The Most Important Conversation to Have Before You Die

Talking about your advance care directive with your loved ones will make life — and death — easier later on.

By Dana G. Smith

Instead of talking about politics around the Thanksgiving table this year, consider a less fraught topic: death.

It’s something few of us want to think about, but death is a fact of life that we will all encounter, often first as a caregiver and then, inevitably, when we reach our own.

As uncomfortable as it can be, discussing what medical care you want to receive at the end of your life is “one of the most loving things” you can do for your family, said Dr. Jennifer Gabbard, the director of the Palliative Medicine Research Program at the Wake Forest University School of Medicine.

Understanding your wishes ahead of time can make difficult decisions a little easier on your loved ones and comfort them in knowing that they’re doing the right thing.

These discussions aren’t just for people in their golden years, either. If you’re young and healthy, you can frame it as an “in case I get hit by a bus” conversation, said Omni Kitts Ferrara, the director of education at the International End-of-Life Doula Association.

Death is a fraught topic, so it’s worth thinking about how to make these conversations less stressful for your family and friends. Here’s a framework for what to cover.

Yes, we’re talking about an advance care directive.

With end-of-life care, there are two main things to think about, discuss and ultimately put into writing. The first is what types of treatments you do or don’t want to receive, often called a living will. The second is who you would like to communicate your preferences and make decisions about your care if you are unable to, known as your health care power of attorney. Together, these instructions make up your advance directive — documents you can share with your family and with your doctor to file away with your medical records.

Advance directives don’t need to be completed by a doctor or lawyer, but they do need to be signed by yourself and at least one witness. The exact requirements differ from state to state — in some places, the forms must be notarized — so be sure to look up what your state calls for.

First, focus on your living will.

Before you discuss your wishes with others, it can be helpful to complete a living will so that you’re clear about your own thoughts on the topic. Some large health care systems have forms that they can provide to patients, or you can find one online. Several experts we spoke with recommended the website Five Wishes as a helpful resource.

Generally, the living will boils down to whether you “want palliative care just to treat your symptoms,” or whether you “want aggressive treatment no matter what the prognosis,” said Caitlin Cassady, an end-of-life social worker and co-author of the book “Dying at Home: A Family Guide for Caregiving.”

Some living wills ask if you would want specific life-extending medical interventions, such as being put on a ventilator or having a feeding tube. However, because it can be challenging to wrap your head around what these procedures might actually entail, many living wills focus on your values and priorities — in addition to, or even in lieu of, specific treatments.

For example, they may ask: What brings meaning to your life, and how would you feel if you were unable to do those things? What living conditions would be unacceptable to you? These types of questions are valuable to think about, and to explore with the people closest to you.

A living will is different from a D.N.R. (do not resuscitate) order or a POLST (physician orders for life-sustaining treatment), which are both intended for people who doctors think have a more imminent risk of dying. These forms are provided and filled out by hospital staff and only cover specific medical interventions, like CPR or intubation.

Keep in mind that a living will is not a “one and done thing,” Dr. Gabbard said. Your desires will likely change as you age, or a terminal illness may adjust your plans, so revisit it every couple of years.

And each time you do, talk it through with your family. Because while completing a living will is a crucial step, discussing your wishes with your loved ones can be just as important.

Next, designate your health care power of attorney.

While your family should stay informed about your medical wishes, your health care power of attorney will officially communicate your preferences to your medical team and make decisions about your care if you are unable.

Your health care power of attorney can be anyone you want — they don’t have to be a relative — but there are a few things to consider when thinking about whom to pick, Ms. Cassady said: How close are you with the person, and can you have hard conversations with them? Would they be able to carry out your wishes, even if that meant stopping lifesaving treatment? How are they in a crisis?

“Who do you think makes really good decisions in stressful situations?” Ms. Cassady said. Living wills “really don’t cover everything, and people often find themselves in situations making decisions that they never even thought they would make.”

It’s essential to talk with your pick ahead of time to make sure they’re comfortable being in that position. And it’s probably worth informing those you haven’t chosen, too. “People can feel really hurt if you don’t communicate” who you chose and why, Ms. Cassady said. The last thing you want is conflict — or an all-out fight — during a medical emergency.

While death can be a scary subject to broach, you may be surprised by how you feel after. “When we consider our own mortality,” Ms. Ferrara said, “it has an interesting way of reflexively reminding us that we are alive.”

