Good Communication Is Often a Scarce Resource

Speaking Stones?

Is Communication a Seasonal Thing?

In my experience working with elders, communication with loved ones can be fraught with difficulties.  Sometimes it can be a dialogue based on relationship and sharing of information, but it can also be a monologue forced onto others by one person (often an adult child) who strives to control the narrative of the family.  The “silent generation” needs to speak up!

Communication can be defined simply as:

a process by which information is exchanged between individuals through a common system of symbols, signs, or behavior

I draw attention to this because it is part of the “holiday season” that causes many people undue stress during the months of November and December!

Money Smart for Older Adults

With the goal of starting a discussion about empowering better communication by elders, I’m sharing a link to a newly published document called “Money Smart for Older Adults.”  It’s a resource guide published by the CFPB, which is known now as BCFP it appears, along with the FDIC.  It’s not a short document (weighing in at 100 pages) and would take some time to read – but it’s chock full of lots of resources.

It has some good information about scams, but keep in mind that most scammers are quite sophisticated and tend to “update” theirs tactics as well as tailor their scams to particular communities or individuals they target.  Think of the scammer as like a virus in this respect!

I think a most crucial factor, particularly for members of the “silent generation” is to communicate: ask first whether the person you have in mind will agree to help you.  This means that an elder should be careful about whom they ask to serve as agent for them under a durable POA.  It may seem like a given that an elder would first ask a family member or friend if they would be willing to serve, but when people think that disability and estate planning is just about filling out some forms, disaster can follow!  This can be hard for people of a certain age, who may not want to be sharing all these details about which they have remained mum most of their lives, but it is the best policy. Why?

Why the Silent Generation Needs to Speak Up

People should tell others whether they have a POA as well as who is the nominated agent so that others can help monitor things and look out for the interests of the elder.  Communication about our weaknesses, shortcomings or frailties is seldom easy for most of us, but when we name people to assist us, it can be helpful for others to know we have made such arrangements as well as who those people are.  For example, in case a neighbor knows that an elder is facing a particular health challenge and really needs help, the neighbor will know that the elder has already made plans and that the agent can be contacted and notified of the elder’s need for assistance.

Another reason to communicate wishes is to clarify the wishes in advance so that there are no surprises in the event of some accident or catastrophic event.  Sometimes there is an adult child who has a chip on their should or perhaps an overweening sense of entitlement, and this child may be sorely disappointed to learn of the parent’s choice of agent when the elder faces a difficult decision about which they may or may not be capable of deciding.  Making one’s wishes known well in advance can often “soften the blow” to such a child, but in the end, it may be of little assistance.

If an agent knows that there are others who might be looking over their shoulder, the agent may take better care of the principal’s interests.

Some Parents Need to Protect Themselves Against a Child Who Wants to Control The Parent

At the other end of the spectrum, I see quite a bit of “misery loves company” behavior as well.  In this type of scenario there is one child who has been selected by the now-incapacitated parent who is effectively being punished by a child who feels left out or believes she should be entitled to make the decisions for the parent – this notwithstanding the fact that the parent did not select that child for such a decision-making role, usually for good reason.  To my mind, there is a fair amount of litigation that is fueled by the “let no good deed go unpunished” and this is very unfortunate.  But I digress….

Over the years, I have only spoken with a few people about including a “POA protector” in the POA document, but it may be that including such a role can be beneficial to a principal and also serve to protect the agent against the hostile actions

I s there anything that can be done about this?  Some trusts are written which name a person known as a “trust protector,” and it may be time for a similar type of office to be created for the POA – like a POA protector.  This can be a third person who keeps an eye on the agent’s record keeping or bookkeeping.

And don’t forget. . . Today is Giving Tuesday! You say you’re not familiar with this new tradition? It’s been around for over six years and it’s dubbed “a global day of giving fueled by the power of social media and collaboration.”

© Barbara Cashman www.denverelderlaw.org 2018, all rights reserved.

Medicare and the Midterm Elections?

On the threshold

The Future of Medicare as We Know It Will Be Affected by This Election

Medicare is the federal health insurance program for people who are 65 and older and a small group of other folks.  It consists of several parts: Part A (Hospital Insurance), Part B (Medical Insurance, which covers doctors’ services, outpatient care, home health services, and other medical services), and Part D (which covers outpatient prescription drugs).  The Congressional Budget Office states that

Nearly all Medicare beneficiaries enroll in the program soon after they become eligible, typically either at age 65 or two years after they qualify for Social Security Disability Insurance benefits. Part A benefits are paid from the Hospital Insurance Trust Fund (funded largely through payroll taxes); Part B and Part D benefits are paid from the Supplementary Medical Insurance Trust Fund (about 25 percent funded by premiums paid by enrollees and about 75 percent funded from general revenues).

