Introduction
A person facing the prospect of long-term care with moderate income and assets may eventually have to rely on Medicaid to pay part or all of the cost of care.
Medicaid planning, using a qualified elder law attorney, allows you to correct inequities in the system. Medicaid planning has gotten a bad name because some individuals, who would normally have too many assets to ever qualify for Medicaid, deliberately use it, many years in advance, to give away everything to their family so as to qualify for Medicaid. It is wrong to abuse the system in this way and to use taxpayer dollars to insure an inheritance for the family. And if that person is not anticipating immediate care, this strategy is just plain dumb. A list of practitioners who specialize in this area of helping people with Medicaid issues can be found at http://www.longtermcarelink.net/a7medicaidplanning.htm
Income Annuity in the Name of the Community Spouse
This technique relies on two Medicaid rules. The first rule is that income between couples is attributed to the spouse who owns the income. Unlike assets which have to be shared for Medicaid eligibility, income does not have to be shared. For example if the Medicaid recipient has a total income of $500 a month and the community spouse has a total income of $4,000 a month the community spouse is not required to contribute any income towards the care of his or her spouse. Medicaid will cover the bill less the $500 a month, which, less a monthly allowance must be spent towards the cost of care. The second rule allows a spouse to transfer any amount of assets to another spouse without penalty of losing Medicaid eligibility.
Using these two rules, here is how a Medicaid annuity strategy works.
The person needing long-term care -- the institutional spouse -- applies to Medicaid in order to receive Medicaid services. In this case suppose the couple has $100,000 of cash equivalent assets and owns a home and a car. As long as the healthy spouse -- the community spouse -- lives in the home she can keep the home and the car and those assets do not prevent the institutional spouse from receiving Medicaid help. In this example, the institutional spouse must spend $50,000 of the couple's assets down to less than $2,000 and have an income insufficient to cover the cost of care and then Medicaid will take over.
Once the Medicaid application has been submitted, instead of starting the spend down to $2,000 and then receiving approval and having Medicaid pick up the balance of the cost, the institutional spouse transfers his $50,000 to his wife. This is allowable and will not disqualify the Medicaid approval process but it does not yet take away the responsibility to spend down the cash. The community spouse then uses the money to purchase an immediate income annuity for a period equal to or less than the allowable life expectancy in the HCFA transmittal 64 table. Assets have now been converted to about $800 a month in income. The income belongs to the community spouse and does not have to be shared with the institutional spouse. Therefore the spend down has been avoided. Evidence of this transaction is presented to Medicaid and because the institutional spouse no longer has any attributable assets, Medicaid starts paying its share of the bill.
This strategy serves two purposes. First, it may give the community spouse a larger income than she otherwise would have had under Medicaid rules. Second, even though it represents income, the community spouse has managed to keep $50,000 that would normally have to be spent.
In the past, some planners have set up annuities that provide a remainder payout should the community spouse die too soon. This is usually paid to the children and in the past was used as a way to transfer assets to the children without penalty. Under the Deficit Reduction Act of 2006, the state must be named as beneficiary for any remainder payout. This new rule discourages the use of these annuities to transfer assets to the next generation.
It is important for the planner to follow Medicaid guidelines in order to avoid a penalty. If the payout period of the annuity exceeds the life expectancy in Medicaid tables, then the excess amount of total income payment over the life expectancy becomes a transfer for less than value and represents a penalty. This in turn results in a penalty period equal to the amount of excess divided by the monthly Medicaid rate in that state. Medicaid will not start paying for care until this penalty period has been met with someone else paying for that care. It's important to use a qualified adviser to make sure you do all of this properly.
Prepaid Funeral Instead of or in Addition to Burial Funds
Federal rules allow a person on Medicaid to keep up to $1,500 for funeral expenses. Most states allow a recipient to buy a prepaid funeral plan. The limit for such a plan is usually higher than the $1,500 allowed by Federal rules. As an example, if your state allows $7,000 for a prepaid funeral plan then you should use the full amount you have money for to buy a plan.
Your state may also allow additional costs such as the burial plots, caskets and vaults to be tacked on, thus raising the limit.