Full Article & Source:
The Most Important Conversation to Have Before You Die

Frequently Asked Legal Questions

• Do I need a Will?  If you do not have a Will, the laws of the State of Colorado determine who is entitled to your assets and they determine who has priority to be your personal representative (executor).
  
  
• How long is my Will good for?  Wills do not expire.  Unless you change or revoke a Will it remains in effect until you die.  Therefore, if your wishes change you must update your Will.
  
  
• Can I write my own Will?  Pursuant to Colorado Law, you may write your own Will.  It will be valid if it is signed by you and if all the material provisions of the document are in your handwriting.  There may be many problems with writing your own Will, because it may not be clear and it may not include all of the provisions that a Will should contain.

• Do I need to go through probate?  In Colorado, if you own any interest in real estate (a home), or if you own other assets which are valued at more than $80,000 your estate must be probated, whether you have a Will or not. 

• What is probate?  Probate is a court process whereby the court appoints a personal representative to administer your estate.  Probate is a process that includes filing an inventory of the estate assets, publishing a notice to creditors in a newspaper, accounting for estate income and expenses and disbursing the estate.

• What documents are included in a good estate plan?  A person should have a Last Will and Testament or a Revocable Living Trust, a health care power of attorney, a general durable power of attorney and a living will.

• I am the agent under a power of attorney, isn’t that all I need to take care of things?  A power of attorney will no longer be valid after the death of the principal.  In addition, it may not be valid once the principal becomes incapacitated unless it has the right language.  You must examine your power of attorney to see what powers it includes and under what conditions the agent may act. 

• What is a trust?  There are many types of trust.  A trust is generally a document which establishes an arrangement whereby property is transferred to a trust with the intention that it be administered by a trustee for someone’s benefit.  A trust may be established for your own benefit.  The biggest advantage for setting up a trust for your own benefit is to avoid probate. 

Tamra K. Waltemath

This article was written by Tamra K Waltemath of Tamra K. Waltemath, P.C.  This information is for general informational purposes only and does not constitute legal advice.  For specific questions, you should consult a qualified attorney. Tamra K. Waltemath is an elder law attorney focusing on wills, trusts, estate and trust administration, probate and non-probate transfers, guardianships and conservatorships. 

 

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Frequently Asked Legal Questions

Why Power of Attorney Can Be Key for Senior Health Care

To make sure all the documents are properly filed, it's usually best to work with an attorney you trust.

In the vast constellation of legal documents you could encounter over your lifetime, some are more critical than others. For older adults, a few legal instruments take on outsized importance, particularly in the context of ensuring adequate health care as we age. While some documents that older adults may need are focused on the financial side of your affairs, others concern how decisions will be made about your health care. The information that follows will focus on the documents related to health care that may come into play as you age.

As you navigate these legal waters for yourself or a loved one, some legal terms and documents you may encounter include:

• Living will
• Advance directive
• Do not resuscitate order
• Physician orders for life-sustaining treatment
• Health care proxy
• Power of attorney
• Guardianship or conservatorship

Living Will, Advance Directive, or Do Not Resuscitate Order

Living wills can go by a number of different names including advance directive, do not resuscitate order or POLST, which is short for physician orders for life-sustaining treatment. This document, which is often printed on brightly colored card stock and is signed by a physician, outlines which specific procedures and actions you do and don't want to receive from first responders in the event of an emergency or from end-of-life health care providers. It may include questions such as: Do you want a feeding tube placed? Do you want to be transported to the emergency room? Answers can help specify how you want to be treated if you can't communicate your wishes directly.

Stuart Furman, an elder law attorney and president of the Southern California Legal Center, Inc., in Valley Center, California, and author of "The ElderCare Ready Book," says the living will or advance directive is sometimes colloquially referred to as the "pull-the-plug" document, meaning that if someone is beyond the hope of resuscitation, then let the person go and don't take heroic efforts to revive them.

Health Care Proxy

Health care proxy is a term used in some states to designate the agent who can make health care decisions on your behalf, and may be a casual term or may reference the agent named in a formal health care power of attorney document.

Power of Attorney

There are many different types of power of attorney documents that can cover financial or health care matters. Furman says that while there are many permutations of these documents that should be tailored by an attorney for your specific situation, generally speaking all of these legal instruments are "giving authority to someone else to make medical decisions for you in the event that you're not able to make them on your own."