I know of baby boomers who aren’t yet able to retire and qualify for Medicare who put off major medical care (to the extent is feasible) until they are covered by Medicare.  Medicare, such that it is, is a bright spot for most Americans who are retired.  But things are changing!

But Medicare may be under attack – at least according to Save Medicare Now,  whose website* lists these good questions to ask our elected officials and candidates:

•What specific steps will you take to preserve and strengthen Medicare for all beneficiaries, whether they are in traditional Medicare or a Medicare Advantage plan?

• How will you make Medicare more affordable for all the people who rely on it to make sure they get access to the care they need?

• Will you fight attempts to privatize Medicare by unfairly favoring private Medicare Advantage plans and/or by turning it over to big insurance companies?

• Medicare is a popular program, but there are significant gaps in what it covers, including most oral health, vision and hearing care. Do you think Medicare should cover these things? If so, how do we get there?

• Most people want to remain in their own homes as long as possible, but Medicare makes it hard for people with chronic conditions and longer-term illnesses to get home health care. Will you help ensure that all people who qualify can get home health care under Medicare?

• Some hospitals pretend people haven’t been formally “admitted” and are just “under observation” so they must pay out-of-pocket for nursing home care after they leave. Would you support pending legislation that would count all time a Medicare patient spends in the hospital toward the 3-day requirement to get nursing home coverage? What about removing the requirement altogether?

• At best you can generally get only 100 days of nursing home coverage if you are on Medicare. Do you think Medicare should include a long-term care benefit? If so, how would you accomplish that?

What Can We Do About Our Ever-Rising Health Care Costs?

This seems to have become something we all expect – that health care costs continue to rise in this country and as the baby boomers age, and these result in greater per capita costs to Medicare.  Did you know that the Affordable Care Act helped to reduce Medicare spending?  Remember all those tax cuts from earlier this year?  Many of the people left behind on those tax breaks are going to start feeling the pinch soon. The midterm elections may determine whether our elected officials in Washington choose to strengthen Medicare or to gut it.

If this is news to you, consider that cutting Medicare is one way that some members of Congress would manage the deficit.  This is an interesting development, particularly considering that a “Medicare for all” options is becoming more popular, even among Republicans.

Hmmm…. Maybe we need a health care revolution to stop our bleeding?

I often wonder when the credit agencies will start asking folks not what their monthly rent or mortgage payment is but rather what their monthly health insurance premium is!  My monthly premium for my HSA qualified plan (among the cheapest available) continues to rise and for the last couple years it is larger than my mortgage payment!

That’s all for now and don’t forget to return your ballots on time!

*Thanks to Professor Rebecca Morgan, a contributor to ElderLawProfBlog for psoting about the Center for Medicare Advocacy’s  website Save Medicare Now changes to Medicare.

©2018 Barbara E. Cashman, www.DenverElderLaw.org

 

 

Memento Mori: Bringing Death Into Conversation

Memento Mori – from Kirkwall, Orkney Islands

Memento Mori: Remember Death, That You Will Die

Last weekend I attended the International Death Symposium in Toronto, Canada. I went with a friend who is a Canadian death midwife.  We both enjoyed it. It was a rather extraordinary place to be, amidst an entire community of folks committed to dispelling the death taboo.  The presenters and attendees were Canadians mostly, some Americans and an Irishman who spoke eloquently about his father’s death and wake.

So, what is conversation anyway?

Definition of Conversation

1 obsolete : CONDUCT, BEHAVIOR

2a(1) : oral exchange of sentiments, observations, opinions, or ideas

… we had talk enough but no conversation; there was nothing discussed.

—Samuel Johnson

(2) : an instance of such exchange : TALK; a quiet conversation.

Of course, I couldn’t mention “conversation” without a reference to The Conversation Project, which is a very useful tool to help people (like many of my clients) toalk about the end of their lives and express their wishes and values around that part of life.

In this post, I’ll share a couple highlights from the symposium. One of the “rocks stars” who presented was BJ Miller, a hospice doctor from San Francisco.  You can watch a video here about the “problem of death” in our medical delivery system.  Part of his presentation at the Symposium addressed the conflict of aesthetics of caring for the dying and the widespread use of anesthesia.

Aesthetic versus Anaesthetic

My late mother, an R.N. who received her nurse’s training through the Nurse Cadet Corps, would have been thrilled to hear an M.D. make reference to the work of a nurse.  The nurse was none other than Florence Nightingale, the “mother of nursing,” who wrote about the aesthetics of caring for patients.  Miller contrasted Nightingale’s insistence on aesthetics – a set of principles concerned with the nature and appreciation of beauty – with the current widespread use of anaesthesia (or anesthesia in the US) which is the numbing or rejection of aesthetics in favor of

Insensitivity to pain, especially as artificially induced by the administration of gases or the injection of drugs

In this place of intersection between our ability to sense and perceive beauty with the selfsame capacity to sense pain, what do we make of our commonly accepted and pervasive use of drugs in this country (and so much of the west) to numb us down to “ease our suffering” regardless of where in our lives we encounter that suffering?  It could be at the end of our life, somewhere in-between for a surgical procedure, or it could become a lifestyle treatment for anxiety and depression.  Does it matter where the suffering occurs for which we seek anesthesia?