Use of Spend Down Resources
People assume money being spent down for Medicaid eligibility needs to be applied to care costs. In reality, Medicaid is only interested in seeing the potential Medicaid recipient's resources reduced to less than $2,000. How the money is spent is only questioned if there has been a transfer for less than value.
In order to qualify for Medicaid more quickly, you may want to use some of the spend down money to pay off debt, trade in the old car and buy a new one. (Medicaid typically allows a community spouse to retain just one car), or fix up the house.
Intend to Return Home
If a single person receiving Medicaid care in a facility has a house, that property could be subject to sale to pay for Medicaid expenses. The house is only protected if a qualifying child or dependent lives there or if the recipient intends on returning home. Some states require a medical doctor to certify a return home, but in many states it only requires the signature of the recipient whether that recipient has justification or not. In the states that allow it, always have your loved one sign an intent to return home. At least you have use of the property while your loved one is still alive.
Most families sell the home and end up with a large amount of cash that must be spent down before the loved one qualifies for Medicaid. Keeping the home avoids losing the entire value of it to spend down. By retaining the home, Medicaid recovery may not come after the full value of the home when the loved one dies.
Potential rental income from the house would also go towards paying the the facility cost and reduce the amount that Medicaid would have to pick up. This could mean that Medicaid recovery using this strategy might go after a smaller share of its cost in the recovery process.
Medicaid treatment of a Home
If the community spouse lives in the home then the home is exempt from determining Medicaid eligibility. It does not count as an asset and prevent the institutional spouse from receiving Medicaid help. On the other hand any other real estate property, not the primary residence, will have to be converted to cash and spent down before Medicaid will start paying the bill.
If the community spouse living in the home does not in turn need Medicaid help in the future then one of two things can happen to the house after the death of the institutional spouse. Legally Medicaid has a claim against the property for recovery services. And in some states a lien against the property, called a TEFRA lien, can be filed in anticipation of Medicaid's cost. The lien can be filed before the death of the care recipient but only a few states actually do that. States that have authority to file these liens often don't so until after the death. At the death of the community spouse, the property cannot be sold until the lien is satisfied. But in states where there is no lien, if the community spouse dies after the institutional spouse it's unlikely that state Medicaid recovery will use the property as an asset for recovery.
And in many states if the property is inside a trust, the state may not consider the house an asset for recovery even though most states have altered their definition of estate to include a trust. Many states still rely on filing a claim in probate court to initiate recovery. The bottom line is very few states are efficient at recovery especially when it comes to a primary residence. Always contact and work with a competent adviser when dealing with recovery issues. You can never assume what your state recovery program will actually do.
Special Home Exemption Rule
It's often the case that a daughter will move in to take care of Mom or Dad or both. In this case Medicaid has a special leniency rule to allow transfer of the home to the daughter and not result in a penalty for a transfer for less than value. If the child provides care for a parent in a parent's home for at least two years, and that care kept the recipient out of a nursing home, the property can be transferred to the child without penalty and the property will not be a subject asset for Medicaid recovery. Medicaid will require some proof of this. Typically an affidavit from a third-party care provider such as a doctor or an agency stipulating that the care was given for at least two years and resulted in keeping the care recipient out of a long-term care facility, will be sufficient evidence. It's important to use a legal adviser to make sure you do this properly.
Joint Tenancy
Many people anticipating Medicaid services are tempted to put a child's or sibling's name on property titles to avoid probate and Medicaid recovery. It may not be a good idea.
There are at least four problems.
• If the other person on the title becomes subject to a judgment, even one arising from an accident, then at least 50% of the property can be lost to the judgment.
• The other person on the title must consent to any disposition of the property. He or she might not be in accordance with what the original owner wants to do.
• Redoing the title must occur at least 5 years prior to claim in order to avoid look back rules and a sanction on a gift to a non spouse owner.
• The person assuming joint ownership has received a gift and loses the step-up in basis at death. Capital gains taxes may have to be paid. And if the property is not the principal residence of the new tenant, the capital gains exclusion cannot be used either.
