When an Elderly Parent is Hospitalized – 7 Tips For Getting Good Care

One of the most stressful moments for any caregiver comes when an elderly loved one is hospitalized. The hospital can be a scary place. The fear that people feel when entrusting the care of someone dear to the vagaries of a large hospital are not unfounded. It is well documented that older patients are at risk for a whole host of complications when hospitalized. Some of these include confusion, infections, bed sores, weakness and falls.

The following are some tips for avoiding complications and getting better care.

1) Avoid the hospital altogether if possible!

Sometimes it is unavoidable – and can provide life-saving care. At other times, particularly for patients with advanced dementia or other severe disease, it may not be what the patient needs or wants. Clarifying advance directives (i.e. living wills or health care proxy) will give you a better sense of what your loved one would like. A good first question for a doctor who advises you to take a loved one to the ER is “what will they be able to do for him or her”. For example, a woman I met told me about her mother-in-law with advanced dementia living in a nursing home. The home had called the woman’s husband because his mother had a bit of a droop in her face and they wanted to send her to the ER to see if she was having a stroke. When the son posed the question “Will going to the ER make her better?”, the doctor at the nursing home said “No, it would just give us a diagnosis”. In this case the son knew his mother would not want to go to the ER and he was OK with not having a definitive diagnosis. As long as his mother was not suffering, he felt she would be happier staying home rather than enduring a lengthy and confusing visit to the ER.

2) Find out which doctor will be in charge of your loved one’s care.

Nowadays many primary care doctors do not take care of their patients in the hospital. Instead they rely on Hospitalists – internists who specialize in the care of hospitalized patients. If admitted through the emergency room, ask the doctor there who the “attending physician” will be. Once admitted, the patient’s nurse should be able to provide this information as well. If no one seems to know who is in charge, see if there is a “patient representative” office in the hospital. They will help you advocate and get what you need.

3) Create (and update) a simple medical record.

Until we have a universal electronic medical record (or chips embedded in our skin!), it is wise to keep a simple and up-to-date medical record for aging parents. This document should include: medical conditions, surgeries, medications (which should include medications that have been stopped and why), test results (colonoscopies, x-rays, mammograms etc, if available), allergies, contact information for doctors and next of kin, advance directives. This simple document will help the doctors know more about their patient and could be life saving when a loved one is in the Emergency Room. It can also prevent unnecessary testing and procedures. Creating this document sends the message that the patient is cared about and has concerned family.

4) Make sure family and friends visit as much as possible.

If patients have mental or physical impairments that limit their ability to express what they need, make sure they have someone to speak for them as much as possible. Whether it is to make sure they are cleaned and fed or that they are not being taken for a procedure that was meant for a roommate – try not to leave them alone. Family members or friends can take shifts, or for those who can afford it, hire a nurse or nurse’s aide. If no one can be there in person, designate someone to be the family representative and make sure that person calls in for each nursing shift to get an update on how the patient is doing and what is planned.

5) Find out who will be in responsible for discharge planning.

This is generally done by a social worker, though on occasion it may be a nurse. Make yourself known to this person early on. With hospitalizations becoming shorter, it is important that this person be aware of any concerns you have about discharge. Let them know if there are safety concerns at home. Also, if your loved one is too weak or sick to be home, the discharge planner can help you find a rehab facility as a transition to going home.

6) Ask for a second opinion.

If a treatment or procedure is being offered and you feel unsure if this is in the best interest of the patient, ask for a second opinion. Medicare will cover this.

7) Ask for a Geriatrics consult.

If your loved one is over 65 and has multiple medical problems, asking for a geriatrics consult can be helpful. These doctors are specifically trained to care for older patients and are skilled in end-of-life care as well.

