The issue of hoarding has recently gathered a great deal of attention, particularly due to news reports and popular television shows. However, hoarding is not a new or a small problem. The problem of hoarding has been documented since the turn of the century and is thought to significantly affect nearly 15 million Americans, many of them elderly. A great article recently appeared in the Boston Hearald dealing with the clinical aspects of Hoarding. Unfortunately, research has been lacking in this area – until now.
On July 14, 2010, a Bellingham, Massachusetts couple and their dog were found dead in their home. The ultimate factor in their deaths: hoarding. Authorities deduced that 75-year-old Richard Lamphere tripped on a pile of trash, fell on top of his wife, 62-year-old Susan Abraham and one of their dogs. Lamphere died instantly from head injuries; Abraham was severely injured in the fall and died later from her wounds. Police confirmed that the couple were hoarders. They had trash and belongings piled everywhere inside their home. The conditions were uninhabitable and clearly unsafe. For the full story, see this article.
When assessing the severity of a loved one’s hoarding situation, several questions are important to remember:
Can the occupant access doors in case of an emergency?
Does he have access to the kitchen to prepare and store food?
Can he access the bathroom facilities? Can the bathtub/shower be utilized?
Can the resident safely reach their bed or have they made other sleeping arrangements?
Are the home’s mechanical systems in working order (electrical, plumbing, heating)?
Are pets being cared for?
What health hazards are present (mold, decaying food, bodily waste, etc.)
If the basic needs of an occupant cannot be met, then it is time to consider intervention.
The difficulty with trying to help a hoarder is that most of them do not seek or want any “help”. In fact, hoarders typically do not comprehend that they actually have a problem. Thus, attempts to “clean out” or assist a loved one in “tidying up” his or her home should be done with care and patience. And, although perhaps difficult, refrain from making judgments.
Tips to aiding someone who hoards include encouraging them and helping them establish new relationships. Gently remind them that their grandchildren will be able to come and visit if they clean their house. Perhaps it is time to participate in a local community activity for seniors. If they are busy with other activities or plans, then getting rid of “stuff” may seem less consequential to them. Many local companies specialize in professional, home organziation and cleanouts. Additionally, you may look into a hiring a certified home maker a few hours a week to keep up with housework and tackle clutter habits.
As a last resort, do not be afraid to contact the authorities or professional help. Let someone else be the “bad guy”. The story of a local hoarder who has made progress over the years can be found here.
Finally, a temporary or limited Guardianship may be necessary, at least until improvements can be made for the individual’s overall safety. For more information and advice contact your local Elder Services or area Agency/Council on Aging.
Some people think that Elder Law and Estate Planning attorneys are only useful further down the road. They think, “I’m healthy. I don’t need to worry about those things now.” Even while you are healthy, there is one document that everyone over the age of 18 should have in place: a Health Care Proxy (HCP). A health care proxy is necessary to ensure that someone, a health care agent, will be available to make medical decisions for you if you are unable to make them on your own because you are incapacitated. Currently, in Worcester County, another form is also worth considering: the Medical Orders for Life-Sustaining Treatment (MOLST) form. This medical order works with the HCP to inform your health care agent and your doctors what you actually want to happen in various circumstances.
In April 2008, the Massachusetts Health Care Quality and Cost Council (MHCQCC) issued its annual report recommending that Massachusetts establish a pilot program to improve communication between patients and clinicians, and other interested parties, regarding end of life treatments. The MHCQCC found that many patients nearing the end of life were unaware of the treatment options available to them, or, if patients had been aware of such treatment options and had discussed them with their doctors previously, nothing was in place to ensure that their preferences were honored. Therefore, the Massachusetts legislature enacted legislation in August 2008 establishing a demonstrative program for the MOLST process in one community in Massachusetts: Worcester. (Yay, Worcester!)
