Personal Care Manager Services
Home Care Services
Aging and the Attitude of Health Care Providers
Medications and the Elderly
Geriatric Health Care Providers
Elder Law
Reverse Mortgage Specialist
Long Term Care Insurance Specialist
Elder Financial Advisor
End-of-Life Services
Dial 211
Elder Mediation Services
eHealth Services For the Elderly
Assistive Technology and Monitoring and Alarm Systems
Government and Community Elder Care Services  

 

Personal Care Manager Services

Also known as Geriatric Care, Elder Care or Aging Care Managers, a Personal Care Manager represents a growing trend to help full time, employed family caregivers provide care for loved ones living close by or needing long-distance care. Care managers are also particularly useful in helping caregivers at home find the right services and cope with their burden.

Below is a partial list of what a care manager or Geriatric Care Manager might do:

• Assess the level and type of care needed and develop a care plan
• Take steps to start the care plan and keep it functioning
• Make sure care is received in a safe and disability friendly environment
• Resolve family conflicts and other family issues relating to long term care
• Become an advocate for the care recipient and the family caregiver
• Manage care for a loved one for out-of-town families
• Conduct ongoing assessments to monitor and implement changes in care
• Oversee and direct care provided at home
• Coordinate the efforts of key support systems
• Provide personal counseling
• Help with Medicaid qualification and application
• Arrange for services of legal and financial advisors
• Manage a conservatorship for a care recipient
• Provide assistance with placement in assisted living facilities or nursing homes
• Monitor the care of a family member in a nursing home or in assisted living
• Assist with the monitoring of medications
• Find appropriate solutions to avoid a crisis
• Coordinate medical appointments and medical information
• Provide transportation to medical appointments
• Assist families in positive decision making
• Develop long range plans for older loved ones not now needing care

Services from care managers should be something that every family takes advantage of but in reality very few families use care managers. Care managers could go a long ways towards helping the family find better and more efficient ways of providing care for a loved one. The concept is simple. The family hires a professional adviser to act as a guide through the maze of long-term care services and providers. The care manager has been there many times. The family is experiencing it usually for the first time.

Hiring a care manager should be no different than hiring an attorney to help with legal problems or a CPA to help with tax problems. Most people don't attempt to solve legal problems on their own. And the use of professional tax advice can be an invaluable investment. The same is true of using a care manager.

Unfortunately there are too few care managers and the public is so poorly informed about the services of a care manager that help that could be provided goes lacking. Let's look at two hypothetical examples to see how a care manager could be invaluable.

Here is the first example:

Mary is taking care of her aging husband at home. He has diabetes and is overweight. Because of the diabetes her husband has severe neuropathy in his legs and feet and it is difficult for him to walk. He also has diabetic retinopathy and cannot see very well. She has to be careful that he does not injure his feet since the last time that happened he was in the hospital for four weeks with a severe infection. She is having difficulty helping him out of bed and with dressing and using the bathroom. She relies heavily on her son who lives nearby to help her manage her husband's care.

On the advice of a friend Mary is told about a care manager, Susan Brown, who helped the friend's family cope with the care of a loved one. The cost of an initial assessment and care plan from the care manager is $300.00. Mary thinks she has the situation under control and $300.00 for someone from the outside to come in and tell her how to deal with her situation seems ridiculous.

One day Mary is trying to lift her husband and injures her back severely. She is bedridden and cannot care for her husband. Her son, who works fulltime, now has two parents to care for. On the advice of the same friend he decides to bring in Susan Brown and pay her fee himself.

Susan does a thorough assessment of the family's needs. She arranges for Mary's doctor to order Medicare home care during Mary's recovery. Therapists come in and help Mary with exercises and advice on lifting. Susan advertises for and finds a private individual who is willing to live in the home for a period of time to help Mary with her recovery and watch over her husband. Susan makes sure the new caregiver is reliable and honest and that taxes are paid for the employment. Susan enlists the support of the local area agency on aging and makes sure all services available are provided for the family. Susan also calls a meeting with Mary's family and explains to them the care needs and how they need to commit to help with those needs. Susan makes arrangements to purchase medical equipment for lifting, moving and easier use of the bathroom facilities. Medicare will pay much of this cost.

Susan suggests using a geriatric care Physician she works closely with to help Mary in the care of her husband. The geriatrician meets with Mary and her husband and spends a great deal of time explaining the proper treatment and care of elderly with diabetes. He rearranges medications and puts Mary's husband on a new insulin regimen to better control his blood sugar. He starts a strict diet and insists on weight loss and exercise. The previous doctor seemed more interested in treating symptoms than in changing lifestyles. Besides, many Physicians reason that the elderly are going to die from one thing or another so there's no sense in trying to bring about a cure. The inevitable outcome of old age is death. In contrast to this philosophy, the geriatric Physician feels that Mary's husband has a chance of improving his health with proper treatment.

Susan also works closely with an elder law attorney and a financial planner who specializes in the elderly. The attorney prepares documents for the family including powers of attorney, a living well and advice on preserving Mary's remaining assets. The financial planner recommends a reverse mortgage specialist to help Mary and her husband tap unused assets in their home's equity. In addition, an income vehicle is put into place to convert assets into income in order to provide for Mary for her life when her husband is gone.

With the help of the care manager, Mary's life and future have been significantly improved. Her husband as well, if he adheres to the care plan, may end up having a better quality of life for his remaining years.

Here is another example of the value of the care manager.

Michelle is a single divorced mother with two teenage children. Her mother, Martha, has a stroke which apparently causes some memory loss as well as some disability in being able to fend for herself. Michelle decides to move in with her mother and take care of her. In return, Michelle who is temporarily out of work, has a place to live and share her mother's retirement income.

Martha is anything but easy to take care of. She has mood swings and often forgets what she is doing. She seems to display a lot of anger and takes it out on Michelle, calling her all kinds of horrible names. She is never happy and is constantly calling for attention. In trying to take care of her own children as well as her mother, Michelle is quickly being drained of her physical and emotional strength. In addition Michelle's brother and two sisters are happy she is taking care of her mother since they are now absolved of the responsibility, but they treat Michelle terribly. They also call her awful names and accuse her of being a "leech". On the other hand they have plenty of advice on how to deal with their mother but never offer any of their own time to help. After all, they reason, Michelle is receiving benefits from caring for her mother and logically she should be responsible for all the care.

On the advice of a friend, Michelle hires a care manager, Brent Smith, who comes highly recommended in solving family disputes. Brent is a licensed mediator. Brent first does a care assessment of Martha and comes away suspecting there is more to her personality disorder than a stroke. He makes arrangements to take Martha to a geriatric Physician who does a complete physical assessment and recognizes that Martha's mental state is due more to improper medications and severe depression. Martha's medications are reduced and changed and she is put on antidepressants. In addition her diet is upgraded, she is to receive more fluids, more healthy foods and especially receive vitamin supplements. Particularly important is a prescription for vitamin B12 shots.

The doctor insists on as much exercise as Martha can handle. Brent, the care manager, helps convince Martha of the need for her new care program and helps oversee her following through on the exercise program. Over the ensuing months Martha's lack of memory and abusive behavior become less severe. She is also better able to care for herself without Michelle's assistance.

In addition to the assessment, one of the first things Brent does is to contact Michelle's older brother who is the family leader. He has a long talk with her brother and gives the brother a different perspective on the issues. With a better understanding of the situation, the brother calls a family meeting and Brent mediates a successful resolution of the family mistreatment of Michelle and the ensuing bad feelings. Everyone including Michelle is called upon to do their part in managing the care of her mother and to work on better family relations. The issue of Michelle "sponging" off of her mother is addressed and an adequate solution is agreed to by all. Brent will follow up in a month to make sure everyone is following through on his or her commitment.

As with hiring a paid provider to come into the home, hiring a care manager is a similar situation. For those who desire to remain in the home the care manager can help make that a reality and keep the care-recipient away from a premature admittance into a care facility.

But the care manager can also help in the other direction. Oftentimes the family is attempting to keep a loved one at home when that is not the best situation. For many and various reasons care in the home may be impossible. For example consider the family where all family members are employed full time and both mom and dad need intensive care at home. There is also not enough money to pay for caregivers to come into the home. In an attempt to cover the situation, the family trades off taking care of mom and dad in the morning and in the evening and on weekends. But they simply can't attend properly to the needs. A care manager may have a better perspective of the situation. In this case an assisted living facility would be a much better choice. If there is not enough money then a Medicaid facility may be the only choice.

Or take the example of an individual who has Alzheimer's and has become difficult to manage. It just may not be possible for a caregiver in the home to deal with it. But yet because of stubbornness or lack of proper judgment the caregiver is trying to cope. Again, a care manager can help in this situation and recommend a different care environment.

Care managers can charge anywhere from $50.00 an hour to $ $200.00 an hour. Or they may charge a flat fee for a care assessment and plan. It is important to check out the background of the care manager for the situation you are trying to solve. For example if it is a family dispute, a care manager with a background of mediation would be best. If it is a matter of proper medical treatment, a care manager with a background of geriatric nursing would be valuable.

