families… don’t need social workers. That’s not the reason my profession exists. The need for a social worker comes with the absence of one or more of the above listed provisions. So for the sake of honesty and transparency, the Old Lady Next Door will continue to reflect a sense of sadness, as is needed. Not to be received as a buzz kill, but I hope, rather, a sobering truth.

On that note, one of my old high school friends recently posted a link on my Facebook wall and commented “this seems like it might be right up your alley.” It was a link to The Julie Project by Darcy Padilla (http://www.darcypadilla.com/thejulieproject/intro.html). Padilla is a photographer who followed a woman named Julie, a homeless mother with HIV, for nearly 2 decades. Talk about a sobering truth, this photo project speaks to, nay proclaims issues that often go well hidden in our society… issues that the mainstream middle class may have nothing to do with, least of all understand. Julie was born to a teen mother and was sexually abused during childhood by her step-father. The Julie Project explores her ensuing life of homeless shelters, drug addiction, disease and the loss of 5 of her total 6 children to child protective services. The emotion of this woman’s short lived life is palpable.

I told my high school friend that I appreciated his post but that The Julie Project was hardcore social work... not the kind I’ve ever actually worked in. I did, however, study this kind of thing during my degrees via text books and case studies. The Julie Project illustrates gaps in our society and in social justice. It also magnifies the polarity of wealth and disparity in our society. Regardless of where anyone stands politically or socioeconomically, lives like Julie’s exist, they are tangible and worst of all they are changeable. Remember in my last post (All You Need is Love) I stated “it makes me wonder if I will ever suffer that way too” in regards to the suffering I see in my work. I guess that is one of my attractions to social work, the fact that I cannot answer the question “why not me?” Why is it someone else that is subjected to such a degraded existences and not me? I guess one of the harder parts of social work is having a foundation and understanding into things like the vicious cycle of poverty and other marginalized aspects of society that perpetuate suffering. Some parts are unexplainable and perhaps nothing can be done to change them… but not all.

One more time for good measure: http://www.darcypadilla.com/thejulieproject/intro.html

All you need is love...

Welcome 2011! I realize the Old Lady Next Door has been MIA for several months… what can I say? The usual excuses I guess… busy, holidays, can’t think of anything to write about. So here goes… I want to introduce you to a few of my current, and some past, clients. The names have been changed to protect the innocent.

Tonight I’ll tell you about Mikey. Mikey is a 91 year old man who lives at an assisted living facility. Not one of those fancy facilities either… the one Mikey lives at does not have chandelier lighting, or room service. It’s old, it smells weird, the carpet throughout desperately needs replacing, the staff speak very little English, and around the same corner I turn every time to get to Mikey’s room is a mentally ill woman who sits talking to herself and screams at me as I pass… every time!

Mikey has lived here as long as I’ve known him. He spends his days in his recliner chair in his tiny room because he has lost most of his vision, he cannot hear well, can't walk, he suffers from chronic pain, and, well, he just doesn’t care to do anything else. His am/fm radio stays close where he keeps it tuned to the country station. I usually have to turn this down when I visit with him. I always ask, “Mikey, how is your appetite? How have you been sleeping? Anything new?” His answers are always the same “I’m not very hungry… I get up about 4 times a night to use the bathroom… nope, nothing’s new.”

Mikey was married for over 70 years. He met and married his wife at the age of 17… she was only 16. They never had any children, which they later learned was because of some inabilities on Mikey’s behalf. I remember when Mikey had recounted for me the conversation he had with his wife after they learned that Mikey was the one unable to have children: “..well, I told her I relieved her of me… told her to go on down to the court house and get a divorce… so she could marry someone else and have children.” Mikey was a lifelong farmer with little education and a serious stutter; conversations like this only magnified these facts. The coddling side of me wants to ooh and ahh at his stories like he is a child (he IS pretty cute). But the social worker in me reminds me that this man has lived 4 and a half times longer than me, has seen and lived things that I have no idea about, and whether he says it or not he demands my respect. Anyway, Mikey sounded downright honest when he spoke about offering his wife a divorce, but she refused. I think the phrase “don’t be stupid” had been used at Mikey in his wife’s rebuttal all those years ago… at least that is how I imagine it. Mikey’s wife has been dead for a few years now. I am not sure how she died, but I know that Mikey told me, on every visit for the first few months after meeting him, that he too wished he was dead so he could see her again. He would tell me how lonely he was, and how much he missed her. How after 70 years with a person it's impossible to experience life with out them. These were the kinds of conversations that had me running home to my own husband and demanding that I die first because I could not stand the thought of being left in my own misery like Mikey. This kind of projection is a hard thing to separate from in my line of work… how could it not be? Seeing someone like Mikey suffering the way he does makes me wonder if I will ever suffer that way too. It’s like the opposite of seeing someone win the lottery… you buy the ticket every week because who knows, that could be you one day!

