Good Medical Care for the Elderly and How to Get It

Social Security & SSI Payments Protected from Creditors

2011-04-30T14:39:14-04:00

The National Consumer Law Center® (NCLC®) is a non-profit organization specializing in consumer issues on behalf of low-income and other vulnerable people. Since 1969, NCLC has worked with legal services and nonprofit organizations as well as government and private attorneys across the United States, to create sound public policy for low-income and elderly individuals on consumer issues. The NCLC has just sent out a press release explaining how recipients of social security and SSI payments will be protected from seizures from bank accounts by creditors because of a recent change in the law. Effective March 1, 2013, both new applicants and current recipients who do not choose another option (and have not been granted a wavier) will automatically receive their payments on the federal government’s Direct Express card.

Current benefits recipients have until March 1, 2013 to choose an electronic payment option. After that date, no payments will be issued via check, unless the person qualifies and is approved for an exemption.

To continue receiving paper checks, recipients must be approved by the US Treasury for one of the following exemptions:

•       Aged 90 years or older, as of May 1, 2011 (no wavier required)
•       Mentally impaired
•       Live in a remote geographic area lacking the capability to support an electronic financial transaction

Here are more details from the press release:

BOSTON, MA - Beginning May 1, 2011, elders, veterans, and the disabled can rest a bit easier as a new federal rule kicks in that will limit creditors’ ability to seize funds from Social Security, Social Supplemental Income (SSI), VA, and other federal benefits held in bank accounts in favor of direct deposit or prepaid cards. New rules making the Direct Express® prepaid card the default method of issuing federal payments and limiting the use of other prepaid cards and paper checks will also be in effect May 1.

If a bank receives a garnishment order, the bank will be required to determine whether an account contains electronically deposited federal benefit payments, and if so, the bank will be obligated to protect two months of those payments from seizure to satisfy garnishment orders. To protect funds deposited before the two-month time period, or deposited by check the recipient will have to follow the state procedure for claiming exemptions.

“This regulation will provide a much-needed protection for exempt federal benefits. We are enormously grateful to the U.S. Treasury Department for its leadership in resolving the difficult issue of how to protect federal benefits in bank accounts from illegal seizure,” said Margot Saunders of the National Consumer Law Center. “We also appreciate the Treasury Department’s efforts in the new prepaid card regulation to protect recipients from overdraft and pay-day type loans attached to these new payment devices.”

The U.S. Treasury recently took a hard-line approach regarding elimination of paper checks. Effective May 1 of this year, new applicants filing for all federal payments including Social Security, Supplemental Security Income (SSI), veterans benefits and wages will receive their payments electronically, unless they qualify for one of a very few exemptions. If recipients do not provide information to the federal payment agency regarding a bank account or prepaid card into which they want their payments electronically deposited, they will be provided the federal government-issued Direct Express® card. The Direct Express card is likely to be the best option for recipients who are unbanked, but pursuant to a new rule, they may also choose privately branded prepaid cards to receive their benefits. Additionally, most current recipients will be required to receive their federal benefits electronically as of May 1, 2013.

The Direct Express® prepaid debit card, issued through the U.S. Treasury, is the best prepaid card available. Direct Express® cards have considerable protections for recipients, including limits on fees, legal protection against unauthorized charges, and requirements for free access to funds. They are likely to be substantially less expensive than other prepaid cards.

Nevertheless, if a federal payment recipient wishes to have funds deposited to a prepaid card other than the Direct Express® card, only certain cards are eligible. The most important conditions are that (1) prepaid cards cannot receive federal payments if they are attached to a line of credit or loan agreement that is automatically repaid upon deposit of the federal payment, and (2) the card must comply with consumer protections required through the Electronic Funds Transfer Act (EFTA). Importantly, the EFTA limits overdraft fees for ATM and one-time debit transactions unless the person opts in for such coverage (opting in for overdraft protection may not be beneficial for the recipient). The EFTA protections against unauthorized charges, billing errors, and disclosure of fees will also be in effect for these cards.

Advance Medical Directives | April 16th - National Healthcare Decisions Day

2011-04-15T16:59:40-04:00

April 16th is National Healthcare Decisions Day. Many people are talking about advance medical directives these days. Some folks want to stop doctors and nurses from talking about end of life care with patients, calling this a "death panel." Others are identifying advanced medical directives as a means by which a person may control the care and quality at the end of life.

I've often written about end-of-life care decisions on this blog. You may access the archives of that topic here.

You may also view a video hereabout Advance Care Directives produced to be aired on community access stations in a program titled Graceful Aging. Michigan elder lawyer Jim Shuster discusses the importance of having an advance care directive (a/k/a "living will"). You may watch the video here.

Consider the Conversation

2011-03-21T09:41:00-04:00

A new documentary is available to the public on DVD to help patients and their families talk with their physicians about end-of-life care. Following a model I’ve seen on Aging with Dignity website, "Consider the Conversation" is a documentary available to the public on DVD to help patients and their families talk with their physicians about end-of-life care. The documentary film will be available on PBS television this Spring and is also available for purchase on Amazon.com. Made in a volunteer effort and funded entirely by donations, the producers explain the film as follows:

“The bottom line is that Consider the Conversation does not seek to hand down answers. Rather, it provides something far more important - the questions all of us need to contemplate. That being said, the producers have three goals for this film: 1) to change the current American attitude from one that predominantly views end-of-life as a failed medical event to one that sees it as a normal process rich in opportunity for human development, 2) to inspire dialogue between patient and doctor, husband and wife, parent and child, minister and parishioner on end-of-life issues, and 3) to encourage medical professionals, healthcare organizations and faith leaders to take the lead in counseling others.”

Dr. Wendy Harpham, who has brought this film to my attention, says on her Blog Dr. Wendy Harpham on Healthy Survivorship, that “release of the DVD has occurred in tandem with a policy statement from the American Society of Clinical Oncology (ASCO) that recommends physicians initiate candid discussions about palliative care and treatment options soon after a patient has been diagnosed with advanced cancer.”

Mike Bernhagen and Terry Kaldhusdal, the producers, were motivated by their personal experiences with loss; they joined forces to make a film that would "shed light on the 21st century American struggle with communication and preparation at the end-of-life."

According to Bernhagen and Kaldhusdal, "Consider the Conversation" examines multiple perspectives on end-of-life care and includes information and experiences gathered from interviews with patients, family members, doctors, nurses, clergy, social workers, and national experts on death and dying."

Talking about End-of-Life Care

2011-03-17T08:31:36-04:00

Thanks to my friend, Wendy Harpham, author of Happiness in a Storm and Only 10 Seconds to Care, for bringing to my attention a new guide for patients and their loved ones helpful to families and patients who are coping with final illness. Written by Paula Span, author of When the Time Comes: Families With Aging Parents Share Their Struggles and Solutions, “Advanced Cancer Care Planning: What Patients and Families Need to Know About Their Choices When Facing Serious Illness” may be downloaded free of charge from the American Society of Clinical Oncology’s website.

I read the guide and believe it may be useful in any kind of situation—not just when a final illness is cancer. Using language that if both compassionate and direct, the booklet is easy to read. It explains, for example, that the word “advanced” is synonymous with 'end-stage' or 'terminal,' and that this doesn’t mean that an advanced illness is untreatable or that death is imminent. It also explains that choices for care relieving pain and discomfort remain when cancer is progressing even though a patient is receiving the best available anti-cancer therapies.

As the booklet’s title makes clear, and Span explains, this is not the ultimate guide but is, rather, "a conversation-starter...[that] makes sense. The free, downloadable booklet includes sections on costs, advance directives, emotional and spiritual needs."

A major goal of the booklet is to help patients and families dealing with serious injuries and illnesses other than cancer. Span says, "[Because] families often complain that they wish they’d turned to hospice or palliative care earlier...[and] we know that some physicians (and patients) have trouble even saying “terminal” or “hospice,” this publication could ease the way for people with other diagnoses than cancer. The questions will be much the same, and help in framing them just as valuable."

Send a link to this article to your friends or clients by copying and pasting this link into an email.

Making Decisions about When to Stop Driving

2011-03-02T13:38:15-05:00

Jane Gross wrote in the New York Times recently about the angst primary care doctors face when confronting a patient and family about whether an aging patient should still be driving. Questions raised are:

When is it time for someone with physical or cognitive problems to give up the car keys?

Who makes that decision?

How can it safely and compassionately be enforced?

Gross provided a link to a comprehensive and thoughtful handbook published by the American Medical Association in collaboration with the National Highway Traffic Safety Administration. Recently updated, the “A.M.A. Physician’s Guide to Assessing and Counseling Older Drivers” can be accessed by doctors and also family caregivers.

The guidebook has covers the following important topics:

Assessing a patient’s driving ability;
Medications and medical conditions that impair mobility, vision, hearing, reflexes and judgment;
Tips on having the conversation with patients and caregivers;
Advice on how to avoid isolation and dependence when driving is no longer sensible or safe;
A doctor’s ethical responsibilities regarding driver assessment;
State-by-state guidelines for reporting drivers to the state department of motor vehicles, which has the ultimate say in who remains on the road.

Family caregivers who are worried about whether their elderly loved ones should still be driving should review these materials and consult with the primary physician to inquire about driver assessment.

Should Doctors Stop Patients From Driving? Jane Gross, New York Times, Feb. 22, 2011, last accessed on March 2, 2011.

Knee & Hip replacement | Good tips from New York Times resources

2010-07-06T08:58:04-04:00

The New York Time published a extremely valuable article about hip and knee implants over the 4th of July weekend. According to statistics, about 806,000 such procedures were performed in the US in 2007. This is twice as many as were performed a decade earlier. Though routine, replacements are not without risk or potential for a future replacement.