The cost of a care manager is shouldered by the family. Long-term care insurance may also cover the cost of a care assessment. Many policies will pay $250.00 to $300.00 for a care assessment. Policy language usually refers to this as care coordination.

 

Home Care Services

Home Health Agencies (Medical home care services)

Home health agencies offer professional nursing and therapy services in the home. These services, provided by Registered Nurses, Licensed Practical Nurses, therapists and social workers include

• Health assessments,
• Patient education,
• Caregiver counseling,
• Physical and occupational therapy,
• Taking samples for lab tests,
• Wound dressing,
• Medication training and compliance,
• Hospice care,
• Management of IVs and more.

They also provide aides, who incidental to medical care, help patients with activities of daily living. Home health agencies rely heavily on Medicare for reimbursement for their services.

Personal Care Home Health Services (Non-medical home care services)

These providers represent a rapidly growing trend to allow people needing help to remain in their home or in the community. The services offered may include:

• Companionship,
• Grooming and dressing,
• Recreational activities,
• Incontinent care,
• Handyman services,
• Teeth brushing,
• Medication reminders,
• Bathing or showering,
• Light housekeeping,
• Meal preparation,
• Respite for family caregivers,
• Errands and shopping,
• Reading email or letters,
• Overseeing home deliveries,
• Dealing with vendors,
• Transportation services,
• Changing linens,
• Laundry and ironing,
• Organizing closets,
• Care of house plants,
• 24-hour emergency response,
• Family counseling,
• Phone call checks and much more.

These providers receive reimbursement directly from families, from other care providers whom they subcontract for or from long term care insurance. It is becoming common for traditional home health agencies, those who offer medical care at home, to have a division that offers non-medical home care as well. Also many non-medical home care providers will contract their services to a traditional home health agency or to hospice.

Integrated Home Health Care Services

Many larger home care providers are integrating both services above. Also many large integrated facilities providers (combined nursing homes, assisted living and independent retirement arrangements) are offering more of the services above.

Home care services can be found in the Yellow Pages under "home health agencies".

 

Aging and the Attitude of Health Care Providers

In many cultures in the world, elderly people are revered and their advice is sought and respected. In our culture, the wisdom, the knowledge and the social skills of the elderly are often overlooked and instead we focus on the mental and physical deficits of our older generation. Because of this prevailing attitude, older people are generally regarded as less valuable than younger people. The younger person has responsibilities of raising a family, maintaining a career and supporting the economy. The older person generally has no responsibilities and in addition is a drag on the economy since a great part of the tax base must go towards the support of older Americans.

It is inevitable that medical care providers will unconsciously have this same attitude towards their older patients. As a result, if an older person has a medical complaint and the cause is not readily apparent, a medical practitioner is more likely to accept the condition as a consequence of old age and treat the symptoms with medication as opposed to aggressively trying to identify the problem. In younger people, if the medical complaint is interfering with normal daily function, typically a more concerted effort will be made to identify and correct the problem.

A 90 year old man meets with his doctor and complains about pain in his right knee. The doctor tells him,

"Well Henry, what do you expect? You're 90 years old."

Henry replies,

"But doctor my left knee is the same age as my right knee, there's no pain and it feels just fine!"

Many in the health-care profession consider old age to be a disease itself. Any medical problems are inappropriately attributed to old age as if it were a medical condition. And since there is no cure for old age, appropriate tests and treatment are never performed. Thus, medical problems that may not be related to age and may just as frequently occur in younger people are often not treated. As an example a recent survey of physicians involved in the health-care of the elderly reported that 35% of the doctors considered hypertension a result of the aging process and that 25% of them felt that treating an 85-year-old for symptoms of hypertension would cause more harm than the benefits it would produce.

Consider these real-life examples.

First example

A 71 year old woman has surgery on her shoulder for a bone spur that is causing her considerable pain. The surgery is successful and she goes through several months of physical therapy to help her recover. But she is not recovering as expected. She continues to experience pain that radiates through her entire back. Her physical therapist does not know how to help her and attributes her failure to recover to old age. She visits her family care doctor at least twice over the next six months complaining of extreme tiredness and lack of energy. Her skin color is gray and she does not look healthy. Finally she visits her doctor and insists he check her for some problem since she is not recovering from the surgery and she feels awful. After her insistence he does a CBC blood lab and discovers she is severely anemic. He puts her in outpatient care and gives her four units of red blood cells and puts her on iron supplementation. Within two weeks the pain has disappeared and within a month she has recovered fully from the surgery. Numerous tests are done but there is no explanation for the anemia. Six months later she is healthy and active and her cheeks are ruddy. When she asks her doctor why he did not suspect anemia he tells her that she has never had anemia and based on her history he would never expect her to develop it. (He obviously has no training in geriatric care.) He then tells her, in an obvious contradiction of his previous position, that older people sometimes fail to absorb iron. Ironically, she defends the action of her doctor and does not feel he acted inappropriately.

Second example

Susan and John have been married for 46 years. Susan has always demonstrated a tendency for depression but it has generally been kept under control with medication. John's health begins to deteriorate and within a year he is dead. Several months after her husband's death, Susan is exhibiting signs of severe depression. She is given ever-increasing levels of various antidepressants but they have no effect. She is also exhibiting signs of a psychosis and is inflicting wounds upon herself. The family puts her in an assisted-living facility but they are unable to deal with their aberrant behavior. Her son who lives in New York decides to bring her to live with him and he admits her to a hospital in New York City . Tests indicate she is suffering from severe hypothyroidism and she is put on appropriate treatment. (Apparently no health practitioner had to this point suspected there may be another condition contributing to the depression other than old age.) The low thyroid undoubtedly was a significant factor in the development of her depression. But treatment of the depression is not addressed in the hospital and it has progressed considerably. She is transferred to a nursing home and wrongly diagnosed with dementia and placed in the dementia unit. She is deteriorating rapidly, she continues to abuse herself and she refuses to speak or acknowledge anyone. Within a few months she will probably be dead. At this point an experienced geriatric care physician steps forward and correctly diagnoses her condition as clinical depression. She is hospitalized for six months and undergoes aggressive treatment for depression. They also discover she is severely malnourished and correct that problem as well. She has now moved back into the home of her son. She is a normal functioning person and is even volunteering to work in the local library. The elderly health care system almost dropped the ball on this one.

Third example

A 65 year old woman, who has been active all of her life, has a small stroke which leaves her with some discomfort and pain in her right arm but does not limit her in any other way. She is anxious and nervous about her condition and the possibility of another stroke and the doctor prescribes pain pills and Valium to help her with her anxiety. Over a period of 15 years, she becomes addicted to Valium and does little else except sit in front of the TV all day long. She makes sure she maintains contact with a doctor who will provide her need for Valium. (No doctor or pharmacist would allow this abuse to go on with a younger person without intervention. Older people are often ignored and allowed their vices.) Early on, her family can see the problem and they decide to intercede. On the advice of friends they contact the geriatric care unit at a local university hospital. A geriatric care physician is alarmed at her addiction and insists they wean her off of the mood altering drug. He is willing to treat her and help her. She refuses to cooperate and in deference the family backs off. Over a period of 15 years she gets no exercise except for trips to the bathroom or trips to the living room to visit occasionally with her family. But family and grandchildren over the years visit less and less often.

After many years of sitting in the same position her knees deteriorate and she finds it difficult to walk. In order to avoid getting up from her chair to walk to the bathroom, she drinks very little fluid and becomes chronically dehydrated. This does not help her mental or physical condition. She has the joints in both knees replaced but does no exercise and the combination of the invasion of muscle tissue and lack of use of her legs causes muscles around her knees to atrophy. No follow-up is done by the orthopedic surgeon to make sure she remains active, after all she is old. She can now barely walk at all. She spends her final three years confined to one room in her daughter's house, refusing the use of a wheelchair and refusing to go anywhere beyond the bathroom.

In this case a general lack of concern by all involved demonstrates the apathy of family and the healthcare community to making sure elderly people can experience a meaningful existence in their remaining years. Had this been a younger person, say in her 40's, everyone involved would have been more aggressive in helping her solve her addiction and in making sure she had a better quality of life.

A Holistic Treatment Approach

Most practitioners who specialize in care for the elderly are aware of the above-mentioned problems with older patients and they take a holistic approach with the medical treatment of these people. An attempt is made not only to treat the specific condition or conditions but to make sure there are sufficient activity, proper nutrition and family support at home. They work closely with family members to make sure their loved ones are taking medications properly and are reporting their symptoms. They require those caring for the elderly to closely monitor health conditions and report any changes before things get worse. They meet with their patients regularly enough to monitor their health. This broad-based approach results in better health and in fewer visits to the emergency room because intervention for a worsening condition is achieved at an earlier stage.

