Lamar W. Hankins : CPR and End-of-Life Decisions

Art from PBS NewsHour.

CPR and end-of-life decisions

Since the story of the 87-year old woman first appeared, more information has come to light. She was aware of and had agreed to the policy of the center where she lived -- that CPR would not be performed in the event she collapsed.

By Lamar W. Hankins / The Rag Blog / March 17, 2013

Cardiopulmonary resuscitation -- CPR -- is as widely misunderstood as it is widely known, especially when it involves the terminally ill and those who are in poor physical condition.

The recent reports of the death of an 87-year-old woman who was living in a facility in Bakersfield, California, have troubled many people. The woman collapsed in the dining room of the facility, apparently as a result of cardiac arrest. Staff called 911, but in keeping with the facility’s policy as they understood it, refused to give CPR to the woman despite pleas from the 911 operator to do so. Emergency medical personnel declared the woman dead after they arrived at the facility a short while later.

Many nurses, at least one nurses' association, and many lay people have viewed this refusal to administer CPR as criminal, or at least unethical. Others have termed the failure immoral and unconscionable. But the outrage may be misplaced and unwarranted.

Indeed, even as someone with 20 years experience studying, lecturing, and writing about end-of-life matters, my first emotional reaction was sorrow at the death of the woman. I knew, however, that it was important to get all the facts before making any judgments about what happened. The initial reporting was sketchy at best. Now that more information has filtered out, we can draw more informed conclusions. But first, it is useful to have basic information about CPR.

The Family Caregiver Alliance in California provides information, educates, does research, and advocates for those who provide care for the elderly and those nearing the end of life because of illness or disease. The information it provides about CPR appears to be in the mainstream of medical knowledge about the procedure. While CPR can have life-saving benefits for people in general good health who have certain kinds of heart attacks and accidents, especially in a hospital, it may be of little benefit to others.

The Alliance describes CPR far differently than it is usually portrayed on television:

Pushing the center of the chest down about one and one-half inches, 100 times a minute for several minutes, causes pain, and may even break ribs, damage the liver, or create other significant problems. CPR produces a barely adequate heartbeat, and doing it more gently is not sufficient to circulate enough blood. Electric shocks and a tube in the throat are also harsh treatments, but may be essential to resuscitate someone.

Other organs that can be damaged by CPR include the spleen and lungs. If CPR is only partially successful, so that normal breathing is not restored, it may lead to the need for a ventilator for days, weeks, months, or much longer. When a person’s breathing or heartbeat fails for just a few minutes, the brain is deprived of oxygen and begins to fail, and permanent brain damage can result.

Studies about CPR have shown that only about 15% of patients in a hospital who receive CPR survive and are later discharged. Fewer than 5% of elderly patients with serious illnesses who have CPR will leave the hospital alive. The most likely beneficiaries of CPR are those with an abnormal heart rhythm, people who have respiratory arrest only, and people who are generally healthy.

Those with the least chance of survival from CPR are people with one or two medical problems, the frail and elderly, people who are dependent on others for care, and people who have long-term or terminal illnesses.

Some people, because of their physical condition or a permanent decline in the quality of life, decide not to have CPR if their heart fails. All Americans have a constitutional right to make this decision. The U.S. Supreme Court, in the 1990 Nancy Cruzan case, recognized a constitutional right of an individual to make decisions about life-sustaining medical treatment and held that that right did not end if the person became mentally incapacitated.

Now, through advance directives, all competent adults can assure that their wishes are respected. And our constitutional right to decide the kind of healthcare treatment we want, before we need it, allows us to appoint a surrogate to make healthcare decisions for us if we become incapable of making those decisions for ourselves.

While the Cruzan case clarified the law on end-of-life care, it also illustrates the tragedy of not having end-of-life medical care plans, no matter how young we are. Cruzan was only 25 when she was seriously injured in a car accident and drifted into a persistent vegetative state. Most people would not want to spend years in such a condition or suffer from other conditions that permanently make life impossible to enjoy and participate in.

But whatever your feelings about these matters, advance directives give all mentally competent adults a way to make their views known about these medical issues before they confront a serious medical problem. Each individual who uses advance directives wisely controls such decisions.

Most states now provide statutory forms for both Directives to Physicians and Medical Powers of Attorney, but these forms may be expanded and revised to reflect a person’s precise wishes about medical care in the future. People may draft their own directives if the state directive is inadequate to express their wishes.

In Perspectives on Death and Dying, authors Gere Fulton and Eileen Metress provide the history of such directives and explain that advance directives help ensure that a person’s “wishes concerning treatment options will be respected,” and “they protect... family members, health care professionals, and others from the stress and potential conflict of making critical decisions without sufficient information concerning [a person’s] wishes if [the person is] incompetent.”

Further, the federal Patient Self-Determination Act, signed into law in 1990 by President George H. W. Bush, requires all healthcare facilities and programs serving Medicare and Medicaid patients to establish written policies and procedures to determine their patients’ wishes about end-of-life care and to make sure these wishes are honored. Such facilities and programs must also implement ways to educate their staff and community about advance directives. As a result, most hospital patients are asked if they have advance directives when they enter the hospital.