Transfer Title of the Property to The Community Spouse
Transfers to a spouse of any assets are exempt from Medicaid eligibility rules. An institutional spouse, anticipating Medicaid, can transfer title in the home to the community spouse and it has no effect on Medicaid eligibility. This can be done either with a quit claim deed or through a trust. With the asset no longer in the name of the care recipient, Medicaid recovery cannot use the house as a basis for recovering its costs. And the community spouse can transfer the house to a member of the family and as long as this is done beyond the five-year look back period, then Medicaid can't assess a penalty period for a transfer of assets for less than value. It's important to use a legal adviser to make sure you do this properly.
Trust to Avoid Probate
Common trusts to avoid probate are called "living" or "inter vivos" trusts. A trust never dies, thus it is not subject to probate. Most arrangements make the trust the owner of the property with the original owner(s) as trustee(s) (caretaker as it were) and beneficiaries(s). Thus the property reverts to the estate at death. Most people initiate these trusts to avoid probate. Assets in these trusts, other than a primary residence, are transparent to Medicaid. These trust assets are subject to Medicaid spend down rules.
The trust can be used in states where Medicaid recovery only uses primary residences passing through probate as being subject to recovery. However, a growing number of states do not recognize these arrangements to avoid probate estate recovery and go after primary residences in revocable trusts regardless of ownership.
To do it right for these states requires an irrevocable trust with no life interest, set up 5 years or more before a Medicaid claim. Very few people are willing to do these kinds of trusts.
Some people also include a so-called "life interest" in property in arrangements where property is gifted or in irrevocable trusts. The life interest gives them use of the property until their death even though they don't own it. Medicaid in many states does not recognize life interest and the property is considered to be in the ownership of the person who gifted it and subject to look back rules and recovery.
Move Loved One Needing Care to Another State
A person needing Medicaid covered care in one state may not qualify under that state's rules but might qualify under the rules of a neighboring state. Of particular concern are candidates suffering from dementia or Alzheimer's. It's difficult to quantify their need for care and in some states, those people who are cognitively impaired might not get help with Medicaid even though their needs might be greater than the needs of those who are physically disabled.
Families should consider moving loved ones who have been declined in one state, to live with a member of the family in another state and possibly qualifying in that state. In addition the new state may be more lenient with Medicaid recovery procedures.
A second reason may be that the current state of residence has a very tight supply of Medicaid beds and there is a waiting list. Moving the loved one to a state where there are more available Medicaid beds may avoid the family having to temporarily cover the cost of a non-Medicaid nursing home bed while waiting for one to become available.
Give Away Assets
We have already discussed the moral implications of using Medicaid planning strategies for unfairly qualifying for Medicaid and shifting the burden of cost to the taxpayers. New look back rules under the Deficit Reduction Act have effectively done away with gifting strategies used in the past to accelerate eligibility for Medicaid. This does not mean that gifts cannot be used, but planning must be done many years in advance. Under these new circumstances the whole concept of gifting in order to qualify for Medicaid probably makes little sense.
http://www.reversemortgageloans-rates.com/
http://www.mireverse.com/
Monday, November 30, 2009
Wednesday, November 11, 2009
Seniors Relocation and Real Estate Services
As people age, they often become overly attached to their homes and even though there may be compelling reasons to find other living arrangements, these folks will go to extreme lengths to remain in their homes.
Notwithstanding the affection for their dwellings, there is oftentimes undeniable pressure for seniors to move out and into a different living arrangement. Consider the following:
•The challenge of maintaining a yard and providing upkeep has become too great.
•There is a need for long term care that can't be handled in the home.
•The older person needs supervision that can't be provided in the home.
•The neighborhood has deteriorated and safety is a concern.
•There is a desire to be near children or grandchildren (70% of those 65+ live within 1 hour of a child).
•The home cannot accommodate disability needs.
•There is a need to avoid climbing stairs.
•Assets are tied up in the home and cash is needed through selling the property.
•Driving is no longer possible and available local transportation is not adequate.
•There is a desire for a warmer climate, a yearning for new vistas or a need for challenging new experiences.