Pamela D. Wilson, a caregiving expert, advocate and speaker based in Golden, Colorado, says that a durable power of attorney is an important document that older adults should seek to organize sooner rather than later. "In very simple terms, power of attorney is either somebody to help you manage money or your health at a point when you either can't take care of yourself or at the point that you become incapacitated," Wilson says. Incapacitation, also sometimes called incompetency, is a legal term that generally refers to someone who "can't review information or logically think through things," such as may occur after a stroke or with later-stage dementia or Alzheimer's disease. When this occurs, the durable power of attorney would come into full force, meaning that a designated overseer or agent steps in to make decisions on behalf of the individual.

It's important to "get your ducks in a row" early, with regard to organizing your legal documents for health care, says Megan Carnarius, a registered nurse, founder of Memory Care Consulting and author of "A Deeper Perspective on Alzheimer's and Other Dementias: Practical Tools with Spiritual Insights." Particularly if there's a family history of Alzheimer's or dementia, you need to make arrangements before the diagnosis is made, because "you can't typically write a power of attorney if someone has this diagnosis." A dementia diagnosis often means the person is considered legally incapable of making those decisions. Therefore, "if families have a suspicion that the person is getting more confused and they feel like they need to go to the doctor to get a diagnosis, they should have already taken care of the financial and decision-making stuff. You don't want to wait until you've gotten a diagnosis, because then (attorneys) worry about competency."

In a perfect world, we'd all set up a durable power of attorney as soon as we turned 18, as that's when things can get dicey legally if you're incapacitated. Wilson shares the story of a young man who fell off a retaining wall and sustained injuries that rendered him incapacitated. A lengthy legal battle ensued over who would make medical decisions on his behalf because he didn't have any power of attorney documents drafted prior to the accident. For seniors, it becomes even more important to get these documents sorted out, as conditions can deteriorate quickly and catch everyone off guard. If the power of attorney assignation is left too late, the person will be forced into guardianship, Wilson says.

Guardianship or Conservatorship

Guardianship, which Furman says is called conservatorship in California, comes into play when someone is unable to make decisions for themselves and there is no power of attorney in place. Many power of attorney documents also include provisions for that same person to become guardian. But there is a distinction in the level of power each role has, Wilson says. "An example would be an older adult living at home who's burning food because they have poor memory. They're not showering, they're not taking medications and they refuse to move to assisted living." The power of attorney designee "can't put that person into a care community because that person could say, 'Hey I'm leaving,' and power of attorney can't stop them. But a guardian can. A guardian has absolute power of appointment through the court. It's a very serious appointment, because when you have a guardian, you give up all your rights to decide about health care and money." Therefore, "it has to be a very trusted person."

Who Should Be My Power of Attorney?

Typically, power of attorney and guardianship responsibilities are vested in a family member, such as the adult child of a senior. But there are lots of other relationships that can work, from close friends to hired professionals. Wilson is one such professional advocate who takes power of attorney assignments for people who don't have an appropriate agent in the family.

Choosing the right person to act on your behalf as your power of attorney is critical, Wilson says. "If a parent chooses a child who has been terrible at financial management to be their financial power of attorney, it's going to be a disaster. Same for health care. If they choose someone who can't advocate with doctors and the care community, it's not going to work out," and this is where professionals like Wilson can help. Appointing a professional can also be a savvy way of avoiding conflict if you anticipate such could occur in choosing one sibling over the other, for example. "You really have to plan for conflict if it exists in family members because all of this gets so very, very nasty," when wishes aren't clearly communicated.

It's also important to designate one or more successors, or backups, to your first-choice power of attorney. A successor would step into the role of power of attorney if your first choice can't or won't serve. "If you don't appoint a successor and the appointed person resigns, and you can't do another power of attorney, you're forced into guardianship. So, you always want to have backup successors in your documents," Wilson says.

Who Can Help Me with Power of Attorney?

To make sure all the documents are properly filed, it's usually best to work with an attorney you trust. "There's all sorts of forms you can pull off the internet," Wilson says, "but it's better to use an attorney in the state where you live because laws differ by states. Have an attorney draft them and look at them every 10 years to see what needs to be changed."