To avoid unwanted medical services or assure that the ones you want are provided, everyone should discuss advance medical planning with physicians, family, and caregivers. Such discussions may be organized around three legal documents, identified in most states as advance directives. One form (called a “Directive to Physicians, Family and Surrogates” in Texas) allows mentally competent persons to decide what sort of medical interventions are appropriate for them if they are faced with certain medical conditions. This form is sometimes termed a Living Will.

A second form provides for the appointment of a medical agent or surrogate to make medical decisions for a person if that person should become unable to make such decisions. This form is called a “Medical Power of Attorney” in Texas, and is termed a “Durable Power of Attorney for Health Care,” or something similar, in other states.

The third form, which must be ordered by a physician in Texas at the request of a patient or medical agent is the “Do Not Resuscitate” (DNR) order. This order can be used in a hospital setting or out of the hospital, in which case it is termed an out-of-hospital do not resuscitate order (OOHDNR). This order provides that if a person’s heart stops beating, no efforts should be made to revive the person. This decision is made by the patient, or the person’s agent if they are cognitively incapacitated, with the doctor’s agreement.

A few states have more comprehensive documents called “Physician Orders for Life-Sustaining Treatment” (POLST) or “Medical Orders for Life-Sustaining Treatment” (MOLST). These are not available in Texas.

Since the story of the 87-year old woman first appeared, more information has come to light. The woman was not in an assisted living center or nursing home, but in an independent living center. It appears now that she had a stroke, not cardiac arrest. And she was aware of and had agreed to the policy of the center where she lived -- that CPR would not be performed in the event she collapsed. The staff followed the agreed procedure and called 911 immediately.

The elderly woman’s family said she was aware that the facility did not offer trained medical staff, yet opted to live there anyway:

It was our beloved mother and grandmother’s wish to die naturally and without any kind of life-prolonging intervention. We understand that the 911 tape of this event has caused concern, but our family knows that mom had full knowledge of the limitations of Glenwood Gardens and is at peace.

Dr. Jennifer Black, a family and palliative medicine physician in Bakersfield, summarized the dilemma we all face:

[W]e must accept that death is an inevitable life event, not a medical problem that can be "solved" with medicine, surgery or CPR. Next, we must learn the facts about CPR, and discuss these with our patients/doctors/loved ones. One of these facts: foregoing CPR is frequently not a matter of "letting" someone die, but simply of minimizing the pain and suffering associated with an inevitable death. Finally, we must ensure that our patient's -- and our own -- end-of-life wishes are known and clearly documented in an advance directive... By doing these things, we can best assure wishes are respected, harm minimized and dignity preserved.

A widespread discussion of this case may lead more people to have discussions with their physicians, families, and care-givers about their medical choices at the end of life. If so, all the alarm, name-calling, and misinformation now being sorted out may help move more people to take charge of their end-of-life planning.

[Lamar W. Hankins, a former San Marcos, Texas, city attorney, is also a columnist for the San Marcos Mercury. This article © Freethought San Marcos, Lamar W. Hankins. Read more articles by Lamar W. Hankins on The Rag Blog.]

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Lamar W. Hankins : Alzheimer's and Another Face of Elder Abuse

Image from In Good Feather.
Elder abuse is a complicated matter:
Dementia and the issue of passive restraint

By Lamar W. Hankins / The Rag Blog / March 9, 2011

During my visits with Dad at the group home, I witnessed several people with Alzheimer’s harm themselves because they did not have adequate passive assistance devices.

The Senate Special Committee on Aging this past week held hearings titled “Justice for All: Ending Elder Abuse, Neglect and Financial Exploitation.” The hearings were stimulated in large part by a Government Accounting Office (GAO) report that identified elder abuse -- physical, economic, and psychological -- in just over 14% of the elder population living in the community, rather than in institutions.

The GAO report defined neglect as “refusal or failure to fulfill a person’s obligations or duties to an older adult.” Specifically, the report provides that neglect means “refusing or failing to provide an older adult with such necessities as food, water, clothing, shelter, personal hygiene, medicine, comfort, personal safety, and other essentials.”

While honoring obligations to older adults can be a challenge, whether in the community or in institutions, those obligations are particularly challenging when the older adult has cognitive incapacities. I use as an example my father, who died recently at the age of 94, after living and declining with Alzheimer’s Disease for 15 years.

The most prominent and widely-recognized characteristic of Alzheimer’s is the loss of memory for recent events or knowledge that once seemed almost in-born. My father spent 44 years as a machinist. It was from him that I learned about tools, automobile maintenance, and general repairs.

After he retired, he fixed a small lock for a roll-up closure on a Hoosier chest we own. The lock had been broken and he fashioned the missing part on his lathe. I admired his skill. His ability to use algorithms and other complex math always amazed me, especially because he completed only one semester of college before learning the machinist trade and spending all of his working life at The Texas Company (which became Texaco and then Chevron).