A good example of this holistic approach is the Veterans Administration health care system. The VA system over the years has become the nation's largest geriatric care provider for older men. Almost all veterans are men and because most veterans hearken back to World War II, the Korean conflict and the Vietnam War most of them are older than age 60. Because of this the VA has found it necessary to adapt its health-care to this age group. The VA schedules regular exams at least every six months or yearly depending on available funds and personnel. A health examination always includes lab work. Screenings for cancer, cardiovascular problems, eye problems, hearing problems and many other conditions common to aging are a routine part of veteran's administration health-care. The VA was one of the first health providers in the nation to require its local hospitals to keep their records on computer and in a central database. This allows health practitioners in the system to quickly and efficiently access all information and avoid misdiagnoses and possible drug interactions. By taking a hands-on, preventative approach to the treatment of older men the system is able to keep its patrons healthier and avoid costly medical interventions due to lack of follow-up.

A significant problem with providing holistic treatment is many health insurance providers, including Medicare, will not pay for routine office visits without an underlying medical complaint. Some private health plans are starting to use so-called "pay for performance" or "outcome based care" where the overall health of the patient takes precedence over the procedures used to get there. But Medicare, up to this point, has not made this change. This makes it extremely difficult for the geriatric care provider to monitor his patients and intervene before a health problem becomes bad enough to require hospitalization or major surgery. Doctors practicing this type of medicine have to be inventive in order to provide adequate treatment. Family of the elderly can also help in this respect by "finding" medical complaints to justify setting regular appointments with the doctor.

Treatment of Depression

Older Americans have a suicide rate that is four times the national average. Much of this is a result of depression. It is estimated that 20% of the aging population suffers from depression. Practitioners not trained in geriatric care automatically assume that depression is a normal part of the aging process. This is not true. Depression can be treated just as effectively in older people as it is in younger people. But sometimes medications are not as effective in older people as they are in a younger population. Unfortunately, practitioners often rely too heavily on medications and don't try other non-medical therapies.

Many doctors simply don't choose to recognize depression and help their older patients with it. It is interesting to note that over 70% of elderly suicide victims committed suicide within one month of seeing their health care practitioner. Many of these people were not referred or treated for depression by that health care practitioner.

 

Medications and the Elderly

Facts about Medications and the Elderly

• Older Americans comprise about 13% of the population but they consume over 30% of all prescription drugs.
• It is estimated that 30% of the older population taking medications have had an adverse drug reaction.
• Up to 20% of hospital admissions for the elderly are due to adverse drug reactions.
• It is estimated that over half of the deaths attributed to adverse drug reaction are for people age 60 and above.
• The Journal of the American Medical Association recently reported that if adverse drug reactions were classified as a disease it would rank as the fifth leading cause of death in the United States .

A major problem with medical treatment for the elderly is the large number of prescription medications the average older person is taking. On average a person over age 75 has five prescription drug medications and is using at least two over-the-counter medications as well is taking herbal supplements. Due to impaired ability to "clear" medications from the body, recommended dosages of prescription drugs are generally too much for older people. This can result in over-dosage and drug reaction and in some cases even death. The medical community is well aware of this problem, but finding the right dosage is often a problem because drug reactions are often masked by symptoms of the many chronic medical problems most elderly endure. In addition older people often don't recognize or they fail to report drug reactions. Another huge problem is that the primary care provider may not be aware of all of the prescriptions being taken and some of these drugs may be causing interaction with each other. Finally, many elderly either over-dose or under-dose or fail to take medications.

The most common problem with medications is that the doctor or the pharmacist may not be aware that a patient is taking a number of drugs prescribed by other doctors. Many older patients continue prescriptions with a number of doctors and specialists and no one doctor, not even the primary care physician, often knows the number or extent of medications being taken. Add onto this the fact that the elderly are most likely consuming a variety of over-the-counter medications as well as herbal supplements and it is not surprising to see the large number of adverse drug reactions and hospitalizations and deaths due to drug reactions among the elderly.

Elderly people also often fail to adhere to proper dosage and frequency of dosage with their medications. Some will take more pills than prescribed because they think more is better and will cure the condition faster. Others have a noncompliant attitude towards medical treatment in general and often refuse to take any drugs prescribed for them. Many are confused or have memory problems and aren't even aware they have taken pills or need to take pills. Oversight and administration of medications by a responsible person is an extremely important duty for caregivers of the elderly.

Controlling Problems with Medications

Here is a list of herbal supplements that may interact or interfere with prescription drugs.

•  Ginkgo Biloba

•  St. John's Wort

•  Saw Palmetto

•  Ginseng

•  Yohimbine

•  Senna Or Cascara

There are also a number of prescription drugs that should be avoided with the elderly. The elderly person or a responsible family member should always consult with the doctor and asked that doctor if he or she is sure that the medication is safe for an older person. It is not inappropriate to challenge a physician. If prescription drugs are bought through a trusted pharmacist, the pharmacist may also be willing to consult on the safety of the medications for an older person.

Doctors and pharmacists are generally careful about overdosing or using harmful mixtures of drugs but other than dosages based on body weight, most prescription drugs do not have recommended dosages for older people. Often the doctor must experiment to find the right dosage and the problem is that many older people or their families fail to recognize drug reactions or they fail to report them. Without the proper feedback, under-dosage or over-dosage might occur and effective treatment of the condition is not possible. And of course over-dosage may cause more severe problems than the condition being treated.

Controlling the Problem of Multiple Medications

In order to control the problem with an older person taking multiple prescriptions from many doctors, the older person or a responsible family member should bring all medications being taken by the patient to a doctor's appointment. This definitely includes all herbal supplements and over-the-counter medications as well. It is useful to go over with the doctor what each medication is for. If there is no reason to take that medication or if it may be causing interaction the doctor should indicate that and should withdraw the prescription. As a general rule the more the medications the more the potential problems. A concerted effort should be made to prescribe the fewest medications possible to control a medical problem.

One way to combat the problem with an older person not complying with taking pills at the proper time or not taking enough or taking too many is to use the popular "pill calendar box". Most people have adopted this idea but for those who haven't this is an extremely effective way to administer medications.

Many elderly order their medications through the mail and some may even obtain prescriptions on the Internet. Internet prescriptions might be a common practice for very popular medications such as phetermine or Viagra. It is recommended that all medications be ordered through one pharmacist particularly a pharmacist that has a certification in geriatric pharmacy. By controlling all medications through one database, the pharmacist can alert the older person or his or her family about a possible drug interaction or adverse drug reaction. This central database approach should become much easier for those older people who enroll under the Medicare part D drug program. Presumably the company offering the drug benefit will have a database for its insureds.

 

Geriatric Health Care Providers

Geriatric Physicians

There is currently little incentive to encourage established doctors or students in medical school to specialize in geriatric medicine. Even though it is a recognized specialty, according to the American Geriatrics Society, there are only about 9,000 M.D. Geriatricians and several hundred osteopathic physicians (DO) certified in geriatrics, as well as some 2,400 board-certified geropsychiatrists in the United States . (A geropsychiatrists it is a psychiatrist trained to deal with the mental health needs and specific syndromes faced by older adults).

According to the statistical abstract of the United States there are approximately 770,000 practicing doctors of medicine in the United States . This means there is roughly 1 doctor, including specialists, for every 300 persons in the United States . Based on the numbers above there is only about 1 Geriatrician for every 3,000 elderly persons in this country. Because there are so few of them, it may be impossible to find a physician specializing in geriatric care in some areas of the country.

There are probably many more family physicians or internists who specialize in treating older people and from experience they have probably learned many of the issues associated with treating the elderly, but many of these practitioners could probably benefit from more specialized geriatric training if it were available.

Out of 145 medical schools in the United States only five have geriatric care departments. Many more medical schools offer elective courses in geriatrics but only 3% of all medical students ever enroll for such classes.

Helping elderly people who are nearing the end of their lives and who suffer from multiple, incurable and chronic disorders is often not an appealing prospect to family doctors or to young medical students. Besides, geriatric care typically does not produce as much income as other specialties.

Most doctors who treat the elderly are reimbursed either through Medicare or sometimes through Medicaid or sometimes a combination of both. These government programs have become more and more stingy over the years. Many doctors who in the past have accepted Medicare find that they have better paying opportunities treating younger patients and they will no longer accept new Medicare patients. And as long as those younger patients are available for treatment, few doctors are going to go out of their way to seek out Medicare or Medicaid reimbursement.

There are doctors, geriatric nurse practitioners or physicians assistants who derive satisfaction from working with older people. And they may be taking a cut in pay by doing this. These practitioners are most likely going to be Geriatricians. An older person or his or her family should seek to find these geriatric care specialists in their area or if that is not possible an effort should be made to locate a geriatric clinic in the area. Geriatric clinics are becoming more popular and even though the doctors who staff them may not always be geriatric physicians they are likely to be well aware of the problems associated with treating elderly people. Many geriatric clinics include a team of specialists to help older people. Here are some of the specialists who may be available in a geriatric clinic.

•  Geriatrician

•  Nurse

•  Social worker

•  Nutritionist

•  Physical therapist

•  Occupational therapist

•  Consultant pharmacist

•  Geropsychiatrist

If there are no Geriatricians or geriatric clinics in the area, an attempt should be made to find those doctors who specialize in elderly care. This can be done by making phone calls to various doctor's offices or by checking in the Yellow Pages. Too often, the elderly or their family is content to work with the doctor whom they like but who has little experience in geriatric care. Personality is an important issue but it is more important to find a qualified doctor to care for an aged loved one.

