Thus far our “Estate Planning Basics” series has focused primarily on financial documents, but the documents pertaining to your health care are an equally important part of any estate plan.

The most important healthcare document in your estate plan will be your healthcare directive. Depending on where you live, this document naming a healthcare agent and detailing your wishes for decisions made on your behalf and end of life treatment may also be called a living will, an advance healthcare directive, healthcare power of attorney, or a personal directive.

Perhaps the most important part of a healthcare directive is the nomination of your healthcare agent. This is the person who will be making decisions (potentially life-and-death decisions) about your medical treatment in the event that you are unable. The person you choose should be trustworthy, sensitive to the concerns of your other loved ones, and have the strength to ensure that your wishes are followed—even if those wishes are difficult or unpopular.

Like a financial power of attorney, the advance healthcare directive can be very general or very specific in its instructions. In addition to a nomination of agent, most healthcare directives also include (but are not limited to):

• Instructions for life-saving treatment (or your desire for a DNR order)
• Any existing medical conditions
• Your preferences for alternative medical treatment, if any
• The name of your primary care physician
• Your instructions for the final disposition of your remains

While some people have very specific preferences for medical treatment and end-of-life care, others prefer to leave these decisions in the hands of their loved ones, letting those who care about them make the choices that will bring the most comfort. Whether you choose to leave detailed instructions for care or leave the decision-making to others, your healthcare directive should reflect your choice. We all know the tale of Terry Schiavo, whose lack of a living will resulted in a seven year court battle between her husband and her parents over her end of life care… Don’t let the same thing happen to you or your family.

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One of the most difficult aspects of caring for an elderly parent (or helping an aging parent who lives far away) is keeping one step ahead when that parent begins to lose the ability to manage his or her own finances. Many seniors can be very resistant to discussing what they feel is an extremely private and sensitive topic. Furthermore, according to this article in AgingCare.com, “for many elders, being able to take care of their own finances is an important symbol of independence and self-worth,” and one that they are not likely to relinquish easily.

Unfortunately, an elderly parent’s ability to manage their own money may cease before they are willing to ask for help. In these cases, it may be up to their children and loved ones to step in and help as best they can. What follows is a list of some non-invasive, non-offensive steps adult children and caregivers can take to help aging parents manage their finances.

• Ask for a list of important people and information you might need in case of emergency. This list would include contact information for an attorney, financial advisor, primary care physician, and insurance agent.
• Ask where your parent keeps important documents and how an executor or advisor could access those documents upon your parent’s death or incapacity.
• If your parent is willing, discuss their estate plan with them, including who they have chosen as their agent or executor, and what you can do if something happens.
• Ask your parent to make a list of monthly bills, expenses and account numbers. Although your parent may not want to hand over this information right away, the list should be stored with other important estate planning documents so that it can be accessed in case of emergency.
• As you keep track of your own financial deadlines (tax filing deadlines and the like) set up reminders for your parent as well.
• Ask that your parent list you as an “emergency contact” with their utility services, this means that you would be informed if your parent’s service is in danger of being terminated.
• And finally, talk to your parent as often as you can. Keeping open lines of communication is the very best way to stay informed about the abilities and well-being of your aging parent.

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Alzheimer’s Disease is a devastating illness which affects families all over the country; from the adult child who fears that her father’s recent forgetfulness might be a harbinger of something more sinister, to the elderly gentleman who wonders how he will possible pay for the care his beloved wife requires.

Over the years, the treatment received by Alzheimer’s patients has depended in part on how the disease is diagnosed; and according to this article from a New York Times blog, “new criteria [for diagnosis], unveiled on Tuesday by the National Institute on Aging and the Alzheimer’s Association, will have consequences for family caregivers. Informed by research showing that changes in the brain may be under way a decade before any symptoms appear, the guidelines are likely to lead to increasingly early diagnoses.”

One of the most significant results of these new criteria is the establishment of three distinct stages of Alzheimer’s disease:

Pre-Clinical Dementia, wherein “There’s some biological or structural brain evidence that the Alzheimer’s process is under way, but the person’s not disabled and the family doesn’t notice any problem.”

Mild Cognitive Impairment, in which “someone has problems that don’t cause disability, but they’re evident enough that the patient and a family member or another observer agree, ‘Yes, it’s noticeable.’”

And finally, actual Dementia, which includes the signs and symptoms we all already associate with Alzheimer’s disease.