Typically, the thought of giving up their residence, finding new accommodations, downsizing personal possessions and executing the move can seem overwhelming to many older people.
Perhaps another obstacle for many seniors, contemplating a move, is the lack of support or help from family members. In fact, some seniors have no children. For others, the children are living far away or are extremely busy with their jobs or their own families. And in some cases -- because people are living so long -- the children are elderly as well and find it difficult to help with the move.
This overwhelming pressure and stress relating to moving can often result in gridlock -- a failure to make any decision at all.
Because many elderly people face such a daunting task with moving, a growing number of seniors relocation specialists are stepping forward to provide assistance. These individuals or companies provide or arrange for the following services:
•advice and counseling,
•help with finding new accommodations,
•downsizing possessions through personal, caring assistance with discarding, donating or arranging estate sales,
•selling the existing property,
•organizing, arranging and scheduling the move,
•unpacking at the new location and removing boxes and other debris,
•setting up and arranging furniture.
And it isn't just the elderly person, contemplating a move, who is hiring these specialists. Active senior communities, independent living facilities, nursing homes and assisted living often retain a relocation specialist to provide advice and arrange services to help seniors with a move. Family members of seniors have also found it more convenient to hire a specialist to help their loved ones with relocation.
So who are these companies or individuals who provide seniors relocation and real estate services? (A list of these providers can be found at www.longtermcarelink.net.)
Seniors Real Estate Specialists
A Seniors Real Estate Specialist (SRES) is a real estate agent who specializes in helping the elderly transition to a new location. The specialist has been trained to recognize the special needs of seniors and understand the various living arrangements available to older people. Most of these specialists concentrate on selling the property and do not directly provide relocation services but they will arrange for companies or individuals or advisors who can provide these other services.
Senior Move Managers
A Senior Move Manager is a member of the National Association of Senior Move Managers. These people often have a background in social work or case management and have experience working with the elderly. As such, they understand the needs and desires of seniors. Senior Move Managers can provide or arrange for any needed service such as counseling and advice, selling property, downsizing or relocating their clients.
Moving Companies
Many independent moving companies recognize the special needs of seniors and they will provide moving services, storage and other specialized programs for this unique group of customers. These companies will often work together with senior advisors and relocation specialists.
Specialists with Developers or Senior Communities
Active senior community developers, senior residences and care facilities have recognized that providing relocation services will help their clients or residents transition more quickly into the new living arrangements. This not only relieves the stress on the seniors but also results in less cost to the providers who might be holding open properties or rooms for a long period of time -- while receiving no income -- due to the difficulty of selling the old residence and relocating.
Professional Organizers
Professional organizers -- many of whom are members of the National Association of Professional Organizers -- have found a unique niche in helping people reduce clutter in their homes or provide a more efficient office or living environment. Because of extensive experience in reducing personal possessions, a professional organizer can be particularly useful in helping to downsize in anticipation of a move.
Professional or Geriatric Care Managers
Care managers help the elderly and their families deal with the issues of long term care. Most care managers also help people, needing long term care, to find appropriate living arrangements. A natural outgrowth of finding new accommodations has resulted in many care managers specializing in relocation services as part of what they do.
Adding Value by Helping to Obtain the Veterans Aid and Attendance Benefit
About 30% of seniors over the age of 65 are war veterans or they are the surviving spouses of these veterans. Under the right circumstances these people could be receiving a veterans benefit called "aid and attendance" which, under the right circumstances, could furnish up to an additional $1,800 a month in income. This is such a well-kept secret that only a fraction of eligible veterans are receiving the benefit. Relocation specialists who are experts on obtaining the veterans aid and attendance benefit are helping seniors find additional income to pay for assisted living or nursing home costs. Seniors are also seeking out these veteran-savvy relocation specialists for help with moving and creating new income after the move. Click here to learn more.
http://www.mireverse.com/
http://www.reversemortgageloans-rates.com/
Notwithstanding the affection for their dwellings, there is oftentimes undeniable pressure for seniors to move out and into a different living arrangement. Consider the following:
•The challenge of maintaining a yard and providing upkeep has become too great.
