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Questioning Aging Answers

Aggressive Medical Treatment- A Crisis Point for the Family Caregiver

Family caregivers of an elder with serious health conditions can often be made to feel that they must assist the elder in obtaining aggressive medical treatment for worsening conditions. In the USA, the use of aggressive medical treatment for patients in the final months of life is increasing significantly. 1

Are the physicians who recommend aggressive medical treatment near the end of life generally helping the elder or are the outcomes of aggressive treatment generally undesirable?

Studies find undesirable outcomes

According to studies published by Medicare News Group 2 and by the Journal of the American Medical Association, JAMA 3, aggressive medical treatment for Medicare patients at the end of life has been on the increase with more people receiving care in intensive care units and more people being shuffled between hospital, home and skilled nursing care in the final months of life.

Unfortunately, according to the same studies, it appears that aggressive medical care is not helping the people who receive it live longer or enjoy a better quality of life than people who receive more conservative treatment. Consumer Reports 4 has reported that “too much healthcare” can actually shorten a person’s life.

In fact, aggressive treatment can cause stress and pain for the elder and for the family caring for that elder. Consumer Reports notes that families who have lost loved ones after aggressive treatments often say they regret not having recognized sooner that treatment was not beneficial, and adjusting plans and expectations accordingly.

How do physicians fit into this problematic puzzle?

Some experts note that fee for service Medicare rules can lead physicians to pursue more treatment because fees are paid per service. This idea may have some validity, but it may be more illuminating to look at physicians’ attitudes towards aggressive care in general.

Interestingly, a new study from Stanford School of Medicine 5 and a recent poll on the physician social media site SERMO 6 both indicate that regarding their own medical care, physicians would very rarely choose aggressive treatment, but for their patients facing the same prognosis, they tend to pursue aggressive treatment.

The Stanford study noted that advanced healthcare directives had little impact on aggressive treatment even though, “more than 80 percent of patients say that they wish to avoid hospitalizations and high-intensity care at the end of life.”

Finding the Physician’s Blind Spot

Physicians have a laser focus on diagnoses and treatment of disease, but this laser focus can also cause a major blind spot. A whole person is much more than his or her body’s condition or disease, and yet in the medical treatment process, the person can be “lost” in favor of a focus on a  particular physical condition.

Physicians are trained to provide technical services based on specific and technically definable perimeters. They are not trained or paid to deeply examine a patient’s personal life philosophy, personal history and life experience, emotional life, cultural influences, spiritual beliefs, or family and personal relationships.

To put it another way, what doctors know about a patient may represent very little of what a patient may consider to be essential to “who they are.”

In this context it makes sense that a physician, who knows herself as a whole person, would choose less aggressive treatment for herself and pursue more aggressive treatment for her patient, whom she knows primarily as a condition or disease. This outcome is probably unrelated to whether or not the physician is a caring or compassionate person and is rather a result of the constraints of time, function and capacity.

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What can families do?

Firstly, patients and their families need to recognize the limitations of physicians and medical systems in general. These systems and professionals do not have a complete understanding of patients’ personal lives and issues.

When faced with significant medical decisions, it is essential to seek out as much family, friend, professional and spiritual support as is needed.

Taking the time to draft a well considered Advanced Directive for Health Care (ADHC) is a key step. Realize most “check the box” ADHC forms pertain solely to life support and tube feeding. Preferences regarding other aggressive medical treatment must be written out separately. Therefore, multiple conversations will probably be needed with a primary care provider as well as other medical specialists to draft an effective document.   

Discussing the ADHC with the persons who may act as authorized representatives is essential.  The representative must understand the principles and desires outlined in the ADHC as issues may arise in practice that are not directly addressed in the document. Choosing a representative who has the mental and emotional maturity and capacity to be an effective advocate is also extremely important.

Having an authorized representative who can successfully advocate for the principles of the ADHC to be followed may be as important as the ADHC document itself.

Anne Conrad-AntovilleAnne Conrad-Antoville has worked with hundreds of families regarding senior healthcare issues and is CEO and a founder of Champion Advocates LLC, a geriatric case management firm serving elders is Portland, Oregon and  family caregivers across the USA and Canada.