Home Visiting Doctors

Many doctors are returning to the practice of medicine a hundred years ago and are making house calls. Health insurance plans including Medicare will now reimburse a doctor and possibly a staff member, if test equipment is involved, to visit homebound patients in their homes.

To qualify for a home visit the patient must have to experience great difficulty in leaving the home in order meet with the doctor in his or her office. This does not however mean the care recipient need be totally disabled. It simply means that transportation requirements or help needed to get to a doctor might be very expensive or difficult to provide or the patient's safety might be jeopardized by leaving the home. Doctors are willing to visit in the home and provide service because they are paid more money by health insurance providers to compensate them for their time and their loss of efficiency in meeting patients in their offices. Probably the insurance providers reason that the additional cost of meeting with patients at home, before major medical problems evolve, is more cost effective than paying for ambulances and treatment in emergency rooms.

Doctors who make home visits are more likely to be experienced in geriatric care. This is because most homebound patients are typically older. This is a positive advantage for a family using a home visiting physician since we have been making a point that it is better for the older person to be treated by a doctor with experience in this area. It will typically result in better care.

There are also a number of advantages to using home visits as opposed to office visits. The patient will be more relaxed and cooperative in familiar surroundings. Older people are thrilled that a doctor would take time to visit them in their home. They will be more compliant, more open and as a result receive better treatment as opposed to receiving care in the doctor's office. Typically the doctor will take more time and be able to establish a better rapport with his patient. The idea of the doctor not having to hurry off to another patient in another room is comforting to an older person.

A very important benefit is that a physician can see the environment in which his patient is living and have a better understanding of how that environment may affect his patient's health. By seeing it first-hand he can make recommendations for care that would have been impossible in his office. In essence the doctor learns much more about a patient in her home and he can achieve a personal connection that would have been difficult to establish in the office. The ultimate outcome of a house call is that the doctor can provide a greater degree of holistic medicine.

A home visit patient can receive house calls on a periodic or ongoing basis. The patient need not give up other doctors if the reason for being homebound is temporary. Testing equipment in the past few years has become more portable and the doctor can bring an assistant who might provide tests on site. Heart function, lung function and simple blood tests performed on site can give the doctor an immediate feedback on the needs of his patient and allow him to make treatment decisions without the delay of waiting for test results.

Health Care Advocates

Sometimes it's easier for a person to hire someone to walk through the maze of finding doctors, making sure treatments are appropriate and working with insurance companies. There is a growing industry designed to help people in this area. It is also important to remember that area agencies on aging can provide counseling services for Medicare at no cost. But the services of health-care advocates are typically broader and can save a great deal of time for people who have the money to hire someone to be their advocate.

 

Elder Law

The Need for Legal Services for the Aged

Potential for Abuse
Many elderly rely entirely on family or other trusted individuals to help them. Whether it is physiological or psychological, as people grow older they tend to grow more childlike. The dependence upon care givers or family members makes an older person more vulnerable for abuse. For example an older person relying on her children to provide meals and transportation and make financial decisions finds it difficult to complain when one of her children takes advantage of her. If for instance the child takes her money, slaps her or is neglectful in caregiving, the parent may be threatened with loss of support if he or she complains. The child may also use threats of violence to keep the parent in line.

It is estimated that 5% to 10% of elderly Americans are suffering abuse. But nationwide only about 10% of it is ever reported. Much attention has been focused on abuse in nursing homes but most of the elder abuse in this country is at the hands of family members in the home. Most states have laws protecting the elderly from abuse. Here is a description of the various types of adult abuse.

• Sexual abuse
• Physical abuse
• Emotional abuse
• Financial abuse, stealing money or changing title on assets
• Active and passive neglect by caregivers, "Active neglect is the willful failure by a caregiver to fulfill care-taking functions and responsibilities. This includes, but is not limited to, abandonment, deprivation of food, water, heat, cleanliness, eyeglasses, dentures, or health-related services. Passive neglect is the non-willful failure to fulfill care-taking responsibilities because of inadequate caregiver knowledge, infirmity, or disputing the value of prescribed services."
• Self-Neglect, which means an individual is failing to care for his or her own self needs.

All states have agencies that receive complaints of abuse. In some states failure to report abuse of the elderly is a crime. To contact an abuse complaint department, call your local area agency on aging.

Potential for Financial Exploitation
The trusting nature of many elderly people also makes them vulnerable to financial exploitation. Here are some examples of the most common types of financial exploitation.

• Telephone Solicitations for Dishonest Charities or Fraudulent Investments
• Identity Theft to Get Credit Card Numbers and Other Information
• Pay in Advance Prize-Winning Schemes
• High-Pressure Door-To-Door Sales
• Dishonest Home Improvement Contracts
• Dishonest Miracle Health Cures
• Unnecessary Living Trusts through a Trust Mill
• Dishonest Funeral Arrangement Plans

All elderly should be made aware of and told to avoid any financial transactions that require upfront deposits. No contracts are to be signed without two or three days of consideration in consultation with knowledgeable family members. All dishonest schemes promulgated through the mail are guilty of mail fraud and appropriate complaints should be filed. All states have consumer reporting departments to take complaints on consumer fraud. Again a good source for help is your local area agency on aging.

Help with Medicare and Medicaid
Qualified legal help is available from elder law attorneys to help individuals in applying for and accelerating payments for Medicaid. An elder law attorney can also help with disputes with Medicaid. Likewise attorneys who specialize in Medicare can help with disability claims and sometimes this help is the only way claims are ever granted. The local area agency on aging has an advisory service for help with understanding Medicare, Medicare supplements, Medicare advantage and Medicare part D.

Inability to Handle One's Affairs

Private legal help or free community legal services for low income people are available to help people with advanced directives. Advance directives are such things as living wills, medical powers of attorney or do not resuscitate orders.

Guardianship or Conservatorship . According to the American Bar Association Commission on Law and Aging, guardianship and conservatorship involve the following:

"Guardianship or Conservatorship is the legal tool of last resort for decision-making and management of your affairs.

Generally a guardianship involves the court appointment of someone to act as guardian to manage the property and/or personal affairs of an incapacitated person (commonly referred to as the ward). Conservatorship typically involves management of just one's assets without control over the person. However, definitions vary, and to simplify we will just use "guardianship" here.

In addition, limited guardianship is recognized in most states. Under it, the court can limit the guardian's authority and tailor it to the specific areas of incapacity of the ward. Limited guardianship offers a more finely tuned and less restrictive approach to guardianship, but some courts have been reluctant to use it.

If someone is appointed your guardian, but you already have an agent under a durable power of attorney or under a health care advance directive, the court will normally determine whether the agent's authority shall continue.

When is it appropriate?

People need a guardian:

•  when they can no longer manage their affairs because of serious incapacity, and

•  no other voluntary arrangements for decision making and management have been set up ahead of time, or if they have been set up, they are not working well, and

•  serious harm will come to the individual if no legally authorized decision maker is appointed.

Guardianship is a major intrusion into one's life and should be used only where there is a serious inability to make or understand the consequences of decisions.

The criteria courts use to determine "incapacity" or "incompetency" was described at the beginning of this chapter. A decision to seek guardianship should never be based on stereotypical notions of old age, senility, mental illness, or handicaps. A person has a right to make foolish or risky decisions. These decisions by themselves do not mean that the person lacks capacity. A competent person chooses to run risks. An incompetent person runs risks not by choice, but by happenstance."

Estate Planning

11 reasons for estate planning.

Take care of your family financially and legally when you are gone

1. Provide instructions, in the event of death, for guardianship of minor children.
2. Provide for disabled adult children, elderly parents, or other relatives.
3. Get your property to chosen beneficiaries quickly and determine in advance who gets what.
4. Plan for incapacity
5. Minimize expenses of transferring property
6. Choose executors or trustees for your estate.
7. Ease the strain on your family by making funeral arrangements and having your financial affairs in order.
8. Create tax savings and leave money to charity
9. Reduce state and federal estate taxes
10. Provide a plan for an orderly transition of your business ownership to others

Settle Family Disputes
It is becoming more common to use an attorney, an arbitrator or a mediator in solving disputes among family members relating to the care of elderly parents. For instance, one child may have stolen assets and the rest of the family wants that person brought to justice. Or there may be a disagreement over the final disposition of property in an estate plan and it may take an attorney to solve that. Or one member of the family may want the parents declared incompetent but other members don't agree. A lawyer may be necessary to settle the differences either through the courts or through mediation.

Age Discrimination in the Workplace
The Age Discrimination In Employment Act protects people who have been laid off or fired because of age discrimination. We have discussed in earlier sections how in some companies older employees are considered less valuable than younger employees. As baby boomers approach their 60s many will be opting to continue employment or find employment with another company. Age discrimination issues will become more prevalent in the coming years.