Mikey’s nephew is his medical and financial power of attorney and he helps Mikey manage his finances, make medical decisions, and maintains communication with Mikey’s care providers. His nephew and I at one time attempted to help Mikey move to a nicer assisted living facility with a nicer environment, more attentive staff, better services, and, where we thought he might be happier. Mikey refused. He didn’t want to mess with the hassle of moving. So he stayed in that same recliner chair day in and day out with his country music and his hasty statements about wishing he was dead.

I’ve continued to see and visit with Mikey for over a year and a half now. Recently, I learned that Mikey had met someone (wink wink). In fact, that someone was another one of my clients! She lived in the same building and had met Mikey in the hallway one day while helping to push him in his wheel chair. As it turns out, Maggie too is a widow… and a caregiver at heart. Maggie is 85 years old, has all her own teeth and is still able to walk (these are serious points of interest between the elderly… believe you me!). Maggie attached to Mikey’s neediness like flies on honey. Before I knew it Maggie was making arrangements to have Mikey moved into her room. I did the responsible social work thing and contacted each Maggie and Mikey’s families to ensure all parties were on board with the couple living together. And, when I spoke to Mikey, although I definitely got the sense that Maggie drove him a little nuts at times, he did state “she keeps me company.”

Today, Maggie is in the hospital after a surgery, and Mikey is desperately awaiting her return. I think he’s been reminded of the loneliness from last month, and the years since his wife’s death, before Maggie came into the picture. I am nearly certain that Mikey is still waiting to die so that he can see his wife again… but at least now he has someone to wait with him.

Loneliness... what is it good for?

I spent a few days last week in a little city 115 miles south of Denver called Pueblo, where our newest health care center opened just a few months ago. Unfortunately, they’ve recently lost their only social worker, and I requested to travel on down to assist while the search for a replacement began. After all, everyone needs a little change from time to time, and if that happens to also include a free hotel and food for a few nights … well, then I figure why the heck not? However, what I found to be the most worthwhile part of the gig was the small caseload in Pueblo. The healthcare center there currently has only 50 clients since its opening. I normally carry a caseload of 70 by myself, this in addition to the caseloads of my 4 other co-workers in our Denver office, proves for a very busy office. Needless to say I was amazed at how much work I could accomplish at this new and seemingly bare facility.

One thing that I should probably mention is our health care centers not only house doctor’s offices and rehab gyms, but we also offer adult day centers. Here, seniors who are in need of socialization, or those who require daily supervision due to dementia, etc., can attend our center Mondays through Saturdays. As well, our philosophy of care strongly revolves around these client’s rights, and as such, those who are competent to do so are welcome to wander about the building as they wish. This creates a work environment that encompasses a lot of people seemingly just hanging around. I often receive ‘drop ins’ at my office throughout the day from clients who have questions, those just saying hello, or, more often than not, clients who simply want to talk. This is great, except that I am typically in the middle of WORK. I’ve found that some of my most beloved clients can tip toe on my last nerve when I’m taking a phone call and they are hovering in my doorway, or plopping down in a chair awaiting my attention. I am sure we’ve all experienced this kind of annoyance in the work place at some time.

But, how can I honestly blame them… being that I work with seniors, the one thing they love to do is TALK. If you’ve ever spent any amount of time with a senior, you may know that they love conversation, to a point that breaks all social boundaries. I first learned this growing up around my grandfather, who, at the young age of 13, could corner me for over an hour talking about his time in the war. Much like grandpa, my clients don’t recognize normal social cues that indicate someone has lost interest or has checked out of the conversation. It’s not rare for me to spend hours at a person’s home during a routine home visit listening to their life time’s worth of experiences and stories, often not having even a chance to interrupt or mention that I’m late for my next appointment.