Our Sense or Capacity to Appreciate the Beautiful is Inextricably Linked to Our Capacity to Feel Pain

Isn’t the pain of dying just the pain of living at a time of greater uncertainty?  Why do we pretend we can draw the distinction so clearly –  particularly during a time of unprecedented numbers of people dying of drug overdoses?  I’m not talking about the present opioid crisis – a recent study has shown that our current opioid overdose epidemic actually began forty years ago and has been increasing – exponentially – since then!

How and why we distinguish between the pain of living and the pain of dying . . .  well, that’s a topic for another blog post!

I’ll write more soon about the Symposium.

I’ll close with Emily Dickinson’s Because I Could Not Stop For Death

Because I could not stop for Death –

He kindly stopped for me –

The Carriage held but just Ourselves –

And Immortality.

 

We slowly drove – He knew no haste

And I had put away

My labor and my leisure too,

For His Civility –

 

We passed the School, where Children strove

At Recess – in the Ring –

We passed the Fields of Gazing Grain –

We passed the Setting Sun –

 

Or rather – He passed us –

The Dews drew quivering and chill –

For only Gossamer, my Gown –

My Tippet – only Tulle –

 

We paused before a House that seemed

A Swelling of the Ground –

The Roof was scarcely visible –

The Cornice – in the Ground –

 

Since then – ‘tis Centuries – and yet

Feels shorter than the Day

I first surmised the Horses’ Heads

Were toward Eternity –

From The Complete Poems of Emily Dickinson, Thomas Johnson, ed.

That’s all for now, next time I’ll post about the Phone of the Wind, a.k.a Kaze No Denwa

© 2018 Barbara Cashman  www.DenverElderLaw.org

More about Preventing Elder Abuse With Prosocial Behaviors

Who You Callin’ Stubborn?

 

This is a follow-up post about WEAAD.  Elder abuse is a phenomenon that affects not just the victim of abuse, but threatens the fabric of our community.  Besides mandatory reporting, prosecuting perpetrators and enforcing existing laws prohibiting elder abuse and exploitation, there are prosocial behaviors which can serve as powerful and effective preventive interventions to guard against the isolation and vulnerability which often lead to elder abuse.

What Are Some Examples of Prosocial Behaviors?

The term was coined as an antonym of the more prevalent term “anti-social” behavior.  It comes in many different theoretical forms, but they all recognize that we humans are social beings and depend upon one another, notwithstanding many of our “atomistic” beliefs about who we are and how we interact with each other.  In this respect, prosocial behavior is tied to our very survival, but a functional approach is what I’m concerned about here because I’m looking at ways to foster elders remaining visible members of our community.  The basic behviors might include: demonstrating concern for others, sharing time and resources, caring for others and active empathy.

Isolation as a Precursor to Elder Abuse, Inclusion as the Antidote

It may not occur to many of us that someone’s ability to live independently in the home – a/k/a aging in place, can have disadvantages and drawbacks.  From my experience, I see plenty – but don’t get me wrong, I am definitely not against aging in place!  I am concerned that sometimes it gets glamorized in unhelpful ways.  I have seen some elders dig in their heels at the suggestion by loved ones that they bring in some help to perform household chores or share in meal preparation.  In its worst expression, it becomes a vow by the elder that they will only be removed from their home “on a gurney.”

How Our Focus on a Rights-Based Approach to Elderhood Often Overlooks the Prosocial Activities of Inclusion and Participation

Most elder abuse occurs in the home.  Many elders face abuse and abusive situations in skilled nursing facilities or other facilities and these tend to be the attention grabbers.  I think of this fact when I read the ruling on appeal issued by the U.S. Tenth Circuit Court of Appeals last May, which upheld a jury verdict of $1.21 million in damages against an operator of an Oklahoma City, Oklahoma nursing home for abuse of one of its residents by nursing home employees. Keep in mind that nursing home administrators have many resources to assist them in training and supervising staff, one of these tools is known as TPAAN and here’s more information about it.