One of the most practical implications of these new criteria will be the early diagnosis—and thus the earlier treatment—of Alzheimer’s. The article mentions that these treatments are not yet curative, but there are medications that can help with the symptoms, and there is some evidence that “if you optimize the treatments for other diseases that make Alzheimer’s worse, like diabetes and heart disease, that increases the likelihood that Alzheimer’s will not accelerate.”

Perhaps of the most significance to elder law attorneys is the fact that early diagnosis can allow families to make the legal arrangements they need before the disease progresses to the point where it is too late. If the disease can be diagnosed in the Pre-Clinical stage, or even the stage of Mild Cognitive Impairment, the person receiving the diagnosis may have the time to consult with an attorney and put their affairs in order, helping to ensure that they—and their family—are provided for in the years ahead.

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We have recently seen one or two stories in the news that have brought the issue of health care directives to forefront of people’s minds. Most people know that a healthcare directive is one of the primary documents of any complete estate plan, but not everybody knows exactly what should be included in the document itself. Do you have to specifically name your spouse if you want that person making decisions for you? Is the healthcare directive the place to include a DNR (Do Not Resuscitate) statement? What about funeral arrangements or organ donation—does a healthcare directive deal with things that happen after death?

These are all good questions; here we attempt to answer these questions and more, as well as list some of the important things to know about—and include in—your healthcare directive:

1. Healthcare directives can have many names depending on where you live and the exact nature of the document. Some common names are: Advanced healthcare directive, Advance directive, Healthcare power of attorney, or living will. (Note: These are not all the same document with different names, but they do all serve similar or related functions. Contact our office for more information)
2. A healthcare directive should first and foremost name your healthcare agent: the person you want making decisions for you when you are unable.
3. A healthcare directive should absolutely include your wishes and preferences for healthcare treatment, including a DNR statement, preferences for artificial nutrition and hydration, antibiotics, pain relief, and other medications.
4. Your healthcare directive should include the name of your primary care physician, if you have one, as well as any pertinent medical history or conditions.
5. Healthcare directives can be written to reflect your religious or spiritual beliefs, including religious beliefs relating to blood transfusions, end of life care, and pregnancy.
6. A healthcare directive can and should make reference to post-mortem issues such as organ donation and funeral arrangements. Whether or not your wishes can be enforced may depend on your family and the state in which you live, but including your wishes may be of considerable help and comfort to your family.

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A recent article in the Wall Street Journal shines the light on a new program being instituted by a growing number of states called “Physician-Orders for Life Sustaining Treatment,” or POLST. “A POLST, which is signed by both the patient and the doctor, spells out such choices as whether a patient wants to be on a mechanical breathing machine or feeding tube and receive antibiotics.”

Creating a POLST is an important step toward getting the care and medical treatment you want at a time when you may no longer be able to communicate those wishes to your family or medical staff. As estate planners we know just how important it is to communicate these preferences for health care; in fact, creating an estate plan with our office includes drafting a document called an advance directive, in which you specify which medical treatments or interventions you would or would not like, and more importantly, it is the document in which you nominate a health care agent to serve as your proxy if and when you are unable to speak for yourself.

Keep in mind that although the POLST is an important step in making your wishes known, the POLST is not intended to replace an advance directive. The POLST programs “are meant to complement advance directives, sometimes known as living wills, in which people state in broad terms how much medical intervention they will want when their condition no longer allows them to communicate.”

The WSJ article states that “A study supported by the National Institutes of Health last year found that patients with POLST forms were more likely to have treatment preferences documented than patients who used traditional documents such as living wills and do-not-resuscitate orders.“ This comes as no surprise, considering that executing a POLST includes getting the document signed by your doctor, thus ensuring that you doctor is not only aware that you’ve expressed your wishes for end-of-life care, but has also likely had a part in helping you understand exactly what your options are.

Our office recommends that our clients go one step further—in addition to having your doctor sign your POLST, give your doctor a copy of your advance directive as well. Once you have things squared away with your doctor we also recommend sending a copy of your POLST and your advance directive to the person you’ve named as your healthcare agent.

The more informed you doctors and family are about your wishes for end-of-life care, the more likely it is that you will receive the treatment you prefer.

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It’s flu season again, and the strain going around this year has been a difficult one, mainly because of how long it keeps its victims out of commission. So the article we recently found on Time.com about Long-Term Care seems particularly timely and relevant, if only because this year’s flu could be seen as an omen of what’s to come as Baby Boomers age into their golden years.