References

1 Changes in End-of-Life Care Over the Past Decade:More Not Better  Grace Jenq, MD; Mary E. Tinetti, MD; JAMA.

2 The Cost and Quality Conundrum of American End-of-Life Care Medicare News Group, (reprinted by HealthManagement.org

3 Change in End-of-Life Care for Medicare Beneficiaries; Site of Death, Place of Care, and Health Care Transitions in 2000, 2005, and 2009, JAMA

4 Too much treatment? Aggressive medical care can lead to more pain with no gain Consumer Reports

5 Most physicians would forgo aggressive treatment for themselves at the end of life, study finds Stanford Medicine News Center

6 How Doctors Die: Only 7% Choose Extraordinary Measures; SERMO

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Questioning Aging Answers

2015 McGinty Alzheimer’s Conference- Portland Oregon

This year’s annual McGinty Conference on Alzheimer’s will be held November 3 at the Oregon Convention Center. It is open to family caregivers and professionals.

Register at: alz.org/oregon

Be sure to attend breakout sessions presented by dementia and aging experts including:

The Action-Compassion!Technique Series:
Redefining the Assessment Process for Improved Outcomes
Session B2 from 12:45-2:15PM

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Champion Advocates LLC

Geriatric Case Management Services

 

The Action-Compassion!Technique is a dynamic methodology in long term eldercare management focusing on the multi-level challenges of the diagnosed elder through the lens of the family caregiver. Effective assessment processes are the first step to good care planning and worthwhile service implementation. By better understanding the full range of challenges faced by the family, it is possible for the professional to save valuable time and energy for everyone involved. This technique is designed for the case manager within a private practice, yet can be used across multiple service fields, including medical, social, legal and financial services to better
serve elders and their families when facing the many issues of long term care for dementia.

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Future Vision

Champion Advocates Supports New Medicare ACP Coverage

Champion Advocates LLC geriatric case management services endorses the plans announced in July 2015 for Medicare to reimburse medical providers for having Advance Care Planning conversations with their patients.

Champion Advocates LLC joins numerous other organizations that have called for this proposed change, including: AARP, Alzheimer’s Association, American Geriatrics Society, American College of Physicians, American Medical Association, American Nursing Association, Gerontological Society of America, National Academy of Elder Law Attorneys, National Alliance for Caregiving, National Council on Aging, National Partnership for Women & Families, The Pew Charitable Trusts, among many others.

Dr. Patrick Conway, the chief medical officer for the Centers for Medicare and Medicaid, which administers Medicare stated in a July 8 New York Times article, “We think that today’s proposal supports individuals and families who wish to have the opportunity to discuss advance care planning with their physician and care team.”

Dr. Conway clarified that the proposal will not limit the number of conversations to be reimbursed to qualified medical professionals.

“The reality is these conversations, their length can vary based on patients’ needs,” he said. “Sometimes, they’re short conversations – the person has thought about it. Sometimes, they’re a much longer conversation. Sometimes, they’re a series of conversations.”

As reported by the Associated Press, “Medicare is using a relatively new term for end-of-life counseling: advance care planning. That’s meant to reflect expert advice that people should make their wishes known about end-of-life care at different stages of their lives, as early as when they get a driver’s license.”

Even though some private insurers have been providing reimbursement for Advance Care Planning, this new rule change would open these meaningful conversations to almost 55 million Medicare beneficiaries. According to The Kaiser Family Foundation, about three-quarters of the people who die each year in the US are 65 and older, making Medicare the largest insurer at the end of life.

Christian Sinclair, MD and Assistant Professor of Palliative Medicine Division Internal Medicine Department at the University of Kansas Medical Center, Sinclair is one of the leading US authorities on palliative care and advance directives and was on a national committee that last year produced a report called “Dying in America.”

The Kansas Health Institute news service reflected Dr. Sinclair’s enthusiasm for Medicare to cover advance care planning, as other private insurers are likely to follow. “That’s important,” Sinclair said, “because Medicare primarily covers Americans age 65 and older. Making decisions about resuscitation and living on feeding tubes or ventilators is something everyone should do once they’re mature enough to understand the choices,” he said.

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Last year’s National Academy of Sciences’ report titled “Dying in America” clearly summarized that, “As much as people may want and expect to be in control of decisions about their own care throughout their lives, numerous factors can work against that desire. Many people nearing the end of life are not physically or cognitively able to make their own care decisions. It is often difficult to recognize or identify when the end of life is approaching, making clinician-patient communication and advance care planning particularly important.”