The MOLST form is fairly simple and easy to read; the most difficult part is actually making the decisions and putting them down on paper. The form is only two pages long, and only two sections must be completed in order for the form to be honored. These two sections are Section D (patient information – specifically who is signing the document on behalf of the patient) and Section E (physician information). In Section D, it is possible for the patient, the patient’s health care proxy, or the patient’s guardian to sign on his or her behalf. If a guardian is signing for the patient, the guardian must ensure that s/he has the legal authority under the guardian appointment to do so. This may require consultation with the patient or guardian’s Elder Law attorney.
If any other section of the form is not filled out, the health care agent is not limited in his or her decisions for life-sustaining treatment for the patient. Sections A, B, C, and F ask the difficult questions regarding resuscitation, intubation and ventilation, hospitalization, respiratory support, dialysis support, and artificial nutrition and hydration. It is critical that you speak with a physician before making these decisions so that you fully understand the meanings of the terms used and the potential consequences. Once these sections are filled out, they must be honored by all health care professions in Massachusetts, where clinically appropriate. The MOLST form is different from a Living Will or another document expressing your “final wishes” because it carries more authority and is more likely to be honored. A Living Will or final wishes document is only used by health care professionals to keep your wishes in mind when making decisions about treatment. While the MOLST form is not currently legally binding, health care professionals are strongly encouraged by the state to honor it.
Finally, Section G simply asks for the contact information of the health care agent. There is also room on the form for other treatment preferences, in which you can more clearly articulate your wishes. There is an expectation that the form will be reviewed throughout the patient’s life so that if his or her preferences change, those preferences will still be honored.
Are you a family member or guardian of someone that suffers from dementia? Is s/he living in a nursing home? Do you know what medications s/he is taking? Do you know what the dosages are? When was the last time those medications were reevaluated to determine if they are helping in any way, or if they are even necessary? These are all important questions to keep in mind and to continue asking the administrators of the nursing home and the physicians who care for your loved one.
On March 10, 2010, Massachusetts joined a federal suit against Johnson & Johnson for paying millions of dollars in kickbacks to Omnicare, Inc., the largest pharmacy in the US that specializes in providing drugs to nursing home facilities. United States Attorney Carmen Ortiz argues in the complaint that substantial monetary kickbacks can be especially harmful in the nursing home context because nursing home patients have little to no control over the medical care they receive. He states: “Nursing home doctors should be able to rely on the integrity of the recommendations they receive from pharmacists, and those recommendations should not be a product of money that a drug company is paying to the pharmacy.”
The primary drug at issue in this case is Risperdal, an antipsychotic drug that is usually prescribed for patients with severe mental illnesses, such as schizophrenia. It is legal to prescribe antipsychotics for “off label” uses to treat people with dementia, but these drugs may also raise the risk of death among such patients. At the same time, antipsychotics can help patients with dementia suffering from extreme agitation and sleeplessness. When prescribed in small doses, these drugs can actually have amazing effects on making the lives of patients with dementia more bearable. However, it is important that the prescriptions and dosages be reevaluated regularly to determine their effectiveness and potential harm to the patient.
On March 8, 2010, the Boston Globe reported that 2,483 nursing home residents in Massachusetts were treated with powerful antipsychotic drugs in 2009. This data was collected by the federal Centers for Medicare and Medical Services, and Massachusetts has the 12th highest rate in the nation for nursing home patients on antipsychotic drugs. While these statistics may appear alarming at first glance, any good researcher knows they don’t paint the whole picture. Many patients with dementia are only put on small doses that do not harm them in order to lower their agitation and improve their sleeping habits, but it is also critical not to simply overlook these statistics. As noted earlier, two after the data was published in the Boston Globe, Massachusetts joined an important federal suit against one of the drug companies that promotes these potentially harmful practices.
It is extremely important to be educated and informed regularly about the drugs your loved one is taking, especially if s/he is in a nursing home. While issues concerning antipsychotic drugs are currently making headlines, it will take individual conversations to ensure that your loved ones are being treated appropriately. Sometimes antipsychotic drugs are extremely beneficial for a patient with dementia, but if not administered properly, they can also be very damaging. Open communications between you, the patient, the patient’s guardian (if that is not you), the patient’s primary care physician, and the administrators at the nursing home s/he lives at, will make it possible to ensure that your loved one is on the right medication so that s/he is safe and comfortable.