•There is a need for long term care that can't be handled in the home.
•The older person needs supervision that can't be provided in the home.
•The neighborhood has deteriorated and safety is a concern.
•There is a desire to be near children or grandchildren (70% of those 65+ live within 1 hour of a child).
•The home cannot accommodate disability needs.
•There is a need to avoid climbing stairs.
•Assets are tied up in the home and cash is needed through selling the property.
•Driving is no longer possible and available local transportation is not adequate.
•There is a desire for a warmer climate, a yearning for new vistas or a need for challenging new experiences.
Typically, the thought of giving up their residence, finding new accommodations, downsizing personal possessions and executing the move can seem overwhelming to many older people.
Perhaps another obstacle for many seniors, contemplating a move, is the lack of support or help from family members. In fact, some seniors have no children. For others, the children are living far away or are extremely busy with their jobs or their own families. And in some cases -- because people are living so long -- the children are elderly as well and find it difficult to help with the move.
This overwhelming pressure and stress relating to moving can often result in gridlock -- a failure to make any decision at all.
Because many elderly people face such a daunting task with moving, a growing number of seniors relocation specialists are stepping forward to provide assistance. These individuals or companies provide or arrange for the following services:
•advice and counseling,
•help with finding new accommodations,
•downsizing possessions through personal, caring assistance with discarding, donating or arranging estate sales,
•selling the existing property,
•organizing, arranging and scheduling the move,
•unpacking at the new location and removing boxes and other debris,
•setting up and arranging furniture.
And it isn't just the elderly person, contemplating a move, who is hiring these specialists. Active senior communities, independent living facilities, nursing homes and assisted living often retain a relocation specialist to provide advice and arrange services to help seniors with a move. Family members of seniors have also found it more convenient to hire a specialist to help their loved ones with relocation.
So who are these companies or individuals who provide seniors relocation and real estate services? (A list of these providers can be found at www.longtermcarelink.net.)
Seniors Real Estate Specialists
A Seniors Real Estate Specialist (SRES) is a real estate agent who specializes in helping the elderly transition to a new location. The specialist has been trained to recognize the special needs of seniors and understand the various living arrangements available to older people. Most of these specialists concentrate on selling the property and do not directly provide relocation services but they will arrange for companies or individuals or advisors who can provide these other services.
Senior Move Managers
A Senior Move Manager is a member of the National Association of Senior Move Managers. These people often have a background in social work or case management and have experience working with the elderly. As such, they understand the needs and desires of seniors. Senior Move Managers can provide or arrange for any needed service such as counseling and advice, selling property, downsizing or relocating their clients.
Moving Companies
Many independent moving companies recognize the special needs of seniors and they will provide moving services, storage and other specialized programs for this unique group of customers. These companies will often work together with senior advisors and relocation specialists.
Specialists with Developers or Senior Communities
Active senior community developers, senior residences and care facilities have recognized that providing relocation services will help their clients or residents transition more quickly into the new living arrangements. This not only relieves the stress on the seniors but also results in less cost to the providers who might be holding open properties or rooms for a long period of time -- while receiving no income -- due to the difficulty of selling the old residence and relocating.
Professional Organizers
Professional organizers -- many of whom are members of the National Association of Professional Organizers -- have found a unique niche in helping people reduce clutter in their homes or provide a more efficient office or living environment. Because of extensive experience in reducing personal possessions, a professional organizer can be particularly useful in helping to downsize in anticipation of a move.
Professional or Geriatric Care Managers
Care managers help the elderly and their families deal with the issues of long term care. Most care managers also help people, needing long term care, to find appropriate living arrangements. A natural outgrowth of finding new accommodations has resulted in many care managers specializing in relocation services as part of what they do.