About 16 years ago, I was installing a handicapped toilet for my mother at their home and he was helping me. I asked him to hand me the crescent wrench and he was unable to make the distinction between a crescent wrench and an open box wrench, tools he had spent a life working with, and that he had taught me how to use.

That was when I first felt that something was wrong. Mother confirmed that there had been other signs of a cognitive problem. Eventually, he was diagnosed with Alzheimer’s and prescribed various medicines that seemed to slow his decline. When my mother’s abilities started waning and Dad’s disease was clearly advancing, my parents asked if they could move in with us.

Just over two years later, mother died. Ten days later dad tripped over his own feet, breaking his left hip. Until then, despite all the reading I had done about Alzheimer’s, I had not known that walking and balance could become a special problem for Alzheimer’s patients.

As the brain becomes more and more affected by Alzheimer’s, the functions controlled by the brain diminish or simply disappear. After his hip surgery and rehab, we established elaborate precautions to prevent him from having another fall. He could walk on a walker only with a wide web belt (commonly called a gait belt or transfer belt) around his chest held by someone to keep him from falling should his feet become tangled up.

When he was in a wheel chair, a seat belt connected to an alarm would alert a caregiver that he had unbuckled it and was about to stand up and someone could assist him. One morning, a caregiver failed to activate the alarm when the seat belt was fastened. After she left the breakfast table for a moment, dad got up to get some milk from the refrigerator, not remembering that he could not walk safely without assistance. He fell and broke his right hip.

For the next year or so that he lived with us, we established simple, but thorough protocols to prevent another fall. Whoever came into our home to assist him was educated about the need always to follow the established protocols. There was a bed alarm, a chair alarm, and the wheelchair seat belt alarm. All of the alarms kept him from another damaging fall.

When an Alzheimer’s Group Home opened in our town and the expenses of home care exceeded the cost of the group home, we moved him to the group home where he lived with a dozen or so other, mostly Alzheimer’s, patients. All of the protocols we had established at our home were put in place at the group home, but we had to get a written order from a physician for the seat belt alarm because the facility’s manager believed that the seat belt was a restraint. Under state rules, it is not.

The Texas Department of Aging and Disability Services provided me with the official definition of a restraint: “Restraints (physical) -- Any manual method, or physical or mechanical device, material or equipment attached, or adjacent to the resident's body, that the individual cannot remove easily which restricts freedom of movement or normal access to one's body.” Dad often released the seat belt, the alarm sounded, and someone was able to assist him before he stood up and fell.

During my visits with Dad for the 20 months he lived at the group home, I witnessed several people for whom Alzheimer’s was a dangerous condition that caused them to harm themselves because they did not have adequate passive assistance devices.

I saw people lurch out of their chairs and smash their faces on the floor, requiring trips to the emergency room or hospitalization. I saw others who had become so unstable that they could not walk unassisted, yet they had no protections other than the alertness of a sometimes overburdened staff to keep them from falling and hurting themselves.

Alzheimer’s patients need to have protocols developed to protect them from harm without unnecessarily restraining them from normal daily activities. Such protocols are not now mandated by regulations or institutional procedures at most facilities serving Alzheimer’s patients.

Dad had been receiving hospice services for more than two years before his death. A few months before he died, the hospice nurse had recommended that I find a nursing home that would better meet his increasing needs for more nursing care. I started looking around for an appropriate nursing facility. I was pleased that several new nursing homes had opened within 15 miles of our home.

What I found when I visited most of these facilities was that they prided themselves in being “restraint-free.” To them, in spite of the regulatory definition of restraint, the seat belt was a restraint. Several refused admission for him if he kept the seat belt on his wheel chair.

I explained to all that the seat belt was necessary to prevent him from harming himself because he could not remember that he was unable to walk unassisted -- an effect of the Alzheimer’s Disease. When he removed the belt, the alarm alerted staff to assist him so that he did not stand up, fall, and hurt himself.

Yet some facility managers insisted that the seat belt was a restraint. I met with facility administrators, nursing directors, and admission officers at several facilities. At one facility, after a meeting with me to discuss the matter, the manager recognized that the seat belt was not a restraint and was needed to protect my father from harm.

For those who insisted that the seat belt was a restraint, I explained that I was my father’s medical agent under a Medical Power of Attorney. According to law, therefore, when I spoke about what was acceptable medical treatment, it was as though my father were speaking. If I said he needed the seat belt to prevent harm, it was as though he had said, “I need the seat belt to keep me from harming myself.” Some of them understood. Others did not care.

Two weeks before his death, I contacted two legal groups that litigate on behalf of the disabled. I intended to sue any facility that would not accept him because of his disability, which necessitated the use of a seat belt alarm system to protect him.

Dad died before we arranged for him to move to a nursing facility, so the principle for which I was prepared to fight on his behalf was not satisfactorily resolved. Nevertheless, at the time of his death he had been accepted, seat belt and all, by at least two nursing facilities.