Our Collective Fear of Dementia Often Means We Shun People Affected by Dementia

When we’re talking about elders aging in place, we have to consider folks with dementia.  People with dementia have trouble thinking and sometimes their loved ones in particular (most of whom have no special training in communicating with people with dementia) or other community members have a difficult time not correcting those errors in thinking, cognition or memory impairment.  But what if we looked at those “errors” not as errors but simply as a different way of being in the world?  How could we get through to see and listen to someone in that different world the person with dementia inhabits?  Remember, there is still much opportunity for communication, which can and does still happen.  The more challenging question is how we can facilitate it.  I think of music and its use in Alive Inside and I recently learned from a Canadian friend of the Butterfly Model, a new version of person-centered care that recognizes that

for people experiencing dementia, feelings matter most, that emotional intelligence is the core competency and that “people living with a dementia can thrive well in a nurturing environment where those living and working together know how to “be” person centered together”

We Can Still Be in Relation With A Person Whom We Struggle to Understand

This person-centered care is a relational way of engaging with a person affected by dementia. It also reminds me of Naomi Feil’s validation therapy, which is also relational.  So, this leads me to the inevitable question, can people engage in this type of relational work without specific training and/or outside the context of institutionalized care?  I will write more about this soon….

©2018 Barbara E. Cashman, www.DenverElderLaw.org

Dreaming Into Dying: A Practice for Letting Go

 

dreaming-into-dying

Patience

I thought since last week I wrote on the topic of dreaming into retirement, well – why not take it a step further and look at dreams of the dying or dreams of death?

Research Into Dreams of the Dying

Here’s an interesting article from the New York Times February 2, 2016.  The story is about some work from a team of researchers led by Dr. Christopher Kerr at Hospice Buffalo.   The study was conducted with fifty-nine terminally ill patients, nearly all of whom reported having dreams or visions, most of which were comforting.  The article noted that

The dreams and visions loosely sorted into categories: opportunities to engage with the deceased; loved ones “waiting;” unfinished business. Themes of love, given or withheld, coursed through the dreams, as did the need for resolution and even forgiveness. In their dreams, patients were reassured that they had been good parents, children and workers. They packed boxes, preparing for journeys, and, like Mr. Majors, often traveled with dear companions as guides. Although many patients said they rarely remembered their dreams, these they could not forget.

Reading about “traveling companions” reminded me of a dream my father related to me some weeks before he passed away.

Dreams and Dying as Part of Life’s Process Toward Completion

The article and the research it discusses are remarkable because it addresses one of the taboo subjects around dying as a life process – is there preparation for it with our psyche’s assistance (through dreams or visions) and whether persons sometimes know in advance that death is imminent (notwithstanding the lack of knowledge of an illness).  Our cause and effect, materialist-objectivist obsession with measuring what we can know (or pretend to know, if enough people are in agreement) generally simply denies outright the mystery of the end of life.  But as more people die at home or with hospice and palliative care providers who are not leading a pitched against the “enemy” – collectively disease and death – it seems that we are gaining more personal experience with death and dying.  It might represent a gradual questioning or moving away from the model of technocratic dying in hospitals, where expressions of our relationship with and compassion for dying loved ones generally had to be subjected to the intrusions of our medical-industrial establishment and its protocols administered by “experts.”

A Scientific American Mind article entitled “Vivid Dreams Comfort the Dying” also explored Dr. Kerr’s work, which was published in the American Journal of Hospice & Palliative Care.  It seems that the conclusions are likely to be consistent with dreams of dying and deathbed visions and visitations recorded throughout history: that most of the time the person is comforted by the dream or vision of their impending demise, as if Psyche were assisting with the transitions as a kind of midwife.

The Experience Is More Likely to be Labelled a “Vision” if it is Comforting to the Dying Person

If the experience is upsetting to the person, typically a patient receiving hospice care, it might otherwise be termed a “hallucination” or “delirium.”  But I like the unequivocal language of this post from Crossroads Hospice about end-of-life visions:

These visions are not hallucinations or a reaction to medication. The most important thing to do if your loved one is seeing visions or having visitation dreams is to acknowledge and support them. Do not argue with your loved one about the experience, correct them, or try to explain the vision. Do not panic as that can upset your loved one. Instead, take them at their word and encourage them to share the experience with you.

“As a caregiver, it is not our job to prove, disprove, or do experiments,” says Carolyn. “We are there to provide support and comfort.

In most cases, these end-of-life visions are indeed a source of great comfort to the person experiencing them.

It’s reassuring to know that as more people are able to die at home with support from hospice care provided, this aspect of the death taboo is losing more of its sting.  A link to one last resource guide is in order, this one McGill University called “Nearing the End of Life: A Guide for Relatives and Friends of the Dying.”

© 2017 Barbara Cashman  www.DenverElderLaw.org

 

Dreaming Into Retirement Planning

Dreamtime Batik

I recently ran across an article by financial “coach” Chris Hogan  about the importance of having a dream to inspire us to plan for and to carry out our plan for retirement.