Lately, the matter of Brooke Astor’s estate has been covered in the media. Like many people she had an estate plan in place which included a Durable Power of Attorney and Health Care Proxy, which nominated subsituted decision makers in the event she would lose the capacity to make important financial and/or medical decisions at some point during her elder years. She did not want to burden her family with obtaining a Guardianship and/or Conservatorship through the courts. She did end up suffering from Alzheimer’s disease and her son took over her financial powers. He just didn’t do a very good job…
The following is an exerpt from this week’s AZCentral.
Anyone who has signed a financial document has to be squirming a bit over Brooke Astor’s estate case.
Her son, Anthony Marshall, recently was convicted of stealing millions of dollars from Astor while she suffered from Alzheimer’s disease before her death. Although the case largely centered on a contested will purportedly signed by Astor, other estate-planning issues also came into play.
One was a financial power of attorney signed by Astor that gave Marshall authority to direct her affairs if she became incapacitated – and the means to steal from her.
The episode provides a wake-up call for people who use financial powers of attorney. These legal documents can be highly effective in ensuring that someone else will be around to handle financial matters for you if you’re alive but unable to do so – as in the case of mental incapacity.
A power of attorney can be as short as a page or much longer, depending on the detail desired. They’re often included with a trust, will, health power of attorney (addressing medical issues) and other estate-planning documents.
For all the benefits of using a power of attorney to avoid a potential court-supervised conservator situation, there are pitfalls, too.
In particular, you need to trust the person whom you designate to act on your behalf. And you should make sure he or she is responsible, diligent and reasonably astute.
“They really are documents that people should pay attention to,” said Denise McClain, a financial principal and attorney at wealth-management firm Lowry Hill in Scottsdale. “You’re potentially passing along a lot of power.”
I see it more and more and it really saddens me: families unable to “get along” when it comes to decision making for elder loved ones. It can be as simple as whether Mom and/or Dad need to meet with an Elder Law Attorney, to concerns over finances and inheritance issues, to whether siblings agree on who should serve as primary caregiver, and/or to whether assisted living/nursing home care is necessary.
Often as family members age, family dynamics can become more complicated. Conflicts that have simmered below the surface can boil up and make conversation impossible. Sometimes the elders are involved in the discussions, but unfortuntately sometime they are too far gone to meaninfully participate.
Either way, even the most harmonized family can sometimes hit a bad note or two and require some assistance.
(Dun, dun, dun, dun!) Enter the Elder Mediator. Mediation provides an opportunity for the Elder and all concerned members of the family to participate in creating a thoughtful plan for future. In most cases Elder Law Attorneys can act as Elder Mediators with certain issues. However the scope of the disagreements can often rest in other issues that are not related to the elder law topic. An Elder Mediator, working closely with your Elder Law Attorney, is trained to assist families in identifying the real issues, separating them from the crucial issues of planning for elder care, and developing the best plan of care.
National Public Radio has recognized the usefulness of elder mediation for families dealing with aging issues.
As baby boomers age and options for their care increase, we will all face many difficult choices concerning how we handle transitions during our elders’ declining years. Families will have to be able to evaluate resources, options and develop flexible strategies to support their elders. Even when not legally competent to make decisions, it is important to include an elder’s wishes and expressed preferences when putting a plan into place. Elder mediation is a rational first step for families to help them address their changing needs while enhancing problem solving/communications skills and avoiding messy litigation.
Occasionally a minor child will end up living with someone else besides his or her parents. This could be temporary, semi-permanent, or permanent. Perhaps the parent is in the military and was called to active duty so the child goes to live with a grandparent. Maybe the parents have a health or substance abuse issues and an aunt/uncle take charge of the child. Or perhaps a child chooses to live with a relative so that they may attend a specific school.