Rights of Persons with Disabilities

According to the American Bar Association Commission on Law and Aging:

"A third of us over the age of sixty-five have a physical disability, as do half of us over eighty-five. A disability does not mean that you must give up the places, activities, and livelihood you have been used to. Three important federal laws, the Rehabilitation Act of 1973, the Americans with Disabilities Act of 1990 ( ADA ), and the Fair Housing Amendments Act of 1988 (FHAA), protect people with disabilities from discrimination. In addition these laws require employers and providers of housing or services to make reasonable modifications to their rules to meet the needs of persons with disabilities."

Rights for Grandparents
The ability for grandparents to see their grandchildren might be impaired when the parents of the children divorce and the parent with custody may deny the grandparents seeing the children. All states have grandparent visitation laws that allow a judge to determine whether the court can order visitation rights or not. But it is not an easy task and can be expensive and time-consuming and at the end grandparents may be frustrated that they come away with no visitation rights.

It is becoming common in our society for grandparents to assume the parenting role of their grandchildren. This may be due to parents who are totally irresponsible, or who have drug problems or who have simply abandoned their children or it may be a single parent who is struggling with earning a living and has asked grandparents to help raise a child. If the grandparent is to assume total parenting for a grandchild the grandparent should ask a state court to grant custody or guardianship depending on rules in the state. This allows the grandparent to register the child for school, get health insurance, get public assistance and so on. If the courts are too expensive or too hard to use, parents may be willing to grant temporary custody to grandparents for certain activities such as obtaining medical records for registering for school.

Finding legal help

Elder Law Attorney

Below is a partial list of what an elder law attorney (lawyer) might do:

• Preservation or transfer of assets seeking to avoid spousal impoverishment when a spouse enters a nursing home
• Medicaid qualification and application and Medicaid planning strategies
• Medicare claims and appeals
• Social security and disability claims and appeals
• Supplemental and long term health insurance issues
• Disability planning, including use of durable powers of attorney, living trusts, "living wills," for financial management and health care decisions, and other means of delegating management and decision-making to another in case of incompetency or incapacity
• Conservatorships and guardianships
• Estate planning, including planning for the management of one's estate during life and its disposition on death through the use of trusts, wills and other planning documents
• Probate
• Administration and management of trusts and estates
• Long term care placements in nursing home and life care communities
• Nursing home issues including questions of patients' rights and nursing home quality
• Elder abuse and fraud recovery cases
• Housing issues, including discrimination and home equity conversions (reverse mortgage)
• Age discrimination in employment
• Retirement, including public and private retirement benefits, survivor benefits and pension benefits
• Health law
• Mental health law

Estate Planning Attorney

An estate planning attorney will help you with the following:

• Give tax advice pertaining to estate issues
• Perform probate services
• Draw up wills and trusts
• Design powers of attorney and other consent documents
• Design special trusts or partnership programs to save estate or gift taxes
• Design charitable gifting programs
• Design programs to pay for estate taxes

State Legal Services
Most state bar associations have attorney referral programs for people seeking specific help. There are also programs to provide some free legal service for people with low income.

Services under the Older Americans Act
State aging departments and area agencies on aging offer limited free legal advice to qualifying persons under the Older Americans Act. Contact your local area agency on aging.

 

Reverse Mortgage Specialist

A reverse mortgage specialist will help you determine whether a reverse mortgage is best for you, which type of loan is best and will help you obtain a loan. Also when you obtain a government-backed reverse mortgage there is a requirement to meet with a HUD counselor to make sure you understand why you are doing the mortgage. A person cannot rely entirely on the counselor to determine whether the mortgage is best or not. A major responsibility for dispensing advice lies with the reverse mortgage specialist.

Many state laws do not allow the specialist to have a conflict of interest such as doing the reverse mortgage in order to put money into an investment. In other words the specialist is not allowed to sell investments or insurance products using the mortgage proceeds. However, this does not dissuade many specialists from teaming up with a financial salesperson and to have an arrangement to refer clients to this person. Some insurance agents have been known to own a reverse mortgage company and they require their loan originators to send clients to these owners in order to invest the money in insurance products such as annuities.

There may be situations where using proceeds solely for the purpose of investing could be a good idea. But in many cases it may only be a good idea for the financial salesperson to create a commission and it may end up being an expensive proposition for the homeowner. For instance suppose a homeowner can get $70,000 out of his or her equity on a reverse mortgage. It might cost $8,000 in origination fees to obtain this money. Then a recommendation is made to invest the money in a deferred annuity which the homeowner does. Suppose that a year later, the homeowner decides to sell the house and move into an assisted living facility. In order to sell the house, the reverse mortgage must be paid off. Suppose also that the value of the home has declined over the previous year and there is little excess equity left to cover part of the payoff. In addition the homeowner is forced to cover some of the closing costs in the sale. In this case, assume the entire $70,000 will have to be taken out of the deferred annuity to cover the cost of selling the home. But there is a 10% early withdrawal charge on the annuity surrender. The total cost of doing the reverse mortgage and buying an annuity is $15,000. In the end the homeowner has taken a loss of $15,000 -- about a quarter of the value -- on the $70,000 in equity that would have been available in the sale of the home had no reverse mortgage ever been done in the first place.

As a general rule it is not a good idea to do a reverse mortgage solely for the purpose of reinvesting the money in something else. Reverse mortgages were designed to help people pay costs or provide extra income to allow older Americans to remain in their homes. Or sometimes older people want extra cash to buy things they currently can't afford. Such things as remodeling, finding money for a down payment for a second property, buying a new RV, financing travel, buying a new car, buying long-term care insurance and so on.

When doing a reverse mortgage make sure all costs are disclosed and the alternatives are discussed as well. When choosing a reverse mortgage specialist ask for a signed statement from that person that he or she has no relationship with insurance annuity or investment companies either directly or through an associate and that he or she will make no recommendations for selling an investment vehicle. If you want to use the money and put it in an investment, that should be your choice alone, and someone wanting to make a commission off of you should not induce you to do the mortgage for that purpose.

 

Long Term Care Insurance Specialist

Increasingly we see insurance agents or financial advisers that are specializing solely in the sale of long-term care insurance. Not only is long-term care insurance a complicated product but companies are constantly coming out with new products as well. In addition a person selling long-term care insurance needs to have an understanding of what long-term care is in order to make suitable recommendations to people buying the insurance. Most insurance agents and financial planners simply don't have the time to keep up with these issues and that is why some of these people have specialized exclusively in long-term care. Here are the advantages of using a specialist.

• The specialist usually works with more than one long-term care insurance company and can find the company with the best benefits and the best price.
• The specialist often has experience with a number of companies and can recommend those that are good at paying claims, are expected to continue selling long-term care insurance or are prone to rate increases.
• The specialist has experience with medical problems involved in the issue and underwriting of long-term care insurance and he or she can find the right company for underwriting or help to get the insurance through the underwriting in a chosen company.
• Specialists are generally experts in understanding long-term care issues, especially those specialists certified to sell partnership policies. Because of this knowledge, the specialist can recommend the best coverage to dovetail with the insured's assets, income and desires for care settings and services.
• Many specialists work with a team of eldercare advisers such as care managers, pre-need funeral planners, elder law attorneys, home health providers, retirement financial planners and reverse mortgage specialists. This allows them to help the pre-retirement generation with long-term care insurance and retirement planning and also help the parents of those people with elder care needs.

 

Elder Financial Advisor

A financial planner or advisor who works with the elderly is going to understand how to invest assets for that age group. This person will also understand how to use assets and income when there is a need for long-term care.

This person will work closely with an estate planning or elder law attorney to make sure all arrangements for the estate, for disability, for loss of capacity, for medical treatment and for long-term care are covered.

An elder financial advisor is also likely to work with a team of eldercare advisers such as care managers, pre-need funeral planners, long-term care insurance specialists, reverse mortgage specialists and home health providers.

 

End-of-Life Services

Advance Directives

Advance directives for medical treatment ordinarily involve the four following written documents.

• Living will
• Health care treatment plan
• Health care power of attorney
• Do not resuscitate at-home (for states that allow a legal procedure for this action)

Many if not all healthcare organizations have standard forms for living wills. Some may also allow for signing a do-not-resuscitate order. A health care treatment plan is usually created between a patient's physician, the patient and an attorney. A health-care power of attorney is a legal document that would not usually be available as a standard form from a health-care provider. The do not resuscitate at-home arrangement is a very complicated procedure where a person needing emergency medical treatment in the home and not desiring resuscitation makes that wish known to emergency medical personnel. This involves an identification bracelet, a complicated verification procedure and an OK from a central clearinghouse not to perform any life-saving actions.

All too often a patient or his or her spouse or a family member will call 911 in the event of a life-threatening emergency. Almost never will the living will, the health care treatment plan or the health-care power of attorney end up with anyone in the emergency room. Without specific instructions, the emergency room will typically have the family sign a living will. But other health treatment wishes of the patient may be at home in the desk drawer. It is therefore extremely important to remember to take these documents to the emergency room whenever a crisis arises. If the patient has a do-not-resuscitate at-home legal arrangement -- for those states that allow such an arrangement -- and is not wearing his or her bracelet to identify this to emergency medical technicians, then it will be ignored and the EMTs will attempt resuscitation because that is what they are legally required to do.