Dr. Henrik Malchau, an orthopedic surgeon at Massachusetts General Hospital in Boston told the NY Times that implants must sometimes be replaced. According to a 2007 study, 7 percent of hip implants in Medicare patients had to be repeated within seven and a half years.

Dr. Malchau states that while this may seem insignificant, the study suggests that thousands of hip patients eventually require a second operation. That translates into additional recoveries, and increased medical expenses. The failure rate should be lower. Dr. Malchau and Dr. Daniel Berry, chief of orthopedic surgery at the Mayo Clinic in Rochester, Minn. had some very good suggestions to improve the success rate for seniors undergoing hip and knee replacements. Photo credit Mayo Clinic.

EXPERIENCE: Choose — or request a referral to — an experienced surgeon at a busy hospital.

VOLUME MATTERS: One study quoted by the Times found that patients achieved better success when having the procedure done by doctors who performed more than 50 of them a year when compared to surgeons who did 12 procedures or fewer a year.

ADJUST EXPECTATIONS: Doctor Berry addressed the issue that joint replacements are not for everyone. There are always complications and risks to be considered. In other words, a benefit / risk analysis should be done.

NARROW YOUR OPTIONS: There are many manufacturer of joints. The patient needs to work with the surgeon to choose one that is appropriate / best for him or her.

the “There is no one best joint,” Dr. Berry said. “A successful replacement depends on selecting the right implant for the patient.”

GATHER INFORMATION: Get more than one opinion. Then do some research on your own to find out what is know about which joint has a better performance history.

You may read the entire article, Getting a New Knee or Hip? Do It Right the First Time , by Lesley Alderman, N.Y. Times July 2, 2010 here.

Internet resources for seniors & others seeking affordable medical insurance

2010-07-02T11:31:32-04:00

Reported in a newsletter by MoveOn.org, here is some valuable information about Internet resources to assist seniors (and others) trying to assess and access affordable health care.

• Yesterday, www.HealthCare.gov, a new online portal where anyone can go to find insurance options in their state, went live. It's a very handy resource for information that used to be difficult to find. It's available to help millions who need insurance find it, and as a resource for those who want to shop around for new options or find out their new benefits under the new law.

• States are starting to create new insurance pools for hundreds of thousands of people with serious medical conditions who had previously been unable to get insurance. Federal grants to help with setup are on their way to states right now. 1

• In June, 80,000 checks were mailed to seniors to help with prescription drug costs not covered by Medicare. By the end of the year, an estimated 4 million checks will go out. 2, 3

• And of course, many of the key insurance reforms—allowing young adults to stay on their parents' insurance until age 26, and making it illegal to deny a child or baby insurance because of a "pre-existing condition"—have already started to take effect. 4

Now, many of the major reforms—the new health insurance exchanges, an end to pre-existing condition discrimination for adults, and more—have yet to go into effect. And of course there's more work to be done to fight for truly universal health care and a public health insurance option. The changes so far will help literally millions of people get or keep insurance.

Sources: 1. "High-risk' pool medical insurance program set to begin," The Los Angeles Times, July 1, 2010

2. "D.C., Md. and Va. to get $207 million to operate high-risk insurance pools," The Washington Post, July 1, 2010

3. "First 'doughnut hole' checks go to seniors to help with Medicare prescription shortfalls," San Jose Mercury, June 13, 2010

4. "Insurers to Comply With Rules on Children," The New York Times, March 30, 2010 "Health care reform begins to be felt," The Modesto Bee, June 28, 2010

Delirium | Why family caregivers need to assist in diagnosis & prevention

2010-06-28T08:49:48-04:00

In the New York Times on June 24th, Pam Belluck reported on the risk that elderly patients may become confused and delirious while in the hospital. She offered suggestions for family caregivers on how to assist their loved ones from suffering irreversible or serious complications.

The elderly frequently develop hospital delirium (about 70% in research). When I was writing Taking Charge: Good Medical Care for the Elderly and How to Get It, I read one study that said that delirium was missed as a diagnosis about 95% of the time, even though the nursing notes usually carried enough information that a doctor should have called it right. Unfortunately, the consequences of delirium can be serious: these detrimental consequences are common:

delay in a patient’s recovery
placement in a nursing home
increased likelihood of developing dementia later on
increased mortality rate.

You may read more about delirium in Chapter Three of Taking Charge. "Delirium, Dementia, Depression, and Psychosis: The Importance of the Correct Diagnosis" You can access this chapter without charge online at this link.

Appendix C "Diagnosing Delieium and its Underlying Causes may be accessed free of charge here.

Appendix D "Risk Factors for Delirium" may be accessed free of charge here.

Pam Belluck's article "Six Questions to Protect Elderly Patients" may be read here in the New York Times. Some of the comments are quite informative as well.

FDA Warns About Unapproved Nitroglycerin Tablets

2010-03-29T09:32:35-04:00

Patients who take nitroglycerin tablets may ask whether they are receiving an unapproved brand subject to recent FDA action, as reported in the New York Times on Friday. The FDA sent warning letters to two major manufacturers of unapproved nitroglycerin: Konec, Inc. and Glenmark Generics, Inc. The drugs are not being recalled; the manufacturers have 180 days to stop shipments.

According to the article, some manufacturers previously argued that they didn't need approval because nitroglycerin was available before the FDA was formed. The FDA says the drugs need prior approval and that some unapproved versions have "significant quality and efficacy problems." Only Pfizer has FDA approval to market nitroglycerin tablets.

The FDA recommends patients continue taking their nitroglycerin tablets but contact a physician to discuss treatment options.

New York Times story (Free)
FDA's Q&A on unapproved nitroglycerin tablets (Free)
FDA news release (Free)

Apply for social security online

2010-03-26T17:50:48-04:00

<p>Chapter 2. Civil Procedure</p>

CMS sent out a message this afternoon announcing that people can now apply for Medicare on line at www.socialsecurity.gov. The Social Security web page has a "Retirement/Medicare" link in the middle of the page.If seniors have access to the Internet, this could be a real time-saver.

Palliative care | Dignity and peace

2010-03-21T12:47:23-04:00

Jane Brody writes about palliative care at end of life for her husband of 43 years in the New York Times. Her column is moving and tender.

"This is a very personal story of living gracefully with a fatal diagnosis. When I wrote Jane Brody’s Guide to the Great Beyond, I had no idea that I’d be putting its precepts into practice in my immediate family within a year of publication. But as I said in the book, 'You never know.' You never know when your time will be up, and so it is best to prepare for the end sooner rather than later.

"On Feb. 2, we learned that my husband of 43 years had Stage 4 lung cancer. There was no asking 'Why me?' Richard knew very well why. He’d been a pack-a-day smoker for 50 years. Although he quit for good more than 15 years ago, it was far too late. After a few weeks of encroaching weakness and coughing, a PET scan showed that cancer was ravaging his body, taking up residence in both lungs (along with emphysema), in his spine, his adrenal glands and his brain. It was inoperable and incurable. He was looking at weeks or months of remaining life, maybe a year at most."

Jane Brody's column ">When the Only Hope is a Peaceful Ending" here.

My friend Wendy Harpham's blog about Jane's column is here.

Jane Brody has long written for the New York Times. In the past few years, she has been on leave from her regular columns, contributing occasionally on issues related to health and aging. First, it was her mother's death. Jane took some time off and wrote a wonderful book "Jane Brody's Guide to the Great Beyond," helpful to the legions of family caregivers tending to parents or other loved ones at life's end. I wrote here about her book on April 12, 2009.

What it means to be a health care proxy

2010-02-26T12:33:50-05:00

I just watched Keith Olbermann's Special Comment -- MSNBC -- February 24, 2010. Olbermann spoke movingly about what it means to be a patient advocate for a loved one and about the importance of end-of-life planning, both for the patient and for the loved one(s) who may be chosen to make health care decisions when a patient is no longer able to do so. Olbermann also spoke passionately how important it is for our Congress to make health care accessible to all Americans.

I have to say that, having acted as a health care proxy for my parents at the end of their lives, I wept throughout Olbermann's extremely moving plea.

Keith Olbermann opened his emotional Special Comment on health care Wednesday with the story of his father's six-month-long hospitalization suffering through a colon removal, pneumonia, kidney failure, liver failure, and many infections.

After a particularly difficult week, Olbermann said he went into his father's hospital room to find him "thrashing his head back and forth" and mouthing the word "Help."

"It was just too much for my father," Olbermann said. "'Stop this,' he mouths. 'Stop, stop, stop.'"

Olbermann said he resorted to gallows humor, asking his father, "What, you want me to smother you with a pillow?" And his father responded, mouthing, "Yes, kill me."

Olbermann spoke passionately in favor of patients' rights to decision-making at the end of life and to have the right to discuss options, including an end to treatment even though it could mean the patient dies. "This is not a death panel . . . it's a life panel!" Olbermann stated emphatically. You may watch Olbermann's plea here.

Visit msnbc.com for breaking news, world news, and news about the economy

Palindrome - From AARP for all generations

2010-02-12T14:08:22-05:00

A palindrome is a word that may be spelled the same backwards and forwards. My last name "Hannah" is a good example. AARP has published a video on YouTube that is a little different. It is named "Lost Generation" and begins with with sentences written on a blackboard, read aloud by a teenager. This video reads the exact opposite backwards as forward. Not only does it read the opposite, the meaning is the exact opposite. It is a brilliant assemblage of thoughts and values.

This video was submitted by a 20-year old in a contest sponsored by AARP, and titled "u @ 50" I'm told that this video won second place, but what could possible top this? The concepts are simple, and yet they are brilliant.