All nursing facilities should be required to recognize the special needs of Alzheimer’s and other dementia patients and adjust their procedures to the needs of such patients. No one should be restrained without medical necessity, but when protective assists are needed, no definition or public relations concept -- such as “we are a restraint-free facility” -- should be used to prevent needed care.

Disability advocates should broaden their views, and all medical agents should be prepared to take whatever actions are necessary to protect those to whom they have a legal and moral obligation. Otherwise, our system of advance directives is meaningless, and disability rights is farcical.

Elder abuse takes many forms, as testimony before the Senate Special Committee on Aging has shown. But financial exploitation, physical neglect, and psychological mistreatment are not its only manifestations. The lack of attention to the special needs of Alzheimer’s patients and others with cognitive disabilities must be considered realistically and identified clearly as another form of elder abuse deserving resolution.

We have legal and moral responsibilities to all of the elderly to make sure that our institutions that serve them satisfy their obligations of appropriate care.

[Lamar W. Hankins, a former San Marcos, Texas, city attorney, is also a columnist for the San Marcos Mercury. This article © Freethought San Marcos, Lamar W. Hankins.]

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Joan Wile : Gray Panthers Fight Social Security Cuts on Capitol Hill

Image from People's World.
Gray Panthers to Deficit Commission:
Don't mess with our social security

By Joan Wile / The Rag Blog / November 23, 2010

Representatives of the national Gray Panthers went to Capitol Hill in November to present their position regarding Social Security. They spoke with members of the Deficit Commission and presented their counter proposals against anticipated recommendations by the Commission to cut Social Security benefits.

Susan Murany, Executive Director of the national Gray Panthers, told the Commission:

For 75 years, Social Security has remained a promise of economic protection and stability for the Americans who have paid into this program. As we now celebrate three-quarters of a century of accomplishments for this program, we must also do our part to ensure that Social Security is not weakened by those who wish to balance bailouts on the backs of Americans.

Problem:

Social Security is America's most successful anti-poverty program and remains the most fiscally responsible part of our federal budget. In fact, recent polls from the National Committee to Preserve Social Security and Medicare indicate that 85% of adult Americans are opposed to cuts to Social Security to decrease the deficit. However, while many Americans remain united on this issue, Social Security continues to face threats from increased polarization in Congress and those with anti-entitlement agendas.

The 2010 Social Security Trustees report shows that Social Security is not facing an immediate threat. The surplus within the Social Security trust fund is estimated to grow to $4.3 trillion by 2023 and remain able to pay benefits in full through 2037, and 76% of benefits thereafter. Yet, the opposition continues to project "doomsday" crisis reports and myths to the American public in their efforts to garner support for cuts to the Social Security program.

Proponents of these cuts, such as House Republican Leader John Boehner, would rather cut Social Security in order to pay for the war in Afghanistan. Outrageously, Boehner stated that, "Ensuring there's enough money to pay for the war will require reforming the country's entitlement system." Boehner also calls for increasing the Social Security eligibility age. However, a raise in the Social Security eligibility age would result in about a 20% benefit cut for recipients, hurting lower income beneficiaries working in manual labor and those with shorter life expectancy the most.

While it is evident that our government must make tough decisions to revive our down-turned economy, it is important to remember that cuts to Social Security would not only hurt seniors, but will also detrimentally affect people with disabilities, people who are unemployed, and women and children of deceased spouses/parents. Cuts to this program stand to unfairly burden the most vulnerable populations of Americans.

While Former Senator Alan Simpson, the Co-chair of the National Commission on Fiscal Responsibility and Reform, declares that the “Gray Panthers... don’t care a whit about their grandchildren," we adamantly refute his comment and we vow to continue working to ensure that Social Security remains there for them in their future.


Solution:

Gray Panthers oppose any efforts to cut benefits! Instead of balancing the budget on the backs of Social Security recipients, especially those most dependent on its benefits, here are some of the proposals we support:

• Eliminate the annual cap on taxable income and raise that cap so that wealthier people are paying more to Social Security. Under current law, wages over a certain yearly total ($106,800 in 2010) are exempted from Social Security payroll taxes. This means that a worker earning $106,800 a year pays the same amount of FICA taxes as a CEO who makes millions of dollars a year.
• Let the Bush tax cuts for the wealthy expire. The revenues gained from these expirations are far more than enough to fill current state budget deficits for the next 10 years while still leaving an additional $2.76 trillion dollars left over to promote further economic recovery. There is no place for tax cuts in a deficit reduction proposal as was suggested by the Chairmen of the Deficit committee last week!
• End the wars. Funds saved from Social Security should not be used to pay for wars; rather, we should cut funds for wars to finance Social Security. The Gray Panthers support the Chairmen’s proposed cuts to Defense spending, but more cuts can and should be made!
• Extend outreach and enrollment. Gray Panthers believes that not only should Social Security be kept intact, but that outreach should be increased and enrollment expanded to get a greater number of older adults in poverty into the program.

The retirement age increase proposed by the Commission is just a particularly cruel way of cutting benefits. The age at which the elderly can retire on full Social Security benefits is already increasing to 67 by 2027. The Chairmen’s plan would “index” the retirement age to increase in longevity, meaning it would hit 68 in about 2050 and 69 in about 2075.