Without the advance directives in hand for an emergency room or for a standard hospital admission many patients and family will be given the opportunity to sign a standard form from the health-care provider. Many hospitals, nursing homes and home health agencies have confusing, nonstandard living will forms that allow or disallow a number of treatments. It is extremely important for the patient or the family to read these institutional advance directives thoroughly before they sign them. We have seen a number of these documents that are both contradictory and confusing. Some of these documents claiming to be a living will, in effect, allow life-saving heroic efforts to be performed in contradiction to the principles of a living will.

Palliative Care and Hospice Care

Providing Comfort in a Facility or at Home
Palliative care is a new trend in medicine to provide comfort for the symptoms of the disease while not directly treating the disease itself. It is being used more and more in hospitals, nursing homes and by home health agencies to support the disease process. It is primarily used for people with severe illnesses and suffering from chronic pain, anxiety or discomfort.

Hospice is a form of palliative care for patients who are terminally ill. A commonly used definition for terminally ill patients is, "patients who have a progressive, incurable illness that will end in death despite good treatment, and who are sick enough that you would not be surprised if they died within six months." Whereas hospice comes into play when a patient is diagnosed as terminal, palliative care can be used at any stage in the treatment of a severe illness, from diagnosis on.

Because it is new, palliative care may or may not be covered by insurance plans such as Medicare. Or only certain protocols or medications might be covered. As it evolves so will the definitions, procedures and treatment plans. The concept involves a team approach using doctors, nurses, social workers and chaplains, similar to the hospice team. If a loved one is experiencing a great deal of discomfort or pain in the treatment process for a serious illness, the family should inquire whether the institution or care provider has a palliative care plan. Use of this care will help alleviate the suffering.

Hospice care has been around for 30 years and is a much better defined subcategory of palliative care. Hospice involves a team approach using the following providers.

• Family caregivers;
• The patient' s personal physician;
• Hospice physician (or medical director);
• Nurses;
• Home health aides;
• Social workers;
• Clergy or other counselors;
• Trained volunteers; and
• Speech, physical, and occupational therapists, if needed.

The purpose of hospice is the following:

• Manages the patient's pain and symptoms;
• Assists the patient with the emotional and psychosocial and spiritual aspects of dying;
• Provides needed medications, medical supplies, and equipment;
• Coaches the family on how to care for the patient;
• Delivers special services like speech and physical therapy when needed;
• Makes short-term inpatient care available when pain or symptoms become too difficult to manage at home, or the caregiver needs respite time; and
• Provides bereavement care and counseling to surviving family and friends.

A person can receive hospice from Medicare if he or she is

• eligible for Medicare Part A (Hospital Insurance), and
• the doctor and the hospice medical director certify that the person is terminally ill and probably has less than six months to live, and
• the person or a family member signs a statement choosing hospice care instead of routine Medicare covered benefits for the terminal illness, and
• care is received from a Medicare-approved hospice program.

A person may continue to receive regular Medicare benefits from his or her customary doctors for conditions not related to the hospice condition.

Although hospice is an outstanding service, Medicare does not pay enough or provide enough care for many patients. For those who have long-term care insurance, they may be able to get more hospice coverage from the insurance than from Medicare.

Pain Management
Pain management is the process of bringing pain under control. Pain can be a problem with many people at the end of life. Persistent pain can accelerate the decline in health due to poor nutrition, depression, lack of social stimulation and lack of exercise. And persistent pain becomes a form of disability, interfering in the ability to perform common daily tasks. Here is a list of problems that pain causes to one's self or to others:

• It is difficult to sleep
• It is difficult or impossible to pursue hobbies or personal activities
• Exhaustion can become a constant companion
• Depression is a very likely outcome
• There is little desire to eat
• It is difficult to enjoy the companionship of one's family
• There is reluctance to move about or exercise
• The patient and the caregiver become more isolated from the community because of the disability
• Family and friends who are caregivers become exhausted because of constant worry.

Chronic pain is a problem most often experienced by terminal patients who are dying from cancer. But non-cancer patients at the end of life may have other pain-causing conditions in addition to their terminal illness. This may be caused by such conditions as neuropathies, chronic back disorders or arthritis. Chronic or ongoing pain only adds to the suffering of a critically ill person. If the pain can be brought under control, a seriously ill patient can have a better quality of life for the remaining time available to him or her. Constant pain can also bring on depression which in turn could lead to suicide. Many people who cannot endure chronic pain take their own lives or seek out assisted suicide. Pain management may be a better alternative than suicide, not so much for the patient but more for the family. If a loved one takes his or her life, that can produce a permanent scar of shame or guilt within the family.

A major problem with persistent or chronic pain is that allowed to go on without treatment, the pain can become harder to treat. Research indicates that, over time, stimulation from persistent pain produces neural pathways in the brain that increase the intensity of the pain. In addition, pain receptors in the skin that are normally inert, may start transmitting sympathetic pain signals making the patient even more miserable. This can create a condition where a mere breeze or the wearing of clothing can be excruciatingly painful. Taking a pain pill occasionally as needed is not an effective treatment. Initially, it takes large doses of pain medication, on a regular schedule to bring the situation under control. Once the pain is under control, it is easier to maintain with continued lower doses of medication.

Sometimes people refuse to take strong pain medicine on a regular basis fearing dependency. But knowing that persistent pain itself becomes addictive should be incentive enough for people to seek treatment. Which is worse, addictive pain or reliance on medication? It is important to seek professional help with pain management and to establish an ongoing daily program to keep it under control. There are also numerous other non-drug techniques being developed for controlling chronic pain. Some of these might involve mind control techniques, acupuncture, electrical nerve intervention, massage or a host of other holistic approaches.

It is not necessary to refuse pain management because of a desire to display courage in dealing with terminal illness. A person is not a complainer because he or she admits to having pain. It is important to remember that caregivers are also susceptible to the stress of pain in their loved ones. The constant worry to the caregiver from ongoing suffering with the loved one will adversely affect the physical and emotional health of the caregiver. If not for themselves, persons experiencing persistent pain should seek their own treatment out of consideration for others who are concerned about their welfare.

The most common line of treatment in pain management is the use of medications. Here is a list of medications commonly used with three levels of pain.

• Mild pain - For mild cancer pain, acetaminophen or nonsteroidal anti-inflammatory medications (NSAIDs), such as ibruprofen, are often used.
• Mild to Moderate Pain - For mild to moderate cancer pain, when pain relief is not achieved with acetaminophen or NSAID medications, opioid medications are often used, usually as combination tablets with NSAIDs or acetaminophen. Some of the opioid medications used as combination products are hydrocodone, codeine, or oxycodone. Adjuvant medications may also be used for pain that is difficult to manage. Adjuvants are medications that were originally designed to treat conditions other than pain, such as tricyclic antidepressants.
• Moderate to Severe Pain - Moderate to severe pain is usually best treated with higher doses of opioid medications often not given as combination products. Adjuvant medications, NSAIDs, and acetaminophen may also be used. The opioid medications used to treat moderate to severe pain include morphine, fentanyl, oxycodone, and hydromorphone.

If the attending physician does not seem to know much about pain management or is unwilling to provide a referral to a pain clinic, the patient or caregiver need to take matters into their own hands to bring the situation under control. Referral from a friend or a listing in the Yellow Pages can lead to specialists who can help.

Choosing Where to Die

Birth and death are consequences of life. They happen to every one of us. Where birth is often a joyous occasion, death is often a sad occasion. But it not need be. It is hard to let go of someone we are close to but death also releases the loved one from pain, anxiety and unhappiness. For a caregiver, death is a welcome relief from years of sacrifice, stress and financial burden. And for those who believe in a life after death, a loved one has been released from a life of burden to a life of happiness.

Regardless of religious belief, the death of a loved one can often be a spiritual experience. But dying in the wrong setting can often lead to the departure of a loved one being an upsetting experience for the family. When a person expires, at peace in his or her own home, in a familiar setting and surrounded by loving family, that death can be an experience that the family cherishes forever. When a person dies in a hospital or nursing home amid the confusion of busy workers, tied to tubes and noisy machines and agitated by the lack of a familiar setting, that death may be remembered as an unsavory experience.

A recent survey by the End-of-Life Care Partnership, a Utah nonprofit end-of-life support group, sheds some additional light on the preference of Utahns where they would have chosen to die. A random phone survey of 150 survivors of recently deceased people was conducted. The deceased ranged in age from 23 to 100 but the mean age was 74 and over 75% of those who died were 65 or older. Over 80% of the respondents were spouses or children with the remainder having some other relationship to the deceased. The chart below indicates where the decedent's actually died.

About 54% of the subjects died where they wanted. This means the other half of the group were denied their preference of their place of death. Those who were 65 or younger more often died at home (55%) and 97% in this group preferred their home as a place of death. Of those over 80, 38% actually died in a nursing home whereas 76% of those over 80 wanted to die at home. Comparing their last desires to where the study group actually died indicates we are doing a very poor job in meeting the end-of-life wishes for terminally ill patients. The study also compared these results to national statistics reporting where death occurs and found that people from Utah died more frequently at home than people nationally. Also studies done nationally indicate that those who are currently living, predominantly would prefer to die in their homes.