Making the Choice to Execute a Health Care Power of Attorney and Living Will

Advances in medical technology, recent court rulings and emerging political trends have brought with them a number of life-and-death choices which many have never before considered. The looming prospect of legalized physician-assisted suicide is one such choice which severely erodes the inherent value and dignity of human life. The much-publicized efforts of certain doctors to provide carbon monoxide poisoning or prescribe lethal drugs for their terminally ill patients constitute euthanasia. So may the removal of certain life-sustaining treatments from a patient who is not in a terminal condition. Euthanasia and willful suicide, in any form, are offenses against life; they must be and are rejected by the vast majority of U.S. states.

However, people faced with these difficult dilemmas should be made aware that there are morally-appropriate, life-affirming legal options available to them. One such option, for Catholics and others, can be a “health care power of attorney” and “living will.” South Carolina State law allows you to appoint someone as your agent to make health care decisions for you in the event you lose the ability to decide for yourself. This appointment is executed by means of a “health care power of attorney” form, a model for which can be obtained from your attorney.

A health care power of attorney can be a morally and legally acceptable means of protecting your wishes, values and religious beliefs when faced with a serious illness or debilitating accident. Accordingly, for persons wishing to execute health care powers of attorney, see the following instructions and guidance from the authoritative teachings and traditions of various religious faiths.

The intent of the health care power of attorney law is to allow adults to delegate their God-given, legally-recognized right to make health care decisions to a designated and trusted agent. The law does not intend to encourage or discourage any particular health care treatment. Nor does it legalize or promote euthanasia, suicide or assisted suicide. The health care power of attorney law allows you, or any competent adult, to designate an “agent,” such as a family member or close friend, to make health care decisions for you if you lose the ability to decide for yourself in the future. This is done by completing a health care power of attorney form.

You…

o Have the right to make all of your own health care decisions while capable of doing so. The health care power of attorney only becomes effective when and if you become incapacitated through illness or accident.

o Have the right to challenge your doctor’s determination that you are not capable of making your own medical decisions.

o CAN give special instructions about your medical treatment to your agent and can forbid your agent from making certain treatment decisions. To do so, you simply need to communicate your wishes, beliefs and instructions to your agent. Instructions about any specific treatments or procedures which you desire or do not desire under special conditions can also be written in your health care power of attorney and/or provided in a separate living will.

o Can revoke your health care power of attorney or the appointment of your agent at any time while competent.

o May not designate as your agent an administrator or employee of the hospital, nursing home or mental hygiene facility to which you are admitted, unless they are related by blood, marriage or adoption. 1996

Your agent…

o Can begin making decisions for you only when your doctor determines that you are no longer able to make health care decisions for yourself.

o May make any and all health care decisions for you, including treatments for physical or mental conditions and decisions regarding life-sustaining procedures, unless you limit the power of your agent.

o Will not have authority to make decisions about the artificial provision of nutrition and hydration (nourishment and water through feeding tubes) unless he or she clearly knows that these decisions are in accord with your wishes about those measures.

o Is protected from legal liability when acting in good faith.

o Must base his or her decisions on your wishes or, if your wishes cannot be reasonably ascertained, in your “best interests.” The agent’s decisions will take precedence over the decisions of all other persons, regardless of family relationships.

o May have his or her decision challenged if your family, health care provider or close friend believes the agent is acting in bad faith or is not acting in accord with your wishes, including your religious/moral beliefs, or is not acting in your best interests.

CONSIDERATIONS FOR ALL PEOPLE FROM CHRISTIAN/CATHOLIC TEACHING

The following is an attempt to gather information from the doctrines of Christianity, Catholicism, and Judaism to see if there are any commonalities with regard to health care agencies and living wills. We will see that all three religions have placed a value on dying with dignity and the right of the person to direct how their dying process will occur.

A major tenet of the faith is that it is unethical to take a life. It is not the highest of all values to stay alive, but you cannot affirmatively take steps to kill someone. The church is strongly against euthanasia and suicide. But often if the patient and medical care providers permit nature to take its course without heroic intervention, the person’s life may be taken by God.

