This is definitely a Reverse Mortgage blog; but reverse mortgages are not done in a vacuum, are not needed in a vacuum, and anyone involved in this "reverse mortgage culture", as more than a money seller, must be concerned about the lives and care of the people in retirement that they serve, and try to help educate them and their families in all manner of issues facing America's oldest generation. I strive to have this blog do that. Below, are stories from another senior blog.
Jane Gross writes a blog for the New York Times that is dedicated to the issues and needs of the very elderly and their families. Below are three informative and heartfelt recent articles in her blog that have been published by the NYT. They cover the costs of caring for the elderly by the family, how our policies for the elderly demand their pauperization (or divorce if one doesn't want to end up a penniless widow or widower), and the more and more open and acceptable discussion of life-ending processes.
Today, we divide up our elderly into the "young seniors" and "the elderly". Usually this is defined by age - 80-85 to be "elderly", or by the strength, health and independence of a senior. So, a man or woman frail and dependent on others for assistance in daily living at the age of 65, could be considered "elderly"; whereas a vibrant, strong, mentally sharp 87 year old would still be considered a "young senior".
I strongly encourage you to read these articles, both for yourself, or for the senior parents, relatives or partners you may be caring for. And, I cannot stress enough that you educate yourselves about the ins and outs of eldercare before you need it.
Please don't hesitate to leave comments for me, or to send them to Jane Gross at the New York Times. You can reach Ms. Gross at newoldage@nytimes.com.
Gloria
________________________________________________
Always Making Up the Difference
By Jane Gross
September 4, 2008
Like Anne, a reader whose comment to a recent New Old Age blog post is excerpted below, my brother and I contributed in ways large and small to my mother’s care at the end of her life, both before she ran out of her own money and went on Medicaid and after.
We neither resented nor calculated what we spent during those years and, indeed, would have spent more but for worries about our own retirements and old age, a worry that Anne shares.
Responding to a post about what Medicare and Medicaid pay for — and what they don’t — and how adult children often make up the difference, Anne wrote:
"For the past three years, my mother lived at home with me. She received at
home services … from Medicaid, which could not exceed $1,680 per month. The benefit provides for a maximum of 28 hours per week of assistance by an aide and/or medical supplies. Since my mother received incontinence and medical supplies plus nutritional supplements, she was only allowed 21 hours per week of assistance from a home health aide….
The home health aide agency receives $15 per hour from Medicaid. The aide receives $6.00 - $8.00 per hour less taxes from that amount…. Several times a year, when I was on the verge of a breakdown, I would beg her case manager to give us an extra hour or two of aide services so that I could take half a day off. I would literally have to beg.
…My mother visited her primary physician twice a year for a general
physical exam paid by Medicare. Medicare Part D covered a discount on her
vitamins and minerals, which saved us several dollars a week. Medicare and
Medicaid do not cover eye care, hearing aides or dental care. I decided not to get her hearing aides which cost around $10,000 since her hearing loss was only 20 percent. I paid $500 for eye care and new glasses. I paid $5,000 for dental care last fall.
Late last winter my mother suffered from pneumonia and a series of small
strokes affecting her motor skills and ability to swallow. She was hospitalized for a week and sent to rehab at a nursing home — all paid for by Medicare. At the end of the 100 day Medicare benefit, my mother was transferred to the long-term wing.
Medicaid has now begun to pay a monthly fee to the nursing home. I do not
know what the amount is. But now I have to pay the nursing home my mother’s entire Social Security check — her only source of income — less $40 per month.
That’s right — she is allowed “to keep” $40 per month for personal care.
That pays to have her hair done once a week. I pay for the tips, hair cuts, hair color and perms. I pay for the plants and flowers that always adorn her room. I pay for the TV and telephone…. I pay $50 per week in gasoline to visit her every other day plus $1,500 this summer in car repair bills due to the extra wear and tear on my old car.
Now she needs new clothes since she has gained weight. New shoes and
clothing will run around $500. Soon there will be expenses for cards and gifts she’ll want to give. I am so thankful that libraries are free so I don’t have to buy books.
