Peninsula Daily News Column 12-29-11 "Planning, living key for long-term care"

            It’s Christmas Day, and try as I may to ignore it for the purposes of a column, I can’t seem to evade that simple, irrevocable fact.

            It’s Christmas Day, and depending on who you are, where you are, who is or isn’t there with you and what you believe about the 25^th day of December, it may be a wonderful day, a horrible day, a meaningful day, a great TV day, a terrible TV day, a loud, busy day, a lonely, dreary day, an emotional day or just another day – But there’s no escaping the fact that it is Christmas Day.

            So, near as I can tell, here’s the one thing that every, single one of us, regardless of today’s circumstances, can agree upon: We aren’t dead. I know this to be true because every applicable marketing study and poll reveals that very few dead people read this column.

            So what? Well, it’s Christmas Day! So what?? No, try “NOW what?”

            Right: Now what? What now? What next? The end of the world, in another form or in another place or in another way, depending upon which talking head has captured our imaginations. All bad. All crises. The end of freedom, the end of capitalism, the end of everything we’ve ever known. Crime, viciousness, brutality.

            Greed.

            All around us, all the time, 24/7: What was wrong, what is wrong, what will be wrong – Fear motivates! Us vs. them! – And you know who’s right, right? Sure: Us!

            Us. We. And “we” are all having Christmas Day.

            And every single one of us feels very…small. Powerless. Inconsequential. There’s no way that any of us can possibly solve all the world’s horrible problems, so we just agree with whomever seems less harmful and call it “us.” Or just ignore it all, in the name of “mental health” – I get that.

            And we hope. We hope for something better, something saner, something more civilized. We hope for a time when people take care of one another and share the burdens. We hope for a society in which people encounter people as “people,” not political, philosophical or religious partisans – People. People can be good and decent people, and still disagree. Bigotry, in the name of being correct, is still bigotry.

            We hope that people we are supposed to be able to believe will just tell us the truth. We hope that we will be able to vote for someone instead of against someone. We hope that common sense will become a common commodity and we hope that aging really will be an achievement, and not an affliction.

            We hope that people will still hold doors open for other people. We hope that people will say “please” and “thank-you” – And mean it.

            We hope that people will share when they can, take when they need to and be able to remember which is which.

            We hope for fewer raised voices and blood pressures and we hope for gentleness.

            We hope for privacy as we hope for “community,” and we hope more for health care than we do for health insurance.

            We hope for dignity, personal responsibility and self-determination – And we wonder how many laws we really need.

            And we wonder when we’ll remember that we are our brothers’ keepers.

            We hope that people will stop doing bad things for good reasons and good things for bad reasons.

            We hope that we can take care of ourselves and take care of the caretakers. We hope that longevity won’t be a curse and we hope that the good don’t die young.

            We wonder if our leaders will ever figure out that the planet isn’t getting any bigger and we hope that the babies will be fed. And clothed.

            And loved.

            We hope for patience, civility and courtesy, while we hope for honesty.

            And we hope that “we” get so big that we totally consume “them!”

            We hope for love, in all its many colors.

            We hope, because it’s Christmas Day.

                

Peninsula Daily News Column 12-18-11 "Make life-sustaining treatment clear"

            Here we are on December 18^th, squarely in the middle of Phase III of the 2011 “Holiday Season” (well, I start counting at Halloween)!

            If you’ve just been dropped-off by the Mother Ship, allow me to point out that you have exactly seven days left until December 25^th, but I acknowledge that many of us are probably still suffering from a post-Medicare “open enrollment” hangover, so take two aspirin and call somebody else in the morning.

            Now, if “open enrollment” didn’t successfully put you in the holiday spirit, let’s pick up (as threatened) where we left off last week, which was talking about happy little documents called “advance directives.” These are the pieces of paper that tell doctors and other healthcare professionals what you do-or-don’t want done, if you can’t tell them yourself.

            There is a specific document called a “POLST” form, which stands for “Physician Orders for Life-Sustaining Treatment,” and this is one of the few times that you really do want to remember what an acronym stands for. Here’s why:

            Let’s say that I have an advanced, life-limiting illness (probably induced by “open enrollment”) and I’m at home (it could be “wherever,” but let’s say home) and something medically bad happens. Somebody calls 911 and the EMT’s (the “Good Guys”) come rushing in to save me. That’s their job, which is why they’re the “Good Guys.”