Hogan’s tactic is to motivate, not intimidate or strike fear. His book “Retire Inspired: It’s Not an Age, It’s a Financial Number” and if you’re interested in listening to one of his podcasts, here’s a link to that.

I liked this idea and of course it wasn’t new.  I thought of Richard Leider, the author who penned the book “Life Reimagined” in 2013 and has championed risk-taking for folks over 50 while cautioning us against being a “former” anything in retirement.  You can watch his Ted x talk about the importance of finding your purpose, particularly to motivate retired people to get out of bed in the morning.

Can we dream into our purpose when we are facing retirement?

Dreaming can, at any time or stage of our lives, help us find our place in the world and to help identify the challenges which face us.   Dreams can help us construct our own personal mythology, our story in terms of what we are here to do and how we are meant to be in this world.

I suppose it depends on how you define “dreaming “of course  – and whether we work on the dreams or they work on us.  I am rather fond of Dr. Jung’s quote from Dreams, Memories, Reflections, which he wrote when he was eighty-one:

Who looks outside dreams; who looks inside awakes.

It’s a rather slippery slope, isn’t it?  Particularly for us Americans who have always felt so strongly about being in charge of our lives.  We who know such boundaries and demarcations flowing from our sense of autonomy. Retirement forces us to think differently about what we do with the rest of our lives.  We often thing about this as a sad, backward gaze, held and nurtured for its lost glory.  But it can be a time for us to lighten our load of our thinking about our lives and about its doings.  Perhaps it can be liberation.

Leider talks about the three “M’s” of money, medicine (health) and meaning – the fundamental things that help us identify what we really need so we can be free to leave behind the other things that may simply distract us.

I think for many of us the fear of retirement, and why we are loath to plan for it, is that we don’t want to allow ourselves the space to dream because, well, it might not be what we think we “always wanted” or what was expected of us.  I think it also has a lot to do with our fear of aging in general as the run up to the inevitable end of our lives.

So what to do in the meantime?

Start dreaming, particularly your own dream, not someone else’s!  And if you don’t want to dream because it sounds too silly, then take Leider’s napkin test and see if you can pull that off!  Get together with a loved one or colleague and take “the napkin test” to discover what is really important to you, what gives you joy and allows you to feel connected to others.  Stop and reflect.  You can watch (on Daniel Pink’s website) a one minute and twenty second video featuring Leider explaining how to do this

I’ve condensed a bit of Hogan’s advice here from that Washington Post article above:

  • A secure retirement isn’t accidental;
  • Dream your dream and make a plan that will get you to that dream;
  • Execute the plan with a commitment to do what is necessary to bring it to fruition.

Lastly, here is another article by Hogan about  What do you need to do to retire with $1 million?

Happy dreaming!

© 2017 Barbara Cashman  www.DenverElderLaw.org

The Eclipse and the End of Life As We Know It

True Illusion

The eclipse that is set to occur on Monday, August 21, 2017 is a big deal. I have several friends who are traveling to get a better view of this event.  One couple I know is going to Fort Laramie, Wyoming and other friends to McCook, Nebraska.  Here’s a handy map that shows the strip of total eclipse. Based on my research, the last coast to coast eclipse in the US was ninety-nine years ago.  I remember seeing a partial eclipse in Denver almost thirty years ago.  It was pretty cool.  So, if you want to “prepare” for this eclipse, go to this link on the NASA website.  After all, it’s set to last for nearly three hours, reaching its maximum at 11:47 a.m. in my neck of the woods.

So what is it about the eclipse that would cause me to couple it with. . . the end of life?!  Well, here goes.

The word eclipse comes from the Greek ekleipsis, which means abandonment, cessation, failing, omission or flaw.

But remember that the eclipse merely obscures the sun from our sight – the moon appearing before the sun to block it does not extinguish the sun, but from our eyesight-based superficial understanding of what we think we see. . . . well, what’s the difference?

It’s a matter of vision, not eyesight.

Perhaps we eclipse-seekers are simply in search of awe, what some of our forebears would call miracles. Where should we search – in the familiar places or the unfamiliar, even uncomfortable ones? That’s hard to say. Few of us look for that awe in the mundane and everyday, but that is almost always where it seems to be found, discovered, seen.

This awe can cause a cognitive shift in our awareness, as in the “overview effect.” The term was first coined by Frank White in his 1987 book The Overview Effect — Space Exploration and Human Evolution and is described in this Wikipedia entry as

the experience of seeing firsthand the reality of the Earth in space, which is immediately understood to be a tiny, fragile ball of life, “hanging in the void”, shielded and nourished by a paper-thin atmosphere. From space, national boundaries vanish, the conflicts that divide people become less important, and the need to create a planetary society with the united will to protect this “pale blue dot” becomes both obvious and imperative.