I cannot imagine what we would do without the “safety net” of Medicaid. But it isn’t enough. I am 50 years old. I have to begin to plan on buying long-term health insurance for myself soon.
Where will I find an extra $10,000 per year? Will that be enough? How much benefit will I require 40 years from now? Will it be double or triple today’s cost?….
The multi-millionaires who troll the corridors of the White House and Congress will never have to face the financial nightmare of long-term care. They have forgotten the old adage of “to who much is given, much is expected.”
So what caregiving expenses did my brother and I have? When my mother lived in Florida, along with airplane fares to spend time with her, we stocked her assisted living apartment with hundreds of dollars of staples from the supermarket each time we visited and bought her furniture that she needed but was reluctant to buy because money was tight.
When she relocated to another assisted living community in the New York area, we paid for her move and a new winter wardrobe. There, on our frequent visits, we filled her little refrigerator with diet Snapple, bought her ginger snaps and coffee candy from Trader Joe’s and frozen dinners for the microwave when she could no longer easily go to the dining room for meals.
Once her medical needs made a nursing home necessary, we paid for private duty aides on holiday weekends, during shift changes and at other junctures when the staffing was inadequate. I had ignorantly thought her long-term care insurance, which we also had paid for, would cover this kind of assistance, unaware that the insurance benefit would go to the nursing home while she was still paying her own way and to the government once she was on Medicaid. My mistake for not reading the small print or asking the right questions.
We lied to her about how we paid for those private aides so she wouldn’t feel guilty or worried we were spending too much.
During those nursing home years, we bought her a motorized wheelchair when she no longer had the strength to operate a manual one, and a “talking board’’ with recorded requests so she could make her needs known when she lost her ability to speak.
Both might — repeat might – have been covered by Medicare, but we were warned the process was arduous and our claim would likely be denied. We were fortunate to be able to afford those big ticket items, without first waging a losing battle with Medicare — and also pay for denture paste, a new bedspread and a VCR.
Only later, when I heard similar stories from friends and colleagues, did I begin to wonder about these out-of-pocket expenses, the ka-ching, ka-ching of elder care. How much did other people spend? Did they keep track? What did they do without in their own lives in order to keep their parents safe and comfortable? In a 2006 story in The New York Times, I interviewed dozens of adult children about the incidental costs of caregiving, ranging from rent for a big enough apartment to accommodate an ailing parent, to full price plane tickets for long-distance emergencies, to shower chairs and grab bars.
At that point, there was no research on this subject, but a study soon followed, which showed that out-of-pocket caregiving costs on average $5,500 a year, more than the average American household spends on health care and entertainment combined. My hunch is that those numbers are low, and the study’s authors agreed.
Inspired by Anne’s comments, The New Old Age would like to hear your stories of out-of-pocket spending for your parents. We’d also like to hear from them directly, since I’m sure it pains them deeply, as it did my mother, to depend on the children who once depended on them.
__________________________________________________
A Policy of Pauperization
By Jane Gross November 5, 2008
Middle-class, middle-aged Americans are stretched to their emotional and financial limits caring for sick parents and spouses, a situation guaranteed to get worse, given our demographic trends, without a top-to-bottom overhaul of the health care system and its focus on acute, rather than chronic, long-term care.
This, of course, is the overarching subject of this blog, but also the agenda for several recent expert panel discussions, including one sponsored by the American Academy of Nursing and hosted by The John A. Hartford Foundation.
I was struck by this compelling account of the program, entitled “Taking Care of Your Aging Parent: What Families Need to Know.” Panelist Gail Sheehy, a best-selling author and wife of the late Clay Felker, the iconic magazine editor, vividly described the plight of all but the wealthiest Americans. Despite fame, success and a well-connected lifestyle that would be the envy of most of us, Ms. Sheehy, in her late 60s, and Mr. Felker, 82 at the time of his death last July, all but ran out of money paying for care in the last year of his life.
