Friday, November 30, 2012

Promoting Patients’ Life Plan


Promoting Patients’ Life Plan

By Rosemary Laird, MD, MHSA, AGSF, and Peggy Rapp, MSW, PhD
Providers can play a critical role in promoting patients’ consideration of their end-of-life medical treatment and disposition of assets to achieve peace of mind.
While more people live longer, healthier lives than at any other time in history, disability remains increasingly common as individuals age. People intent on maintaining their independence as long as possible and avoiding the possibility of burdening families any sooner than necessary should complete a life plan and review it annually. Such a plan should include a clear and complete advance directive for healthcare decisions, current information about key financial documents and insurance products that may contribute to care in the case of incapacitation, and plans for how family members should manage affairs after death.
Creating a life plan allows communication of patients’ wishes to trusted family members and future decision makers as well as to the primary care provider. A life plan serves as a welcome final gift to family members and future decision makers. Advance planning documents reassure and empower decision makers to feel confident they are making appropriate decisions.
Difficult Conversations 
Thinking about death or losing independence is unpleasant. Compound these fears with worries about running out of money or burdening family members, and making a life plan often falls to the bottom of an individual’s to-do list. Patients shouldn’t let these fears keep them from taking control when they still have the ability to plan. Encourage patients to provide guidelines for future treatment.
Responsible planning provides control over wishes regarding mind, body, and spirit even if decision-making capacity is lost. Involving family members in such decisions empowers them to feel confident about making future decisions, if necessary. Studies have demonstrated that those who are most willing to engage family members and friends in the decision-making processes are most likely to live more contentedly in their later years.
Discussions about end-of-life decisions can be overwhelming or difficult, but the following information can help identify the key elements patients should address. If patients have no family or do not want to involve family, a care advocate or lawyer can be hired to help make arrangements to ensure wishes are honored.
Advance Directives
The first step to making a life plan is creating a clear and complete advance directive. A balance exists between personal freedom to choose and the responsibility of the state in which a patient resides to protect individuals who cannot protect themselves. At the crossroads of these rights and protections are state-specific documents designed to allow individuals to express their wishes for care and indicate to the state the individual to whom responsibility for decisions shifts if patients can no longer make those decisions for themselves.
Many people die without having a will or an advance directive in place. In some cases, their lives are extended beyond any reasonable quality of life due to dementia, severe disability with accompanying lack of brain function, or other issues prohibiting the individual from communicating his or her wishes. Advance directives are a must and form the foundation of a life plan.
Advance directives are documents identifying an agent a patient chooses to make decisions for him or her in the event he or she can no longer make them. There are two main categories for which patients need to identify a decision maker. Both healthcare and financial affairs need a proxy decision maker for cases in which an individual cannot make decisions personally. Some people choose one person to manage both areas; other times it may be appropriate to choose different individuals for each area. The specific document required depends on the state of residence. (Access for each state form and law can be found here.)
Types of Advance Directive Documents
• Living wills: These documents describe an individual’s choices pertaining to his or her healthcare should that person be unable to express his or her wishes at any point. Living wills are the most commonly known advance directive but in day-to-day situations are not as practical or useful as identifying a trusted individual (power of attorney) to make complicated decisions or react to unanticipated situations requiring decisions.
• Power of attorney: This is a notarized document that gives specific powers to an individual to act on another’s behalf. These powers can include making healthcare decisions or handling financial affairs. There are several key types of power of attorney:
- Medical: This is a legal document accepted in all states whereby an individual identifies a health advocate/proxy and may or may not list his/her treatment wishes. (Often a living will contains the treatment wishes.) This document specifically identifies an individual to serve as the proxy decision maker. It is this identification of a trusted individual that gives such importance to this position. Many decisions in healthcare settings are complicated and cannot be managed by the one-time determinations set forth in a living will document. That document provides a good foundation, identifying for the power of attorney the patient’s basic wishes. Having a power of attorney for healthcare provides a greater chance that patient wishes will be carried out regardless of the situation that arises.
Durable: Some states require a durable power of attorney to be in place if an individual is unable to revoke the power of attorney. It is important to note that a regular power of attorney and sometimes a medical power of attorney are not acceptable if the individual becomes brain injured or has dementia, for instance, and cannot speak for him or herself. The key word is “durable” and ensures that the patient’s power of attorney cannot be revoked if the individual cannot speak for him or herself.
Springing: This document appoints a decision maker who may become the decision maker on behalf of the individual only if and when the individual becomes incapacitated (not available in all states).
Financial: This names an individual to handle financial matters. This document is distinct from the medical power of attorney. A financial power of attorney may or may not be the same person as the medical power of attorney. It is up to the individual to decide who will represent him or her in each of the various duties and responsibilities.