It strikes me that this eclipse, and its draw to our experience of life, is not unlike the awe at the end of life. The drawing and that movement is perhaps generated in different directions so to speak. We can “attend” the eclipse and experience it in ways we enjoy, but the end of our life demands a different kind of presence – one no less awe-some, one that we may think we are not quite ready to experience.

In his book Places of the Heart: The Psychogeography of Everyday Life, Colin Ellard looks at places of awe.  At 154 of the book he looks at research into experiences of awe which focus on two essential aspects: a feeling of vastness and a sense of accommodation.  Vastness is the feeling of hugeness and grandeur, while accommodation describes our response to what created the feeling.  Ellard notes this often involves contradiction. An excellent article on awe (and its self-diminishing aspects) and prosocial behavior can be found here.

What is the inevitable here? We can easily face and even celebrate the inevitable when it is. . . . not too close and personal!  But what of dying and how can we recognize it as it approaches and obscures our sight ? Most of us don’t want to see death coming, so we turn away!

When people refuse to have the conversation about dying and its uncertain circumstances, to name or appoint someone to speak for them in the event they are unable to do so on their own, well – then the doctors will decide for you.  Here’s an interview with Dr. Jessica Zitter, ICU and palliative care doc and author of Extreme Measure, a book about the ethics of end of life medicine. Thanks for sharing that with me Georgine!

So maybe there is some preparing we can do for the eclipse(s) of our life. . . .   I think these Buddhist sayings (dhammas) sum up this essential changeable quality of our nature and that of the cosmos most succinctly:

I am of the nature to decay, I have not gone beyond decay.
I am of the nature to be diseased, I have not gone beyond disease.
I am of the nature to die, I have not gone beyond death.
All that is mine, dear and delightful, will change and vanish.

It’s a hard place to just be, to be with the uncertainty – will there be a sun that returns after the moon passes over it completely?

The eclipse of –  disease, misfortune, old age, fear of change, death.

Perhaps we can see this eclipse opportunity as an invitation, a path, to assist us in recalling how to revere, to feel deep respect or awe for something, for our relationship with the world and with each other.  In this respect, we remember reverence through nature – our nature – not outside, but inside each of us.

© 2017 Barbara Cashman  www.DenverElderLaw.org

When the Decedent Was a Hoarder

Tightrope

What is hoarding? I like this simple definition from the Anxiety and Depression Association of America.

Hoarding is the persistent difficulty discarding or parting with possessions, regardless of their actual value. The behavior usually has deleterious effects—emotional, physical, social, financial, and even legal—for a hoarder and family members.

Hoarding is “officially” a disorder, meaning it was reclassified as such in the Diagnostic and Statistical Manual (DSM-5) in 2013.  Prior to its recent “promotion” to a disorder, it was considered an aspect of obsessive-compulsive disorder, so many folks who suffer from OCD (or OCPD) are also hoarders. Hoarding has also been linked to attention-deficit/hyperactivity disorder (ADHD) and depression. Sometimes hoarding may be associated with an eating disorder like pica (eating non-food materials), Prader-Willi syndrome (a genetic disorder), psychosis, or dementia.

Hoarding for elders can be indicative of depression and/or anxiety and for those elders who may have been “pack rats” in younger years, the compulsive habit can worsen in later life.  Here’s a link to a University of California at San Francisco study that looks at elders’ hoarding as a health concern.  That study concludes that hoarding in elders often seems to worsen and becomes more problematic, but for reasons that remain unclear.

How does hoarding impact one’s life? There seems to be, to a certain extent, an inverse relationship of stuff hoarded to quality of life. The more stuff clutters a home, the unhealthier and more dangerous can be the living conditions. Shame, fear of judgment, distrust of others being allowed in to the hoarder’s living space can contribute to the hoarder’s sense of isolation.

It seems straightforward that an elder who has a dwelling place crammed full of junk is much less likely to allow caregivers into the home or others who might able to otherwise assist an elder with managing the challenges of independent living.

What can be done to help a hoarder while they are still alive?  The answer to that depends on the type of hoarding behavior as the intervention must be tailored to it.  And yes, in case you’re wondering, there is a Hoarders Anonymous, but my antivirus software won’t let me visit their website. . ..

So, this post is about hoarding in the estate context – what does that mean?

It means that the job of identifying the decedent’s assets can be difficult, at best.  Finding relevant information can be extremely challenging or impossible due to the sheer volume of papers collected by the deceased hoarder.  Many years ago, I represented the personal representative of an estate of someone who was a hoarder.  The decedent had died in a skilled nursing facility, but inside her home remained dozens of filing cabinets as well as many boxes of papers.  When I informed the personal representative about some documentation I would need, she informed me that she was fairly certain that the papers I needed were kept in the home, but it would take several weeks to go through those storage places to try and locate them.