Throat cancer left him with a tracheotomy, a feeding tube, and the need for constant home care after he was discharged from a hospital and rehab center. Neither Medicare nor private insurance covered the home health aides and other assistance the couple needed, Ms. Sheehy told the audience, until they turned to hospice. It was the only way to get subsidized, comprehensive home care, but hospice is only available to those certified by a physician as having just six months to live.
The alternative was for the couple to exhaust their remaining assets, except for $5,000, in order to qualify for Medicaid, essentially leaving Ms. Sheehy a penniless widow. They were not willing to do that. Nor were they willing to divorce so that Mr. Felker could receive Medicaid while Ms. Sheehy would be shielded from impoverishment.
These apparently extreme solutions are commonplace when facing the astronomical costs of long-term care. But my hunch is that many readers will be surprised that a glamorous couple like Ms. Sheehy and Mr. Felker could have found themselves in the same bind as the rest of us, which Carol Raphael, president of the Visiting Nurse Service of New York, calls “a policy of pauperization.”
The numbers, as reported by HealthDay.com:
* U.S. Census Bureau figures project that the number of Americans 65 or over will double by 2030, and that two-thirds of today’s 65-year-olds will require some period of long-term care later in their lives.
* At the same time, according to one recent study, the number of geriatricians has actually declined in recent years, to about 7,750; that translates to one for every 4,254 older Americans. In addition, the country will face a shortage of more than 800,000 nurses by 2020.
* According to U.S. government surveys, there were 2.5 million Americans living in either nursing homes or assisted living facilities in 2004. The average cost of a private room in a nursing home, according to a recent MetLife study: $75,000 per year.
* The AARP notes that two-thirds of older Americans who needed long-term care now rely completely on unpaid help — in most cases, family.
Since many of you are spousal caregivers like Ms. Sheehy, I wonder how many of you ever considered spending down to Medicaid eligibility as a couple, despite the fact that the surviving spouse would then be all but penniless? Have any of you divorced, or seriously considered it, so one spouse would be eligible for government help and the other spared impoverishment?
____________________________________________________
At the End of Life, a Delicate Calculus
By Jane Gross November 6, 2008
On Tuesday, Washington State joined Oregon as the second in the nation where physicians are allowed to prescribe lethal doses of medication to terminally ill men and women who want to hasten their own deaths. But the remedies available to suffering patients have expanded dramatically in the 11 years since the Oregon measure took effect, one expert recently noted, and the question of whether doctors should help patients die is far more nuanced than it once was.
The Washington State proposition, Initiative 1000 (PDF), passed by a margin of 59 to 41 percent, and like the Oregon measure, which withstood several legal challenges, contains many safeguards intended to prevent hasty and ill-considered decisions. Patients requesting this assistance must be mentally competent, residents of the state, have six months or less to live according to two physicians, wait 15 days after their initial request and then repeat that request both orally and in writing.
They must be capable of administering the lethal medication themselves and agree to counseling if their physicians request it. In addition, these patients also must be informed by their health care providers of other feasible alternatives.
In the view of Dr. Timothy E. Quill, director of the palliative care program at the University of Rochester, these options have expanded and gained acceptance in medical circles over the past decade. In 1997, in two important cases (Dr. Quill was a plaintiff in one), the U.S. Supreme Court ruled there was no constitutional right to physician-assisted suicide and upheld a prohibition against it. But in the same ruling, the justices conceded that terminally ill patients are entitled to aggressive pain management, even if high doses of opiates or barbiturates have the “double effect” of hastening death.
That seemed a footnote at the time to the larger issue, but it arguably cracked open the door to those other feasible options, which Dr. Quill and other end-of-life experts refer to as “last resorts” in jurisdictions where it is a crime for physicians to assist in dying.
Dr. Quill’s views on physician-assisted death — a term preferred by many palliative care doctors and right-to-die organizations — are outlined in two essays published by the Hastings Center, the nation’s oldest bioethics research institute.