Adding Value by Helping to Obtain the Veterans Aid and Attendance Benefit
About 30% of seniors over the age of 65 are war veterans or they are the surviving spouses of these veterans. Under the right circumstances these people could be receiving a veterans benefit called "aid and attendance" which, under the right circumstances, could furnish up to an additional $1,800 a month in income. This is such a well-kept secret that only a fraction of eligible veterans are receiving the benefit. Relocation specialists who are experts on obtaining the veterans aid and attendance benefit are helping seniors find additional income to pay for assisted living or nursing home costs. Seniors are also seeking out these veteran-savvy relocation specialists for help with moving and creating new income after the move. Click here to learn more.
http://www.mireverse.com/
http://www.reversemortgageloans-rates.com/
Wednesday, November 4, 2009
Medical Care at the End-of-Life
Medical Care Immediately Prior to Death
In the first half of the 20th century, most people who died had an accident or contracted a disease or they had a physical disorder that inevitably lead to death. Life-saving medical interventions such as sophisticated resuscitation, complicated surgeries, life-saving treatments, ventilators, feeding tubes and other life-support were rarely used or even available. Nowadays there is great emphasis on curing medical problems sometimes to the exclusion of recognizing that death might be a more welcome outcome.
Surveys indicate that older people are often more afraid of death than younger people. But for all Americans -- young and old -- there is a great fear of death and oftentimes the families of those loved ones, who are near the end-of-life, will go to great lengths to try interventions that may be ineffective in prolonging life. We need only look to the Terri Schiavo case as a reflection of the attitude of many Americans who are unwilling to let loved ones pass on. Estimates are that about 30% of Medicare reimbursements are spent on people in the last year of their life. It is a fact that much of this medical care did little to prevent death and prolong life.
According to the Dartmouth Atlas study on death:
"The quality of medical intervention is often more a matter of the quality of caring than the quality of curing, and never more so than when life nears its end. Yet medicine's focus is disproportionately on curing, or at least on the ability to keep patients alive with life-support systems and other medical interventions. This ability to intervene at the end of life has raised a host of medical and ethical issues for patients, physicians, and policy makers.
The Dartmouth Atlas project uncovered some startling differences in what happens to Americans during their last six months of life. In some parts of the country, nearly 50% of people are in the hospital at the time of death, rather than at home or in a nursing home or other non-hospital setting. In these areas, the likelihood of being admitted to an intensive care unit during the last six months of life is also higher than average - as is the likelihood of being admitted to an intensive care unit during the hospitalization at the time of death. In other parts of the country, the likelihood of a hospitalized death is far smaller, and people who are dying are much less likely to spend time in hospitals during their last six months of life.
The Atlas asked why this was so - why someone living in Miami was so much more likely to receive a great deal of high-tech, expensive medical services, while someone with the same condition who lived in Minneapolis received so much less. The answer appears to be that the capacity of the local health care system - the per-capita supply of hospital beds, doctors, and other forms of medical resources - has a dominating influence on what happens to people who are near death. Those who live in areas like Miami , where there are very high per capita supplies of hospital beds, specialists, and other resources, have one kind of end of life experience. Those who live in areas like Minneapolis or San Francisco , where acute care hospital resources are much more scarce, have very different kinds of deaths.
The question, then, is which is better? From the dying person's perspective, more is not necessarily a good thing - more visits to doctors for someone who is very sick can be stressful and exhausting. For many people a hospitalized death is something to be avoided if at all possible. From the perspective of the health care system, much of the care being given is futile, and accomplishes little. People who live in areas with very high utilization of hospital resources do not live longer than people who die in areas where utilization is lower - and if extension of life is not the goal of intervention, what is? From society's perspective, the cost of this kind of intervention is high, futile, and takes resources away from places where the money might be spent far more productively."
Deciding How and When to Stop Curing and Start Caring
Some people are content to leave decisions regarding their death in the hands of others. By doing so, they may expose themselves to unnecessary and futile treatments as outlined above. They may experience numerous visits to the emergency room in the last stages of their life. And their dependency on others often results in great stress to family members when loved ones at the end-of-life lose their capacity and didn't make their last wishes known. Families are often forced to make decisions about life-support and treatment without knowing whether their loved one would have wanted these interventions.
Medical providers have come up against this situation many times and as a result there are written guidelines for doctors dealing with end-of-life issues. Here is a listing of the titles of official positions taken by the American Medical Association on a number of end-of-life actions. The actual content can be found online on the AMA website.