What if the deceased was an “organized” hoarder and kept only certain types of items?

Well, that might not be so bad, but I haven’t seen that one yet.  In my experience, there are few “selective” hoarders.  I think that has to do with the fine line between collecting and hoarding!

And if the deceased was an indiscriminate or disorganized hoarder? Well, I don’t think there’s a patron saint of the chronically disorganized who happen to be hoarders – but maybe there should be.  You might recall that Dante’s Inferno, in the fourth circle (of hell) to be precise, identifies the twin opposite behaviors of those hoarders and wasters (or prodigals).  That circle is all about greed as the Fourth Circle of Hell is guarded by Pluto, the Greco-Roman god of wealth:

Here, too, I saw a nation of lost souls,
far more than were above: they strained their chests
against enormous weights, and with mad howls
rolled them at one another. Then in haste
they rolled them back, one party shouting out:
“Why do you hoard?” and the other: “Why do you waste?”

Canto VII, lines 25–30, Ciardi translation.

So, it is apparent that the proliferation of stuff and its unceasing accumulation has obvious negative effects on one’s relationships with others and the outside world in general, but. . .

What can we do about detecting the causes of hoarding and helping a hoarder?

It’s a fine line indeed between “collecting” and “hoarding.”  That Depression-era mindset of scarcity, coupled with distrust (anxiety) about the future – the origin of one’s next meal, etc., can contribute mightily to a worsening of an already latent propensity to collect.  Here’s an article about that topic.

And if you think there isn’t an opposite extreme that people can engage in (see Dante’s reference to the “wasters” above), here’s an article about compulsive decluttering.  The root of the problem may be the link between either type of activity and its origin with obsessive thoughts.

In short, there are ways to help a hoarder – and in particular to avoid making the person (not their affliction) a spectacle of ridicule.  If this sounds like self-interest for the family members of a hoarder, as in those persons who will be responsible for going through the hoarder’s possessions – well it certainly is in their interest to help!

© 2017 Barbara Cashman  www.DenverElderLaw.org

Dementia, Fear and Aid in Dying

Sunset on an Artificial Lake

 

For this first post of June, I am revisiting a topic that has been discussed in previous posts: Alzheimer’s (or other forms of dementia) and the fear of aging.  Combining that volatile mix with the question of assisted dying presents a long list of novel questions.  The topic  was sparked by a phone call I received from someone residing in another state but who was looking for information about Colorado’s End of Life Options Act.  The specific query concerned the caller’s desire to explore options to end a spouse’s suffering from Alzheimer’s disease.  My response was fairly straightforward and I think the caller was a bit surprised by my candor.  I explained that under the Colorado law a patient or “qualified individual” was required to, among other things, have the capacity to give informed consent to the  receipt of the aid-in-dying medication to end the qualified person’s life.  See Colo. Rev. Stat. § 25-48-102(13) defining “qualified individual” and § 106(e) which concerns more details of the individual’s “informed decision.”

The caller was surprised when I explained that the only legislature which has to date considered expanding the aid-in-dying law to dementia patients was Oregon.  The Oregon Senate Bill 893 would allow for those persons otherwise qualified for administering receiving life-ending medications under Oregon’s Death with Dignity Act, except that the  patient who ceases to have capacity to give informed consent can still be given life ending medication if there is a specific advance medical directive which expressly authorizes an agent under a medical power of attorney to collect and administer the life-ending medication if the incapacitated person previously received a prescription for such medication.

Alzheimer’s Disease and other forms of dementia (here I will collectively refer to them as AD) are typically the most feared diseases of post-modern westerners who privilege their rationality (remember the Cartesian mantra “I think therefore I am”) and perceived autonomy over all else.  Further, our techno-medical way of examining aging, of parsing out different functions of one’s life ascribed to different body parts, leads us to believe that whatever form of cognitive impairment – age related or otherwise – might just be a part in need of fixing or a disease waiting to be cured. This type of reductionist thinking refuses to look outside its own narrow pigeon hole. In the meantime, those of us who do not perish will age in our own unique ways and many of us will struggle with its challenges.

Whose fear is it – and whose suffering?

What do we make of this fear of AD and fear of a person’s – er – a personality’s – disintegration?  I think in several important ways it is the same fear as the terror of dying, just a bit more latent and prolonged, and therefore more menacing than death for some people.  I’ll quote from Shakespeare’s Julius Caesar (III.i. 102-105) here, the conversation between Cassius and Brutus:

Cassius: Why he that cuts off twenty years of life

Cuts off so many years of fearing death.

Brutus: Grant that, and then death is a benefit:

So are we Caesar’s friends that have abridged

His time of fearing death.