The report further outlines, “Advance care planning conversations often do not take place because patients, family members, and clinicians each wait for the other to initiate them. Understanding that advance care planning can reduce confusion and guilt among family members forced to make decisions about care can be sufficient motivations for ill individuals to make their wishes clear. Yet even when these important conversations have occurred and family members are confident that they know what the dying person wishes, making those decisions is emotionally difficult, and families need assistance and support in this role.”

Since its formation, Champion Advocates LLC has been focusing on end of life conversations as one of our core areas of care planning to support an older individual or couple’s ability to aging in place in their own home. Routinely, we discover elders may have documented advance healthcare directives but with no practical or specific understanding as to what life sustaining measures they would actually desire when unable to speak for him or herself at a critical time.

We view this proposed Medicare change to be a good initial step for older persons considering what medical actions they would want to have performed, including the potential ramifications (positive and negative) from such procedures. Therefore, advanced directives will have more worthwhile meaning for everyone involved.

Champion Advocates recognizes that the next significant, yet more complicated, step is to ensure that agreed upon actions are timely and properly taken by creating a process whereby the patient, the medical provider and the designated healthcare agent are all on the same page before the end of the patient’s life is ever confronted.

In a future posting, we will will continue this topic by distinguishing the purpose and effectiveness of Advance Health Care Directives and the Physician’s Orders for Life Sustaining Treatment (POLST).

© Anthony Antoville 2015

Anthony Antoville is Care Manager, Certified and COO of Champion Advocates LLC in Portland, Oregon providing geriatric case management services. Anthony is a published expert on long-term care with Edwin Mellen Press and co-created the Action-Compassion!Technique as an innovative approach to geriatric case management. Currently, he serves on the State Plan for Alzheimer’s Disease in Oregon (SPADO) Taskforce to Optimize Quality Care and Efficiency.

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Nuts & Bolts

New Year’s (re)Solutions: Actions to Take for the Elders in Your Life

Did anything alarm you when visiting with older relatives during the recent holidays?

You may have detected any one of the classic red-flag indicators that an accident or injury could be on their horizon.

Perhaps, you saw a trip hazard that can lead to a fall, so consider removing:

  • Coffee tables and ottomans
  • Throw rugs
  • Clutter in pathways
  • Electrical cords from foot traffic

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Also, repair:

  • Unstable walking surfaces, like loose steps or paving-stones
  • Handrails that are not properly secured to walls or posts

Maybe, you recognized poorly lit areas that can cause an accident.  Light up and brighten up:

  • Cooking area and surfaces
  • Sewing, woodworking and other hobby stations
  • Hallways and pathways

Focus on:

  • Seasonal Affective Depression with appropriate lighting by introducing bright light therapy and/or using blue or blue-green spectrum light.

Did prescription and non-prescription medications appear to be a source of concern?

  • Get an updated list of current medications from all prescribing physicians and compare with the medications in the home.
  • Safely get rid of any outdated medications.
  • If there is any confusion regarding medications for you or your loved one, request a pharmacological review from the primary physician.

The New Year is a great time to resolve lingering concerns and worries from last year. By acting now, you can head into 2015 with greater confidence that older family members are in a better place to begin another year.

 

© Anthony Antoville 2015

Anthony Antoville is Care Manager, Certified and COO of Champion Advocates LLC in Portland, Oregon providing geriatric case management services. He is a recognized expert in eldercare and home safety, internationally published with The Edwin Mellen Press.

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Questioning Aging Answers

Advanced Directives May Not Prevent Aggressive Medical Treatment

Aggressive medical treatment for Medicare patients at the end of life has been on the increase according to studies published by Medicare1  and by JAMA2.

This aggressive treatment leads to more people receiving care in intensive care units and more people being shuffled between hospital, home and skilled nursing care in their last several months of life.

Unfortunately, the aggressive medical care is not helping those patients studied to live longer, nor are they experiencing a better quality of life than people who receive more conservative treatment.

When polled, people do not generally want this type of care. A Stanford School of Medicine Study3  found that more than 80 percent of patients say that they wish to avoid hospitalizations and high-intensity care at the end of life.