The person who is dying can choose the setting if he or she wants. There is no reason to die in an institution unless there is little time to transport the person to a more familiar environment or unless a person specifically wants to die in a facility. A person who is cognizant always has complete control over the medical care he or she receives. If the person who is terminal cannot make such a decision, then the family can. There is no reason for anyone to accept death in an environment not of his or her choosing. Too often people accept the situation and don't act aggressively in making their needs known. Too often for a loved one at home, who is dying, and who is in crisis from pain or other acute attack, calling 911 becomes the first option. The loved one in crisis is transported to a hospital where death may occur. With proper planning a crisis need not result in transportation to a hospital emergency room.

Palliative end-of-life care is now a commonly available alternative for people at home who are in the last stages of their life. This could be hospice or some other form of palliative care. A crisis under palliative care would result in a call to the attending nurse or doctor and based on prior arrangements or advice, the crisis would be handled without calling an ambulance. We recommend that all terminally ill patients and their family make planning for death, using palliative care, a routine part of the preparation for the end of life.

Assisted Suicide

Our purpose in discussing this subject is not to pass judgment or to create controversy but simply point out that there is a growing movement for people to end their lives in order to avoid suffering from a debilitating terminal illness. And people seeking assistance of others, primarily the medical profession, to help them take their lives is becoming more common.

Assisted suicide basically hinges on a religious debate as to whether suicide is morally right or wrong. Those who profess no religious foundation for their actions may not see a moral problem with assisted suicide. There is however the legal issue which makes it unlawful in all states except for Oregon . Oregon has had an assisted suicide law on the books for a number of years.

Other cultures will condone suicide under certain conditions. For instance in Japan a person can take his life to protect his honor. It appears that in Muslim culture, suicide is a noble act when one destroys enemies in the taking of one's life. But even in our society, suicide is forgiven when a person sacrifices himself for the greater good of saving others.

Here is the position of the American Medical Association on allowing a member of the medical profession either assisting someone to take his or her life or in an act of compassion -- called euthanasia -- taking that life without permission.

Euthanasia
Euthanasia is the administration of a lethal agent by another person to a patient for the purpose of relieving the patient's intolerable and incurable suffering.

It is understandable, though tragic, that some patients in extreme duress-such as those suffering from a terminal, painful, debilitating illness-may come to decide that death is preferable to life. However, permitting physicians to engage in euthanasia would ultimately cause more harm than good. Euthanasia is fundamentally incompatible with the physician's role as healer, would be difficult or impossible to control, and would pose serious societal risks.

The involvement of physicians in euthanasia heightens the significance of its ethical prohibition. The physician who performs euthanasia assumes unique responsibility for the act of ending the patient's life. Euthanasia could also readily be extended to incompetent patients and other vulnerable populations.

Instead of engaging in euthanasia, physicians must aggressively respond to the needs of patients at the end of life. Patients should not be abandoned once it is determined that cure is impossible. Patients near the end of life must continue to receive emotional support, comfort care, adequate pain control, respect for patient autonomy, and good communication.

Physician-Assisted Suicide
Physician-assisted suicide occurs when a physician facilitates a patient's death by providing the necessary means and/or information to enable the patient to perform the life-ending act (eg, the physician provides sleeping pills and information about the lethal dose, while aware that the patient may commit suicide).

It is understandable, though tragic, that some patients in extreme duress-such as those suffering from a terminal, painful, debilitating illness-may come to decide that death is preferable to life. However, allowing physicians to participate in assisted suicide would cause more harm than good. Physician-assisted suicide is fundamentally incompatible with the physician's role as healer, would be difficult or impossible to control, and would pose serious societal risks.

Instead of participating in assisted suicide, physicians must aggressively respond to the needs of patients at the end of life. Patients should not be abandoned once it is determined that cure is impossible. Multidisciplinary interventions should be sought including specialty consultation, hospice care, pastoral support, family counseling, and other modalities. Patients near the end of life must continue to receive emotional support, comfort care, adequate pain control, respect for patient autonomy, and good communication.

The AMA does not condone such actions and the statements imply that a physician engaged in such practice would be committing an undesirable act not in keeping with the purpose of medicine. But notice also that the AMA does not prohibit such activity.

This leaves open the possibility that medical professionals living in a state where euthanasia under certain circumstances or assisted suicide might be legal, could engage in such a practice if they chose to.

The biggest problem with using suicide to avoid prolonged suffering at the end of life is the effect it has on family. If there is no family or the family has been consulted and is at peace with such a decision, then suicide might be acceptable. But our society does not generally except suicide and for someone to take his or her life willingly could be a great psychological blow to the family. The stigma, guilt and shame a family may carry from someone committing suicide could cause emotional wounds in family members for the rest of their lives. Anyone, not suffering from severe depression--which can cloud rational thinking, should be counseled to consider the consequences of suicide before using it as an option to avoid the distress of an unpleasant natural death. The person contemplating suicide may not know of options other than suicide, such as treatment for depression and hospice care and pain management

When Death Occurs

When a loved one dies at home, family or others who are there must often cope with the reality of the dying process. We recommend strongly that when a person is first considered being terminal, the doctor should be asked to order hospice care. We cannot stress enough how hospice care can help those involved get through a death at home or even in a care center. Oftentimes the family waits until a loved one is well along towards the end of life before hospice is considered.

Hospice is generally used for cancer patients because it is often easy to determine in advance whether a person will survive or not. If the cancer is not cured and continues to spread, death is usually inevitable. Whether that occurs in a matter of weeks or months is not important to the doctor prescribing hospice. The only requirement is the doctor must have a reasonable expectation that his patient cannot survive beyond six months. Sometimes hospice patients can receive care for years before they succumb.

For other medical conditions hospice may be just as appropriate but oftentimes the family fails to inquire or the family doctor simply doesn't consider it. Hospice should be considered for such conditions as congestive heart failure, advanced diabetes, advanced lung disease, advanced autoimmune disorders, advanced kidney disease and so on. Even in the absence of any medical condition, a person can still qualify for hospice if he or she is deteriorating rapidly and overall health is declining. Another condition often overlooked for hospice is advanced dementia or Alzheimer's disease. Family often wait until a loved one starts shutting down before hospice is ordered. Or sometimes hospice is not even considered for Alzheimer's because doctors are so used to using palliative care only for cancer. If a loved one is not improving, family should always ask or even press for hospice. Remember not to wait until close to the end but order hospice at an earlier stage since it will help provide the necessary transition to the death of a loved one.

Why are we so adamant about using palliative care? Because these services focus on dying patients and will help the family get through not only the death but also give physical and spiritual comfort to the person dying as well as offering bereavement support after the death. We simply can't stress enough the importance of using this type of support when the end is near.

When a person is close to death, physical changes occur. Blood flow slows down and fingers and toes may start turning blue or black. Breathing is labored, there is a rattling at the back of the throat and the breathing process may even cease for long periods and then resume again. A loved one will be cold and it is important to provide blankets for warmth. A loved one may be confused or he or she may simply sleep a lot. Since these changes will be noticeable to the caregiver, a call to the hospice will receive immediate response with either a visit or instructions over the phone.

Remember hospice is on call 24 hours a day and the service is there to provide exactly this kind of support when death is imminent. Because of this support, the caregiver and other family members will be able to spend more quality time at the bedside of their loved one. Their fears for their loved one will be dealt with by a staff that can be relied on for knowing exactly what to do. Supportive services with the death of a loved one can make a huge difference in the way family handle the consequences of the death.

After death occurs, the hospice workers will also make arrangements for a funeral home to pick up the body. They will also help clean up any soiled bedding and talk to the attending physician about other follow-up, say an autopsy.

Coping with the Loss of a Loved One

Understanding Bereavement, Grieving and Mourning
Bereavement or grieving is the process and period of time during which someone suffers grief from the loss of a loved one. Mourning is a public display of grief. In our culture, mourning is not an officially prescribed ritual except perhaps for certain religious groups. In other cultures it can become a prolonged public display lasting for many days or even many weeks. This might include multi-day public wakes, the use of professional mourners, the wearing of black attire, remaining sequestered in the home or the prescribed use of religious rituals.

Grief is a condition experienced by all where someone suffers a loss of another person who is close. When we love someone and they die, the feeling of loss can often become an overpowering experience. It is almost like a part of us has been torn out and we can't cope with the feelings it brings upon us. Grief is a normal part of our human experience. As human beings, we work together and rely on each other as a part of our existence. Human culture could not exist without this inter-cooperation. This reliance on others, especially someone we love, becomes over time intertwined into the function of our brain. When a loss occurs, our mental process must physically readjust to a new reality and the period of grieving is the process we go through to retrain our minds.

Even though no one really ever completely recovers from the loss of a loved one, most of us tend to find strategies that allow us to push it into our distant memory. It lingers there and we can retrieve it from time to time but it does not evoke the same powerful emotional response it once did. On the other hand, some people simply never deal with the emotions of grief and it remains in the forefront of their minds for a long time if not forever. This can have a powerful disabling effect on a person and may prevent that person from leading a normal life. It is extremely important to learn to deal with grief not only for personal reasons but for the sake of other loved ones who are still alive.

