Aging Parents Have Health Directives–(Health Care Proxy, DNR etc.) Now What?

Dentist’s vetting Aging Teeth-2 post not back in time. Thus, thoughts about Tuesday’s NY Times’ New Old Age Column “Where is That Advance Directive?” generates this replacement post.

Much time, thought, and energy–under the best of circumstances–go into planning end-of-life directives. In the olden days this no doubt consisted primarily of a will. Today, in our more complex society, additional important aspects of Estate Planning impact not only who is beneficiary of our worldly goods after death, but–on earth– our very life itself.

4 previous posts have addressed aspects of this subject: Health Care Proxies, Do Not Resuscitate orders, Power of Attorney, family disputes, remarriage to name some. The October 17, 2013 New Old Age column focuses on bringing one’s advance directives to the  hospital.

We never know when something serious could happen that sends us to the hospital; and I doubt any of us keep advance directives in our purses, wallets, or smartphones. Thus, this New Old Age column (which instructs us to give copies to our primary care doctor, “health care decision-makers” and keep copies for ourselves) is worth the quick read.

Check out the related posts below, especially noting the importance of adult children’s knowing where important end-of-life papers are (or–conversely–if parents don’t want adult children to have this information ahead of time, how to handle it).

Related: The Astors and Us
                12 Key Pieces of Information Children of Aging Parents Should Have
                Aging Parents, Adult Children: Control and End-of-Life Issues
                Aging Parents and Emergencies: First Responders, 911, Hospitals

                Acute and Critical Care Choices Guide to Advance Directives
(Am. Assn. of Critical Care Nurses) Excellent!
Copy and Google
(it downloads from Google much faster than linking from our blog)

Changing weekly: “Of Current Interest”(right sidebar). Links to timely information and research from top universities about cancer, dementia, Parkinson’s, plus some free and some fun stuff–to help parents age well.



Aging: Life Can Change in an Instant. Are We Prepared? cont. 7 “To-Do’s”

RHW’s wife, in essence, had neither control nor a Plan B.  She stepped back, relying on her husband’s good judgment, accepting the fact that he was going to consult one other specialist, then proceed as he thought best. All worked out well, but not without stress and worry. A pre-thought-out/pre-discussed plan for such emergencies would have–no doubt– made decisions easier.

Perhaps businesses do better in this regard when they require employees’ emergency information and keep it on file. A friend’s sister, (a widow on Medicare) had a seizure while at work. Her first ever seizure. 911 was called immediately and she was taken to the nearest hospital for stabilization and evaluation.

What about her emergency information? She listed just one person to call in an emergency. A MISTAKE– list at least 3 people if possible. 1st person was her adult son, a teacher. He couldn’t be reached–his class was on a field trip, scheduled to return after school hours. Her granddaughter (from another country) was in the US for the summer, working nearby; she was young; clueless about making health care decisions. The initial major decision: which (of 3) hospitals’ neurological centers should her grandmother be taken to. Evidently 911 responders made the decision. Several hours later the adult son made the decision to have his mother  transferred to a different hospital for further treatment. It was a good decision, made under tough circumstances.

7 “To-Do’s” can help us prepare as well as possible 

1.  Make time to sit down with aging parents, discuss and prioritize whom to put on an emergency contact list, their relationship or reason for being on the list. Include a person knowledgeable about healthcare management in the event others on the list aren’t available. Know what hospital(s) they prefer–or their doctors are affiliated with–should there be an emergency.

2. Make the contact list (3 people). Keep it in an easy-to-find place. 

3. Two additional lists–medications (dosage and frequency) as well as list of allergies and medical issues–keep with the contact list.

4. If parents have a Do Not Resuscitate (DNR) directive, it’s essential that 911 responders (if called) have–or can easily find– the DNR (otherwise they must do all they can to save a life).

5.  When elders have a good mind and want to participate in–or dictate– actions taken for their care, we need to ask ourselves “what’s the goal” (as did RHW’s wife); then decide how involved we need to be.

6. For elders still working, it’s important that their emergency contact information at work stays updated.

7. US News’ Best Hospitals yearly publication in July is an invaluable resource and good conversation-starter. This link from CBS News about the 2013-2014 publication contains a video with excellent additional advice–including having an “electronic healthcare buddy.” Don’t miss it. 

Yet, with our busy lives, will we set aside time for the 7 to-do’s? We know, intellectually, that being prepared saves time. In our situations it can help parents age well–or at least better–and save us some additional stress

Aging Parents and Emergencies: 911 Responders, DNR and Hospitals

When Mother Almost Died

In our attempts to help parents age well, one may wonder why Eloise (last post), who was living alone after her husband died, placed DNR post-it notes (see last post) throughout her home. The answer:

Advance directives do not take effect in 911 emergency situations. All 911 responders are legally bound to exercise every life-support measure possible unless there is a legally valid, state-recognized do-not-resuscitate (DNR) order completed and presented to the 911 responders….(Once the patient is in the hospital, 911 procedures are no longer in place and advance directives can take effect.) Courtesy “Acute and Critical Care Choices Guide” see link below.

I wasn’t aware of the above and how it plays out, especially in old people, until an incident with Mother required us to call 911.  Mother ended up in Emergency.  Likewise I wouldn’t have understood the reasons for Eloise’s DNR post-it notes–so deliberately placed neither you nor a responder with much less than 20/20 vision could miss them.

In Mother’s case, she almost died due to a heart valve issue we were unaware of. After calling 911 we quickly followed the ambulance to EMERGENCY. It took time to park our car. By the time we were ushered to one of the emergency room’s little rooms, they were “working on” Mother and whispered they weren’t certain she would “make it.” The next hour would tell.