There are many ways to respond to one’s own AD and to that of a loved one’s.  One way is to project our own fears onto the other person, who appears a shadow of the former self or as completely incapacitated.   But there is no standard response, even though some “conventional wisdom” (I use the term tongue in cheek here) might be welcomed by many who find the disease and its process most bewildering.  A slight detour here . . .

Bewilder is defined in the Merriam Webster online dictionary as (transitive verb):

1:  to cause to lose one’s bearings (see bearing 6c) bewildered by the city’s maze of roads;

2:  to perplex or confuse especially by a complexity, variety, or multitude of objects or considerations His decision bewildered her. utterly bewildered by the instructions.

And what if we break down that verb into a command – be wilder, wild from the noun wild) to be:

1: A natural state or uncultivated or uninhabited region.

2: (the wilds) A remote uninhabited or sparsely inhabited area.

Now back to my topic. . .

My concern is that there are many faces of Alzheimer’s Disease just as there are many aspects to an individual’s response to a loved one affected by AD.  I am thinking particularly of a recent article published in Kaiser Health News, entitled “How to Help Alzheimer’s Patients Enjoy Life, Not Just ‘Fade Away,’” and you can read that here.  The fact remains that each person is affected by AD is his or her own way and the “preoccupation with the cerebral pathology” (which the psychiatrist Dr. David Rothschild criticized in his 1936 paper on the psychodynamic model of senile dementia) often serves to fan the flames of fear and anxiety over our collective preoccupation with the losses of aging.  There are many other paths to choose here – not just the one of least resistance which is fear based.

© 2017 Barbara Cashman  www.DenverElderLaw.org

Planning for Aging

Florentine graffiti… what me worry?

How does one assess the value of planning for one’s retirement, potential incapacity and/or eventual demise?  That is a very personal assessment, notwithstanding that the failure to plan has enormous financial consequences – for the individual, their loved ones and society as a whole.  Perhaps a prime and popular example is the failure to make advance heath directives – including appointing an agent under a health care power of attorney and signing a statement of end of life wishes – a/k/a a living will or in Colorado the Declaration as to Medical Treatment.  Read here for more useful information from the Colorado Advance Directives Consortium.  Many of us, perhaps most, would rather not entertain the idea that our lives will eventually change.  Our lives change every day, but whether we mark those changes is up to us!

“In the beginning is relation”

This famous quote by philosopher and theologian Martin Buber is a favorite of mine.  In my line of work relation and relationships are keys to planning and realistically assessing how far one can plan as well as the extent to which we must rely on others to assist us in the execution of our planning.

Aging and planning can give us the space to reflect on our values, what has been and remains important to us, and planning can also take much of the burden off our loved ones in the event we face a health crisis during we might be unable to make decisions.

I recently came across Sharona Hoffman’s 2015 book “Aging With a Plan,” and found it very insightful.  Hoffman is a law professor and, like many of us who practice in elder law, has life experience with an aging and frail parent.  She uses that experience, along with a systematic big picture discussion of a realistic conversation to consider all the alternatives in making plans for one’s aged self.

Many of us assume that, if we have lived in our home independently for 30+, we would never have an intention of leaving that space of storied independence and autonomy.  I note here that many elders (I’m including a number of clients and others) are coming to understand that there are good and workable alternative options for housing and community involvement that can nourish and sustain one’s basic human need to be part of a community and to contribute to that community.

I liked Hoffman’s approach to her book because it is founded on the importance of maintaining relationships, through social interaction and being useful (at whatever level).  The latter, being useful and having something or someone to take care of, is a fundamental premise in the “green house” nursing home alternative.  You can read about that in an article here from the Atlantic Monthly, or more about Dr.  Bill Thomas in a 2016 Washington Post article.  But I don’t want to get off track in talking about “green houses”  . . . .

So what are the components of a plan for aging? We are all familiar with retirement planning (even if the majority of us barely engage in such planning) and its focus on finances.  I think part of the repulsion in retirement planning is the focus on finances, many people simply find the savings part a difficult conversation and so stop before considering other aspects of retirement planning or aging with a plan.  I consider neither of these often heard comments a plan:  “X will never happen to me because my family doesn’t live that long;” or “if I can’t go to the bathroom or feed myself on my own, then just shoot me.”  We still don’t understand the role of genetics and epigenetics on the aging process very well and not deciding this very grown-up matter of “what happens if” means that we are shirking the responsibility be forcing someone else to choose for us…..

I recommend Hoffman’s book – it’s easy to read and its focus on several practical concerns including: finances; elders driving; person-centered (not disease-based) health care; and the importance of an exit strategy; demonstrate that the book is very useful – for an elder or elder-in training, or for an elder’s family member to assist with the awkward place of overcoming years of inertia.

© Barbara E. Cashman 2017   www.DenverElderLaw.org