•Living will
•Health care treatment plan
•Health care power of attorney
•Do not resuscitate at-home (for states that allow a legal procedure for this action)
We will go into greater detail on these forms in a future article but will mention here some important points to consider with these documents.
•Many if not all healthcare organizations have standard forms for living wills. Some providers may also allow for signing a do-not-resuscitate order. Some of these documents may not be what they claim to be. Read them carefully.
•A health care treatment plan is usually created between a patient's physician, the patient and an attorney. This is a detailed agreement on how to handle certain medical interventions.
•A health care power of attorney is a legal document that would not usually be available as a standard form from a health care provider. This document should supersede any other guidelines that physicians use for making medical treatment decisions.
•The do-not-resuscitate-at-home arrangement is a very complicated procedure where a person needing emergency medical treatment in the home and not desiring resuscitation makes that wish known to emergency medical personnel. This involves an identification bracelet, a complicated verification procedure and an OK from a central clearinghouse not to perform any life-saving actions.
A patient or his or her spouse or a family member will typically call 911 in the event of a life-threatening emergency. Very seldom will the living will, the health care treatment plan or the health care power of attorney end up with anyone in the emergency room. Medical decisions for someone who cannot make those intentions known, generally devolve to family members who show up at the hospital. The actual health treatment wishes of the patient may be at home in the desk drawer. It is therefore extremely important to remember to take these documents to the emergency room whenever a crisis arises.
Without the advance directives in hand for an emergency room or for a hospital admission, many patients or family will be given the opportunity to sign a standard form from the health care provider. Many hospitals, nursing homes and home health agencies provide forms that allow or disallow a number of treatments. It is extremely important for the patient or the family to read these institutional advance directives thoroughly before signing. Some of these documents, claiming to be a living will, are in fact not, but are other types of advance directives that may not fit the needs of the family.
More detailed information about this subject and about other issues dealing with long term care planning can be found at http://www.longtermcarelink.net/.
We will discuss in more detail, specific issues dealing with end-of-life, in future articles.
http://www.mireverse.com/
http://www.reversemortgageloans-rates.com/
Troy Freesemann
In the first half of the 20th century, most people who died had an accident or contracted a disease or they had a physical disorder that inevitably lead to death. Life-saving medical interventions such as sophisticated resuscitation, complicated surgeries, life-saving treatments, ventilators, feeding tubes and other life-support were rarely used or even available. Nowadays there is great emphasis on curing medical problems sometimes to the exclusion of recognizing that death might be a more welcome outcome.
Surveys indicate that older people are often more afraid of death than younger people. But for all Americans -- young and old -- there is a great fear of death and oftentimes the families of those loved ones, who are near the end-of-life, will go to great lengths to try interventions that may be ineffective in prolonging life. We need only look to the Terri Schiavo case as a reflection of the attitude of many Americans who are unwilling to let loved ones pass on. Estimates are that about 30% of Medicare reimbursements are spent on people in the last year of their life. It is a fact that much of this medical care did little to prevent death and prolong life.
According to the Dartmouth Atlas study on death:
"The quality of medical intervention is often more a matter of the quality of caring than the quality of curing, and never more so than when life nears its end. Yet medicine's focus is disproportionately on curing, or at least on the ability to keep patients alive with life-support systems and other medical interventions. This ability to intervene at the end of life has raised a host of medical and ethical issues for patients, physicians, and policy makers.
The Dartmouth Atlas project uncovered some startling differences in what happens to Americans during their last six months of life. In some parts of the country, nearly 50% of people are in the hospital at the time of death, rather than at home or in a nursing home or other non-hospital setting. In these areas, the likelihood of being admitted to an intensive care unit during the last six months of life is also higher than average - as is the likelihood of being admitted to an intensive care unit during the hospitalization at the time of death. In other parts of the country, the likelihood of a hospitalized death is far smaller, and people who are dying are much less likely to spend time in hospitals during their last six months of life.