In fact, aggressive treatment can cause chaos and pain for patients and their families. Consumer Reports4  notes that families who have lost loved ones after aggressive treatments often say they regret not having recognized sooner that aggressive treatment was not beneficial.

Are physicians working with the intention of Advanced Directives?

Interestingly, both the Stanford study and a recent poll on the physician social media site Sermo5  both indicate that physicians, regarding their own medical care, would very rarely choose aggressive treatment. On the other hand, these same physicians tend to pursue aggressive treatment for their patients facing the same proposed prognosis.

The Stanford study noted that advanced healthcare directives had little impact on aggressive treatment:

“In fact, the type of treatments they (the patients) receive depends not on the patients’ care preferences or on their advance directives, but rather on the local health-care system variables, such as institutional capacity and individual doctors’ practice style…”

Why are physicians pursuing aggressive treatment?

Physicians have a focus on diagnoses and treatment of disease, so this singular focus can also cause a major blind spot. A person is much more than his or her condition or disease, and yet in the medical treatment process, the person can be “lost” in favor of a focus on their condition.

As noted by Dr. Periyakoil, author of the Stanford study, “Patients’ voices are often too feeble and drowned out by the speed and intensity of a fragmented health-care system.”

Physicians are not generally trained or paid to deeply examine a patient’s personal life philosophy, personal history and life experience, emotional life, cultural influences, spiritual beliefs, or family and personal relationships.
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To put it another way, what doctors know about a patient may represent very little of what a patient may consider to be essential to “who they are.”

It makes sense that a physician, who knows herself as a person, would choose less aggressive treatment for herself and pursue more aggressive treatment for her patient, whom she knows primarily by condition or disease. This outcome is probably unrelated to whether or not the physician is a caring or compassionate person and is rather a result of the constraints of time, function and capacity.

What can you do to have your healthcare preferences followed?

Patients and their families must recognize the limitations of physicians and of medical systems, in general. These systems and professionals cannot have a complete understanding of patients’ personal lives and issues.

When faced with significant medical decisions, it is essential to seek out as much family, friend, professional and spiritual support as may be needed.

An advanced directive is an excellent starting point, but having a professional or family member who can successfully advocate for its intentions to be followed may be most important.

Anne Conrad-Antoville is CEO and a founder of Champion Advocates LLC, a geriatric case management firm serving Portland, Oregon and Northern California. She has worked with many hundreds of families regarding senior healthcare issues for the past 30 years.

1The Medicare News Group: “The Cost and Quality Conundrum of American End-of-Life Care”

2JAMA: “Change in End-of-Life Care for Medicare Beneficiaries
Site of Death, Place of Care, and Health Care Transitions in 2000, 2005, and 2009”

3Stanford Medicine News Center: “Most physicians would forgo aggressive treatment for themselves at the end of life, study finds”

4Consumer Reports: “Too much treatment?
Aggressive medical care can lead to more pain with no gain”

5SERMO: “How Doctors Die: Only 7% Choose Extraordinary Measures”

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Questioning Aging Answers

Medical Alert Devices – Too Little, Too Late

An older woman cries out pleading for help from the bottom of a stairway in a large and empty house, and we are led to the conclusion that if only she had a medical alert device worn around her neck she could have emergency first responders there in minutes.

But what then…? How does the second half of this supposedly “averted” tragedy play out?

As reported by the Centers for Diseases Control and Prevention (CDC)*:

“In 2010, 2.3 million nonfatal fall injuries among older adults were treated in emergency departments and more than 662,000 of these patients were hospitalized.”

“People age 75 and older who fall are four to five times more likely than those age 65 to 74 to be admitted to a long-term care facility for a year or longer.”

So instead of lying on the floor for hours or days incurring additional life threatening conditions or worse, our female victim is whisked to the hospital and most likely will be treated and then discharged to a long-term care facility, either an assisted living or a skilled nursing facility for a year or more or until the end of her life.

The ability to lie on the floor and push a button may provide some level of comfort and security to seniors and their families yet when the fall has already occurred and resulting injuries sustained, the reality is your parent is lying there just pushing a button for help.

Now, a life will change in ways not to be desired by anyone. He or she will most likely be shuttled into a vast medical system to wind up in a bed that is not theirs and to no longer live in their own home.