One, entitled “Physician-Assisted Death in the United States: Are the Existing ‘Last Resorts’ Enough?” appeared in the center’s bimonthly report this fall. The other, intended to be a resource for policymakers, political candidates and journalists, is one of 36 topics framed and amplified in the center’s more recent “Bioethics Briefing Book.”
In these articles, Dr. Quill enumerated “last resort” options in the order he advises they be considered, both because of what is involved in each practice and because of the degree of acceptance among ethicists, legal experts and the general public. The essays were written, obviously, before the voting in Washington State.
Dr. Quill considered it “a good time to review areas of progress in palliative and end-of-life care and consider whether [laws or ballot measures of this type] are either necessary or desirable.”
He concluded with a cautious “yes” but makes a compelling case that adding physician-assisted death to the repertoire is not, for him, the singular solution it was when he made history by publishing an account in a medical journal about his own role in a patient’s death.
First and foremost, Dr. Quill and others say, all terminally ill patients should have access to state-of-the art palliative care, both to relieve pain and other symptoms and to provide emotional support to patients and families. Often delivered as part of hospice, palliative care has come of age in the last decade: it is now a board-certified sub-specialty, Dr. Quill noted, offered in a growing number of teaching and community hospitals.
Dr. Quill recommended that a palliative care consultation be mandatory before anyone considers the following “last resorts,” which he listed from least controversial to most:
1. In the rare cases where pain and suffering remain intractable, despite top-notch palliative care, the next option should be pain management so aggressive that it may well hasten death, although that is not the primary intention. This is the doctrine of “double effect,” articulated by the U.S. Supreme Court’s decision in 1997 and relatively uncontroversial.
2. Rarely challenged, too, is a patient’s right to forgo life-sustaining therapies or discontinue them once begun. This likely would include feeding tubes, ventilators and other life-support machinery. But it could also include chemotherapy, blood pressure medication, insulin or garden-variety antibiotics. The legal and ethical argument here is that we all have the right to autonomy and bodily integrity, and to control what is done or not done to us.
3. Also considered by some to be a matter of bodily integrity is V.S.E.D., short for “voluntarily stopping eating and drinking.” Dr. Quill believes this is “more morally complex” choice than the second option, because over the last decade the practice has expanded beyond those with end-stage cancer or Alzheimer’s disease — who often lose interest in food or forget how to eat and drink — to people who are not “actively dying” but nevertheless have had enough of disability or dependence.
V.S.E.D. requires “considerable resolve,” Dr. Quill said, because thirst can be persistent and death can take as long as three weeks. Physicians do not “assist” these patients but support them with symptom relief for dry mouth or sedation in the event of delirium or other complicating discomforts.
4. The “last, last resort,” and by far the most controversial of the legal methods, is sedation to the point of unconsciousness, also known as palliative or terminal sedation. Endorsed earlier this year by the American Medical Association’s Council on Ethical and Judicial Affairs, it involves an explicit decision to render a patient unconscious if pain can be controlled no other way. Food and fluid may be discontinued, and in one to three days the patient dies of dehydration.
According to data from Oregon, 341 people have died in 11 years as a result of lethal doses of medication provided by a physician. That amounts to 1 in 1,000 deaths overall per year, according to the state health department, although 1 in 50 dying patients have discussed the possibility with their doctors and one in six with their families. “Most patients will be reassured by the possibility of an escape,” Dr. Quill said, “and will never need to activate that escape.”
By contrast, when physician-assisted death is a covert operation, far more people seem to grab the chance. Data on this secret but apparently widespread practice is hard to collect, because physicians can be charged and prosecuted for a crime. But in the mid-1990s a team of researchers, Dr. Quill among them, tried to investigate the question using techniques that protected anonymity.
The researchers found that between 1 and 2 percent of deaths per year had been aided, illegally, by physicians through assisted suicide or euthanasia — 10 to 20 times the rate observed in Oregon since legalization of this practice.
Posts
0 Comments Welcomed:
Post a Comment