These variations from state to state can become problematic if your loved one moves, says Lindsay Perrin, co-founder of Ro & Steve, an independent online review site for senior living facilities and other businesses related to senior care that sprang out of her and her husband's challenges in finding the right care scenarios for their aging parents. "We drafted these documents for my dad years ago," when he was living in Massachusetts prior to his diagnosis with Lewy body dementia. But since then, he's moved in with Perrin's family in New Hampshire, and sometimes the personnel the family encounters at health care centers aren't familiar with the out-of-state documents. This can cause significant hassle, leading to "stressful situations in the hospital where I'm trying to sign for Medicare and the desk staffers aren't familiar with my Massachusetts documents." Sometimes they need to make calls to an attorney to clear up confusion.

Perrin says it's not possible now to have new documents drawn up in New Hampshire because her father's condition has progressed to the point where he's unable to sign new documents, so they soldier on with the out-of-state but still completely legal documents they have. Still, Perrin recommends thinking ahead about where you're likely to be living when the power of attorney will come into force and have the documents drawn up in that state. "Technically my Massachusetts documents should be well understood. They work here. It's just that not everybody has that education, so think about the next phase," and where you might be living when you'll need the assistance of a power of attorney.

Power of Attorney and Assisted Living

Matt Perrin, Lindsay's husband and co-founder of Ro & Steve, has also had to navigate these legal waters in caring for his mother who's currently in an assisted living facility. He says it's very important to have all of your legal documents in order before making the move to an assisted living community.

Some facilities may require that such documents be in place before they will admit your loved one, particularly if that person is incompetent. "There's no authority for that person to sign the contract," Furman says. "That's a cardinal rule across the country – incompetent people have no authority to sign contracts. It's like a child." Even if you're entering a facility while you're still considered competent, it's wise to have a power of attorney in place so that if your situation changes rapidly, as can happen with a stroke, for example, the community will know whom to contact when decisions need to be made. Having the appropriate type of power of attorney in place "gives us the tools in our toolbox," to be able to act in the best interest of the individual, Furman says.

Matt says drafting a power of attorney was easy and straightforward – the hardest part was having the conversation with his mom about initiating the process. On the advice of a friend, he approached that difficult conversation delicately, seeking consensus with his mother rather than being prescriptive. "It did make it easier to cut through what's not the easiest of discussions," he says of taking a collaborative approach. His mother's 40-year career as a nurse also meant she was open to talking about end-of-life and what arrangements needed to be made for her care. "She sees the value in these sorts of things, but even then, when it comes time to have the discussion about you, it's hard. It's just a tricky discussion, but you're doing it hopefully at the right time and not when you're in dire straits." As with most anything related to aging and health care, getting ahead of any coming crisis is best.

To draft the documents, the family worked with an attorney they'd known for years, though Matt says if he were to do it again, he'd probably opt for an attorney with specialized expertise in estate planning. "We're not wealthy. My mom has very few assets, but thinking we didn't need an estate plan was sort of a naive mistake. And from what I can tell it's a common misconception." Rather, estate planning is an important aspect of the whole picture no matter how much money you have. "I would tackle (estate planning and power of attorney) in tandem. It's one less thing for you to do later," when perhaps your loved one's condition has deteriorated, making even a small task like seeking a notary's signature seem like a much bigger chore. "It adds up, and you need to save your mental space for the real stuff," he says.

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Why Power of Attorney Can Be Key for Senior Health Care

Tonight on Marti Oakley's T. S. Radio: Hospice Survivors and Victims with Carly Walden

7:00 pm/CST.... 8:00 pm/EST

Tonight we will be discussing what you need to know to protect not only yourself, but also your loved ones, especially the elderly from the growing efforts to cull and euthanize as many as possible using legal and medical means. Hospice in most cases, is no longer the Good Samaritan and has instead become the weapon of choice for prematurely ending the lives of those unfortunate enough to find themselves in one of these facilities or, under Hospice care in a hospital.

Do you know what a Patients Protective Medical Directive is? Why you should have one?

Https://www.pateintsrights.org

Do you know what a "Living Will" really is? Did you know that it is actually an advanced directive for assisted suicide/euthanasia?

Hospice Discharge, Revocation and Transfers

Medicare Benefit Policy Manual (CMS Pub. 100-02), Ch. 9, §20.2

The Medicare hospice benefit is only available to beneficiaries who are terminally ill. A hospice may discharge a beneficiary in certain situations. A beneficiary or representative may choose to revoke the election of hospice care at any time.