This is a narrow path. Taking a life is inappropriate; on the other hand, using heroic medical measures to keep a body biologically functioning would not be appropriate either. Mere biological existence is not considered a value. It is not a sin to allow someone to die peacefully and with dignity. We see death as an evil to be transformed into a victory by faith in God. The difficulty is discussing these issues in abstraction; they must be addressed on a case-by-case basis. The Christian church’s view of life-and-death issues should ideally be reflected in the living will and health-care proxy.

Roman Catholic teaching celebrates life as a gift of a loving God and respects each human life because each is created in the image and likeness of God. It is consistent with Church teaching that each person has a right to make his or her own health care decisions. Further, a person’s family or trusted delegate may have to assume that responsibility for someone who has become incapable of making their decisions. Accordingly, it is morally acceptable to appoint a health care agent by executing a health care power of attorney, provided it conforms to the teachings and traditions of the Catholic faith.

While the health care power of attorney law allows us to designate someone to make health care decisions for us, we must bear in mind that life is a sacred trust over which we have been given stewardship. We have a duty to preserve it, while recognizing that we have no unlimited power over it. Therefore, the Catholic Church encourages us to keep the following considerations in mind if we decide to sign a health care power of attorney.

1. As Christians, we believe that our physical life is sacred but that our ultimate goal is everlasting life with God. We are called to accept death as a part of the human condition. Death need not be avoided at all costs.

2. Suffering is “a fact of human life, and has special significance for the Christian as an opportunity to share in Christ’s redemptive suffering. Nevertheless there is nothing wrong in trying to relieve someone’s suffering as long as this does not interfere with other moral and religious duties. For example, it is permissible in the case of terminal illness to use pain killers which carry the risk of shortening life, so long as the intent is to relieve pain effectively rather than to cause death.”

3. Euthanasia is “an action or omission which of itself or by intention causes death, in order that all suffering may in this way be eliminated.” “[Euthanasia] is an attack on human life which no one has a right to make or request.”

4. “Everyone has the duty to care for his or her own health and to seek necessary medical care from others, but this does not mean that all possible remedies must be used in all circumstances. One is not obliged to use ‘extraordinary’ means – that is, means which offer no reasonable hope of benefit or which involve excessive hardship.

5. No health care agent may be authorized to deny personal services which every patient can rightfully expect, such as appropriate food, water, bed rest, room temperature and hygiene.

6. The patient’s condition, however, may affect the moral obligation of providing food and water when they are being administered artificially. Factors that must be weighed in making this judgment include: the patient’s ability to assimilate the artificially provided nutrition and hydration, the imminence of death and the risks of the procedures for the patient. While medically-administered food and water pose unique questions, especially for patients who are permanently unconscious, decisions about these measures should be guided by a presumption in favor of their use. Food and water must never be withdrawn in order to cause death. They may be withdrawn if they offer no reasonable hope of maintaining life or if they pose excessive risks or burdens.

7. Life-sustaining treatment must be maintained for a pregnant patient if continued treatment may benefit her unborn child.

Such principles and guidelines from the Christian heritage may guide Catholics and others as they strive to make responsible health care decisions and execute health care proxies. They may also guide Catholic health care facilities and providers in deciding when to accept and when to refuse to honor an agent’s decision.

CONSIDERATIONS FOR ALL PEOPLE FROM JEWISH TEACHING

Jewish tradition as understood by Conservative Judaism teaches that life is a blessing and a gift from God. Each human being is valued as created b’tselem elohim, in God’s image. Whatever the level of our physical and mental abilities, whatever the extent of our dependence on others, each person has intrinsic dignity and value in God’s eyes. Judaism values life and respects our bodies as the creation of God. We have the responsibility to care for ourselves and seek medical treatment needed for our recovery-we owe that to ourselves, to our loved ones, and to God.