• Healthcare proxies: In certain states where living wills are not acceptable, healthcare proxies have been used. These are state forms that can be signed by the patient, with some requiring notarizing. There usually is a place for the patient to include his or her wishes about types of care and situations when no care should be given other than palliative care.
• Preneed guardian: This document, available only in Florida, designates a person to become an individual’s guardian if and when the individual becomes incapacitated.
• Physician orders for life-sustaining treatment (POLST): This is the newest mechanism for physicians and patients to determine what forms of life-sustaining treatment should be utilized. Availability varies by state, with information available here.
• Do not resuscitate (DNR) order: Available medical resources include the ability to restart the heart and/or support a patient’s breathing if either of these vital activities has stopped. In both situations, if emergency treatment is not performed, an individual will soon die. In cases of terminal illness or advanced chronic illness, it may be the desire of the individual to decline such resuscitation attempts. However, if the situation arises in a hospital setting or with emergency personnel available, there is an obligation to provide resuscitation. To choose to forgo resuscitation, one must provide documentation of a doctor’s order in support of this decision.
A DNR order is a physician’s order directing emergency responders or medical personnel not to resuscitate an individual who has died. It may be initiated by the patient, his or her representative, or a physician but must be agreed upon by both the patient or representative and the physician. Both parties’ signatures are required, with some states requiring two physician signatures. Patients should carry a wallet-sized card with information about the DNR order and post such information visibly in the home so emergency personnel know about a patient’s wishes. Otherwise, the patient will automatically receive life-supporting treatment.
Insurance Documentation
The second step for patients to create a life plan is to document insurance and financial information.
In later years, the nature of individuals’ insurance needs changes. Life insurance becomes less necessary as a tool to replace income or ensure children’s education. More importantly, older adults need to think about healthcare costs, a surviving spouse’s welfare, and personal care assistance.
• Life insurance: If possible, patients should have some life insurance for family members to use to settle affairs such as funeral expenses and outstanding bills. Current life insurance options include typical policies that pay at the time of death and those compounded with annuities attached and offering a monthly retirement income at a certain age. A financial planner should be consulted to determine the best vehicle for patients’ needs.
• Health insurance: Medicare is available to individuals who have contributed to the Medicare fund via employment, either personally or through a spouse. Medicare includes parts A, B, C, and D and provides partial coverage for hospital care (Part A); outpatient care, home care, and diagnostic testing (Part B); and prescription drugs (Part D). Notably there is no coverage for long term care needs. (This is managed under the Medicaid program discussed below.) It is critical to understand that Medicare pays only about 40% of the total cost of healthcare. Individuals are responsible for coinsurance of varying amounts.
• Supplemental care insurance: This covers expenses not paid for by Medicare. The market is flooded with various policies so encourage patients to select a reputable company that has been in business for more than 10 years and to carefully examine policy exclusions or limitations, particularly with respect to personal healthcare. Many state and local government offices and volunteer organizations provide free counseling regarding insurance needs. The Medicare websitealso provides resources and information, including links to low-income resources.
Another key element of health insurance for older adults is hospice care, provided to individuals in the last six months of life. Hospice is now fully covered by Medicare.
Changing Aspects of Healthcare
The Affordable Care Act (ACA) and its implications are still unknown. Each state is charged with implementing various programs under the ACA, and how those programs will look as they emerge remains a question.
Some aspects of the ACA aim to create bridges between Medicaid (the medical assistance program for the impoverished and long term care of the poor elderly) and Medicare. How this will impact elder care is unclear. This uncertainty increases the importance of physicians’ vigilance in encouraging patients to address and plan for future needs.
• Long term care insurance: No one wants to live in a nursing home or burden family members with personal care needs. But increasing longevity sometimes results in the need for personal care support, and some individuals need to spend time in a long term care facility. Medicare does not cover the routine care needs of older adults in assisted-living facilities, memory care units, and/or nursing homes. For impoverished elders, Medicaid will provide certain daily care in nursing homes. Many older adults will have no coverage. To provide an alternative, long term care insurance offerings have increased in recent years.
Long term care insurance policies vary significantly, but in general they cover the costs of care for activities of daily living, such as grooming, bathing, and dressing, when a person is unable to safely perform these activities. Variations in services and policies can make this insurance very difficult to understand. Key areas for a patient to carefully examine include the level of care covered and the locations of services offered; limitations on the numbers of hours or days per week or monetary limitations (upper limit of payment per year and/or per policy) that can result in nonpayment even if the service was once covered; transferability from home, personal care home, rehabilitation center, or nursing home; and the cost of the premium in exchange for reduced risk for the cost of care.