This and much more "need to know" info tonight with Carly Walden

LISTEN LIVE or listen to the archive later!

5 Estate Planning Documents Every Young Professional Should Have

After graduating from college, and even law school, the thought of drafting your estate plan probably did not make the top twenty on your "to-do" list, and why should it? The only thing most young professionals have when they first start out is debt. However, after you land your first job, preparing your estate plan needs to move quickly to the top of that elusive "to do" list. It's especially important if you are starting a family. Below are five documents that should be part of your estate plan.

1. Durable Financial Power of Attorney.
2. Health Care Power of Attorney.
3. Last Will and Testament.
4. Beneficiary Designation.
5. Beneficiary Deed.

After the necessary documents are executed, be certain that one set of originals is placed in a safe or safe deposit box in your bank and let your family know that the documents are there. It is wise to re visit these documents when a major life event occurs, such as a wedding, a birth or even a death, to ensure no changes to your documents should be made. If no major life events occur, it is always a good idea to contact your estate planning attorney every five years to ensure there have been no substantive changes in the laws that may affect your documents. The above information is based on the laws of the State of Arizona.

Full Article and Source:
5 Estate Planning Documents Every Young Professional Should Have >

Complexities of Choosing an End Game for Dementia

Jerome Medalie

DEDHAM, Mass. — Jerome Medalie keeps his advance directive hanging in a plastic sleeve in his front hall closet, as his retirement community recommends. That’s where the paramedics will look if someone calls 911.

Like many such documents, it declares that if he is terminally ill, he declines cardiopulmonary resuscitation, a ventilator and a feeding tube.

But Mr. Medalie’s directive also specifies something more unusual: If he develops Alzheimer's disease or another form of dementia, he refuses “ordinary means of nutrition and hydration.”

A retired lawyer with a proclivity for precision, he has listed 10 triggering conditions, including “I cannot recognize my loved ones” and “I cannot articulate coherent thoughts and sentences.”

If any three such disabilities persist for several weeks, he wants his health care proxy — his wife, Beth Lowd — to ensure that nobody tries to keep him alive by spoon-feeding or offering him liquids. VSED, short for “voluntarily stopping eating and drinking,” is not unheard-of as an end-of-life strategy, typically used by older adults who hope to hasten their decline from terminal conditions. But now ethicists, lawyers and older adults themselves have begun a quiet debate about whether people who develop dementia can use VSED to end their lives by including such instructions in an advance directive.

Experts know of just a handful of people with directives like Mr. Medalie’s. But dementia rates and numbers have begun a steep ascent, already afflicting an estimated 30 percent of those older than 85. Baby boomers are receiving a firsthand view of the disease’s devastation and burdens as they care for aging parents.

They may well prove receptive to the idea that they shouldn’t be kept alive if they develop dementia themselves, predicted Alan Meisel, the director of the University of Pittsburgh’s Center for Bioethics and Health Law.

“People in their 50s and 60s frequently say: ‘I don’t want to be in that situation. I don’t want to put my family in that situation,' ” he said. “And people will increasingly voice those views to others, sometimes in a formal way through advance directives.”

Mr. Medalie, fierce-eyed at 88, has seen people close to him die lingering deaths from dementia and has already decided. His motto, pithy enough for a T-shirt: “If I’m not me, I don’t want to be.”

Dementia, though a terminal diagnosis, presents unique obstacles for those who want some control over the way they die. It generally kills slowly, over years, and “there is often no plug to pull,” said Dr. Stanley Terman, a psychiatrist in Carlsbad, Calif., who specializes in end-of-life decision-making and estimates that several hundred people have requested copies of his Natural Dying Living Will. “There’s no high-tech, life-sustaining treatment that can be withdrawn or withheld.”

Even in the few states where physicians can legally prescribe lethal medication for the terminally ill, laws require that patients be mentally competent and able to ingest those drugs themselves. Mr. Medalie would prefer that option if he were to become demented, preferably with the barbiturates dissolved in “a little vodka.”

But demented patients don’t qualify for so-called death with dignity. VSED is a lawful way to hasten death for competent adults who find life with a progressive, irreversible disease unendurable. Several medical studies have reported that, with proper oral and palliative care, it can also be a comfortable way to die.

The question for proponents of VSED by advance directive is whether the practice can also provide a humane exit for those who, years later, no longer remember or understand why they wanted to use it.