See Lost Generation here:

Exploitation of the elderly

2009-12-17T11:48:26-05:00

There's been a lot of focus lately on how to avoid exploitation of the elderly and also domestic violence perpetrated by caregivers and/or family members.
Josh Ard, a noted elder law attorney who practices in Williamston, Michigan called to my attention an interesting case involving aspects of both issues (if one counts financial exploitation as a form of domestic abuse. I believe that financial exploitation is a form of abuse. See the Power and Control Wheel). In this case, the adultery and perjury of the elderly nursing home resident's husband trumped the lack of notice (and a false statement about notice) required by a guardianship petition filed by a granddaughter. The case occurred in Mississippi, but the concepts are equally applicable under Michigan law. These are the facts:
Ruby Chism Ellis, married to Bobbie Ellis since July, 2000, entered a nursing home in June, 2006. In 2008, Ruby’s granddaughter, Stephanie Chism Turner, filed a petition to be appointed as Ruby’s conservator. Stephanie represented to the court that she served the petition on Bobbie although she had not. 
The court appointed Stephanie as conservator and, according to Bobbie, his first notice of the proceeding was when Stephanie showed up at the home with the conservatorship papers, demanding that he vacate the premises. Bobbie, for his part, had been carrying on an affair over the previous eighteen months, even moving his paramour into Ruby’s home. 
After Stephanie moved money from Ruby and Bobbie’s joint account, placing it in a conservatorship account, Bobbie sought to have the conservatorship set aside or, in the alternative, to replace Stephanie as conservator. Bobbie argued that he was Ruby’s appointed agent under a power of attorney. It was at this point when Stephanie’s perjury became apparent. 
A guardian ad litem was appointed who prepared a detailed report quoted at length in the appellate opinion. Significantly, the guardian ad litem found that Bobbie’s loyalties had been transferred to someone else and may once again. The trial court declined to dissolve the conservatorship, but ordered Stephanie to submit an accounting. The court noted that Mississippi law does not give a spouse preference in a guardianship proceeding and that any procedural deficiency in Stephanie’s appointment was resolved by later hearings. On appeal, the judgment was affirmed. The presence of a power of attorney does not deprive the court of jurisdiction and, although the court was displeased with the conduct of each party, the determining factor appeared to be Bobbie’s shifted loyalty.
You can read the appellate court's opinion (and the GAL's accounting) here. In re Conservatorship of Ellis, 2009 Miss. App. LEXIS 873, Appeal No. 2008-CA-01993-COA (December 8, 2009)
 The opinion gives you the understanding about what types of conduct may fit into the pattern that will be helpful for the court in making an informed decision.



Cuts in home health care?
2009-12-05T22:05:45-05:00
The New York Times reported on December 4, 2009 on concerns of home health care patients about possible cuts that may occur if the legislation passed by the House and also passed in the Senate. 
Many elderly patients rely upon home health care - both supplies anxd visits by home health care nurses to keep them out of the hospital. Home health care nurses can review and monitor a patient's condition and medications. The proposed legislation would reduce Medicare spending on home health services, a lifeline for home bound Medicare beneficiaries, which keeps them out of hospitals and nursing homes.
Under the pending legislation, more than 30 million Americans would gain health coverage. The cost would be offset by new taxes and fees and by cutbacks in Medicare payments to health care providers. 
See Home Care Patients Worry Over Possible Cuts By ROBERT PEAR - The New York Times here. Contact your representatives in Congress today.


Pandemic swine flu news
2009-10-16T18:40:00-04:00
Several articles in the New England Journal of Medicine concerning
Pandemic Influenza A (H1N1) Virus (”Swine Flu”) are offered free of
charge to all. One of those articles indicates that early results on
testing show that one dose of the vaccine may be sufficient for most
groups. The NEJM calls the preliminary studies “reassuring.”


In one study, supported by drug-makers and done in Australia and the
U.K., researchers used a variety of dosages and schedules. The study
group comprised about 300 healthy adults. Efficacy of the vaccine was
evaluated the immunogenicity three weeks after administration. (One
vaccine, derived from viruses grown in cell culture and not hens’ eggs,
contained adjuvant, which is not expected to be licensed for use in the
U.S. this year.)
The immune response to a single 15-µg dose of vaccine not containing
adjuvant was rated as “robust” by researchers. Both vaccines showed
good immunogenicity. The journal’s editorialist says the data suggest
that the single 15-µg dose “should be immunogenic” in the groups
prioritized for vaccination; however, younger children will probably
still require two shots. Side effects included tenderness at the
injection site and pain.
Recall that in a recent article in my family lawyer blog,
I noted that research is shows children and young adults are more
susceptible to this flu than seniors. Frequent hand-washing and use of
alcohol hand-cleaners is urged.
Regarding safety: An editorial in the NEJM observed that “[i]t is
reassuring that the manufacturing process for these vaccines is
identical to that used for seasonal vaccines, which have a strong
record of safety.”
You may read the following helpful information about swine flu here:

NEJM article on single-dose vaccine (Free)
NEJM editorial (Free)
NEJM article on adjuvanted vaccine (Free)
NEJM/Journal Watch H1N1 Influenza Center (Free)
FDA news release (Free)

H1N1 Update September 16, 2009: The FDA approved four vaccines
against 2009 H1N1 influenza on Tuesday, according to an agency news
release. Several studies have showed that most healthy adults had a
strong immune response after one dose. An optimum dosing schedule for
children has not yet been determined.
National distribution of the initial lots is expected within 4 weeks.


Choosing a nursing home - A checklist
2009-10-15T19:01:00-04:00
 Jane E. Brody, columnist for the Health section of the New York Times wrote about how to choose a good nursing home on October 5, 2009. She said:

I have often said in no uncertain terms that I never want to be placed in a nursing home unless it is to recover from a treatable illness or injury. I have heard so many horror stories of neglect, mistreatment, under-staffing, poorly trained attendants and even corruption. I shared the common perception of a nursing home as the last place you go before you die, and this was not how I wanted to spend my last days.


Brody was then invited to tour one of the largest nursing homes in Florida. She came away with an entirely different perspective. 

Citing Taking Charge: Good Medical Care for the Elderly and How to Get It, Brody set out a checklist of concerns that family caregivers will want to address when faced with the issue of choosing a nursing home for a loved one. Brody's article "Nursing Homes That Belie the Bad Image" may be read here. 

The following day, Dr. Wendy Harpham author of five books about healthy survivorship also blogged this issue. You can read Dr. Harpham's blog article here.


Living wills & "death panels"
2009-10-14T18:32:41-04:00
In a recent blog post, "Dollars & Health: Living wills, death panels and my dad," Andy Miller advocates for use of "living wills." These documents are also called "advance directives" or "patient advocacy designations." This topic is timely given the growing health care reform debate and concerns about so-called "death panels."
Miller's father was 88 and had multiple health problems when he was hospitalized. He did not, however, have a terminal illness. Miller and his brothers soon discovered that they would need to make decisions about their father's health care.

Their father was comatose, on a ventilator, and unable to participate in these decisions. Fortunately, he had given one of his sons a medical power of attorney to make decisions on his behalf. Unfortunately that document only granted authority. It did not describe specifically the kinds of medical treatments and procedures their father wanted in this situation. 
Miller's father had spoken only vaguely to his children about how he wanted to be treated if he were unable to make medical decisions for himself. Miller says: "A document spelling out what our dad wanted in medical care, though, would have made our decision-making a little easier." 
Miller points out that only about 25% of Americans have an advance directive.

Fortunately, it is not difficult to execute a living will or advance directive. Such a document allows you to express your ideas about what kind of treatment you would prefer if you're unable to make decisions for yourself and to designate a person to make decisions for you if you're incapacitated. You may decide whether or not you want treatments such as a ventilator, tube feeding, hydration, etc. 
These documents may also define treatment based upon an assessment of your condition. In other words, you can designate different levels of "extraordinary measures" depending upon whether there is a likelihood that you can recover or whether this is definitely a situation where you're not going to get better and life can only be prolonged. 
You can change an advance directive at any time, or cancel it. If you can answer medical questions yourself and are competent, you can verbally revoke the advance directive if you wish and medical caregivers will follow your instructions. 

I was grateful that my parents had written advance directives with very specific instructions. Each had designated my sister Jill and me as co-patient advocates. We knew exactly how they wanted to be treated when it was obvious that the end of life was near. It made our decision-making much easier because we were carrying out their wishes and honoring the decisions that each had made when competent. 
Different states have different laws and you might wish to consult a lawyer. However it is not required that you have a lawyer to execute an advance directive. State-specific forms can be obtained from a hospice organization, a hospital, or state aging office. The National Hospice and Palliative Care Organization offers free forms at http://caringinfo.org/. Note that there are also some very helpful articles on the caringinfo website to help family caregivers decide just how to approach the issue of making a living will with an aging parent. 
A document local residents may obtain free of charge from any Munson Healthcare facility is "Five Wishes." This advance directive has been called by many "the living will with a heart." If you can't stop by Munson to pick one up, you can order one online at http://www.agingwithdignity.org/ for a nominal charge of $5.00. Or download it here. http://tinyurl.com/yljkc2t 
Miller's article "Dollars & Health: Living wills, death panels and my dad" may be read here. If you are undecided about whether to make an advance directive, I encourage you to read it.
For another perspective on end-of-life treatment and health care, see this blog article 
"Whose Death Is It Anyway?" By Tara Parker-Pope -- New York Times Health blogger. There she writes of a patient who, while competent, chose Hospice over invasive cancer treatments.


Care coordination | A life-extender for seniors
2009-07-29T09:56:11-04:00
Earlier this year, Anne Underwood wrote about a program called Guided Care in Caring and Coping, a "New Old Age Blog" featured by the New York Times. The Guided Care program provides services from a registered nurse to help seniors get coordinated care. Research shows that repeat hospital re-admissions caused by often life-threatening complications are significantly reduced when care is carefully transitioned between the hospital and another care setting (home, assisted living, rehab, etc.)