New York Times opinion columnist Paul Krugman has pointed out, that “the people who really depend on Social Security, those in the bottom half of the distribution, aren’t living much longer. So you’re going to tell janitors to work until they’re 70 because lawyers are living longer than ever."

Is this how a humane society proposes to care for its less fortunate? Not if the Gray Panthers have anything to say about it!

[Joan Wile is the author of Grandmothers Against the War: Getting Off Our Fannies and Standing Up for Peace (Citadel Press, May, 2008).]

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Glimpses of Our (North American) Future?

Here's a cheery holiday story from exotic, picturesque Japan.

Mariann Wizard / The Rag Blog

An elderly man walks away from a Tokyo grocery store after being observed stealing medicine for an upset stomach. Photo: CNN.
Report: More elderly Japanese turn to petty crime
From Kyung Lah / December 24, 2008

TOKYO -- Beset by economic worries and loneliness, elderly Japanese are turning to petty crime in increasing numbers, the nation's Justice Ministry reports.

In 2007, 48,605 persons age 65 and older were arrested in crimes other than traffic violations, more than double the number five years earlier, according to a ministry report.

Thefts such as shoplifting and pick-pocketing were the main offenses, the ministry report said.

"The main reasons they shoplift are poverty and loneliness," said Kazuo Kawakami, a former federal prosecutor. "The traditional Japanese family is gone, and now our elderly live alone."

Morio Mochizuki, who heads SPUJ, one of Japan's largest security firms, said the stories of shoplifting suspects at the thousands of stores his company oversees across Japan bear that out.

And the problem becomes more acute during New Year holidays, traditionally a time for family gatherings in Japan, Mochizuki said.

Economics also plays a role. Japan's economy went into recession this year, the government says. And the country's national pension system has been bogged down with mismanagement and corruption, leaving many pensioners with fears their lifetime savings will be lost.

"I feel sorry for them. When I talk to them, they don't have enough money for food," Takayuki Fujisawa, an employee of SPUJ, said of the elderly he's caught shoplifting.

SPUJ recently allowed CNN to follow its security team at one Tokyo grocery store. In just moments, they nabbed a 69-year-old woman, allegedly trying to steal food worth about $10.

One hour later, officers stopped a second suspect, an 80-year-old man. He had enough money to pay for all of his groceries, but security officers said he tried to leave the store without paying for medicine for an upset stomach.

"I'm so sorry," he told officers. "I live alone. My wife is in the hospital."

Population trends offer little hope for a turnaround in the elderly crime trend. Twenty percent of Japan's population is older than 65, the largest percentage of elderly of any country in the world. Compounding the problem, Japan has one of the world's lowest birth rates.

On Japan's northern island of Hokkaido, more elderly than teenagers -- by a 3 to 2 ratio -- were arrested in 2006, police said.
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Despite the arrest numbers, prosecutions of the elderly in a culture that holds them in high regard are rare. Stores often don't even report the crime to police, according to security experts.

The 80-year-old man who stole the stomach medicine was eventually led to his bicycle by store security. The security officer helped the man with his groceries and bowed in respect, hoping the elderly man had learned his lesson and would return as a good customer.

Source / CNN Asia

Thanks to Mariann Wizard / The Rag Blog

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Dr. Stephen R. Keister : On Aging

Sir William Osler: "Pneumonia is the old man's friend."
'In the United States, for oh so many years we have merely warehoused the disabled, senile and near senile elderly, in nursing homes of variable competence.'
By Dr. Stephen R. Keister / The Rag Blog / November 19, 2008

I do not imagine that my thoughts will engender accolades from many readers; however, I honestly desire to share some inner thoughts. At the age of 87, with a mind remaining fairly alert, but with a gradually failing body, one is bound at times to become introspective. In today's world, with the impending equivalent of The Great Depression of 1929, one develops an increased concern and urgency regarding ones impending fate. Have you looked at your IRA or brokerage account recently?

I may tread on some cultural precepts or religious teachings, but so be it. My attitude is that of the secular humanist; although some of my friends are quite “religious,” a fact, that among intelligent individuals, causes no concern or impaired relationship. We share ethical and moral values (“moral” in the broad sense as per Matthew 5-7), and make no effort to dispute our theological differences, as civilized, thinking individuals. Further, we agree on many concepts in which disagreement would be anticipated.

I am influenced largely by the thinking of Rene Descartes: "I think therefore I am,” and memories of Sir William Osler's statement, made in the early part of the 20th Century, when he was professor of medicine at Johns Hopkins, and prior to the antibiotic era; "Pneumonia is the old man's friend.” I am influenced by, in my days of active practice, attending a patient in a nursing home, and seeing gray haired individuals, diapered, sitting in wheelchairs, blankly watching a television screen. I would finish my rounds, depart and think to myself, "can this be me someday”?