Proponents of the approach acknowledge that dementia patients and their health care proxies will face great controversy if they try to cut off food and water; so will the professionals who care for them.

Nourishment carries connotations, from infancy, that make stopping it feel different from rejecting medical machinery.

“It’s the rhetoric more than anything,” said Mr. Meisel, the author of the legal treatise “The Right to Die.” “You can apply the word ‘starvation.'”

If those opposed to removing patients from ventilators had thought to call it “suffocation,” he adds, the issue might be similarly contentious.

Moreover, the legal status of VSED by advance directive remains untested. In a recent article in The Hastings Center Report, two advocates argued that food and water should not be withdrawn until severe dementia has eroded the patient’s quality of life and “the self has withered.”

That approach would probably pass legal muster, said Paul Menzel, philosophy professor emeritus at Pacific Lutheran University, and an author of the piece.

Spoon-feeding may constitute basic care, however, more akin to changing sheets or bathing than to medical interventions.

“People get in trouble — nursing homes, even family members — for inadequate nutrition or letting someone dehydrate,” said Thaddeus Pope, the director of the Health Law Institute at Hamline University School of Law. “Neglecting basic human comfort care is a big source of elder abuse complaints and criminal prosecutions.” And if a patient demands that his basic care be withheld in the event of dementia? “Nobody from a legal perspective has really meaningfully grappled with that,” he said.

In several states, including New York, Wisconsin and New Hampshire, statutes have made it difficult to withdraw oral nutrition or hydration, sometimes even if that instruction is included in a directive.
 

A court case unfolding in British Columbia shows just how tricky these judgments can be.

Margo Bentley, 83, is a retired nurse with advanced Alzheimer’s disease. Her advance directive specified “no nourishment or liquids” if she became incapacitated.

When her husband and daughter attempted to honor her wishes, the care facility where she lived refused, sending the family to court.

Last February, a judge ruled that although a health care provider could legally honor such a directive, Ms. Bentley’s feeding should continue in part because she swallows food placed in her mouth. That constitutes consent, the judge ruled. The family has appealed.

If swallowing is all it takes to legally invalidate an advance directive, Mr. Pope said, then patients will never be able to specify that they want for food and water to be withdrawn should they become demented.

The moral and ethical aspects are even more dizzying. Can one’s current, competent self make decisions on behalf of one’s future demented self — who may find modest pleasure, years later, in a life once deemed intolerable? What if that later self asks for, or points to, applesauce?

“I can imagine people saying, ‘You’re starving this vulnerable person who’s dependent on us for care when this person is willing to eat,' ” said Rebecca Dresser, professor of law and medical ethics at Washington University in St. Louis.

At the other end of the ideological spectrum, Dena Davis, a Lehigh University bioethicist who has published articles on “pre-emptive suicide,” disputes the notion that withholding food should wait until the advance directive writer has reached a severe stage of dementia.

By that point, “you lost your dignity a long time ago; you’ve probably been a burden on your family for six or seven years,” she said. “It’s too little, too late for me.”

Religious organizations, disability groups and uneasy nursing home administrators will also surely weigh in if patients and families try to enforce VSED as detailed in advance directives. Catholic authorities, for example, have generally opposed removing terminally ill patients’ feeding tubes or IV fluids.  

“We should not encourage people to think their life has no meaning or value because they’re in a fragile, vulnerable and terrible situation,” said John Brehany, a former executive director of the Catholic Medical Association. He predicted that Catholic-affiliated hospitals and nursing homes wouldn’t honor such directives.

None of this remotely dissuades Jerome Medalie. For now, “life is exceptionally good.” A veteran of bypass surgery, multiple angioplasties and two knee replacements, he exercises daily, canoes on the nearby Charles River with his grandchildren in summer, and uses a voice-controlled computer to counter the effects of macular degeneration.His wife and children — and nearly everyone he has met in the last 20 years — are fully aware of his desires and instructions, however, and they are committed to carrying them out.

“I want to go out on my own terms,” he said. “I don’t want any church, the government, any doctor or hospital or even any member of my family to contradict what I want for my death.”

But he hasn’t persuaded everyone. Dr. Susan Mitchell, a Harvard Medical School geriatrician and researcher, has met Mr. Medalie and read his advance directive.