According to the article, “A huge wave of baby boomers may need long-term care in their golden years — and yet fewer than half have taken steps to prepare for it… two-thirds of Americans believe it’s important to plan for long-term care, but only 44% have taken steps to protect themselves.” Part of the reason for this lack of preparedness is that Baby Boomers underestimate the likelihood that they’ll need long-term care, or they overestimate the likelihood that their children or families will be able (or willing) to provide that care.

But there’s another reason why Baby Boomers are statistically unprepared for the crisis of old age; to put it simply, there aren’t any clear avenues to solid and reliable financial preparedness. “While it’s clear that not enough people are thinking about preparing for their long-term-care needs, it’s not at all clear what, if any, the best solutions are.”

Some think that extra savings in the bank will cover the cost of long-term care; others believe that government programs such as Medicaid or Medicare will take care of them. Unfortunately, both of these beliefs are mistaken. “The average cost of a nursing home ranges from $85,000 to $120,000 a year, while hiring an aide to spend six hours a day on average in the home starts around $40,000 a year… Medicare, meanwhile, only covers up to 100 days of long-term care and often involves co-payments. Medicaid will cover long-term nursing-home care but only after the person has drained his or her savings account.”

The only other obvious solution is long-term care insurance; but even with long-term care insurance, nothing is clear cut, and too many people have found themselves paying into a policy and ending up with no return on their investment. This isn’t to say that long-term care insurance shouldn’t be an option, only that it’s one to be well-researched. Long-term care insurance is still one of the best options out there, but “There have been horror stories of people paying premiums on long-term-care insurance policies for years, only to find the benefits won’t cover their needs 20 or 30 years down the road when health care and long-term-care costs are significantly higher.”

The best advice we can give is to do your research and ask for the help of an advisor with experience in elder law, elder care, and senior financial planning. Whatever you do, don’t throw the baby out with the bathwater—we may have no clear and easy answers yet, but that’s no excuse to remain completely unprepared.

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As estate planning attorneys we help our clients plan ahead. We help them create the documents and take the legal action they need to protect themselves and those they love. We help them talk through painful possibilities, and support them as they make difficult decisions. We work to ensure that our clients and their families will be prepared for any eventuality—but deep down we hope that they will never really need to make use of some of these documents and plans.

One of the situations that estate planners (or any compassionate advisor) dreads is one that is happening right now in Minnesota. According to the Minneapolis Star Tribune the family and friends of 85 year old Al Barnes are struggling to make a difficult decision about his end-of-life care—a decision made no easier by the fact that not all family members (or Mr. Barnes doctors and health care providers) can agree on the next course of action.

“Numerous doctors have assessed Barnes in the past year, and agree on his prognosis. According to court records, Barnes suffers from a level of dementia so profound that doctors believe it is pointless to treat his kidney failure and respiratory failure.” But this isn’t the whole story. Al Barnes’ wife Lana Barnes believes that “her husband suffers from chronic Lyme disease, and that antibiotic treatment of the tick-borne bacterial infection would reverse his dementia — and necessitate treatment for his other conditions as well.”

Mr. Barnes does have a Health Care Directive which lists his wife Lana as his agent, but it apparently goes no further than that, giving no specific instructions or information about what his wishes for end-of-life care would be. And herein lies the dispute. “A Methodist Hospital doctor wants to take decisionmaking rights from [Mrs. Barnes] because he believes she is demanding hopeless and painful treatments. The 56-year-old wife is accusing the doctor and others of misdiagnosis that has left Barnes substantially — but not irreversibly — incapacitated.”

The Minneapolis Probate Courts temporarily took away Mrs. Barnes’ authority over her husband’s care earlier this month after the disagreements between wife and doctors came to a head. “Lana and doctors from Methodist Hospital [are] due to resume arguments over his medical care Wednesday in Hennepin County Probate Court… After Wednesday’s hearing, a judge will decide whether Lana Barnes remains in charge.”

This is exactly the kind of situation we hope to help our clients avoid by encouraging a little bit of forethought, conversations between family members and loved ones, and by preparing a thorough, decisive, and well-thought-out health care directive.

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Apparently the suspicion surrounding end-of-life planning is not as far in the past as we might have hoped. The recent Medicare regulation which would have allowed the government to pay doctors who advise patients on options for end-of-life care was rescinded only days after it was enacted.

Why such an abrupt turnaround? The reason is probably not too difficult to guess. Most people know that Medicare-covered end-of-life planning has a tempestuous history both in politics and in the media. This article in the New York Times stated that “while administration officials cited procedural reasons for changing the rule, it was clear that political concerns were also a factor.”