When purchasing long term care coverage, urge patients to investigate whether the company and agent have been in the business for at least 10 years and to carefully examine reputations. Older adults need to assess the level of tolerable risk, availability of family members who are willing and able to provide care, and the statistical probability of the need for long term care. More than 70% of Americans over the age of 65 will need some type of long term care services at some point in their lives, according to a study by the US Department of Health and Human Services.
Important Patient Considerations
To assess the need for long term care insurance, patients should explore the following issues:
• Is there a risk that a patient may develop a genetic disease such as Alzheimer’s disease, heart disease, or diabetes that may leave him or her debilitated?
• Are there limited assets that can diminish the patient’s ability to stay in his or her home or community? Is there enough money to self-insure or cover healthcare costs should the need arise?
• Are family members supportive and in agreement about providing care? 
• Does a legal partner have assets that could be depleted by healthcare costs? (Legal partners are required to support the partner in all areas, even long term care.)
• Is there personal opposition to nursing facility placement and care?
If the answer to any or all of these questions is yes, patients may want to consider purchasing long term care insurance. It should have the flexibility of being transferable from a facility (rehabilitation) to home care, and the limitations on costs of coverage should be considered, including caps on weekly hours of care and the upper limit of total costs. The limitations on a long term care policy can make care ineligible so it’s important to have all the information at hand before making a decision.
Disability insurance is insurance that pays benefits if the policyholder becomes unable to work. It does not cover those who retire and develop a disability after retirement.
Critical illness insurance is a type of coverage that, in the case of cancer or another life-threatening illness, pays a tax-free lump sum over the duration of the illness, provided there are no other limitations. Again, an individual must be cautious about limitations and the cost of the insurance.
Financial Documentation
Financial documentation should include a listing of all active accounts patients’ loved ones would need to manage following death. It should include contact information with correct account numbers, updated passwords/log-ins, expiration/maturity dates, etc for bank accounts; certificates of deposit; money market accounts; stocks or bonds; credit cards; and sources of income, such as Social Security or pensions.
Family Information
The third step in creating a life plan is providing family members with instructions on managing the funeral and affairs immediately after an individual’s death. Remind patients to gather all the information in one or two places so that the appointed representative(s) has easy access. There are various ways to accomplish this, including the following:

• E-mail general information to family or loved ones.
• Keep a strong box in the home that is accessible to trusted individuals.
• Rent a safe deposit box that is held in joint ownership so it is accessible to approved family members or proxies.
Documents older adults may choose to make available include the following:
• assets, including bank accounts with numbers and locations, pensions, Social Security, and other income;
• debts, including outstanding loans; credit cards with numbers, expiration dates, and phone numbers to cancel; and property liens;
• insurance policies, including life, health, and long term care along with policy carrier names, numbers, and contact information;
• properties, including homes, rental properties, cars, and boats; and
• funeral information, including a preferred funeral home with contacts.
Last Will and Testament
It is difficult for physicians to know how much to become involved with patients’ decisions about insurances and advanced directives. It is even more difficult to give advice about types of insurance and levels of coverage because it is dependent on the individual’s personal assets, property, and personal preferences. Individuals should, at minimum, have a will with expressed wishes, including funeral arrangements and dissemination of assets.
— Rosemary Laird, MD, MHSA, AGSF, is medical director of the Health First Aging Institute and president of the Florida Geriatrics Society. She is a coauthor of Take Your Oxygen First: Protecting Your Health and Happiness While Caring for Someone With Memory Loss.
— Peggy Rapp, MSW, PhD, is an associate professor of social work at Misericordia University in Dallas, Pennsylvania. Experienced in community services for older adults as well as nursing home, adult day care, and home care, she has taught for 12 years and continues to advocate for older adults.

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