            Now, being the totally-on-top-of-it person that I am, I’ve diligently prepared an advance directive that spells out what I do-and-don’t want, and since this “medically bad thing” is preventing me from speaking for myself, everybody in the house is relying on the advance directive to tell the EMT’s what to do or not do, right?

            Wrong. EMT’s are required by law to do EVERYTHING THEY CAN to keep me going, and they will, which is why they’re the “Good Guys,” but it’s not what I wanted! How could I have prevented this??

            POLST. Remember that the first two letters stand for “Physician Orders?” That’s what allows the EMT’s to respect whatever it is that I did-or-didn’t want; in other words, it lets them off the proverbial legal hook.

            You might have seen these POLST forms around – They’re bright, electric green! – One piece of paper, front and back. These things are NOT for everybody and they are NOT a substitute for an advanced directive. Here’s why:

            POLST forms are designed for folks who have an “advanced, life-limiting illness;” in other words, you have a condition (or conditions) that could rise up and seriously whack you all of a sudden, potentially sending you on to the Promised Land. If you have some arthritis, maybe a little high blood pressure, maybe a controlled bit of this-and/or-that, POLST is not your thing – But, if you have something seriously serious, it might be.

            Also, a POLST form doesn’t necessarily do or say everything you might want (or not want), so it makes perfect sense to have BOTH an advanced directive AND a POLST.

            Are you “required” to have a POLST form? Of course not, it’s completely up to you, and if you want the Good Guys to rush in and perform all of their miracles, good for you! – In fact, the various sections of the POLST specifically allow you to say, “I want the full boat!”

            The form itself addresses issues like yes-or-no to CPR, extent of medical interventions, antibiotics, medically assisted nutrition, and a field for whatever else. The smart thing would be to get your hands on one of these and read through it, to see if it fits for you. They’re easy to find – Most clinics, facilities and certainly hospitals have them around. You can also go to www.wsma.org/patient_resources/polst which happens to be the Washington State Medical Association’s web site for some great info. More questions? Good! Talk to your doc or healthcare pro.

            So, let’s say I did a POLST form, and conscientiously provided copies to my doc and hospital, but I’m mostly at home – What should I do with this electric green eyesore? Well, you want it to be conspicuous, right? Remember the scenario: Something medically bad has happened and the EMT’s come charging in! They’re not likely to stroll casually through the house attempting to detect where I might have hidden the POLST form – They’re going to ACT! So, put it on the refrigerator or the bedroom door, in-or-on the medicine cabinet, on the bedside table – I’ve seen folks tack it to the wall right above the bed! Make it easy, and make it conspicuous!

            Now, I know what you’re thinking, because I know what the next question always is because I know what my next question would be: If I do all these forms correctly and give them to everybody who ought to have them and put them in all the right places blah blah, can I count on everything going the way I want everything to go?

            Look: I’ve heard and read horror stories, just like you have, about when these things didn’t work or some offspring defied them by screaming, “LIABILITY!” or whatever else. What you haven’t heard are the hundreds and thousands of times that they did work, and people’s wishes were respectfully respected, and I speak from experience – But if you want an iron-clad guarantee that everything will go perfectly no matter what, then I suggest that you signal the Mother Ship, because you are on the wrong planet.

            This is about – This whole “Boomer Primer” thing is about – Increasing the odds; Making it more likely that things will go the way you hope they will go. Here’s the only thing I can “guarantee” today: Tomorrow there will be six days until December 25^th .

            Everything else is a crap-shoot.

Peninsula Daily News Column 12-8-11 "Advance directives kick in near end"

            So, how did Part D “open enrollment” go? Mostly OK? Good! Are you just fed up with thinking about it?

            Me, too, so here we go, back to the “Boomer Primer” – If you don’t know what this is all about, please ask somebody else, because the rest of us are trying desperately to move on.

            And what we’re trying desperately to move on through is the paperwork part of this whole “aging thing,” so hang in there because this won’t go on forever (rather like “open enrollment”).

            OK, wills and probate and community property agreements and durable powers of attorney (which beat-the-heck out of guardianships) – What NOW?? Now, advance directives.

            “Advance directives” is an umbrella term; if you’ve heard other terms, like “living wills,” “healthcare directives” or “directives to physicians,” we’re talking about the same things. What these come down to is a document that tells your doctors, or other folks providing your healthcare, when you want them to stop life-sustaining treatment and let you die – I’m sorry, but that’s the truth of it.