Trained and experienced coordinators can do for our aged loved ones what we family caregivers wish we could do. They can ask the right questions, make sure that medication regimens are reviewed to make sure all of the meds are appropriate and that dosages are correct given other health factors such as dehydration, kidney failure, and other conditions.
Anne Underwood echoed my feelings exactly: She said, 
"I remember the helpless feeling I had during my own mother’s final hospitalizations a year ago. It seemed as if I was at the wheel of a car that I wasn’t licensed to drive.
"Should I authorize more invasive care? Should I agree to additional tests and procedures that might help or hurt? Should I put her on hospice care rather than make her suffer any longer? I made the best decisions I could, but to this day, wonder if I made the right choices. I would have loved a program like Guided Care."
Studies show, however, that guided interventions like this can cost about $1,300/year. Savings for Medicare are not that huge. In this economy, sadly, it seems unlikely that programs like Guided Care will be covered by Medicare despite the findings that lives are extended and quality of life is improved.
Underwood cited various components of the most effective programs. Should you be in a position to pay a geriatric care manager, these are some of the things you will want to make sure the GCM will do for your loved one:

Care coordinators need to interact in person with patients and not simply deal with them by telephone.
They must collaborate closely with the patients’ physicians.
Services are particularly important during transitions, when patients are entering and leaving the hospital.
And when it comes to cost savings, the benefits are greatest when services are directed to patients with the most complex problems.


You can read Underwood's New York Times article Care Coordination: Too Expensive for Medicare? here.
You'll be able to read or download in PDF format Appendix F from my book Taking Charge: Good Medical Care for the Elderly and How to Get It here. Appendix F explains how you can find a geriatric care manager.
See earlier posts on how caregivers can reduce complications: Lack of communication in ER results in post-discharge complications explaining the research and conclusions of Dr. Eric Coleman on this issue and The checklist | A simple way to reduce medical error. The latter will help those who cannot afford a care manager negotiate the often difficult transition from hospital to another care setting.


The "Don't kill Granny" list
2009-07-02T05:30:55-04:00
Rosanne M. Leipzig is a physician and professor at Mount Sinai School of Medicine. She wrote in the New York Times today about how lacking in skill and training most doctors are in the practice of geriatrics. This is particularly troubling to her because geriatrics is not a required course in medical schools around the country. If you’re a caregiver or if you are one of those who is “of a certain age” to need competent curative and/or preventative care from a doctor, you’ll want to read what Dr. Leipzig has to say.  In a nutshell . . .

“I was part of a group of doctors and medical educators who recently published in the journal Academic Medicine a set of minimum abilities that every medical student should demonstrate before graduating and caring for elderly patients. Nicknamed the “don’t kill Granny” list, it includes being able to prescribe medicines, assess patients’ ability to care for themselves, recognize atypical presentations of common diseases, prevent falls, recognize the hazards of hospitalization and decide on treatments based on elderly patients’ prognosis and their personal preferences.
“The 2008 Institute of Medicine report “Retooling for an Aging America” resolved that all licensed health care professionals should be required to demonstrate such competence in the care of older adults. But this resolution lacks teeth. Medical resident training programs that receive Medicare money should be required to demonstrate that their trainees are competent in geriatric care. Medicare should finance medical training in nursing homes. And state licensing and medical specialty boards should require demonstration of geriatric competence for licensing and certification.
“Basic geriatric knowledge is preventive medicine. Nurses, social workers, pharmacists and other health care professionals should have it, too, in order to improve care for older people. But until doctors get this basic training, we can’t even begin to give 80-year-olds the care they need.”

Dr. Leipzig’s entire op-ed piece can be read here.
For more information see Elsevier Health's publication: "Human Anatomy Books" 


Are you going to finish strong?
2009-06-15T23:10:56-04:00
This is amazing. What strength and courage. Are you going to finish strong? We could all learn from this young man. 


As famiy caregivers, we all need to find motivation and encouragement. Try this:




A good death | Jane Brody's Guide to the Great Beyond
2009-04-05T22:05:57-04:00
I have just finished reading an extraordinary book, a book so remarkable that I am making a list of all of the people with whom I will share it. The book is Jane Brody's Guide to the Great Beyond: A Practical Primer to Help You and Your Loved Ones Prepare Medically, Legally, and Emotionally for the End of Life. Imagine next time you celebrate an occasion, giving your spouse, your child, or children a book about preparation for dying. The idea may seem strange to you. I ask you to suspend your negativity until you’ve seen this book.

Most people my age have experienced many losses in their life. For me, those losses have included my grandparents, parents, and my dear sister Kay who died of cancer at the age of 47. Many of the vignettes and insights shared by Jane Brody resonated with me. Brody shared her personal experience of her mother dying in 1958 of complications of ovarian cancer only weeks before Brody graduated from high school. What she described was not much different from the experience of my
nephew Kris and my niece Trisha. More than ten years after Kay’s death,
Kris said to me, “Aunt Jeannie, I don’t understand why you knew that
Mom was dying and no one even told us.” It wasn’t that Kris and Trisha
weren’t right there. It’s that no one, not even Kay, could or would
admit that she was dying. Had she told me? No. I only knew because I
was in daily communication with Kay and my intuition picked up on what
was not said to me. Brody encourages me to believe that we can and should learn to talk about death openly.
Brody’s wise advice and advocacy is reflected in this note: “From the start, consider the finish.” Her comment reminds me of an old saying: “Nobody gets out of here alive.” That is not to say that Brody destroys the idea of hope. In fact, she advises hope with a healthy dose of reality. Brody has provided a wonderful guide to help families negotiate the pitfalls from a time of diagnosis through those inevitable experiences of grief. Her advocacy for palliative and hospice care and the idea of dying what I would call “a good death” provides valuable help for those who are living with a fatal illness, as well as for their family members and caregivers. 
Brody’s book is organized into 18 chapters, including "Uncertain Future," "Living Well to the End," "Hospice and Palliative Care," "Spiritual Care," "What to Say," "Grief" and "Lasting Legacies." Thus, it’s possible to pick the book up and read a few chapters at a time. Each chapter concludes with a list of relevant resources providing the reader with additional information.
Brody’s “voice” provides not just a guide to compassionate care but also a helpful hand to family and caregivers who want to say the right thing and do the right thing when helping loved ones toward the great beyond. Brody writes hopefully about death, saying, "You've got time." Preparing for death and mending fences can provide great comfort for a dying person. Brody shares personal stories about friends and family that help the reader face a terminal illness with realism and prepare for death with hope, compassion and even humor. New Yorker cartoons disarm the reader throughout the book. This comic relief is a tasteful and healing ingredient in dealing with such a painful and frightening topic. Brody provides checklists of things that patients and family members may want to ask doctors and nurses that make this book practical and very useful.
As one who frequently tells clients that “Knowledge is power,” what impresses me the most about Brody’s book is that she provides readers with a sense of empowerment that encourages the reader not just to take charge of our health but also to take charge of our dying. 
The gift Brody shares in her book can help parents prepare their children for death and lead them to healing of grief. A road map guiding people to put their affairs in order, to designate a health care proxy, to plan a funeral or memorial service can ease a dying person’s concerns about his or her wishes being carried out, about pain being controlled, and about children not being burdened by having to make decisions that they are, perhaps, ill-prepared to make. 
You can listen to an interview of Jane Brody on the Diane Rehm show. [Windows Media] [Real Audio] 
Guide to the Great Beyond: A Practical Primer to Help You and Your Loved Ones Prepare Medically, Legally, and Emotionally for the End of Life is available in your local book store and also online at Amazon.com.


2009-03-18T05:28:43-04:00
Can you imagine spending two weeks in the hospital after suffering a seizure, being cared for by nurses, seen by doctors, having medications prescribed, being transferred for "rehab" to a nursing home, then arriving home to find that most of your care wasn't covered by Medicare?
That's exactly what is happening to some patients. The Chicago Tribune published an article on March 10th explaining a little known category of hospital care called "observation stay."

It is very important that you or your patient advocate confirm with your hospital that you have actually been "admitted." Unless you are admitted to a hospital for three days, Medicare will not cover the hospital care or, upon discharge, rehab in a nursing home or rehab facility. The Tribune article explained that some medications may not be covered by Medicare. if you are confused about whether or not you have been admitted, you may need to contact an elder lawyer. There are many fine elder lawyers in the area and I would be pleased to refer you to one.
One reason why the failure to admit a Medicare patient troubles me is that I am fairly confident that had the ER doctor in Saginaw admitted my mother - had he recognized that her hallucinations were delirium and not "psychosis" - she could have had appropriate care and she would have survived for years. Instead she suffered a precipitous decline and died in 65 days. (She had a urinary tract infection! Not unusual and easily treated.) Delirious patients need a calm, safe, supportive environment, supervision to ensure that they are adequately hydrated, and appropriate diagnosis and treatment of the underlying cause of the delirium. Often, these needs are beyond the capability of a family caregiver - especially a working caregiver who is providing care and supervision from a distance. 
You can read about how you, as a family caregiver, are in the best position to help the medical professionals distinguish delirium from other possibilities in Chapter Two of Taking Charge: Good Medical Care for the Elderly and How to Get It, available here without charge to read online, print, or download to your computer.
Read the Chicago Tribune story  "Hospital use of 'Observation Stay' is questioned" here. A one-time registration may be required.


Parents' Wish | Preserving dignity for your loved one
2009-03-17T18:54:28-04:00
My niece sent me a link to a web site featuring a very powerful message about how our elderly loved ones wish to live and to die with dignity. Set to the music of Josh Groban ("You Raise Me Up"), this is very thought-provoking. I'll be honest. It moved me to tears.
Parents' Wish - view it here.