We have a gradually increasing number of the elderly in our population, as do the Western European nations. I do note in scanning the European press that the individual countries, as well as the EU as a unit, are starting to make the care of the aging a priority issue. In the International Herald Tribune of April 13, 2007, there is an article entitled "In Europe, care for the elderly is being transformed.” The United States is in arrears as would be expected after the past eight years of the Bush administration’s neo-liberal economics which according to script has ignored social programs, poverty, and care of the helpless. I would trust that the Obama administration would face this issue early by appointing an active, dedicated under-secretary on aging in HHS.

In the United States, for oh so many years we have merely warehoused the disabled, senile and near senile elderly, in nursing homes of variable competence. The costs to individuals, families, states, have ranged up to $3000-$4000 monthly. To allow an individual with a blank mind, or totally despondent, not wishing to live, to sit all day in front of a TV set is not realistic or kind. This is a matter that is rapidly going to become a major issue as the various fundings fade and the disposition of these poor folks becomes an overwhelming issue. I would not be arrogant enough to presume to know the final solution. However, we are faced by some basic ethical as well as financial challenges.

The State of Oregon, and I believe, more recently, Washington, as well as various European nations, have shown the moral and intellectual courage to permit individuals to determine their own fates rather than be tied to laws engendered by medieval theological rite. We need as well to have the elderly population educated in depth about the need for advanced directives, i.e. living wills. We can have overwhelming ad campaigns for Viagra, or for fuel consuming automobiles, abounding in our society; hence, why not a major educational push to educate the public as to the fact that one need not put up with interminable dialysis, or be kept for days, brain dead, on artificial ventilation?

I feel that Dr. Osler was correct in his observation, but that point in time has passed, and life has become very much more complicated thanks to medical 'science'. Yet, two out of three folks I talk to know little or nothing about advance directives. The nation needs to move on this. As I recall, the majority of Medicare funding goes to support those in the last month or two of life.

I can see families facing bankruptcy in the next year or two in an effort to pay the nursing home. Perhaps we should consider government subsidized home care which can be much less expensive than inpatient care in a profit making facility. For example, hereabouts a "non-profit" retirement community has increased its monthly fee by 7% (roughly $200), in spite of being aware that their residents savings accounts are rapidly being depleted, The corporate managers are well aware that the residents are not well enough informed, or motivated, and are too passive to respond to such a swindle. I am aware, as well, that this problem is being faced by the local religiously sponsored homes, Catholic, Presbyterian, or Episcopalian in an effort, perhaps futile, to reach an accommodation with the declining economy.

I note as well that the elderly who signed up for the severely flawed "Medicare Prescription Plan" are once again going to be taken to the cleaners. As per ARA. Nov. 14, 2008, their deductibles and co-payments are going to rise as of January 1, 2009. Further, according to an analysis of Medicare data by Alvalere Health, the largest drug plans will raise their premiums by an average of 31% and some by more than 60%. Seniors who signed up for Humana's standard plan, a policy marketed as the low price leader in 2006, will pay $40.83 monthly next year up from $9.51 in 2006. Once again the matter of profits exceeds that of ethics or morality. Congress must modify this plan to work for the Medicare beneficiary rather than for the profits of the insurance and pharmaceutical industries, and at the same time do away with the "Medicare Advantage Plans,” the Bush administration’s subtle way to privatize and gradually do away with Medicare as a program.

Finally, to take the burden off future generations this country must get in step with Western Europe in quality and extent of health care for all. According to the Commonwealth Fund our health care rates 26th in the world and as of Nov. 13 UPI.com reports that, according to the Commonwealth Fund, U.S. patients, compared to seven other countries, suffer the highest number of medical errors. 44% of chronically ill patients did not get recommended care, fill a prescription, or see a doctor when sick because of costs. 41% of U.S. patients spent more than $1000 in the past year on out of pocket costs, compared to 4% in Britain or 8% in the Netherlands. We must make sure our elected representatives are not taking baksheesh from the pharmaceutical and insurance industries and support single payer, universal health care devoid of insurance company participation. The nation and your family depend on you not sitting idly on your butt. Call, E-mail, demonstrate!

In the overall aspect of cost containment regarding elder-care and health care costs, one would take a hard look at the multiplicity of tax-free, "non-profit" facilities and institutions involved. The Congress should be aware of their costs, their overhead, their depreciation, executive and other managerial salaries, bonuses, and perks, including executive seminars at fine golf resorts. One may
note that in financial reports, when available, one does not see the word "profit," but instead "surplus" or a variety of terms. I find that the general public, especially the elderly, confuse the term "non-profit" with something akin to a legitimate charitable institution, which it may well be. However, a retirement home should not be confused with Doctors Without Borders, Catholic Charities or The Friends Service Committee.

I grow weary and frequently feel that eternal sleep might be a viable option, but there is so darned much needs to be done!

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Dr. S. R. Keister : An Aging Population Faces Financial Panic

'I, as a member of a fading generation, have a few observations about the fate of the aging citizens of the United States in this time of impending economic crises.'
By Dr. S. R. Keister / The Rag Blog / November 11, 2008

As one who has experienced the panorama of our nation and culture since arriving in this world in 1921 I have a few observations that, I fear, will not make the way easier for President Elect Obama, who appears to be a gentleman of intelligence and compassion. To date I have seen little energy expended in addressing this possible impending serious problem.