            Now, are you “required” to have one of these? No. If you want ALL the “heroic measures,” right down to the bitter end (which is an absolutely fine thing to want!), then don’t do anything and go cruise catalogues for fruitcakes; however, some folks feel rather strongly about when to say, “Enough is enough” – If that sounds like you to you, stay with me.

            An advance directive can only take effect in two situations: (1) you’re terminally ill and will die soon, so life-sustaining procedures will only prolong the process, or (2) you’re in a permanent, unconscious condition (you may have heard the phrase, “permanent vegetative state” – Same thing). “Life-sustaining procedures” could include things like CPR or the use of a respirator or any number of other procedures. They do NOT include procedures to ease pain! – So, you’re going to get those, either way.

            Now, remember this: These things only kick-in if you can’t speak for yourself! – If you can, healthcare pros are going to go with what YOU say, regardless of what’s in any pretty piece of paper, OK? You call the shots, as long as you can call the shots.

            A healthcare power of attorney (familiar phrase?) allows someone you designate to make medical treatment decisions for you, if you can’t, and it doesn’t just have to apply to “life-sustaining procedures” – It can apply to any medical decisions. An advance directive can be combined with a healthcare power of attorney in one document.

            So, what would happen is that the person you designate in the healthcare POA could make decisions that might not have been considered when you were making out your advance directive, guided BY your advance directive, get it?

            Are there forms out there, so you could do one of these yourself? Yes. You know by now that my bias is to work through an elder law attorney (and, again, all these documents can often be included into a “package deal”), because they know the right questions to ask so that we think things through and the documents actually say whatever it is we want, but you can do them on your own, if you’re pretty darned sure that they say what you want them to say.

            To be valid, an advance directive has to be dated and signed in the presence of two witnesses, who also have to sign. These two witnesses CAN’T be: (a) related to you, by blood or marriage; (b) entitled to inherit, if you move on; (c) people you owe money to; (d) your attending doctor or the doctor’s employee, or (e) an employee of a healthcare facility where you are a patient – All of which make pretty good sense, when you think about them.

            It does not have to be notarized.

            OK, let’s say you’ve done this thing and you have the piece of paper – Now what? Keep one for yourself, give one to your doctor (and talk it over with him or her, so we know that we’re all thinking the same thing) and copies to anybody else that might need it, like the facility you live in or the hospital you’re in-and-out of or whomever.

            Now, let’s overstate the obvious, because it, often, isn’t obvious: What I hope you did was to talk this over with your family (think, “kids!”) before you went out and made pretty paper, because if they don’t know about it, don’t “get it” or (WORSE!) won’t go along with it, this is not going to go well. Forgive the cliché, but everyone needs to be on the same page of this pretty paper!

            Can you change your mind about this stuff? Sure! You can change your mind about any of this stuff, anytime! If you want to “cancel” an advance directive, all you have to do is (a) destroy it (or tell someone else to do it, in your presence); (b) write out a “cancellation” (no “form” needed, then sign and date it, or (c) just say so, to your doctor (or whomever). Period.

            BUT! If you’ve strewn copies of this thing hither-and-yon, remember to backtrack and let everybody in on what you’re doing, and please let me repeat myself repeat myself: These things ONLY take effect if you can’t speak for yourself! If you can, none of this means anything to anybody!

            I go on and on about these, because they are very important to a lot of people, but please don’t take all this as a “hint” that I think that you “should” do this. I don’t. I think you SHOULD think about it, then make any decision you care to make, which is the point of this whole “Boomer Primer” thing, anyway.

            I’d hoped to get into a specialized type of document called a POLST (“Physician Orders for Life-Sustaining Treatment”) form today, but I’m running out of newspaper (again), so we’ll bump that to next week, then we’ll be done with all this cheery, pre-holiday paperwork

            OK, now take a few minutes to think about what you want to do next about all of this stuff, then make a note to actually do whatever that is, including nothing; then, go cruise catalogues for fruitcakes.

            Then, order a pizza.  

Peninsula Daily News Column 12-1-11 "Get guardianship while you can"

            Welcome to the first day of December! You have exactly six days left in 2011’s “open enrollment” for Medicare’s Part D and Advantage Plans, so just get it done and enjoy the holidays, for a change.

            But today is Thursday and it’s time to move on…Well, “back;” specifically, back to our old friend, the “Boomer Primer.” You remember what we’re doing here, right? The idea is to present a list of “things to think about,” then (hopefully) do something about, so we can take on this “aging thing” with a respectable degree of competence.