Survey shows many primary care doctors plan to quit or cut back
2008-11-18T08:42:16-05:00
Reuters reports that a survey
released on November 18, 2008 shows that nearly half of the primary
care
doctors in the United States feel overworked and nearly half of
them plan either to retire or to cut back 
on how many patients they see
or to quit the practice of medicine altogether. This poses serious 
problems for the elderly, most of whom are cared for
by primary care doctors, either family practice 
doctors or internists.
In the survey 60 percent of 12,000 general practice physicians surveyed said that they wouldn't 
recommend medicine as a career.

The survey was conducted by the 
Physicians' Foundation. One doctor participating in the survey was quoted as saying: "The whole thing has spun out of control. I plan to retire early even though 
I still love seeing patients. The process has just become too burdensome."


As I've written earlier, there is a crisis in medical care,
particularly for the elderly. Insufficient numbers of medical students
are choosing to train in and/or to practice internal medicine or family
practice medicine. Medical students are opting for specialties that
don't involve treatment of geriatric patient. One of the primary
disincentives is the lack of sufficient compensation provided to
doctors by Medicare and Medicaid.
Dr. Joseph F. Friedman of Brown University Medical School wrote Chapter Two of Taking Charge: Good
Medical Care for the Elderly and How to Get It. This topic is explored
thoroughly in Chapter Two which you may read without charge online here.


You may need to be in touch with your representative in Congress. Both Congress and president-elect Barack Obama have stated that health care reform is a top priority for them. Doctor's groups are, according to the Reuter's report, lobbying for 
action to reduce their workload and hold the line on payments for treating 
Medicare, Medicaid and other patients with federal or state health 
insurance.

You may read the full Reuter's report in the Boston Globe at this link. A one-time registration may be required.


Lack of communication in ER results in post-discharge complications
2008-09-16T13:50:59-04:00
The New York Times reports on September 16, 2008 that most ("a vast
majority") of emergency room patients are discharged without
understanding the treatment they received or how to care for themselves
once they get home. As borne out by earlier studies, and in particular, by the research of Dr. Eric Coleman who is the director of the Care Transitions program at the University of Colorado, the lack of communication when patients are discharged from one care setting to another can lead to medication errors and serious complications that can send them right back to the hospital. 

You can read the entire New York Times article here. E.R. Patients Often Left Confused After Visits

For more information see Dr. Coleman's website caretransitions.org. Be sure to look at the intervention section and also to access a Caregiver's Tool kit for caregivers and patients. This toolkit will help you safety negotiate not only safe care in the emergency department, but also to handle successfully transitions between hospital and home or hospital and another care facility such as a rehab center.


Evercare private Medicare plans under scrutiny
2008-07-31T18:04:53-04:00
Thursday, July 31, 2008: According to the Boston Globe, Massachusett’s Division of Insurance is investigating sales of Evercare private Medicare plans following complaints from Massachusetts seniors about sales representatives using misleading and abusive marketing. These plans are sold in Michigan, according to the company’s website. [Enter a zip code.]  NOTE: I checked this. These plans are being sold in Michigan.
The Centers for Medicare and Medicaid Services, the federal agency that
oversees the insurance plans, said it has stepped up oversight of
Evercare, a subsidiary of insurance giant UnitedHealth Group Inc. of
Minnetonka, Minn. CMS, claims that it will scrutinize Evercare very,
very closely for marketing abuses in the future. 


The Globe reported Saturday that Massachusetts seniors have filed
dozens of complaints with the state and senior service agencies about
how Evercare sold private health insurance for disabled seniors who
qualify for both Medicare and Medicaid benefits. According to
complaints filed with senior advocates, independent insurance agents
lied about what was covered, called seniors after they were asked to
stop, and may have gone door to door in violation of marketing
guidelines.


You may read the Boston Globe article here. Evercare practices reviewed by state




The importance of eliminating risks for falling
2008-07-12T08:17:52-04:00
Falls can be deadly. About 10,000 elderly persons die every
year in the U.S. as a result of injuries suffered in falls. Over one-third of
these deaths occur among persons older than 85 years. The vast majority of
these deaths are related to hip fractures; patients with hip fractures are 15
to 20 times more likely to die than those who have not had a fracture. Even
when falls do not cause death, they can cause significant disability in the
elderly, such as minor soft tissue injuries, hip fractures, other types of
fractures, and serious soft tissue injuries. Injuries from falls may mean that your loved one won't be able to grow old in his or her own home.
Falls also have the potential to significantly reduce the
life styles of the elderly. Many who have fallen change habits just to avoid
falling again. They may stop socializing with friends or attending church.
Loneliness may become a problem. Some elderly persons begin to limit their
fluid intake to avoid the need to rush to the bathroom. This can have serious
consequences for a person who takes many different medications. Because most
drugs are eliminated through the kidneys, our bodies natural “filtration system,”
if a person doesn’t drink fluids to keep flushing the system out, the drugs can
build up in the body and reach toxic levels. In fact, I learned that this was a
primary cause of my mother’s death in November 2000.

This is a major reason why family caregivers should
evaluate their loved one’s risk for falling and take steps to reduce or
eliminate the risk of falling. You will find a helpful form to help you assess
risk of falling on my website at Appendix K. You can read the page here, and
you can download a PDF copy of it here, free of charge.

The next task is to take steps to reduce the risk factors. This
could be as simple as increasing the lighting in hallways and stairwells, eliminating
throw rugs that can cause a trip and fall, and making sure that your loved one
wears sensible supportive shoes rather than slippers that lack any non-slip
soles that help grip the floor. Chapter 5 of Taking Charge: Good Medical Care for the Elderly & How to Get It has many other suggestions for reducing falls.

A major cause of falling are medication side effects.
Therefore, an important part of reducing or eliminating falls is to review your
loved one’s medications with his or her doctors. Researchers at the University
of North Carolina have published a long list of drugs that increase the risk of
falling among adults. You can download a copy of that list here. How many of
the drugs that your loved one takes are on that list?



See a New York
Times article “A List of Drugs that Increase Falling Risk” here.



Download the
list here.







Antipsychotics inappropriately prescribed for dementia
2008-07-02T09:03:08-04:00
Even short-term use of typical or atypical antipsychotic medications in the elderly with dementia produces serious events. 
If you are a regular reader of this Blog, then you know that I frequently write about the dangers of using antipsychotic medications with the elderly. My earlier posts may be accessed here.
A new study, released on May 28, 2008, makes clear that even short-term use of these drugs may cause serious complications and even death for the elderly patient. That study was discussed in my May 27 Blog article, and is discussed in a recent article in Journal Watch Psychiatry June 23, 2008
Antipsychotic medications are increasingly used to treat agitation in elderly patients with dementia, even though this use has been associated with increased risks for adverse events. Dr. PA Rochon is the principal author of “Antipsychotic therapy and short-term serious events in older adults with dementia,” published in the Archives of Internal Medicine on May 28, 2008. Dr. Rochon and his colleagues report that antipsychotic medications increase risks for serious adverse events and that typicals appear to be somewhat more risky than atypicals. I summarized this article here.

Black Box Warnings. Starting in June 2008, the FDA will require U.S. packaging of both antipsychotic types to carry boxed warnings against their use in treating dementia-related psychosis, which is a much less frequent target than agitation in this population. I’ve earlier commented on this Blog that avoiding psychiatric hospitalizations for the elderly is important in avoiding inappropriate prescription of antipsychotics for these patients.

Since June, the FDA has required “Black Box warnings” on antipsychotics prescribed to the elderly. 

Using Ontario administrative health data, Dr. Rochon and his fellow researchers examined the risk for serious adverse events (SAEs) resulting in hospitalization or death within 30 days of initiating antipsychotic treatment in elderly patients with dementia.

The study looked at the risk for groups of community-dwelling patients separately from the risks for nursing-home residents. Patients receiving atypical antipsychotics were matched with those receiving typical antipsychotics and with those receiving no antipsychotic (almost 7000 patients in each of six groups). 

The SAEs were significantly high: 

For community-dwelling patients, SAEs occurred as follows:

16.0% of the typical-antipsychotic group

13.9% of the atypical group 

4.4% of the control group

For the nursing-home group, SAEs occurred as follows:

11.6% of the typical-antipsychotic group

9.4%, of the atypical group, 

5.6% of the respective groups

All classes of events showed the same pattern, including worse effects with typicals than with atypicals.
Comment: This excellent analysis demonstrates that antipsychotic medications increase risks for serious adverse events and that typicals appear to be somewhat more risky than atypicals. 
The study concludes that the risk appears greater in community-dwelling patients than in nursing-home patients. One reviewer, Dr. Peter Roy-Byrne, MD, stated in Journal Watch Psychiatry June 23, 2008 that “the frequency of events is particularly striking given that the time frame was restricted to the initial 30 days after treatment initiation. These rates are likely underestimates because only serious events were studied, the follow-up was relatively short, and some events may have been avoided by discontinuing medication when early warning signs occurred. These findings are consistent with the U.S. Food and Drug Administration black-box warning and suggest that antipsychotics be prescribed with great caution in this population and only after consideration of all other possible interventions.”

The article is: Rochon PA et al. Antipsychotic therapy and short-term serious events in older adults with dementia. Arch Intern Med 2008 May 26; 168:1090. 

•    Original article (Subscription may be required)  

•    Medline abstract (Free)




Antipsychotics prescribed to elderly | Adverse event
2008-05-27T13:52:19-04:00
Today, the Archives of Internal Medicine published a "retrospective cohort study" in which is is reported that the short-term use of antipsychotic therapy in older people with
dementia is often followed by adverse events leading to hospitalization
or death. 