The Atlas asked why this was so - why someone living in Miami was so much more likely to receive a great deal of high-tech, expensive medical services, while someone with the same condition who lived in Minneapolis received so much less. The answer appears to be that the capacity of the local health care system - the per-capita supply of hospital beds, doctors, and other forms of medical resources - has a dominating influence on what happens to people who are near death. Those who live in areas like Miami , where there are very high per capita supplies of hospital beds, specialists, and other resources, have one kind of end of life experience. Those who live in areas like Minneapolis or San Francisco , where acute care hospital resources are much more scarce, have very different kinds of deaths.
The question, then, is which is better? From the dying person's perspective, more is not necessarily a good thing - more visits to doctors for someone who is very sick can be stressful and exhausting. For many people a hospitalized death is something to be avoided if at all possible. From the perspective of the health care system, much of the care being given is futile, and accomplishes little. People who live in areas with very high utilization of hospital resources do not live longer than people who die in areas where utilization is lower - and if extension of life is not the goal of intervention, what is? From society's perspective, the cost of this kind of intervention is high, futile, and takes resources away from places where the money might be spent far more productively."
Deciding How and When to Stop Curing and Start Caring
Some people are content to leave decisions regarding their death in the hands of others. By doing so, they may expose themselves to unnecessary and futile treatments as outlined above. They may experience numerous visits to the emergency room in the last stages of their life. And their dependency on others often results in great stress to family members when loved ones at the end-of-life lose their capacity and didn't make their last wishes known. Families are often forced to make decisions about life-support and treatment without knowing whether their loved one would have wanted these interventions.
Medical providers have come up against this situation many times and as a result there are written guidelines for doctors dealing with end-of-life issues. Here is a listing of the titles of official positions taken by the American Medical Association on a number of end-of-life actions. The actual content can be found online on the AMA website.
- Do-Not-Resuscitate Orders
- Futile Care
- Medical Futility in End-of-Life Care
- Quality of Life
- Withholding or Withdrawing Life-Sustaining Medical Treatment
- Optimal Use of Orders - Not-To-Intervene and Advance Directives
- Surrogate Decision Making
- Advance Directives
•Living will
•Health care treatment plan
•Health care power of attorney
•Do not resuscitate at-home (for states that allow a legal procedure for this action)
We will go into greater detail on these forms in a future article but will mention here some important points to consider with these documents.
•Many if not all healthcare organizations have standard forms for living wills. Some providers may also allow for signing a do-not-resuscitate order. Some of these documents may not be what they claim to be. Read them carefully.
•A health care treatment plan is usually created between a patient's physician, the patient and an attorney. This is a detailed agreement on how to handle certain medical interventions.
•A health care power of attorney is a legal document that would not usually be available as a standard form from a health care provider. This document should supersede any other guidelines that physicians use for making medical treatment decisions.
•The do-not-resuscitate-at-home arrangement is a very complicated procedure where a person needing emergency medical treatment in the home and not desiring resuscitation makes that wish known to emergency medical personnel. This involves an identification bracelet, a complicated verification procedure and an OK from a central clearinghouse not to perform any life-saving actions.
A patient or his or her spouse or a family member will typically call 911 in the event of a life-threatening emergency. Very seldom will the living will, the health care treatment plan or the health care power of attorney end up with anyone in the emergency room. Medical decisions for someone who cannot make those intentions known, generally devolve to family members who show up at the hospital. The actual health treatment wishes of the patient may be at home in the desk drawer. It is therefore extremely important to remember to take these documents to the emergency room whenever a crisis arises.
Without the advance directives in hand for an emergency room or for a hospital admission, many patients or family will be given the opportunity to sign a standard form from the health care provider. Many hospitals, nursing homes and home health agencies provide forms that allow or disallow a number of treatments. It is extremely important for the patient or the family to read these institutional advance directives thoroughly before signing. Some of these documents, claiming to be a living will, are in fact not, but are other types of advance directives that may not fit the needs of the family.
More detailed information about this subject and about other issues dealing with long term care planning can be found at http://www.longtermcarelink.net/.
We will discuss in more detail, specific issues dealing with end-of-life, in future articles.
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