If she encountered a future Jerome Medalie, bed-bound and suffering from advanced dementia, she said, “I would not feel comfortable not gently offering him at least a sip of water and a spoonful of ice cream.”

Full Article & Source:

Complexities of Choosing an End Game for Dementia

3 Powers of Attorney Everyone Needs

The words “power of attorney” can sound like something from a movie or TV show: the villain tricks an innocent, unsuspecting person into giving away their legal rights… until, of course, the hero steps in at the last moment to save the day.

In reality, powers of attorney are tools that can be for good, not evil – especially these:

Health Care Power of Attorney
A Health Care Power of Attorney allows you to appoint another individual, usually called your agent, to make health care decisions on your behalf.

Unlike a Living Will, which typically only addresses situations involving life-sustaining medical treatment, a Health Care Power of Attorney can cover a broad range of health care decisions and is not limited to instances of terminal illness or permanent coma. It’s a comprehensive and flexible document that allows a person you trust to weigh the facts and legally speak for you according to guidelines you provided. You specify that you want all medication options to be exhausted, set in place a blanket do-not-resuscitate order… or any options in between those two extremes.

HIPAA Power of Attorney
The Health Insurance Portability and Accountability Act (HIPAA) controls how health care providers can share your personal health information, protecting your privacy and confidentiality.

Durable Power of Attorney
A Durable of Attorney gives a person, referred to as an agent or “attorney in fact, the legal authority to act on your behalf. Unlike a Health Care Power of Attorney, which covers medical situations, a Durable Power of Attorney allows you to choose who will act on your behalf in a wide variety of financial or business situations.

Durable Powers of Attorney are extremely flexible. You can limit your agent’s authority to a specific situation, like closing on the sale of a home or signing a specific contract, or give them authority over a broad range of situations or circumstances. A Power of Attorney can be temporary or permanent, can take effect only if you are incapacitated or unable to make decisions on your own, and can be revoked at any time.

Full Article and Source:
Three Powers of Attorney Everyone Needs

Special Needs Adult Children Need A Plan for Their Future

After a lifetime of caring for their child at home, parents of children who are intellectually and/or developmentally challenged don't want to give up their authority to strangers, but what happens if they haven't established plans for when they are too sick to provide care or have passed away?

For decades in their homes, many families have provided full-time care for family members who are severely disabled, without accessing in-home social services. They may have resisted tapping into government programs or didn't trust others to help. Some have cared for children with multiple disabilities who don't fit into supported housing scenarios. Whatever the case may be, parents should not hesitate to find out what they can do to provide for their adult child with special needs when they are gone.

With a 10-year wait for home and community-based programs in Texas, it often takes a crisis such as the death of a parent, a medical emergency or another tragic event to get priority on the waiting list.

Establishing a decision-making process during the parents' lifetime reduces distress for the adult child who is disabled when transitioning from home to community services.

If an adult child who is disabled has capacity, then it's important to put advance directives in place, including a Durable Financial Power of Attorney, Medical Power of Attorney, HIPAA Authorization, Physician's Directive or "Living Will," and a Declaration of Guardian to allow trusted decision makers to step in when parents are no longer able to.

If the adult child does not have the requisite capacity to execute advance directives, then a guardianship will need to be established for decision making. Putting a guardianship in place ahead of time, during the parents' lifetime, eases the transfer of decision-making.

Full Article and Source:
Elder Law:  Special Needs Adult Children Need a Plan for Their Future

Learning to Embrace Empowerment in the Last Chapter of Life

~by Jeanne Dennis, Senior VP at VNSNY Hospice Care.

It was Georgia's* 90th birthday party. Unlike several of the other guests (who were at least two decades younger), she was lively, bright and full of optimism. While her party guests shared their fears of disease and economic disaster when they reach the age of the new nonagenarian in their midst, Georgia laughed it off. "There's really nothing to be afraid of," she winked. "The ultimate empowerment is living each day to the fullest, having determined how the end of your life will take place."

 "I can't stop aging, and while I take good care of myself, I don't know if or when I might get terminally ill," Georgia explained. "But it doesn't mean I'm powerless. I don't have to spend my days wondering 'what if.' I made sure I discussed ahead of time with my family what's important to me. That gave me such peace of mind that the last chapter of my life will be the way I want it, and it also gave my loved ones guidance on how to make decisions on my behalf."