Shortly after my mother died in November 2000, I filed a report with the
FDA's Med Watch --a reporting system for adverse medication reactions
causing death and other serious complications. I told the FDA that
risperidone, an atypical antipsychotic, prescribed for my mother when
she was delirious was a likely contributing factor in her death. What did MedWatch do with this report?
Absolutely nothing. They did not even do a follow-up contact.

In 2000 and thereafter, risperidone and other atypical antipsychotics just like it continued to be prescribed for the elderly. I earlier
wrote a Blog article about the importance of avoiding psychiatric admission for the elderly that explored this issue. In this article I discuss and provide evidence that these drugs--dangerous when prescribed for the elderly--are the No 1 drug for which Medicare and Medicaid reimburses nursing homes and medical facilities.

The study reported by the Archives of Internal Medicine examined roughly 21,000 older adults (over 65 years) with dementia in the community and 21,000 in nursing homes. During 30 days' follow-up, those receiving atypical antipsychotic drugs (olanzapine, quetiapine, or risperidone) were two to three times more likely to have an adverse event leading to hospital admission or death, compared with those who were not taking antipsychotics. Adults receiving conventional antipsychotics, such as haloperidol or loxapine, had even higher odds of an adverse event. I want to make clear that my mother died about 60 days after being prescribed risperidone. I will of course state that it wasn't just the risperidone. However, the risperidone did set off a chain-reaction that ultimately led to my mother's early death.

The study's authors note that the agents are commonly used short term to treat agitation, especially when patients are admitted to nursing homes. They say their study probably underestimates the problem's prevalence, concluding that "antipsychotic drugs should be prescribed with caution even for short-term therapy."

Archives of Internal Medicine article (Free abstract; full text requires subscription) You may ask your local library to get this for you through interlibrary loan programs if you'd like to read it.


Is online medical record storage safe?
2008-04-22T15:20:04-04:00
As I have earlier written on Aging in Place, companies like Microsoft
and Google are getting into the medical record storage business.  Last
week, however, the New England Journal of Medicine raised important
questions about whether medical privacy rules should be extended to
these private firms. Steve Lohr wrote in the New York Times that the authors of The New
England Journal article say there are still more questions than answers
about the new “personalized health information economy.'’
According to the NEJM article, Microsoft and Google are not bound by the privacy restrictions of the Health Insurance Portability and Accountability Act, or HIPAA. HIPPA is a law that regulates personal data handling and patient privacy.  Enacted in 1996, HIPAA did not anticipate the kind of Web-based health records systems that Microsoft and Google now offer.

In the NEJM article, the authors say that consumer control of personal data under new, unregulated Web systems could open the door to all kinds of marketing and false advertising from parties eager for valuable patient information.

Worse, Peter Neupert, the vice president in charge of Microsoft’s health group, resisted the suggestion that HIPAA should apply to these services provided by Microsoft and Google.

I initially advocated for online medical record storage since aging Americans often travel and having access to medical records if you’re ill in a strange place can be reassuring and life-saving.  But the New York Times’ story might change your thinking on a major personal health issue. 

To read the full story in The Times, click here. 

The New England Journal provides only a free extract of the original article here. 

More about Google’s innovations in online health information may be read in this August 2007 story from The Times.


Soaring co-pays for prescription medications
2008-04-14T08:48:48-04:00
How many people really read those thick pamphlets that credit card companies, banks, and/or insurance companies send out periodically to advise of a change in policies, interest rates, etc.? Many of these mailings surely end up in a stack that you’ll read when you “get around to it.”

Thus many seniors accustomed to paying a $20 co-pay may have been surprised the last time they went to pick up a refill of commonly used medications used to treat diseases such as multiple sclerosis, rheumatoid arthritis, hemophilia, hepatitis C and some cancers. New pricing systems adopted by many insurance companies now require patients to pay hundreds or even thousands of dollars for medications prescribed to help them save their lives or to slow a disease process.

For more about this troubling trend, see the April 14, 2008 New York Times, 
Co-payments for Expensive Drugs Soar.

See also earlier posts Saving money on prescription medications and   Getting medications without charge


New restrictions on anti-anemia drugs
2008-03-17T10:08:12-04:00


An FDA advisory panel has recommended further strengthening warnings for the 
use of erythropoiesis-stimulating agents in cancer treatment, according to news 
reports.





The panel voted to recommend keeping Aranesp (darbepoetin alfa) 
and Procrit (epoetin alfa) on the market to treat anemia resulting from 
chemotherapy. But it said they should be given only to patients with incurable 
cancer and should not be used for those with breast or head and neck cancer. Evidence that the drugs may 
increase the risks for death and tumor growth led to the new restrictions. 

The panel also advised that patients should sign forms indicating that they consent to receive the 
drugs after being fully informed of the dangers associated with them, according to the New York Times.

The New York Times story may be read here.



Seniors cautioned about reverse mortgages
2008-03-17T09:52:53-04:00
Some seniors struggle financially while trying to age in place. The Financial Industry Regulatory Authority (FINRA) recently advised senior homeowners to proceed with caution before using reverse mortgages to access their home equity. The group warned that a reverse loan--meaning that a bank makes payments to a homeowner instead of the homeowner making payments to a bank--can be a risky financial move.
The transaction is risky because high fees and other problems may frequently occur. For example, reverse mortgages may interfere with a person's intent to leave the
property to heirs in a will. The FINRA warning notes that some of the businesses who make the mortgages available to homeowners may profit from the transaction. Thus, the lender or employee working for the lender has a lot of incentive to talk someone into a loan he or she may not need.
Nevertheless, with foreclosures rising amid the subprime-mortgage mess, some homeowners who have built up equity over the years may
consider a reverse mortgage if that is the only way to avoid losing the house.


Click here to read the entire Wall Street Journal article.      


Heparin contamination
2008-03-06T09:39:03-05:00
If you or one of your loved ones takes heparin, a blood-thinner often prescribed for patients with heart conditions, you should be watchful for the following symptoms:

difficulty breathing

nausea

vomiting

excessive sweating and 

rapidly falling blood pressure
At least 19 deaths have  been attributed to a contaminant in heparin. The FDA has received nearly 800 reports of serious injury.

The New York Times reported on March 6, 2008 that recent testing using magnetic resonance imaging revealed that as much as 20 percent of the product, made in China, was a heparin mimic. The FDA doesn't know what the contaminant was and does not know if the inclusion of the substance with heparin sold to Baxter Laboratories was intentional.

You can read the New York Times article Drug Tied to China had Contaminant, F.D.A. Says here. A one-time registration may be required.


Avoiding an inappropriate psychiatric hospitalization
2008-03-03T11:01:01-05:00
Recently, a caregiver complained that a hospital would not allow her to
elect a transfer to a psychiatric unit for her parent suffering from
dementia. The hospital’s position was that the health care power of
attorney did not allow the patient advocate to make a psychiatric
admission. They said that only the patient could make that choice. The
patient was described as being “delusional.” What seemed probable was
that this patient was delirious, not psychotic. If that were the case,
then a psychiatric admission would potentially be very harmful to the
patient.

Avoiding an inappropriate psychiatric hospitalization for an elderly person can be life-saving for that patient.
Delirium as a red flag.

Delirium is a common condition in the elderly. Undiagnosed delirium puts a patient at risk of serious complications and/or death. All too often, delirium is mistaken for a condition that warrants a psychiatric hospitalization. The consequences for the elderly can be fatal. Thus avoiding an inappropriate psychiatric hospitalization is critical.

Family caregivers and primary care physicians can easily detect delirium. And yet, delirium is missed as a diagnosis about 95% of the time, according to one study. Delirium is easy to diagnose if it’s on your radar screen. Unfortunately, as explained in Chapter Two of Taking Charge: Good Medical Care for the Elderly and How to Get It, delirium is not on the radar screen for most doctors and nurses. This is because, as Dr. Joseph H. Friedman writes in Chapter One of Taking Charge, only 2% of physicians and 1% of nurses have any training at all in geriatrics and, thus, they fail to realize that delirium is an important sign of illness.

Delirium is a red flag that there is a disease process or other abnormality that needs to be diagnosed and treated. Delirium is caused by many common conditions that affect the elderly, including urinary tract infection, an electrolyte imbalance, an adverse drug reaction, etc. If delirium is not diagnosed and if underlying cause of delirium is not treated, the consequences can be fatal. 26% of those who become delirious die within one year, usually of the underlying cause of the delirium.

Psychiatric admissions pose serious danger to the elderly.

Disruption of continuity of care. There are two huge concerns about a psychiatric admission for an elderly person. The first is that such a transfer will usually completely disrupt the continuity of care for the patient. Because most elderly persons suffer from concurrent medical conditions that require monitoring and prescription medications, it is crucial for these patients to remain under the care of a primary care physician. A patient’s primary care physician knows what is “normal” for the patient. Thus, if a new medication were prescribed in the psych unit, a doctor who knows the patient would easily detect the side effects. A physician who is familiar with the patient will more readily detect all drug-disease, drug-drug, and drug-food interactions.

Use of inappropriate psychotropic medications. The second concern about transferring an elderly person to a psychiatric care facility is of even greater importance. If a psychiatric admission is made, the likelihood that an antipsychotic will be prescribed is very high, despite the FDA “black box” warnings advising against use of these drugs for off-label purposes in the elderly. Psychiatrists tend to prescribe antipsychotics for patients with behavioral problems. The fact that atypical antipsychotics are not recommended for uses other than schizophrenia and bipolar disease and that research shows them ineffective in treating dementia seems irrelevant to them.