This is the real fear older people live with. The fear of losing their independence and being institutionalized needlessly or prematurely.

If only the family had pushed beyond the simplistic notion that technology and telecommunications were all that was needed to keep mom or dad safe. If only our fear-based advertising could help us consider what happens after that last ditched effort is activated. Then, we could achieve compassionate aging for everyone concerned, senior and family caregiver alike.
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Like the CDC states*:

“Each year, one in every three adults age 65 and older falls. Falls can cause moderate to severe injuries, such as hip fractures and head traumas, and can increase the risk of early death. Fortunately, falls are a public health problem that is largely preventable.”

Geriatric case managers are qualified professionals to identify and evaluate many safety risks based upon mobility, vision and other physical deficits, environmental factors around the home, medical and behavioral conditions. By providing comprehensive assessments including balance and gait and home safety assessments, appropriate provisions and safeguards can be allotted and falls and many other unrealized dangers can be truly averted.

Medical alert products and services are worthwhile, but they are the very last line of safety. If they are to provide comfort and security, they should be part of a much more comprehensive approach to an elder’s care – one where that button need never be pressed.

© Anthony Antoville 2014

Anthony Antoville is Care Manager, Certified and COO of Champion Advocates LLC in Portland, Oregon providing geriatric case management services. He is a recognized expert in eldercare and home safety, internationally published with The Edwin Mellen Press.

*The Centers for Diseases Control and Prevention (CDC) Website “Home and Falls Among Older Adults: An Overview” Last Updated: 9/20/2013

 

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Aging and Spirit

Self Compassion and Aging

Let’s be clear. Aging begins from the moment we are born.

In contemporary western society, we tend to view the aging process as positive up to a certain point. The turning point is somewhere in that upward “moving target” that counts as mid-life. From that point, we tend to view aging as a negative process and something to be fought against.

We have all become strongly influenced by advertising for a plethora of “anti-aging” products, counterbalanced with a youth-obsessed focus. Medical efforts and campaigns to cure countless conditions and diseases have been woven into our everyday experience, which can create for us a strange unspoken expectation that western medicine will someday cure us of all diseases and even overcome death itself.

We may experience unwanted reactions to these “anti-aging” and medical messages. The reactions can include unrealistic and unattainable expectations for ourselves and for those we may care for.  If our baseline is unrealistic, we can be much too hard on ourselves.

For example, for the person who is a caregiver of an older family member; guilt can become overwhelming when the older person’s health goes into decline. The flawed expectations of a treatment for aging and eventual death cannot be realized. This form of guilt can become self-debilitating and detrimental to the caregiver’s physical and mental health.

For those of us who are passing the mid-life point, our own thoughts can become self wounding and cruel as we find it increasingly difficult to fit ourselves into the a youth-based straightjacket as we age.

Moreover, other cultural conditioning can make it difficult for us to allow ourselves to be self compassionate. At a recent leadership training that I attended, the accomplished female speaker noted in an offside comment, “I have always found it easy to be compassionate for others, but difficult to be compassionate to myself.”
One should make sure that they should get the essential levels of vitamins, minerals and carbohydrates and these requirements can be cialis tabs 20mg rightly met by herbal supplements. It’s like one of the many you see around the mouths of long-term smokers, or on grumpy people who express their displeasure by frequently pursing their lips. purchase female viagra European medical doctors have already been applied healing mineral h2o planning through the Karlovy Change Thermal buy generic viagra robertrobb.com Spring Salt for pancreas, liver and gallbladder health conditions for greater than 250 decades. You pfizer viagra generic are advised to prevent over masturbation.
Why be self compassionate about aging?

Self compassion allows us to be present in the true moment. It helps us to forgive ourselves, to heal our wounds and to appreciate our own best efforts. It allows us to be truly compassionate in our service to others. Self compassion frees us of unnecessary burdens, allowing us to age from our center of being with grace and with wonder.

© Anne Conrad-Antoville 2014

Anne Conrad-Antoville cared for her disabled mother from her pre-teens through her mid-thirties, when her mother passed away. This experience inspired Anne’s eventual work in professional aging services. Anne is currently CEO and a geriatric case manager for Champion Advocates LLC and manages Working Woman Aging Parents.

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