The alteration of the rule may be disappointing, but it shouldn’t stop you from thinking—or talking to your doctor—about your choices for your own end-of-life care. After all, this administrative change of heart does not alter the fact that having these discussions with your doctor (as well as with your health care agent and loved ones) preserve patient autonomy at a time when events may seem to spiral out of control. As National Public Radio pointed out in their article, “it remains perfectly legal for physicians to talk with patients during annual visits paid for by Medicare about how much or little care they want when facing a terminal illness.”

Media firestorms and political debate notwithstanding, your decisions about your end-of-life care are important. When you have these discussions with your doctor and loved ones, and when you have a living will or healthcare directive in place, you are far more likely to get the care you want at the end of your life, regardless of how invasive or restrained you want that care to be.

If you have reservations about what a health care directive might mean to your future medical care, or if you have any questions about this issue, please don’t hesitate to call our office. Your peace of mind is our first priority.

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Advance Health Care Directives (legal documents which include a nomination of your health care agent, and your preferences for end-of-life care) saw a lot of press in 2009 when the Obama administration sought to include end-of-life planning in the new healthcare overhaul. The option was dropped after a media firestorm about “death panels,” but according to this article in the New York Times Medicare-funded end-of-life discussions may be back.

According to the new regulation, Medicare will pay for “voluntary advance care planning” as part of patients’ annual visits with their doctor. “Under the new policy, outlined in a Medicare regulation, the government will pay doctors who advise patients on options for end-of-life care, which may include advance directives to forgo aggressive life-sustaining treatment.”

The reasoning behind the new regulation is simple, and something estate planning lawyers have known for a long time; “research [has] shown the value of end-of-life planning. ‘Advance care planning improves end-of-life care and patient and family satisfaction and reduces stress, anxiety and depression in surviving relatives.’” Additionally, “end-of-life discussions between doctor and patient help ensure that one gets the care one wants.”

So why does end-of-life planning make so many people uncomfortable when research has shown just how beneficial it can be? Paula Span, author of this post on the New Old Age blog thinks it might simply be a matter of semantics, especially when it involved the term “Do Not Resuscitate.” Ms. Span argues that a more friendly term such as “Allow Natural Death” could make all the difference in the world.

“The phrase “do not resuscitate” signals an intent to withhold or refuse… ‘It says you’re not going to do something.’ To “allow natural death,” on the other hand, connotes permission. ‘It doesn’t sound so overwhelming or scary.’”

Whatever term you use, or however you choose to talk about it, the important thing is that you DO talk about it—with your family and loved ones, with the person you choose as your agent, with your doctor… and even with your lawyer. End-of-life planning is about personal and medical preferences, but the document itself is a legal one; your lawyer can help ensure that your Advance Health Care Directive will hold up in a court of law as well as in the hospital.

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November 2010 is Long Term Care Awareness Month, which means it’s the perfect time to talk about your thoughts, concerns, and plans for your own long term care. According to this article by Ken Dychtwald, PhD, “average life expectancy is now at 78 and rising. And, if you’re already 55 or more, life expectancy has soared to around 84.” Furthermore, “Two-thirds of people over age 65 will need some kind of long term care.” This means that it can never be too early to start planning for your future.

Dychtwald points out in his article that “Uninsured medical expenses are the top financial worry among men and women age 55 and over. People… worry most about these expenses’ unpredictability and potential for high costs.” People know that their health is likely to decline slowly as they age, and people know that they will need care—possibly a lot of it—that the cost of this care is rising steadily, and that they will need a way to pay for it. In spite of this, “many Americans are confused about what long term care actually is, and they’re surprised to learn that Medicare and/or traditional health insurance do not cover most long term care needs.”

Life expectancy is rising, and the nature of “old age” is changing quickly. We live longer, but we don’t necessarily live better; and what we’re headed for is an entire generation of people who are unprepared for the rigors and expense of “the new” old-age. Luckily, this doesn’t have to be the case.

The article above suggests that “There are three core topics in family conversations about long term care: (1) what care options are most preferred (e.g. if you needed some help, would you prefer to be cared for at home, in an assisted living facility or in a nursing home?); (2) potential roles and responsibilities of different family members’ (and possibly, help from a professional care coordinator, aid or nurse), should it ever be necessary to manage care; and (3) how to pay for any required long term care (with your or a family members’ savings, through Medicaid or with a long term care insurance policy?).”

We urge our readers to talk about these issues with their loved ones. The conversations may be uncomfortable at first; but fear of the future—lack of preparation for the future—is far worse. Discuss long term care with your loved ones and your trusted advisors. Be ready for whatever the future may bring.

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