In situations such as those it used to be that in order for the caregiver to have the authority they needed to deal with health care providers, medications, and the school systems, a Guardianship was needed. This process was costly, time consuming, and actually replaced the parent’s rights to make decisions for their children during the time that the guardianship remained in effect. A trip to the Probate Court was needed to initiate and terminate the process.
Currently there is a new law which allows a parent to give a caregiver (the person the child is living with) concurrent authority to make educational and health care decisions for the minor child. The Act Relative To Caregiver Education and Health Care Authorization allows a parent to authorize a person with whom their child is residing to “exercise concurrently the rights and responsibilities, except as prohibited by the parent, that the parent possesses relative to the education and health care of the minor children.”
The parents can specify any actions that the caregiver is not allowed to take, and the parents continue to retain their authority to take any and all actions related to their children’s health care and education. The form only needs to be signed by one parent so it can be used to grant limited powers to “step-parents” who are primarily available during school hours and/or who take the children to their medical appointments. This is a wonderful news for blended families with minor children. The parent’s decision supersedes the caregiver’s decision if there are any disputes. The caregiver signs an acknowledgment that they will not knowingly make any decision that conflicts with the decision of the child’s parent or other legal guardian.
The document remains in effect until the date specified by the parent, not to exceed 2 years and the powers can be changed or amended at any time by the parent. The document should be provided to the child’s school and health care providers.
This new law will go a long way to help those families who need some assistance in caring for their children, without needing a costly and inconvenient visit to the probate court.
Vickstrom Law • Kristina R. Vickstrom, Esq. • 7 State Street • Worcester, MA 01609 508.335.6633 • View Disclaimer.
Vickstrom Law specializes in Estate Planning, Elder Law, Medicaid (MassHealth) Planning & Applications and Probate and Estate Administration and services Central Massachusetts including Worcester County, and Metrowest Middlesex County Boston area including Worcester, Marlborough, Hudson, Leominster, Fitchburg, Shrewsbury, Westborough, Northborough, Southborough, Stow, Bolton, West Boylston, Holden, Sterling, Spencer, Grafton, Brookfield, West Brookfield, and Sturbridge.
On July 14, 2010, a Bellingham, Massachusetts couple and their dog were found dead in their home. The ultimate factor in their deaths: hoarding. Authorities deduced that 75-year-old Richard Lamphere tripped on a pile of trash, fell on top of his wife, 62-year-old Susan Abraham and one of their dogs. Lamphere died instantly from head injuries; Abraham was severely injured in the fall and died later from her wounds. Police confirmed that the couple were hoarders. They had trash and belongings piled everywhere inside their home. The conditions were uninhabitable and clearly unsafe. For the full story, see this article.
Elder Needs, Family, Guardianship, Housecalls, Uncategorized | Kristina | 
September 2, 2010 11:07 am | 
Comments (0) 
The primary drug at issue in this case is Risperdal, an antipsychotic drug that is usually prescribed for patients with severe mental illnesses, such as schizophrenia. It is legal to prescribe antipsychotics for “off label” uses to treat people with dementia, but these drugs may also raise the risk of death among such patients. At the same time, antipsychotics can help patients with dementia suffering from extreme agitation and sleeplessness. When prescribed in small doses, these drugs can actually have amazing effects on making the lives of patients with dementia more bearable. However, it is important that the prescriptions and dosages be reevaluated regularly to determine their effectiveness and potential harm to the patient.
The parents can specify any actions that the caregiver is not allowed to take, and the parents continue to retain their authority to take any and all actions related to their children’s health care and education. The form only needs to be signed by one parent so it can be used to grant limited powers to “step-parents” who are primarily available during school hours and/or who take the children to their medical appointments. This is a wonderful news for blended families with minor children. The parent’s decision supersedes the caregiver’s decision if there are any disputes. The caregiver signs an acknowledgment that they will not knowingly make any decision that conflicts with the decision of the child’s parent or other legal guardian.