            The last time we were here, I went on about durable powers of attorney (DPOA’s) and threatened you with “guardianships,” but before I make good on that threat, one more word about DPOA’s; well, actually, a hint for those of us who are all about the details.

            Generally speaking, DPOA’s allow the “agent” (the person who has been granted the legal authority to do stuff on behalf of another person who can’t do it for themselves) to move money around: Write checks, pay bills, etc. There is a nuance that comes up with Social Security: While most sources of income (e.g. retirement pensions, whatever) accept a legitimate DPOA, as do banks, Social Security doesn’t. They want you to fill out another whole set of paperwork to become a “representative payee” – It isn’t insurmountable; it’s just another thing to do at a time when you probably have more than ENOUGH things to do.

            Here’s the work-around: Have the Social Security check deposited directly into your person’s checking account (which most of us do, anyway) – Once the money is in the account, you, as the agent with your DPOA, can access it to pay the bills that need to be paid. Click.

            OK, guardianships. Harken back: Remember the part about how a person has to be able to grant “informed consent” (in other words, they know what they’re doing) to execute a power of attorney or a DPOA? Good; so, what happens when a person didn’t get a DPOA, and now they’ve become incapacitated? An all-too-familiar example for a lot of us is the decline into Alzheimer’s (or any form of dementia) – Now what? Somebody has to make the decisions and pay the bills and and and…

            Right, so you’re left with having to petition Superior Court for a guardianship. A guardian is a person appointed by the court to manage the affairs of another because of a “…demonstrated inability to adequately manage property or financial affairs…” or “…adequately provide for nutrition, health, housing or physical safety.”

            Anyone can file a petition for guardianship over another, and the one doing the petitioning does NOT have to become the guardian. The court then has to decide (a) whether the person is, in fact, incapacitated, then (b) appoint a guardian.

            Here’s what happens after the petition is filed:

1. Notice of the petition is given to the person identified in the petition;
2. The court appoints a “guardian ad litem” to make an investigation and report to the court about whether the person really needs a guardian, to what extent, who it ought to be, etc;
3. The guardian ad litem must get a statement from a doctor or psychologist, and;
4. A hearing – In court! – Must be held.

In my experience, guardians ad litem are sharp, and they care. They also have temporary authority to make decisions if there is something that needs to be addressed right now; also, while the court is not required to follow the recommendations of the guardian ad litem, it usually does.

What if the person in question objects to having a guardian? Well, it’s rather rare, for obvious reasons, but I’ve seen it happen, and it isn’t pretty. That person has a right to be represented by their own attorney at the hearing.

What if the person isn’t totally “out of it,” but still needs help? Good question. The court can appoint a “limited guardian,” who makes some of the decisions (e.g. just financial) while the person makes the rest (e.g. healthcare). The court decides how this will go, so you often hear talk about a “guardianship of the estate” or a “guardianship of the person,” but a limited guardian ship could have pieces of both.

The “good news” about guardianships is that the court supervises how all this actually goes; for instance, a guardian of the estate has to file an inventory with the court and an annual accounting of what-got-done-with-what (NOTE: I’ve seen, and you’ve probably heard, of ugly situations where the “greedy son” is filing for a guardianship to get his sweaty palms on Mom’s money. The courts, and guardians ad litem, are VERY smart about…stuff like that).

Guardians aren’t God, and there are things that they can’t do, at least not without the court’s OK; the most notable is that a guardian can’t put someone somewhere they don’t want to be, like in a nursing home, but here’s the reality: If the person in question is truly “incapacitated” to a significant degree, they probably aren’t going to object because they don’t know where they are, so the absence of “no” defaults to “yes.”

I don’t mean that crack to be disrespectful, but those of us who have walked the “caregiver walk” know darned-good-and-well what’s true, and while that person still deserves dignity, respect and (in most cases) love, what’s true is what’s true.

Is this everything that anyone could possibly need to know about guardianship? Of course not! – But it’ll get you in the ballpark, and if you find you or yours in this unhappy circumstance, find an attorney you can trust, which takes us back to the point of this whole “Boomer Primer” thing:

If everything I’ve just described sounds fun to you (or for the people you purport to love), feel free to do absolutely nothing; if it doesn’t, think seriously about having a DPOA prepared when you’re sitting with that elder law attorney, having your will drawn up. Remember, you can only do it before you need it, because by the time you need it, you can’t do it.

Informed consent.