You may find it surprising that amongst the high rates of dementia and Alzheimer’s disease prevalent in the aging population, depression and anxiety rank right up there. As many clients on Aricept and Namenda (common drugs for memory loss) there are almost just as many on Lexapro and Celexa (common medications for depression and anxiety). When a new client joins our program, my assessment includes tests for both memory loss AND levels of depression. It’s a sad truth but when we’ve all retired, outlived many of our loved ones, and have suffered many debilitating physical losses, such as our eye sight and hearing, our world gets smaller. We end up seeing less of the world and it sees less of us. My belief, based on my experiences, is there is an overwhelming sense of loneliness encountered by the elderly. They have so much to share… and not enough people around willing to hear.

Prior to where I am at now, I worked as a volunteer coordinator for 2 years with a hospice agency. This was an incredibly rewarding job as I traveled throughout the city finding ways to infiltrate social and religious groups with the purpose of educating communities about the need for ‘friendly visitors’ among the senior population. Those home bound or living their life out in a nursing home are at the highest risk of isolation and depression. My current company’s volunteer program has developed much of its purpose around combating this issue of loneliness. We have between 100 and 200 volunteers, many of whom chose to give their time simply to spend an hour or so with a senior, providing companionship, and giving someone a little something to look forward to in an otherwise mundane existence. Just an hour. I’d encourage anyone looking for some way to give back to seek out a local hospice agency or other senior organization utilizing volunteers. My experience is that more often than not, the volunteer gains more than the people whom they are giving to.

So, on every Monday, Wednesday, and Friday when Jo Blow is scheduled to be at the adult day center, I better believe what he is looking forward to is talking to someone; anyone who will listen in fact… including that young, nice social worker at the end of the hallway. Frustration and annoyance aside, I find I must stop what I am doing and listen.

Geriatric terms, acronyms and definitions… words to know when working with or on behalf of seniors.

Dementia- A physical or organic syndrome (meaning not a mental illness nor psychological) which affects a person’s cognitive ability, i.e. memory and reasoning. Dementia is an umbrella diagnoses which envelops several different syndromes, the most notable being Alzheimer’s disease. Others include vascular dementia (often caused from a stroke), dementia with Lewy Bodies, Creutzfeldt-Jakob Disease, and the frontal temporal dementias including Picks disease and alcohol induced dementia (often seen in alcoholics). Dementia is also a standard and expected side effect of Huntington’s disease and Parkinson’s disease. Overall, dementia is a permanent and progressive disease in which a person loses the ability to remember what they had for breakfast, the names of their loved ones, how to get home and limits their reasoning skills. Medications do exist to treat dementia; Namenda and Aricept are two of the most used in my practice. Medication will not cure dementia, but is speculated to slow down its progression. Here, early detection and diagnoses is vital!

Geriatrician- Physician specializing in the elderly care. I highly recommend anyone over the age of 60 (55 depending on the policy) to begin seeing a geriatric physician. This would take the place of one’s primary care physician, which, can be hard for those who have had a lifelong relationship with their doctors. But, from my experience, issues experienced by those who are aging are so very specific, medication doses change, diagnoses suddenly stop being cured and instead become chronic and multiple, and with this is the issue of and counter indications becomes significant. Just like a child sees a pediatrician, as a senior I would encourage finding a geriatrician for my care.

ADLs- Activities of Daily Living- These include the very basic functions of living which are necessary to get by on a daily basis. Dressing, bathing, grooming, eating, ambulating (walking or ability to use a mobility device, i.e. wheel chair) are considered ADLs. When a person is no longer able to manage 1 or more of these functions without assistance, their ability to remain independent may become questioned. Often times a spouse or caregiver may be present to assist a person to complete all of their ADLs, thus enabling them to maintain. However, if there is no assistance available on a regular basis, a higher level of care may be needed, i.e. an assisted living facility or a nursing home.

Nursing home-Often referred to as a Skilled Nursing Facility (skilled, meaning medical) is a residence for people with constant medical need. This kind of facility has 24/hour medical staff consisting of nurses, certified nursing assistants (CNA), dieticians, physical therapists, occupational therapists, speech therapists, recreation therapists, medical directors (physicians who oversee the facility’s residents and daily procedures, etc.) as well as kitchen and housekeeping staff. Here, and ideally, everything a person needs is provided: room and board, medications, etc. A person must qualify, medically or otherwise, for placement at a nursing home. There are 2 components to which a person can be admitted: rehab or long term placement. A patient who’s just had surgery, i.e. a hip replacement, may need several weeks of rehab with a physical therapist, before they are able to successfully walk on their own again, manage pain, or complete ADLs independently. Thus, before going back home, they may spend several weeks at a nursing home and then return to their home. Payment for this is covered under Medicare Part A. As well, someone who is deemed unable to live independently ever again, like our advanced medical conditions and those with significant memory loss, can live permanently at a nursing home. Payment for permanent placement is typically covered either through private pay, some long term care insurances or Medicaid. Often times people must privately pay until their funds reach those of Medicaid criteria, and then Medicaid will kick in and pay for the remainder of the person’s stay.