In accordance with our tradition’s respect for the life God has given us and its consequent bans on murder and suicide, Judaism rejects any form of active euthanasia (“mercy killing”) or assisted suicide. Within these broad guidelines, decisions may be required about which treatment would best promote recovery and would offer the greatest benefit. Accordingly, each patient may face important choices concerning what mode of treatment he or she feels would be both beneficial and tolerable.

The breadth of the Conservative movement and its intellectual vitality have produced two differing positions put forward by Rabbis Avram Israel Reisner and Elliot N. Dorff, both approved by the Conservative movement’s Committee on Jewish Law and Standards. Both positions agree on the value of life and the individual’s responsibility to protect his or her life and seek healing. Both agree on a large area of autonomy in which a patient can make decisions about treatment when risk or uncertainty is involved. Both would allow terminally ill patients to rule out certain treatment options (such as those with significant side effects), to forgo mechanical life support, and to choose hospice care as a treatment option.

Nevertheless, important differences between the two positions may be found regarding both theoretical commitments and practical applications. Rabbi Reisner affirms the supreme value of protecting all life. Even the most difficult life and that of the shortest duration is yet God given, purposeful, and ours to nurture and protect. All nutrition, hydration, and medication should be provided whenever these are understood to be effective measures for sustaining life. Some medical interventions, however, do not sustain life so much as they prolong the dying process. These interventions are not required. The distinction may best be judged by our intent. We may choose to avoid treatments causing us fear or entailing risk or pain, in the interest of the remaining moments of life. We may not avoid treatment in an attempt to speed an escape into death.

Rabbi Dorff finds basis in Jewish law to grant greater latitude to the patient who wishes to reject life-sustaining measures. He sees a life under the siege of a terminal illness as an impaired life. In such a circumstance, a patient might be justified in deciding that a treatment that extends life without hope for cure would not benefit him or her, and may be forgone.

Both Rabbis Dorff and Reisner agree that advance directives should only be used to indicate preferences within the range allowed by Jewish law. They disagree as to what those acceptable ranges are. In completing a health care power of attorney and living will, it is recommended that you consult with your rabbi to discuss the values and norms of Jewish ethics and halakhah. You also may wish to talk with your physician to learn about the medical significance of your choices, in particular any decisions your physician feels are likely to be faced in light of your medical circumstances. You may find it helpful to discuss these concerns with family members.

CONCLUSION

In the end, the decision to execute a health care power of attorney and living will is a uniquely individual choice. Every person has their own set of principles by which they will live, and by which they will eventually pass on. When executing these documents, it is wise to examine how these documents assimilate into your worldview and religious beliefs. While the topic of death and dying is an uncomfortable one, you are well advised to discuss this decision with your family members, friends, and members and leaders of your religious community that you respect. Having done this, you can rest easy knowing that you have made a good decision with regard to your health care power of attorney and last will, and that your last wishes will be respected and undertaken.

The Importance Of Having An Advanced Medical Directive Or Health Care Proxy

Every adult should have an Advanced Medical Directive or Health Care Proxy. This document provides for someone other than yourself to make medical decisions for you in the event that you are unable to make these decisions for yourself because of accident or illness.

I have had one in place for several years with my friend Margarath being the person to make my decisions for me. Margarath, my Medical Directive and I have known each other since High School. She knows exactly what I want should I be in a situation where I am unable to make my own decisions in regard to medical situations. She knows when to pull the plug so to speak.

Late last year I suffered a catastrophic health event and while my own Advanced Medical Directive didn’t come into play while I was hospitalized for my stroke, it could have. I did make it known that I had one because I did not want to relinquish my own control and I was very distraught about my situation when I was in the ER and did not like the doctor who was treating me in the ER.

You may wonder why I didn’t choose my husband or another close relative and it’s quite simple. If I am ever in a situation where my Advanced Medical Directive comes into play, I do not want my husband put in a situation where he will feel responsible for having to make the ultimate decision and then have to live with the “what if’s” that can be associated with that decision.

Choosing someone like Margarath was the best choice for me. This may not be your situation. You have to weigh your own situation as well as who you feel would best represent you in a medical crisis.