On December 4, 2007, the Wall Street Journal reported that atypical antipsychotics are prescribed for the elderly in phenomenal quantities. For the past two years, Seroquel has been the No. 1 drug purchased by Medicaid. Seroquel carries a "black box" warning against use “of all drugs of this class” in dementia patients. The warning is mandated by the FDA. And yet AstraZeneca, the manufacturer of Seroquel,  excuses the use of Seroquel in dementia patients by saying, “decisions about medical treatment are made by physicians.” Somehow, this sounds like a familiar refrain – similar to the excuse used by manufacturer of munitions: “Guns don’t kill people; people kill people.”

Manufacture and sale of antipsychotics for off-label use in the elderly is a multi-billion dollar business. In 2005, the most recent year for which total expenditure figures are available, Medicaid spent $5.4 billion on atypical antipsychotic drugs for nursing home patients. Contrast that figure with what Medicaid spent on drugs to lower cholesterol. ($2.1 billion)

I invite you to read Chapter Two of Taking Charge. This chapter explains delirium and seeks to empower family caregivers so that they can be the front-line of defense for their elderly loved one. In addition to Chapter Two, the following are also available on the Taking Charge website without charge: 
The Introduction, which explains the reasons why this book was written to empower family caregivers to be more effective advocates for their loved ones 

Chapter One, in which Dr. Joseph H. Friedman explains why the elderly are not always getting good medical care. (Only 2% of the doctors licensed in this country and only 1% of nurses have any training at all in geriatrics.) 

The Appendices are available free of charge on the website to read, to print or to download.
See the Table of Contents for links to these materials. I invite you to read these materials on-line, to print them, or to download them to your computer. My goal is to help family advocates ensure good care and safety for their loved ones. 




Reducing incidence of bedsores using teamwork
2008-02-19T08:17:41-05:00
Bedsores can be a serious complication of aging. The clinical name is
pressure ulcers. These ulcers occur when skin breaks down because blood
circulation is cut off by sustained pressure. Bedsores can be so
difficult to heal that prevention is the recommended approach. A recent study shows that a teamwork approach can reduce the incidence of bedsores by 69%.


Patients who are confined to beds and wheelchairs in hospitals and
nursing homes are most at risk for bedsores. Other complications, such
as dehydration and poor nutrition, can put the elderly at greater risk
to develop bedsores. Incontinence also can lead to bedsores.
Sometimes pressure ulcers are so deep and painful that the patient needs narcotics to control the pain. A huge danger is that the pressure ulcer may become infected, leading to fatal complications. In fact, infection of a pressure ulcer was the cause of wheelchair-bound actor Christopher Reeves’ death in 2004. 
A study involving 52 nursing homes around the country shows that a teamwork approach to bedsores can be very effective to reduce the incidence and severity of bedsores. Nursing homes involved in the study reduced bedsores by 69 percent.

Some of the strategies used were:

Having laundry workers alert staff to clothing issues—point out when clothes were restricting a resident’s skin

Having the cooks put protein powder in cookies and other foods to increase nutrition

Instituting buffet dining so that residents did more walking around in the dining room than sitting

 Decreasing the time residents had to sit and wait in the beauty shop and repositioning residents while they were getting their hair done

Giving residents at risk for weight loss and malnutrition yellow plates so that staff members would remember to encourage them to eat

Using mattresses made of high-density foam to reduce pressure in key areas

Keeping feet elevated with pillows so that bedsores would not develop on the heels of bed-ridden residents.

Nursing homes involved in the study educated their staff and increased the awareness of all staff members to the identification of residents who were vulnerable or at risk for bedsores. At one Florida nursing home, a  “skin-watch action team,” or SWAT, was created to identify vulnerable residents, to make sure that their heels were protected, that they were given pressure-reducing cushions and that they were repositioned frequently. Accountability was also a factor in reducing the incidence of bedsores. If a bedsore began to develops, CNAs were asked “how did this happen?” 

You may read a New York Times article Fighting Bedsores with a Team Approach here.


Heparin warnings
2008-02-14T19:55:00-05:00
The New York Times reports today that Baxter Healthcare, the manufacturer of about half of the heparin used in the U.S., has stopped making it after hundreds of patients reported severe allergic reactions to the drug. Heparin is a blood thinner widely used in surgery and dialysis. Reportedly, at least four people have died. It's important to note that the complications reported were related to large dosages being injected in patients. Most of the cases were reported in late December or January. 40 percent of the cases were reportedly serious.
Federal regulators say that a shutdown in manufacturing will surely result in shortages of the drug. 
Alternative drugs do exist. However, doctors were warned today of serious consequences if heparin becomes 
truly scarce.

You may read the New York Times article, Problems in Drug Lead to Halt by Factory here.



The checklist | A simple way to reduce medical error
2008-02-13T14:54:54-05:00


In the December 10, 2008 issue of the New Yorker, author Atul Gawande writes: “If something so simple [as a checklist] can transform intensive care, what else can it do?”

Gawande gives some amazing examples of extraordinary ICU care evolving through the use of checklists. ICU care is complicated. A time and motion study of ICU care in Israel was cited. The study showed that the average ICU patient required 178 individual actions per day, ranging from administering a drug to suctioning the lungs. Any kind of mistake, in the procedure or in the sequence of actions, could result in fatal error.
Gewande also cited a study commissioned by the Michigan Health and
Hospital Association in 2003. Peter Pronovost, who had perfected ICU
checklists at Johns Hopkins Hospital was asked to try out three of his
checklists in Michigan’s ICUs to test whether his checklist idea really
worked. These tests proved to be a huge success.


Family caregivers can benefit from publications that, like the
checklists, help them to participate in their healthcare decisions and
help reduce medical error.


The Joint Commission on Accreditation of Healthcare Organizations has
developed pamphlets to be used by patients and their caregivers. These
publications provide critical information on topics of vital importance
and encourage the elderly to speak up to help prevent errors in their care. Topics include prevention of infections, medical errors, and medication complications,as well as planning
follow-up care after hospitalizations and many other topics useful to
the elderly. 

You can find a complete list of these pamphlets on my website Taking Charge: Good Medical Care for the Elderly and How to Get It. Each of them may be read online, printed or downloaded to your computer’s hard  drive.



You can read the New Yorker article The Checklist here. 


Rizzo & Associates new blog
2008-02-13T10:53:08-05:00
A Traverse City elder law practice, Rizzo & Associates, has just begun a new blog -- Michigan Elder Law Updates. I've already emailed friends in Kentucky a link to the article about changes in Michigan's property tax. As summer residents and property owners in my neighborhood, they will be very interested in this update. 

You'll find Michigan Elder Law Updates here: http://michiganelderlaw.blogspot.com/


Aging in Place | A change in the tax law may help
2008-02-12T12:39:44-05:00
On January 30, 2008 the Wall Street journal reported an important change to the tax code. A cherished tax break is the exclusion of as much as $500,000 of gain from gross income when, as a one-time event, a couple sells their principal residence as long as they file their tax returns jointly. (The exclusion is $250,00 for a single person). Yes, there are some conditions. You aren’t entitled to the exclusion unless you owned the home -- and lived in it as your primary residence -- for at least two of the five years prior to the sale.
That exclusion has been broadened to benefit widows and widowers.
Before the change in the tax code, a surviving spouse must have filed a joint
return in the year of death and also must have sold the home in the
same year to be entitled to the exclusion.


There is am important change in the law. Now, if a surviving spouse
hasn’t remarried, normally he or she may be able to  claim the full
$500,000 exclusion from the gain on the sale of a principal residence,
as long as it was owned with the deceased spouse and the sale occurs
not later than two years after the date of death of the spouse. 


For more details, see the WSJ article and also consult with your tax expert.



Healthy Survivorship | Wendy Harpham coined the phrase!
2008-02-11T18:11:18-05:00
Usually I write about issues important to the elderly. Today, I want to introduce you to Wendy S. Harpham, M.D. I am proud to call Wendy my friend, and I am grateful for her mentoring. Without Wendy’s thoughtful suggestions and encouraging words, Taking Charge: Good Medical Care for the Elderly and How to Get It would not exist. Wendy read the manuscript twice. She helped me “find my voice” as an advocate and she encouraged me every step of the way.

Wendy is an amazing woman. She was a young internist with a thriving private practice when she was diagnosed in 1990 with non-Hodgkin's lymphoma. Her children were 1, 3, and 5. While going through chemotherapy, she was amazed by and grateful for all she was learning about life on the other side of the stethoscope. From her useful perspective as physician-patient, she wrote a manuscript to guide patients through diagnosis, evaluation and treatment. WW Norton, a major publisher, offered Wendy a contract two days after she sent them the manuscript. Now in its third edition, it is entitled, Diagnosis Cancer: Your Guide Through the First Few Months of Healthy Survivorship.
The same week her book was published, Wendy had to close her medical practice to undergo treatment of her first recurrence of lymphoma. In fact, Wendy has been in and out of treatment ever since, most recently for her seventh recurrence. Although forced to leave the world of clinical medicine, she has continued to help patients through her writing and speaking. She has written award-winning books on recovery and long term survivorship (After Cancer), raising healthy children when a parent has cancer (When a Parent has Cancer), and most recently a book on getting good care and finding happiness after any illness or injury (Happiness in a Storm). 

All her work revolves around the notion of what she calls a “Healthy Survivor,” namely a patient who gets good care and lives as fully as possible. 

Sometimes getting the best care means being treated in a clinical trial. Many people consider Wendy a “poster child for clinical trials,” because her participation in three trials saved her life in the 1990s. Clearly, combining science and caring has worked well for her! 

In 2000, Wendy was inducted into the Texas Women's Hall of Fame. You can see a video of Wendy that was used to introduce her by clicking here.  Wendy’s courage and tenacity are surely inspirational, especially because she describes a way of living after illness or injury that is not extraordinary and out of reach for most people. She offers practical philosophy and tips that can be adapted to work for most anyone. “Meeting her” might just change the way you live your life today.