Assisted living facility- A residence for those in need of some assistance on a daily basis. This is a non-skilled facility (meaning does not provide constant medical care) with 24/hour staff, which typically caters to seniors who are still able to manage most of their ADLs. Assisted living facilities provide meals and often times housekeeping and medication management. To be considered an assisted living facility (versus a group home) a nurse is usually required to be on staff for at least 8 hours a day. Other staff includes CNAs (certified nursing assistants), med techs (people trained to dispense medications), administrative staff, housekeeping, and maintenance and kitchen staff. In some situations, recreational staff is also available to provide activities. Some assisted living facilities cater to those with dementia and may be considered a “secured facility” meaning access into and out of the building is restricted without a key or code; this ensures the safety of those who may wander. Like nursing homes, an assisted living facilitie will ideally be all-inclusive providing everything a person needs to sustain, while usually offering a higher quality of life and independent status of living than that of a nursing home. For example these facilities are usually very aesthetically pleasing and people may still be functional enough to have their own cars to come and go and come as they wish. An assisted living facility will likely be a better option than a nursing home. Payment for assisted living is more often than not all private pay. Some long term care insurances may provide coverage and some (very few), and some facilities have limited rooms for those receiving Medicaid. The cost of this kind of facility is anywhere from $2,500 a month on up to $7,000-+$8,000 per month.

Medicaid- A program providing health insurance coverage for those who are considered low-income; children, pregnant women, parents of eligible children, people with disabilities and elderly needing nursing home care. Most residents of permanent stature at nursing home are covered by Medicaid (in a recent blog I noted that there are a million and a half people who currently live in nursing homes). Medicaid is reserved for those with financial and/or physical need. Its policies differ from state to state as Medicaid is jointly funded by states and the federal government. As well, Medicaid policy is changing constantly so it can be difficult to understand what Medicaid covers and what it doesn’t, and how it interacts with Medicare and private insurances.

Medicare- A social insurance program for those 65 and older and have paid into Medicare taxes for 10 years, or being a legal resident of the U.S. for 5 continuous years. As well, there are several stipulations in which a person under the age of 65 may qualify for Medicare, i.e. a person receiving dialysis, or those who’ve been receiving social security disability benefits and are diagnosed with qualifying medical conditions such as Lou Gerihg’s disease or ALS. Medicare has 4 parts to it which a person may be eligible for: Part A- Hospital coverage; Part B- medical coverage (i.e. the doctor’s office), Part C- Medicare Advantage, where a person has the choice to opt for their Medicare benefit to be provided by a private insurance; and Part D- prescription coverage. Most parts of Medicare include a deductible, copayment and/or premium of some sort. Medicare does NOT cover long term care, sitter services, or non-skilled in-home care.

Long Term Care Insurance-Insurance separate from that of health insurance, Medicaid or Medicare providing for the costs of long term care needs; potentially for that of nursing home costs, assisted living costs, sitter services, in home care, respite care, and other needs not typically covered but may be of significant cost to an individual. Coverage policies and rates differ from company to company.

PACE- Program for All-inclusive Care for the Elderly- a Medicaid/Medicare program for seniors in most state providing a holistic approach to healthcare. Criteria for this program include Medicaid financial eligibility and functional limitations that would make a person eligible for nursing home placement.

Private Sitter service- This is a non-skilled (meaning not medical) service that provides oversight to a person who is in need of a “babysitter,” for lack of a better term. Grandpa, grandma or a patient who is unable to remain at home alone, this service will provide a caregiver who is hired on an hourly basis; this caregiver can typically provide light housekeeping, cooking, take walks with clients, and provide stimulation through appropriate conversation and games (i.e. dominoes, cards, etc.). Sometimes families will also hire a sitter service to provide companionship to loved ones who may live alone and may be at risk for social isolation, like those at assisted living facilities, nursing homes, or perhaps someone who lives very far away. The draw back with a service like this is the hourly rates usually start at about $25 and for many people hiring someone to sit with mom, dad, aunt or grandma for a significant period of time can be a financial burden or outside of one’s resources.