One mistake I did make was not letting my husband know that I had this document in place. This did create hurt feelings for him and I should have told him when I set the directive up.

If you are not clear on what an Advanced Medical Directive is and the importance it can play in your life, check with your attorney or estate planner. You can even do a web search to find out more valuable information on this very important document.

The Wall Street Journal has a state by state requirement list for Advanced Medical Directives that is worth checking out to find out what your state requires for this document.

Cherrie Fishlowitz believes that each of us can become a better human being simply by allowing ourselves to find the good in all of our experiences regardless of how bad they may seem to be at the time.

At some point in our lives we all must come to the realization that we must be responsible for our own actions and decisions. Because who we are is based on the sum total of our experiences we owe it to ourselves and those around us to find a positive in each negative.

While we may not immediately be able to grasp the good it’s there, we just have to find it. The experience of finding it is what helps us to become a better person.

Ten Things You Should Know About Health Care Proxies and Living Wills in Massachusetts

It is unfortunately true that we often get what we pay for. If you download your Health Care Proxy from the Internet, get it from a book, or from an attorney who does not adequately explain what you need to know about advance directives, you may end up with an ineffective or unenforceable Proxy. The following list of the ten things you must remember to make your advance directives as effective as possible is specific to Massachusetts, but useful for residents of any state:

1. Executing a Living Will is not enough. Although Living Wills are useful documents, they are not statutorily recognized in Massachusetts, and doctors and hospitals are not required to adhere to the wishes expressed in your Living Will. You need to execute a Health Care Proxy that names an Agent who will enforce your wishes.

2. In addition to identifying the Principal (you) and your Agent, your Proxy must state that you intend to grant to your Agent the authority to make health care decisions on your behalf; describe any limitations you wish to place on your Agent; and indicate that your Agent’s authority becomes effective only if you subsequently lose capacity to make medical decisions. (Also, it is wise to include the addresses and telephone numbers of your Agent and Alternate, so they can be located quickly).

3. Your Proxy must be signed by you or at your direction in the presence of two adult witnesses. The witnesses must then sign and affirm that you appear to be at least eighteen, of sound mind, and under no constraint or undue influence. (It’s a good idea to follow these rules if you execute a separate Living Will.)

4. The witnesses cannot be named as an Agent or Alternate Agent. And an operator, administrator, or employee of a medical facility where you are, or may be, a resident or patient cannot be your Agent, unless she is also related to you by blood, marriage, or adoption.

5. Do not hide your Proxy and Living Will in a safe. Execute five or six originals, one for your primary care physician (with oral and written instructions to place the documents in your medical records), one for your medical records at the hospital you are likely to end up at in an emergency, one for your Agent and one for your Alternate, one for your own records, and a copy for your lawyer’s safe.

6. If you spend a lot of time in another state (winters in Florida, for example) you should consult an attorney in the second state to ensure that your Proxy will also be recognized there.

7. If your Agent is your spouse, and you divorce or are legally separated, your entire Health Care Proxy is revoked. In other words, your Alternate Agent cannot step in and take the place of your spouse. In this case-or if you revoke your Proxy orally or by drafting a substitute-you should collect your old documents, destroy them, and distribute your new Proxy.

8. Select your Agent and Alternate carefully. Make sure they understand your wishes and are willing to do all they can to ensure they are honored. Communication is vital.

9. Express your wishes as clearly as possible in your Proxy and Living Will. Clarity and brevity will help your Agent, family, and doctor understand your wishes.

10. Communicate, communicate, and communicate.
a. Talk to your family about the wishes you have expressed in your Proxy and Living Will and tell them who you have selected as your Agent and Alternate. Surprise, hard feelings, or controversy around your hospital bed may create an unpleasant situation and could result in your wishes not being honored.
b. Talk to your doctor about your Proxy and Living Will. Make sure she, and the facility at which she enjoys staff privileges, are willing to honor your wishes.