Our nurse was impressed by this forthrightness -- it's not often that we encounter such acceptance in our day-to-day hospice work. Georgia must've read her mind, because she continued, "I looked around and saw that too many people die in a manner they would not choose, hooked up to machines or unable to express their needs or preferences because they'd been afraid to prepare when they had the chance. I was determined that wouldn't happen to me. After all, I'm not the only one who would suffer -- think of the toll it would take on my family and friends. I couldn't put them through it."
One of the first steps for anyone, young or old, to prepare is an advance directive. An advance directive is a type of written or verbal instruction about health care which is to be followed if a person becomes unable to make decisions regarding his or her medical treatment. There are four types of advance directives, each enabling an individual to convey end-of-life wishes, in the event that he or she is unable to communicate:

• A Health Care Proxy (also known as a Health Care Power of Attorney) allows you to appoint a person you trust as your health care agent who is authorized to make medical decisions on your behalf.

• A Living Will allows you to document your wishes concerning medical treatments at the end of life.

• A Do Not Resuscitate Order (also known as a DNR) is a physician's order that directs health care professionals and/or emergency medical personnel to refrain from performing cardiopulmonary resuscitation (CPR), if your heart or breathing stops. [A DNR is only completed when someone is chronically or seriously ill.]

• An Organ Donor Designation allows you to document your wishes regarding donating your organs after your death. Even if you have indicated that you would like to be an organ donor, your family or health care proxy/agent must give their permission in order for the donation to take place.

Full Article and Source:
Learning to Embrace Empowerment in the Last Chapter of Life

See Also:
Hospice, Inc.

PA Court Case Examines Health Care Power of Attorney, Living Will

Pennsylvania's Superior Court recently decided an important case concerning the validity of a health care power of attorney and living will once an individual becomes incapacitated: In re: Estate and Person of Russell R. Border Jr., an incapacitated person, 2013 PA Super 94 (April 23, 2013).

 

Because of the importance of the case and the need to recount facts, this will be a two-part article continuing next month.

In 2010, the Berks County Office of Aging filed a petition for appointment of a guardian on behalf of Border, a 62-year old resident of a nursing facility with chronic medical conditions and failing health. Border had a wife and two adult daughters.

 

In 2007, he executed a health care power of attorney naming his eldest daughter, Renee, as his agent.

 

The Office of Aging requested that Renee be appointed as guardian of Border's person and nominated an attorney, Sharon Gray, as guardian of the estate. The Orphans' Court Judge entered an order declaring Border to be an incapacitated person, appointed his daughter as guardian of the person, Gray as guardian of the estate, and revoked any other existing health care power of attorney previously executed by Border.

 

Two weeks later, the Office of Aging filed a motion for reconsideration based upon Renee's decision to remove Border from the nursing facility to return him to his residence, where she intended to care for him. The Office of Aging felt that Renee was not physically able to care for her father and that he belonged in a nursing facility. The Orphans' Court judge agreed and amended its order to appoint Gray as guardian of the estate. For two years, Gray served in the capacity of guardian of Border's person and estate, making all decisions regarding his care and finances.

 

In March 2012, Border was admitted to the ICU at Reading Hospital, placed on a mechanical ventilator with other forms of life-sustaining treatment. Border's physician contacted Gray to advise that Border's health condition was both terminal and futile, and requested that she authorize removal of life support. Border's family, including his wife, brother, sister and both adult daughters, all agreed with this recommendation. Gray disagreed and asserted her authority as guardian of Border's person to prohibit the removal of life support.

 

In 2007, Border executed a durable power of attorney for health care and living will, where he appointed his daughter, Renee, as agent. Border elected to have life-sustaining treatments under all categories of situations listed in the living-will document. He also opted for his preferences to serve as a "general guide," acknowledging that "in some situations, the person making the decisions for him may decide something different ... if they think it is in his best interest." Relying upon the living will and conversations between herself and Border (acknowledging, however, that those conversations took place after Border was already incapacitated), Gray refused to authorize removal of life support.

 

As a result of the conflict between Border's family and Gray as guardian, the hospital filed an emergency petition, seeking the removal of Gray as guardian and suggesting that Border's brother replace Gray. The Orphans' Court Judge did just that, directing that the brother had specific authority to withhold and/or decline any life-sustaining medical treatment, including removing Border from a ventilator.

 

Full Article and Source:
Court Case Examines Health Care Power of Attorney, Living Will