Since I, as a young student, heard of the disposition of the un-well, elderly in the civilizations of the arctic regions, I have given thought to the ultimate nature of things. In medieval times, and even more recently, the care of the elderly was a function of the family. In the lack of family, orders of Sisters such as the Sisters of Charity and Sisters of Mercy provided care and succor to the infirm and the elderly. However, there has been a stark change in this area since approximately 1980, or perhaps a decade or so previously.

With the advent of the amoral entrepreneur a change has occurred. We have seen the introduction of the capitalist philosophy into the "care" of the aging. We now are faced with a multiplicity of "nursing homes,” "assisted care living facilities" and "retirement homes" in excess in this once caring nation. Before beginning the critique of this hypocrisy allow me to digress a bit.

Social Security and Medicare have made dollars available to the elderly, abetted by the industrial and academic pension plans, the IRA and 401K. We have also been blessed to a limited extent by the hospice movement and the death with dignity laws in Oregon and Washington State. The flip side of the coin is the prevalent, and misunderstood, "non-profit" institution that advertises care for the elderly. Non-profit? There are bona-fide charities which are "non-profit,” i.e. Salvation Army, Red-Cross, Doctors without Borders, etc; however, there is another face to this. There is the "non-profit" institution that personifies the retirement homes, and such, that dot the landscape today.

These are basically tax-exempt institutions, sans stock holders, run by directors, and executive staffs who are salaried as per the board’s discretion, and do not show "profit" in their statements, but instead report "excess income.” Many of these are merely money making machines (MMM) that utilize the "care" of the elderly as their source of profit. The sales departments find it very fruitful, playing on the fears, lack of security, and lack of understanding of the aged. Of course we have a careful check of the old person’s financial statement!

We now face an impending crises as many of these residents have been paying their way with a now rapidly diminishing IRA, supported frequently by their children's now rapidly diminishing IRA. Let me illustrate with an example.

The Bountiful Retirement Home (I made up the name) is one of many "homes" owned by the X-corporation and has been hereabouts for 20 years. Business has been good, as there are many oldsters with first rate stock portfolios. Let us say, as of six years ago, grandma applies for admission with a stock portfolio worth $300,000. She is accepted with alacrity and praised for her wise choice. She is "sold" an apartment of 1000 square feet with kitchenette, for $120,000. The funds are held in escrow returnable to her estate. (The fact, as of six years ago, that she loses the 6% interest on the funds, and that X-corporation is now the beneficiary is not stressed). After her death the moneys go to her estate after the apartment is resold/rerented. Of course grandma can furnish the apartment as she desires.

What else are her entitlements? Electricity and heat are provided, although, there is no emergency generator service in case of power failure, and emergency egress is lacking in a three story building, in which 50% of residents use walking aids, in case of fire.(One pays for one’s own phone, TV, and computer connections.) But there are offsetting advantages. For $3000/month one is provided with breakfast and dinner, the latter in a dining room, though no credit is given if one misses a meal when eating out with family or friends 2-4 evenings per week (estimated costs of dinners, $17). A nurse is available who will fill one’s pill box for $10, give an insulin injection for $10, or weigh one for $3. One can get minor repairs in the apartment for a fee, one can have the snow brushed of one’s car for a fee, one can get transportation in the institution-owned van for a fee. One can even have the opportunity of donating escrow moneys to add an Alzheimers Unit to the institution. Entertainment designed for kindergartners is provided. The MOM grinds on.

Now we have the current economic collapse with an estimated loss of 50% in most IRAs. The MOM shows compassion. The management raises to monthly fee by 7%, i.e. $210. The management needs the increased income to cover “rising expenses.” There is a certain problem looming; however, many of the residents are not cognizant of the fact and the mainstream media is not apparently aware of the situation. Other oldsters are terrified but do not know where to turn.

I have indicated merely one example, but there are thousands of the elderly in nursing homes, assisted care homes, etc., facing an imminent disaster. One hopes that some agency of the Obama administration will begin addressing the problem. A problem largely created by the greed of uncontrolled capitalism that has been extant since the Reagan administration and certainly of no interest to the economically neo-liberal Bush administration. Happily many of the legitimate church related housing facilities are looking at the problem and will, I am sure, be privy to its solution.

I would hope that someone, somewhere, is listening.

[S. R. Keister, a retired physician, is a regular contributor to The Rag Blog.]

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How Will the Crash of 2008 Impact the Elderly?

Health care, the nursing home, the retirement home, and, heaven help us, John McCain.
By Dr. S. R. Keister / The Rag Blog / October 15, 2008

One of the most frightening aftereffects of the crash of 2008 will be the impact on the elderly, a subject, by-in-large, as yet unaddressed. More frightening still is the fact that in my talking to the elderly regarding the upcoming election is the fact that the response that I hear most frequently is, "I will vote for Senator McCain, he is old enough to appreciate the problems of the elderly.” The disconnect and absence of information is frightening to say the least, in view of the fact that little time remains until election day.