MMSE- Mini Mental Status Exam; An assessment tool used to asses one’s cognitive functioning, i.e. how well is their memory working and how intact are their reasoning skills. The goal of this assessment is to screen for early stages of dementia and then track any decline from then on. The assessment is on a 30 question scale, 30 being a perfect score. Missing any more than 2 questions/tasks would indicate memory loss, often times associate to dementia. This assessment tool is not an exact science and has some limitations, but overall, it gives professionals an idea of where a patient is at mentally. I use this assessment on a daily basis at work. Per my agency’s policy, I re-assess every client every 6 months utilizing the MMSE in order to compare from year to year how they are doing. Ultimately, a person, professional or family member can be given a clear understanding of a person’s ability to safely remain independent (i.e. live alone) or how much assistance they should acquire on a daily basis, per the MMSE score. Things that may impact one’s MMSE score adversely and should be taken into consideration are mood and thought disorders, such as depression (someone suffering from depression may not score well, but not necessarily due to cognitive ability but rather due to the impacts of depression one’s thought process; here depression can be treated stopping any effects on their cognitive functioning).

SLUMS- St. Louis University Mental Status examination- this is an assessment tool much like the MMSE, but considered, among some professionals, to be a bit more sensitive to ascertaining memory loss, especially in individuals who have learned to compensate, thus, hiding any memory loss (often only possible in early stage dementia). Compensation is often observed in individuals with greater levels of education and economic standing. The SLUMS serves the same purpose as the MMSE but was developed later. Please see the MMSE definition for more detail.

GDS- Geriatric Depression Scale- An assessment tool used to identify depression in the elderly. The assessment asks 30 questions in which a patient will answer either ‘yes’ or ‘no’… Questions may include “Are you basically satisfied with your life?” and “Are you in good spirits most of the time?” A score greater than 9 is indicative of depressive symptoms.

APS- Adult Protective Services- A social service developed to protect senior adults, and sometimes disabled individuals, from abuse, neglect, and exploitation. APS is managed state to state differently by state health regulatory bodies. In Colorado, APS is managed by county. If abuse, neglect or exploitation is suspected, one can call and make a report to APS. Proof is not necessary, and the one reporting may remain anonymous if desired. APS has legal pull and rights to make decisions to protect at risk adults. However, seniors who are competent, those without significant memory loss, dementia, etc., who are making a choice to remain in an abusive, neglectful or exploitive situation, APS cannot force out of such a situation; not without request for help from that senior.

DNR- Do Not Resuscitate-A form which medical professionals facilitate for patients who do not wish to receive CPR (Cardio Pulmonary Resuscitation) or other life saving measures should their heart stop. Signing this form does not indicate that a person should not receive other normative treatments, such as antibiotics, dialysis, necessary surgeries, etc. As well, it’s important to note that CPR on a healthy 30 year old adult is VERY different than CPR on a senior adult. CPR on the elderly is not always a positive thing, even if it works and the person is revived; it often causes broken ribs and brings a person back in worse shape than before undergoing the process.

MDPOA- Medical Durable Power of Attorney- Known by different terms depending on which state a person is in (also known as MPOA-Medical Power of Attorney)- this is a completed form or paperwork in which a person (any person) may designate a person to make medical decisions for them in the event they are unable to do so; either because they are not conscious, or lack decision making capacity (indicated and documented by a physician). An MDPOA must be completed while a person is still competent to do so. After memory loss or dementia has progressed to moderate and especially advanced stages, a person may be deemed NOT competent to designate an agent, or person identified to make their medical decision for them. Again, depending on the state of residence, policies differ affecting whether an MDPOA requires witnesses or a notary to make it official (in Colorado neither are needed).

Where are we all going?

I heard a story on NPR this week about a pastor from a church in Virginia, Kenneth Dupin, who is believed to be revolutionizing life for the elderly who are facing nursing home placement. He is the founder of the MEDCOTTAGE, or as the kids are calling it the “Granny Pod.” It’s basically a home on wheels (portable) with “advanced health monitoring equipment” that is intended to be placed in a family’s backyard where mom and dad or grandpa and/or grandma can live when they are no longer safe or able to remain in their own homes. Instead of facing institutional life, i.e. the nursing home, for a mere $2,000 a month, one can bring mom or dad home to live within arm’s length, and still offer some form of independence.

