planning for the later years

Sunday, August 13, 2017

NFL training camps mark the career beginnings of new stars but also the end of the road for veterans whose desire to play has waned or whose bodies have failed them. Sometimes, the signals marking the end are recognized by the player but for some, the end is marked by a call from the coach asking for a meeting that includes a reminder to bring the playbook.

Life transitions mimic sports timelines in many ways. Decisions that affect how the later years of life are spent often are neglected and delayed, until one day, the choice is no longer that of the person. Instead, circumstances force others to choose where a person might live, how much care they get and ultimately whether treatment should be offered at all.

Everybody gets the concept of financial planning for their later years, but many people fail to get the rest of the planning details. There is always another day to write a will and deal with who gets what, but a will just deals with stuff and there are other more important planning tools that need to be addressed. Living wills, advanced directives, end of life care plans are terms that evoke fear and sadness to the point people choose not to plan how they will be cared for in their old age or in times of medical crisis. Ignoring the paperwork might mean others, perhaps strangers, will try to guess what a person really wanted towards the end of life.

Advanced Directives

Advanced directives, or living wills, write down what type of medical care a person wants and how aggressive that care might be. It starts with the basics. If your heart stops, do you want CPR performed. If you stop breathing, do you want to be placed on a ventilator and have a machine breathe for you. Next questions may ask about aggressive care with surgery, intravenous antibiotics or whether the goal of care is not curative but rather comfort in nature. It’s important to remember that the decisions are fluid and not written in stone; they can be changed at any time and often re-adjusted. When a patient who wanted absolutely everything done, presents in crisis after a prolonged illness, there might be a change of heart. And the same can be said for somebody who wanted nothing done at all, but changes their mind when they became ill.

Power of Health Care

Sometimes people can’t speak for themselves, either because of the criticality of the situation or because their ability to understand has been robbed because of dementia or other illness. Hopefully, a power of health care has been designated by the patient, the person who understands what the thoughts and hopes of the patient were, to best decide what the patient wanted, and not what the designated decider wanted. The power of health care is different than the power of attorney or POA.  The POA deals with money decisions and does not get to decide how much or how little health care is wanted.

Living Arrangements

Perhaps the hardest part of planning has to do with where a person might live if they become too ill or too frail to care for themselves. Often, there has been little thought given on the part of the patient. Most people think that they will be able to care for themselves forever. Families also see people as frozen in time, always going to be as they are now. But one Thanksgiving, people might notice that a parent takes a bit longer to start their day, takes an extra nap and calls it an earlier evening than usual. Next Easter, the naps are longer and the days are shorter.

Family round tables need to talk about the future. Some may decide to care for their own as long as they can, depending upon finances and amount of care a person needs. Some families cannot because of a variety of reasons. Planning home health care, assisted living facilities or nursing homes take time and insight as to availability and finances, especially if the patient is aware and wants input into the decision making. There is nothing worse than having to decide living arrangements at 3am in the ER, where options are limited and decisions seem almost coerced by the situation.

Pro athletes are usually aware when their skills have eroded to the point where they can no longer play at an elite level. And yet, it may take a coach or another player to suggest that they voluntarily retire. If that hint isn’t taken, they may get the call to bring their playbook. In life, there are also hints that cannot be ignored, to allow quality years and dignity in living.


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health insurance does not equal health

Tuesday, August 1, 2017

Dear Politicians. Let me ask a question. If every person in our country had health insurance, would we be any healthier?

-Mark Cuban. Twitter. 7/30/2017

Dear Mark,

Thank you for such an insightful question. Unfortunately, I am not a politician and cannot provide you their perspective, but I do care for patients on weekends, in the middle of the night and whenever they perceive an emergency to exist.  And I wish that I had a satisfying and uplifting answer toyour question. But I do not. The reality is that health insurance and access to health care does not equate to health. This is not an opinion based upon fact but instead, from anecdotal personal experience and bolstered by a few cherry-picked statistics.

Ideally, access to health education and disease prevention would begin before birth and continue through childhood and adolescence so that each person was delivered to adulthood with the best chance of living a healthful life. The concept that health insurance availability alone will reach such a goal fails to account for societal ills and governmental agency policies that are add odds with providing a highway to healthy adulthood.

Beginning with pregnancy, there are too many unlucky babies born to mothers who abused alcohol, opioid narcotics or tobacco during pregnancy. The numbers can be staggeringly high.

  • 21,700 babies were born in 2013 (latest statistics available from the CDC) with neonatal abstinence syndrome, where the newborn goers through narcotic withdrawal because of the mother’s drug abuse. Short term complications include poor growth, dehydration and seizures; the long-term problems are uncertain since there is not enough data yet available.
  • Fetal alcohol spectrum disorder affects between 0.2% and 1.5% of all births in the US. In 2002, the lifetime cost per infant was more than $2 million and a yearly cost to the health care system of more than $4 billion.. In some western European countries, the incidence of fetal alcohol syndrome can be as high as 5%. It seems that universal healthcare can’t stop the adverse effects of alcohol abuse.
  • 10% of mothers smoke during the last 3 months of pregnancy. This affects placenta development and can lead to premature deliveries and low birth weight babies. Other issues include congenital heart problems and cleft lip. There is also increased numbers of asthma, pneumonia and SIDS (sudden infant death syndrome)

Tobacco continues to rear its ugly head in teenage years, when most people begin smoking. More than 90% of people have their first cigarette before age 18. Each year more than 450,000 people die from smoking related deaths, from cancer to heart attack and stroke, to COPD and emphysema.

“The overwhelming amount of death and disease attributable to tobacco is caused by addiction to cigarettes – the only legal consumer product that, when used as intended, will kill half of all long-term users,” – FDA Commissioner Scott Gottlieb

And not to be forgotten, the cost of alcohol abuse in lives lost and broken. More than 10,000 people die each year as victims of a drunk driver. 1.1 million people were arrested for drunk driving. In Wisconsin, known for its beer and binge drinking, there were more than 5,100 alcohol related crashes in 2015, resulting in 2,872 injuries.

US obesity rates have increased to affect nearly 40% of all adults and 17% of all children. Complications include heart attack, stroke, diabetes, sleep apnea and cancer.

Mr. Cuban, you’ve asked a profound question. Regardless, of how many people have health insurance, there is no guarantee that they will pursue a healthy lifestyle. The question then might be asked whether personal choice should affect access to the full spectrum of possible health care available. Most recently, one health authority in England has decided to withhold elective major surgery from people who are morbidly obese or who smoke.

When Congress debates the merits of one health insurance system over another, they forget to consider perhaps the most important intangible. There is an unlimited and insatiable demand for health care and unless society is willing to pay for it all, one day, choices will have to be made about who gets what care.  Welcome to the world of rationing.




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