Wendy continues to write, has at least two manuscripts in process, and recently began a blog Dr. Wendy Harpham | On Healthy Survivorship. Pass this helpful site along to those you know who have any type of illness, especially if the illness is cancer. 

“A cancer diagnosis encourages us to know both the fragility and hopes of life, and with that knowledge to live most fully," Wendy says. "The intimate knowledge of what might have been lost (and might yet be) makes me feel today and everyday in a wonderfully intense way."

Meet Dr. Wendy Harpham on her website as well, where you’ll find links to many useful articles as well as summaries and links to her various books.


Speak up and prevent health care errors
2008-01-31T14:11:52-05:00
Caring at Home has published a valuable article about how seniors can help prevent serious medical errors by paying attention and speaking up when they have questions about their care or the medications prescribed for them.

You can read and reprint this article here.

"To Prevent Health Care Errors, Patients are Urged to SPEAK UP"


Palliative Care & End-of-Life Care articles available
2008-01-15T09:01:15-05:00
 Three articles in the current Annals of Internal Medicine provide useful information about palliative and end-of-life care. A helpful table is included with each article to help caregivers manage decision-making. Although written for doctors, many family caregivers will find this information useful.
The first article contains guidelines written by a committee of the
American College of Physicians to help caregivers manage pain,
difficulty in breathing often caused by lung or heart disease, and
depression -- all common medical issues in aging people. This article
recommends that physicians help family caregivers manage these critical
issues by doing the following:
regularly assess patients for pain, dyspnea (breathing difficulties), and depression; 

use effective therapies to manage pain and depression; 

use opioids to relieve distress caused by refractory dyspnea (For the layperson, refractory dyspnea is shortness of breath that persists despite the use of usually effective treatments; shortness of breath that is resistant to all available treatments. It's common with diseases such as emphysema, or COPD.)

use oxygen for hypoxia (when illness has caused the blood to have insufficient oxygen); 

ensure that planning occurs, including advance directives. 
 
The second article, an "Update in Palliative Medicine," advises doctors to:
use the Seattle model to predict survival in heart failure; 


stop refusing to prescribe opioids for fear they will hasten death. 


consider using intravenous lidocaine or oral mexiletine for refractory neuropathic pain; 


consider referring patients with malignant gastroduodenal obstruction for luminal stenting.
The article "Evidence for Improving Palliative Care at End-of-Life" reviews published evidence in support of various end-of-life measures.
You may access these materials online without charge.

Annals of Internal Medicine coverage of ACP guidelines (Free) (PDF download)


Annals of Internal Medicine update on palliative care (Free)  (PDF download)


Annals of Internal Medicine "Evidence for Improving Palliative Care at End-of-Life" (Free)  (PDF download)

You'll also find information about the "Seattle model for evaluating heart failure" that you can print out and discuss with your doctor. (Free)


Rosalyn Carter's message about caregiving
2008-01-03T19:47:03-05:00
I'd like to share with you today, a wonderful message from Rosalyn Carter about caregiving. Our former First Lady has been actively involved in caregiving for a long, long time. The Rosalyn Carter Institute provides a wide variety of valuable resources for family caregivers and for professional caregivers.

Mrs. Carter writes:

"My interest in caregiving goes back to my childhood. I was deeply influenced by how chronic illness affected and shaped my family and by the heroic and selfless efforts of health care providers, including Jimmy’s mother, Lillian Carter. 

                                                                          * * * 
In fact, the backbone of our country’s long-term, home-based, and community-based care systems is the family caregiver. The approximately 15 million caregivers in the United States provide $306 billion worth of unpaid services each year. That amount is almost twice as much as is spent on homecare and nursing home services combined ($158 billion). 

                                                                          * * *  

But the strains on our society and on these individuals as a result of providing care are becoming apparent. To read more, click here. 


Commonly prescribed drugs cause most adverse drug events in elders
2007-12-04T10:58:14-05:00
When I began my research to learn what had caused the death of my mother only 65 days after she had been diagnosed with a simple urinary tract infection, one of my first goals was to learn whether an antipsychotic medication that had been prescribed for her could possibly be linked to her death. I learned that this drug was frequently used in nursing homes to control “behavior problems,” that the drug was intended for use with schizophrenics and that use in the elderly was “off-label” – meaning that the FDA had not approved the drug for that use.

I also learned that research linked use of antipsychotics in the elderly with unacceptable risk of harm to the elderly. In fact, the FDA has since issued a public health advisory to alert health care providers, patients, and patient caregivers to new safety information concerning an unapproved (i.e., “off-label”) use of certain drugs called “atypical antipsychotic drugs.” No research has demonstrated that antipsychotics are effective in “treating” behavioral problems in the elderly. The side effects of antipsychotics make them particularly dangerous to the elderly. These side effects include anorexia, drowsiness, dizziness, and dangerous “extrapyramidal side effects” such as dystonia (Involuntary movements and prolonged muscle contraction resulting in twisting body motions, tremor, and abnormal posture), Parkinsonism (motor stiffness, difficulty initiating movements, shuffling, stiff gait, resting tremors, and reduced facial movements), and others. EPSs can be life-threatening.
It didn’t take me long to learn about the work of Dr. Mark Beers who
was then, in 2001, the Editor in Chief of the Merck Manual
and the Merck Manual of Geratrics. 


Dr. Mark Beers had been working with colleagues for many years to
develop a list of drugs that are inappropriate for use in the elderly.
He published the first list in 1991. It was updated in 1997 and again
in 2003. Some drugs were listed as “always potentially inappropriate.”




You can access a list of the Beers criteria drugs here (free)



Do not resuscitate orders | A family's dilemma
2007-12-03T10:25:23-05:00
The Boston Globe today (December 3, 2007) explores the complicated subject to DNR orders -- do not resuscitate orders. When are they appropriate? What if the elderly patient waits too long? What decisions must be made and how can they be made? 

The problem is, says the Globe's writer Patricia Wen, many families aren't sure about how to discuss this difficult subject. Often they wait too long, and by the time it's obvious that this decision needs to be made, the elderly loved one is not mentally competent to execute the required documents.

My book Taking Charge: Good Medical Care for the Elderly and How to Get It, discusses end-of-life decisions, the Five Wishes (called by the Miami Herald "the Living Will with a Heart"), and how and when to have this difficult conversation with your elderly loved one.

The Boston Globe article, by Patricia Wen may be read here:

For many, 'Do Not Resuscitate' too painful to discuss
Relatives, doctors often delay in offering patients the option


More from the Hartford Courant - Understaffing
2007-11-20T16:43:17-05:00
The Hartford Courant ran the second of a three-part series today (November 20th) on one of those multi-corporation, tiered nursing homes where the goal is to insulate from liability for harm that befalls the residents through neglect. According to the Courant, the minimum staffing requirements haven't changed in 25 years even though currant research shows serious understaffing in nursing home and shows that this can lead to disastrous results.

The topic this time is understaffing and how this leads to neglect of residents and serious harm or death.  Today, the Courant said:

"For four days in April, Bogardus and his close friend, Leona Brenner,
tried to convince the staff of the Haven Health Center in South Windsor
that he was dying. Bogardus, who had sought nursing-home care after
complications from heart surgery, was coughing, struggling to breathe
and couldn't walk the six steps from his bed to the bathroom, he and
Brenner said.


Only after Brenner threatened to call 911 herself did the nursing staff
finally summon an ambulance, the couple recounted. By the time the
69-year-old retired civil engineer arrived at St. Francis Hospital and
Medical Center in Hartford, hospital records show, he was dehydrated
and his kidneys were failing." More



Dehydration, malnutrition, and falls in nursing homes
2007-11-19T08:37:16-05:00
From the Hartford Courant on November 19, 2007 comes an indepth expose of nursing homes operated by Haven Heathcare, which owns 25 nursing homes -- 15 in Connecticut and 10 in other New England states. The article cites a litany of deaths caused by neglect of the nursing home staff and/or understaffing leading to resident harm.

What good is oversight when nursing homes are fined only a few hundred dollars where a resident dies of dehydration after the home has been cited for violations numerous times, has been made to come up with a plan for correcting the deficiencies leading to harm, but continues to neglect its residents?

The Courant also notes that these nursing homes are owned by limited liability corporations in a maze of three and four-tiered structure, such as the New York Times exposed earlier this year. [See Choosing a good nursing home for your loved one, September 23, 2007] Families can spend a year or more suing a nursing home to recover damages for the needless death of their loved one only to learn that they sued the wrong corporation.

See No Haven for the Elderly: Nursing Home Troubles Show Lack of State Oversight.


Stronger FDA warnings for Procrit, Epogen, & Aranesp
2007-11-09T11:40:50-05:00
Additional boxed warnings and label updates for the erythropoiesis-stimulating agents Aranesp, Epogen, and Procrit have been approved by the FDA. 

Ths issue causing the new warnings relate to drugs dosages that raise hemoglobin levels over 12 g/dL.

Research shows these high dosages stimulated tumor growth and decreased survival in patients with certain cancers: advanced breast, head and neck, lymphoid, and non-small cell lung cancer. It is important to note that researchers have not ruled out higher mortality and tumor progression when hemoglobin rates are raised to levels under 12 g/dL.



Chronic renal failure patients taking these drugs in order to keep hemoglobin levels over 12 g/dL are at increased risk for death, stroke, heart attack, and heart failure. For these patients, the FDA in recommending that hemoglobin levels be maintained between 10 and 12 g/dL.



FDA press release (Free)



Earlier Blog articles related to initial FDA warning, dosing change for erythropoietin 



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