I am myself 87 years old, practiced medicine for 40 years and after retirement worked part time at the V.A. and at St. Paul's Free Clinic. While at the former, before the Bush administration started their budgetary cuts, I was impressed by the excellence of medical care provided by this single example of 'socialized medicine' in the United States. When I first approached the free clinic I anticipated so. These were good, solid, decent people in low paying jobs and unable to afford health insurance. An excellent example of our broken system of medical care in the United States.

Over the past 30 years I have noted the increasing tendency of the commercial interests in the nation to feed off of the elderly, knowing of course that many of these folks were ill informed or even worse misinformed. The advent of Social Security, Medicare, and pensions, whether employer provided, or IRA, gave the leeches a chance to attached to the bloodstream of the income of the elderly. Let us look at some of the examples....

The Nursing Home. These have proliferated like mad since approximately 1980. A recent U.S. Government report indicates that some 90% of these facilities show various deficiencies. There are two groups of nursing homes available. (1) Those sponsored by religious organizations, hereabouts Catholic, Presbyterian, Episcopalian, all of which were founded with good intentions in mind and providing first rate care. (2) The commercial establishments, many of which are large chains, established of course as business enterprises. As we all know a business is intended to make a profit for its management and stockholders. The costs for both groups are approximately $3000-$4000/month; however, objective surveys show that by-in-large better care is provided in the church sponsored homes. Quality control is largely a state matter, and of course is influenced in many instances by the relationship of the commercial management to state government. Did I say baksheesh?

Another booming industry in the past 20-25 years is The Retirement Home. These are of multiple origins. Some are unashamedly related to hotel chains and others masquerade as quasi-church related organizations, but are indeed independent 'non-profit enterprises'. Finally, there are the bona-fide, openly, church related homes.

A word about "non-profits". Talk to the average individual in a "non-profit" home and he/she has the idea that this is in some way related to a charitable organization, and is absolutely dumbfounded when informed that most 'non-profits' are tax exempt businesses that have a well-paid group of businessmen in control, and vary from a commercial business only in not having stock holders. A common ploy to entice residence is an offer to sell them an apartment, for say $120,000, refundable to the estate fully or in part, upon death of the tenant. Of course, and many folks are not aware of this, that under normal stock market conditions, that the individual loses, say, 6% interest on the money while the retirement home takes that interest as their own. (One wonders with the stock market crash how these deposits survived.) In addition the tenant pays $3000-$4000 a month maintenance fee, which includes dinner daily whether it is partaken of or not. Of course there are other fees for changing light bulbs, filling pill boxes, giving insulin injections, etc. In various states there is no legal requirement for intercom systems, auxiliary generators, or emergency notification in the event of power failures, etc.

Many of the commercial “homes” and a few of the excellent church-related homes require the 'purchase' of the apartment, and in house, or on-ground, facilities vary; however, the cost is still in the $3000-$4000 per month range. All of these situations have exploded in number with the advent of Medicare, Social Security, and the aforementioned plans. This burgeoning industry in much greater in the United States than in Western Europe, granted it varies by country, and government implicated Social Services are much more extensive. One can almost relate the creation of these institutes to the advent of "neo-Liberal" economics introduced in this country during the Reagan administration.

For some time Medicade provided a modicum of help to poor nursing home patients but this has been abbreviated by the Bush administration. Concurrently the Bush administration tried to privatize Social Security, and the Congress, in its one of its few brave confrontations, refused to accept the program. The Bush administration has been making a conscious effort to privatize Medicare by establishing the "Medicare Advantage Plans" which deplete the Medicvare Trust Fund by approximately 17% per enrollee per year. The Medicare, Part D, fiasco, establishing a bizarre and costly prescription plan for the elderly, and which was really a pay-off of billions of dollars to the pharmaceutical and insurance industries by the Republicans with Medicare funds. One notes of late that the co-payments have been reduced and prescriptions covered lessened by the insurers as the price of drugs has increased..

Now we must factor in the current economic crises’ effect on the elderly, to continue to pay these folks who have been by hook or by crook sharing their retirement incomes. It would appear that Social Security and Medicare, for the short term, are intact, and hopefully can be saved by an enlightened administration in Washington, free of the economic nonsense inherent in our society since 1970. Those living largely off of IRAs or 401Ks are in a more questionable position. Further, the McCain economic plan, in spite of the disaster of the past several weeks, still includes privatizing Social Security, and reducing Medicare payments by over 1.2 trillion dollars over the next 10 years. What will happen to the thousands of residents if their individual or corporate retirement accounts disappear into thin air?

When I hear the elderly supporting McCain I am reminded of the Greek myth of Erysichthon. If the older American supports McCain he is bringing on his own destruction. Why should an elderly man a professional politician, who has been consumed by self interest all his life, and who is worth millions of dollars, acquired by questionable connections, be interested in the old gentleman in a nursing home? There is a frightening disconnect here.

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