Planning for a parent's decline
What kind of planning can I do to be ready to help a parent if and when they start losing their mental acuity?
My parents are both healthy - for their age, in their 80s - and mentaly sharp and active, so this is less of an urgent question than something I've been thinking I should plan for. Its hard for me to imagine them NOT being fit and mentally sharp, but I also believe its better to have a plan and not need it than to be taken by surprise by something as predictable as a loss of function due to age.
I've had the conversation about funerals and wills and estates and all that, but not about what to do if they can't take care of themselves. I imagine there are a lot of considerations that relate to specific circumstances so I am just looking for some general guidelines?
Answers ( 1 )
All three (or more if you have siblings) of you should see an Elder Care lawyer quite soon.
Your parents need to provide each other, and then someone they can trust, with a Health Care Power of Attorney and a Living Will. These are crucial documents at end of life. https://estate.findlaw.com/living-will/healthcare-power-of-attorney.html
Unlike a run-of-the-mill POA, HPOAs are for health care decisions, only. There is no financial component- other than, in some states (Pennsylvania, I am looking at you) the HPOA can be held liable to some extent for end of life-related bills such as Skilled Nursing Facility bills- but that doesn't happen often. Without that HPOA, unless a person is named a Guardian by the Court system, then in most states, they cannot make health care decisions for another person. https://www.stimmel-law.com/en/articles/basic-law-guardianship
This is important because Medicare rules state that if a Medicare patient can be saved, they must be saved. So, for instance, a person with end stage Alzheimer's-type dementia develops a urinary-tract infection, that person, even though s/he is only awake an hour or two a day, has trouble swallowing, can no longer speak, only meets another's eyes accidently, and is mere weeks from death, if receiving care in a skilled nursing facility, the facility must ship the person to a hospital where the person, due to the fragile health condition, will be admitted for care, to receive any care necessary to save life from that UTI. That's just dumb- although when it is your parent or grandparent, it's not quite as dumb seeming as when it is a stranger. A person with an HPOA is able to step in and speak for the patient who is no longer able to speak for themself.
Especially if there are any financial concerns, the estate of elders needs to be looked at for possible issues which can be put to right before it is too late. Most people are already aware that you cannot simply sell your house to one of your kids for a dollar in order to avoid having to pay for end of life care as indigent or without funds. Medicare/Medicaid rules are on to that one. There are rules in place for spouses, too, so that no one is kicked out of a family home because their spouse's care has become too expensive- these issues should be understood and plans made "just in case" sooner rather than later. https://www.elderlawanswers.com/medicaids-asset-transfer-rules-12015
So see a lawyer specializing in these types of issues as a family, and work the kinks out before it becomes imperative.
Make sure each spouse is allowed protected health care information with the family doctor and any specialists usually seen for the other spouse. These are very simple forms that go into the medical record and allow a spouse to not only know what is going on medically with the partner spouse, but even allows them to question or pay bills! Medicare/Medicaid and any private medical insurance company needs these forms also. These are usually State-based; here is an example of one for California: https://www.cda.org/Home/Practice/Practice-Support/Resource-Library/regulatory-compliance-privacy-and-hipaa-consent-form-for-use-or-disclosure-of-patient-health-information
There are also Code Status forms, and Preferred Level of Care forms, although the latter is used mostly to provide all family members involved of the actual nitty-gritty wishes of a parent- these forms generally have no legal teeth- especially in the face of a Living Will. However, allow me to explain the roles of each:
A Code Status is usually called "DNR", meaning, Do Not Resuscitate. But there is another arm of code status, and that is "Full Code". Both of these statuses are only applicable in one, specific, instance: You are found with no heartbeat and/or not breathing. Nothing more will do. If you are a DNR, medical personnel will check a few times to make sure you have no heartbeat, have no respirations, and then, according to procedures, they will call for Time of Death, and you will be declared dead. If you are a full-code, and are found with no heartbeat/not breathing, other than in extreme circumstances, medical personnel will perform CPR on you until your heart responds, or they are told by a qualified and licensed Physician (or higher level medical person) to stop and Time of Death will be called. The extreme circumstances mentioned earler are events such as found stiff with rigor, or with an obvious mortal injury- and even then, most medical personnel will follow their training and begin CPR. So Code Status is very important, but only in one, specific instance.
A Living Will, on the other hand, is a way to set down your wishes for the level of care you want at end of life. But it has become somewhat tricky- we used to say things like, "No machines- I don't want to be kept alive by a machine" and everyone knew what we were talking about, but that is no longer true. Let's say you have that "No Machines" thing ticked, and you develop pneumonia. Does that mean you do not want intravenous antibiotics? Think quickly- IVs are now machines- you said no machines, so-- do we let you go, to possibly develop sepsis which will kill you? A Living Will can set your wishes down in a much more cohesive manner.
See an Elder Care lawyer for help with all of these instruments covering end of life.
Consider what you will do in the event of one or the other, or both parents, need a little Home Health Assistance. HHAs usually do no more medically than provide medication assistance, but often take over the more-onerous household tasks such as laundry, shopping, cooking and so on- tasks that can be more daunting to elders. There are many Home Health providers, although few medical insurance plans that pay for such assistance, so you need to consider how the expense would be met should the need arise. What about moving into an Assisted Living Community- these are usually private pay, quite expensive, but provide room, board, activities and some medical assistance- such facilities can be a godsend to elders who just need a little more professional-level help than some barely-trained person dropping by once a week to do some laundry and get some more milk and bread. These are things you should discuss, too.
Memory care issues are complex, and need to be discussed separately, really. But, again, such discussions are best had before the information is needed, especially for the HPOA.
If you have any other, more specific questions, please feel free to ask. This time of an adult's life is like a huge empty area on a map: Here Be-- Something--- We Do Not Know Whereof....