Albeit a great concept, Dupin has overlooked several factors that affect a person’s need for a nursing home. Like, how is mom, who is no longer ambulatory, supposed to get to the bathroom on her own during the day when daughter and son-in-law are at work from 8-5pm (sounds like a broken hip if you ask me). And, what about our beloved Alzheimer's patient who will (and I promise THEY WILL) wander out of that MEDCOTTAGE in a state of confusion while looking for ‘their home.’ Or, I love this one, how many seniors and their families can realistically afford $2000 a month for, essentially, rent? Not including monthly food, medicines, supplies, etc. The reality is such a concept may very well appeal to only a very small portion of the population; a portion who can, financially and physically, afford to have options. Of the “million and a half” seniors currently living in nursing homes across America, I doubt this concept will affect even 1% of them.

Let me tell you a little about why the typical nursing home resident goes into the nursing home: 1) their health is so severe that they require 24/hour nursing care simply to maintain; 2) their cognitive status is so lacking, due to some form of dementia, that they no longer recognize their family members, nor are they able to eat on their own, and they spend their days displaying obscene childlike behaviors or unsafe wandering; and 3) their family and loved ones live states away, or for whatever reason are not able or willing to take them in. I’d wage my bet that #3 is in fact the #1 reason any senior is institutionalized.

The sad fact is we live in a society (specifically white American society) that does not value caring for ‘our own.’ Rather than planning how we will care for our parents when they can no longer care for themselves, we PLAN on them going somewhere to live, where OTHER people will take care of them, where we don’t have to worry about it… or perhaps we avoid the subject all together. Because let’s face it, we simply don’t have the time or resources. Rather than handle the stress, the financial burden, or finding the time, we put them away!
But, did you know, in almost every other culture in the world, nursing homes are rare!... even a disgrace! Even in America, I find very few people of Hispanic, Asian, etc., dissents in a nursing home. And, during my master’s degree I had several classes with a girl from Russia, who was specializing in gerontology in order to take back what she learned to Russia, where nursing homes were just surfacing. She told me how in Russia, nursing homes were like 3rd world care, and no one wanted to send their loved ones to one because it was seen as shameful. It was a last resort, often for people without children. I’ll tell you from experience, most (and I say most to be pc, but I’d personally tell you ALL) nursing homes are basically 3rd world care. Compared to the care that one could receive from their own family, from people who actually know and love them… how could it truly compare?

In my practice, I make it a habit of comforting and relating to caregivers and family members who make the decision to place their loved ones in a nursing home. In fact, I am likely the one educating them about their option to do so. And, I especially empathize with the senior who is being placed, as this is not something any person at any time in their life hopes for. Although, I recognize this as the main reason we as a society can plan on life sucking after 70, I realize that society made its choice decades ago. When the family unit changed, i.e. divorce rates sky rocketed, fathers AND mothers began working full time, retirement age breached 73 years, etc., we also began to see the grandparent forgotten. And what decades ago did to produce such a mainstream phenomenon, I am not going to overturn by berating an overwhelmed caregiver for their choice to place their loved one at a facility. I respect this decision and do my best to ensure some quality of life from then on for that senior.

For myself, although my parents are only in their 40s, I am already thinking about how I and my siblings will plan to care for them as part of our individual families. I do hope that in some way, this will validate my parents’ lives as something meaningful… with something to look forward to beyond their retirement years… beyond the time when they can no longer give to society, or produce….. and give them continued hope… where one day they will die not alone in a stale room with unfamiliar things, but with those they love, and who love them… and where they are offered joy even at the end.

Otherwise… what are we all living for?

So, what's it all about?

I often feel I have the most interesting and eventful, as well as stressful, job in the world. Most of my days are spent talking with clients about their needs and comforting them in some way about the process of getting old. Things like, “who will take care of my wife when I have my hip replacement surgery?” or “what will I do when I can’t live at home by myself anymore?” and “I’ve lost my hearing aid.” I find myself saying things like “have you ever considered a long term care facility” and “yeah, no one ever warns you about getting old, do they?” This statement is always and immediately followed by “NO! They don’t!” Nonetheless, and deep down, I love what I do. Most people feel awkward around seniors, or perhaps don’t feel they know how to talk to them. Others don’t pay much attention at all. I find that these people are exceptional and unique personalities with decade’s worth of memories to tell and lessons to teach. Oh to be a fly on the wall in my office! Doting mothers, cursing veterans, and women with blue hair and dentures.