She did “make it” and was flown 100 miles to Los Angeles to a heart valve–or something akin to that– top surgeon. Should I add that the ambulance, driving Mother from the plane at LA’s airport to the hospital, was hit by a car, causing a small accident? Dad and I–driving– arrived at the hospital before Mother. “They’ve lost Mom!” I remember exclaiming to Dad as I’d run (ahead of Dad) to the desk to find out what room she was in, only to learn she hadn’t arrived.

When we all reconnected–approximately an anguished hour later–the nurse assigned to the ambulance had stayed temporarily with mother. She was extraordinary. She not only kept Mother safe and comfortable but Mother, who was evidently conscious throughout, was noticeably stronger and– surprisingly–engaged in what was going on.

We spoke with the surgeon, understood the odds of success and agreed he should perform the procedure. When the subject of DNR was introduced, I was clueless. So was Dad. Were we dooming Mother to death if the DNR order was in effect and the surgery didn’t go as hoped? Would it be worse if she lived in a diminished state, kept alive by modern medicine, as a result of the surgery and no DNR?

DNR was a new term– never discussed before–creating an especially difficult decision at a time of major stress. If surgery was to be undertaken, it had to be asap. A quick decision was in order. Thankfully we never had to use the DNR.

For those who aren’t knowledgeable about advance directives (living will, medical power of attorney)

There’s a wealth of information available, suitable for beginners. The Acute and Critical Care Choices Guide to Advance Directives from the American Association of Critical-Care Nurses.  (Note: Link’s download from our blog is very slow. It’s faster to copy title and paste into Google and link from there.) Written in 2005, it’s easy to read, and has simple chapter headings ie.”What Are Advance Directives,” “Emergency Medical Response 911,” “Frequently Asked Questions About Advance Directives,” and “Key Points” which links to state-specific information.

The guide is instructive and simplifies complex information.  Check out the short chapters that are of interest. In our endeavor to help parents age well until the end, having this information–and making certain that the elderly we care about have advance directives–can save major emotional upset at a time when sound reasoning is called for.

Hospitals, Care Facilities: What We Don’t Want for Aging Parents–Part 2

Part 2 continues with the conversation overheard behind the curtain…..

Daughter: Hi! You’re looking great, Mom. You’re comfortable now, huh? OK…that’s OK”  (sigh)     Horrible noise comes from Mrs. S.

Daughter“It’s awful–(pause)–Sally and Tom are downstairs and the kids are at camp…..”  Another noise from Mrs. S evidently signals recognition of another person who had just made his/her presence known.

Daughter“I wore your watch today, mine broke.”

New Voice: “Hi! I love you.”

Daughter“Betty’s here.”

Betty“Hi Ruth. Gotta smile today?”…. (quietly) “See the tears?”

Daughter: “OK, Mom. I know, I know it’s awful”……(long silence, perhaps rearranging the pillows)

Betty“You look much more comfortable–she looks much more comfortable this way…..”

Male voice“She looks good anyhow–and she looks better than she has. You’re a strong lady, Ruth.”  (An awful loud burp from Mrs. S.)

Voice“It’s good when you can cough–makes you feel better….I know it’s rough and you don’t want to be here.”

More conversation then–
Daughter“Mom, we’re gonna go. OK?” (pause). “OK?” (pause). “It’s OK–OK? Have a good night’s sleep, OK? See you tomorrow.”

And beneath the curtain I watched the stylish sling-back, high heel sandals turn to depart.

During the conversation a male family member became visible on my side of the curtain at the foot of my bed. I acknowledged his presence but it created a moral dilemma for me. Should he know about Mrs. S’s experience the day before? If I didn’t say anything, who would?

My counseling skills surfaced and I settled on something like “I know how hard it must be.”

“It’s like a kick in the butt,” he responded, obviously sensitive to and upset by Mrs. S’s situation.

“She had a difficult time yesterday,” I offered. Pulled out her IV tube, pulled out her nasel tube. You might want to ask the nurse about it.” 

The following day a nurse and an orderly came in and Mrs. S and her possessions were wheeled out of the room. “Where’s she going anyway?” asked the third occupant of our  room.

“Six-South. She won’t be coming back.”
*                          *                         *                          *                         *          

Can  we assume Mrs. S had no advance directives–given no one medical power of attorney? Remember this was several decades ago. If she did, one wonders if she directed that her children make all the decisions or if she ever discussed her wishes with them.

On the other hand, if we want more control at the end of life, meet Eloise, who lived alone in their home after her husband died. Alert and active, she worried about enduring a helpless last stage of life. She left DNR (Do Not Resuscitate) post-it notes where they couldn’t be missed. She filled out her living will, health care proxy, power of attorney documents, completed all other documents and told any contemporary who would listen, to do the same. She unfailingly reviewed her final wishes with her doctor at each appointment and made everyone she knew aware of them. At age 95, after attending a luncheon and lecture, she went home, took a nap, and died in her sleep.

If we’re fortunate, we prepare ahead like Eloise and exit like Eloise. What if we aren’t as fortunate? Yesterday’s Part 1 post  generated one comment. Think about it.We can have everything in place, but unknowingly set things in motion that we can’t control.  For instance, advance directives do not take effect in 911 emergency situations. (Emergency medics are legally bound to try to save a life–probably never know about a person’s advance directives.)  Worrisome? More on this next post.

We try to help parents age well until the very end, but “stuff happens.” How can we protect against that happening?