The intensity of the grief experienced and the subsequent ability or inability to deal with it are often a result of the nature of the loss itself. When a death is anticipated from a long illness or because of extreme old age it is often easier to deal with than an unexpected death. The time between knowing that death will come and the actual death allows for the grieving process to take place in advance. A spouse, children or other close people will rehearse in their minds many times over what will happen when a loved one is gone. This helps prepare them for the day it will happen and often shortens the grieving period. On the other hand, even with an anticipated death, sometimes two married people are so close that when one dies the other is completely lost and never fully recovers. It's not surprising when the survivor dies soon after.

The most difficult death to deal with is a sudden death involving violence or a suicide. Not only is the unexpected event a shocking experience but the nature of the death also leaves the survivors feeling violated, guilty and unprepared. Normally deaths of this type require professional assistance from a counselor to help the living cope with the extreme grief such a death can cause.

There is no timetable for bereavement. Every person deals with it in his or her way. For some the process requires but a few weeks and they can go on with their life as before. For others it may take years. And for some grief becomes a chronic daily burden and if that person doesn't deal with grief then it can prevent one from living. Also chronic grief often results in depression. If the intensity of the grief does not diminish and there are problems with eating, sleeping, continuing feelings of guilt or the inability to function, professional assistance is needed.

Managing the Grieving Process
Some authors like to break down the grieving process into stages. The reason for this is so that those grieving can recognize if they are making progress towards resolving their grief. Recognizing the various emotions associated with the process will help a person determine at what stage they are. Here is one author's dichotomy.

Disbelief
Almost everyone has difficulty accepting a loss. Most people simply want it to go away as if it never happened. They will tell themselves such things as "why me?", "why can't I start over?", "this seems like a bad dream" and so on. Their thinking is numb and they want to forget it, but in the back of their minds there is a deep foreboding of what happened. They can't shake the reality of their experience.

Reaction
After the initial shock has worn off and there can be no more denial then there must be a reckoning. Some will express anger. Some will blame others. Some will retreat and become brooding and stoic. Each person has his own way of reacting to a loss.

Sorrow
When striking back at a loss no longer seems an acceptable strategy, then sorrow sets in. A person might feel sorry for himself or for others or both. A great deal of tears are normally shed and it is at this stage that one seeks comfort from others. The person in mourning may also find it difficult to do anything or to talk to anyone. Family or friends should recognize that comfort is being sought, regardless of the attitude of the person in mourning, and offer their support. But sympathy may not always be the best strategy. Encouraging activity and involvement in other things might be a better way to support someone in grieving.

Acceptance
At some point most people who have lost a loved one have worked through their emotions and no longer have the need to be angry or to feel sorrow. Those emotions may still be there but they are placed in the back of the mind and a concerted effort must be made to relive them. Otherwise they seem as a wisp of smoke, something seen but not recognized.

Some People can work through bereavement very quickly and resolution comes within a matter of days or weeks. They readily accept the loss, work through their anger and sorrow and are ready to move on. Unfortunately some people get stuck in one phase of the process. They may spend considerable time in denial. They may spend months or even years being angry. Or they may have gotten past the anger and they are preoccupied continually with feeling sorry for themselves.

In fact this is the test that one uses to determine if the grieving process is spent. If a great deal of one's waking moments are spent on rehashing what could have been (disbelief) , working on strategies of "getting even" (reaction) or allowing thoughts of the loss to interfere with daily life (sorrow) , then a person is not through the grieving process. By stepping back and looking at oneself as if from someone else's eyes and then recognizing the problems we have just discussed, a person in grieving can then make a decision about what to do next. This may involve seeking help from family or friends or it may involve the services of a professional counselor.

Grieving and depression are not the same thing. Prolonged grieving, however, can often lead to depression. And as we have discussed previously, depression is a major contributor to suicide in older Americans. The suicide rate of the elderly is about four times that of the rest of the population. It is therefore very important to avoid depression with the loss of loved ones. Grief may manifest symptoms similar to depression such as sleeplessness, loss of appetite or a feeling of gloom but unlike depression, grief can be set aside. One way to recognize the difference is if engaging in physical or mind stimulating activities results in the gloom going away, at least for that period of time, it is unlikely to be depression. Depression does not go away regardless of what one does.

As a general rule the grieving process is a mental process that can be overcome by retraining one's thinking. Depression on the other hand may have resulted from improper thinking but it has become a physiological problem with an imbalance of chemicals in the brain. The brain itself is not working correctly. Depression is much harder to treat. It may require medications or it may respond to cognitive therapies but the intensity of those therapies is much deeper than what one would need to work through a grieving issue.

When a person feels he or she cannot cope by themselves with grief or the potential of depression it is time to seek help. It is important for family or friends to realize that many people can't recognize by themselves they have a problem. Especially those who have become depressed. Depression creeps up over a period of time and results in mood changes and changes in thinking patterns that the afflicted person may not recognize have happened. A person with depression often feels he is "normal" and will even resist someone telling him that there might be a problem.

For those needing professional help there are two types of therapy. The first is called grief support. Grief support may simply consist of talking through issues with a counselor and recognizing the faulty thinking and implementing corrective strategies. Or it may involve group sessions with people in a like situation, again with the idea of coming away with strategies to deal with the grief problem. Grief support can be found by contacting a local hospice agency as these people specialize in helping their clients through the bereavement process.

The other therapy is called grief therapy or grief counseling. This usually involves sessions with a trained therapist to resolve underlying issues. Grief therapy is often needed when a person is dealing with very intense grieving issues. This may be a loss of a loved one in an accident or a murder or through suicide. Such losses can be so traumatic that people can't get through them themselves and require professional help to deal with it. For example, grief therapy is an automatic response for students who might experience a fellow student dying in a tragic accident, taking his or her life or using firearms in the school to take the lives of others. Grief therapists are going to be licensed therapists, psychologists or psychiatrists specializing in this practice.

Final Arrangements--Preparing the Body

In the early days of our country when a person died, members of the community would come together, wash the body, clothe it and prepare it for burial. Then often members of the community or family would pay their respects by coming to the home of the deceased for a viewing. Finally, a day or two later, there might be a funeral service followed by a burial. There were no fancy caskets, no embalming (except for a period after the Civil War) and no cemetery vaults. The practice of burning a body after death in a furnace or funeral pyre was not generally done. As a consequence of our history, our culture has become accustomed to preserving the body for burial. This is not necessarily true in other cultures. Hindus and Buddhists almost always cremate their loved ones.

The period of time between interment in a mausoleum or burial in the ground could be as much as a week or more, owing to the need to notify members of the family who are living far away, allowing them to travel to where the interment will take place and allowing time to make arrangements to buy burial plots and so forth. Nowadays, funeral homes and undertakers usually have refrigerators to preserve the remains while arrangements are being made. Also it is common tradition to have a viewing either a day or two before the burial or funeral or just prior to burial or funeral.

Embalming is a common practice in the United States and Canada but is generally not as popular in the rest of the world. For some, embalming is a way of providing respect by retarding the natural decay of human flesh. For others and for certain religions embalming is considered a desecration of the body. Studies done at the University of Tennessee reveal that all bodies decompose, embalmed or not. It just may take longer for the embalmed body to return to the earth. Embalming fluid may also contain dye to make the skin look more lifelike. The embalming process also allows for funeral home workers to safely "restore" the body by repairing injuries, filling out the face through padding, forcibly closing the jaw, injecting collagen and using cosmetics to make the deceased appear "natural", as if he or she were slightly younger and in good health. It is also traditional to dress the loved one in formal or favorite attire. Families appreciate seeing their loved ones in a favorable light. It helps them remember the departed one in a pleasing setting. A common phrase used by those filing through a viewing is "He/She looks so good!" On the other hand, lifelike viewings are sometimes disturbing to people as well.

Embalming and restoration are not a necessary process if there is no viewing or for that matter even if there is a viewing. Even though viewings would be safe without embalming, very few funeral homes will consent to viewing without the process. In many states there are no laws requiring embalming except if bodies are transported across state lines, shipped internationally or shipped commercially. It is never required for the first 24 hours in any state; 22 states require embalming after 24, 48, or 72 hours, but refrigeration is usually an alternative option. (Refrigeration is not an option in Alaska , Minnesota or North Dakota. ). Under certain circumstances, medical examiners may require embalming pursuant to an investigation or if death were due to contagion. Due to the use of refrigeration, the remains can be transferred to a coffin for a funeral or graveside service without incurring this additional cost. For funerals and viewings conducted in the home, dry ice is often used to retard decomposition.

The cost of embalming and restoring as well as the cost of expensive coffins and vaults can be avoided by using cremation. Cremation is typically a much less expensive process and some families prefer it to keeping the body in its natural state. It is also a simpler process as far as making arrangements for viewings and services if such services are not desired. Since a funeral and interment can often be the third largest expense a family can incur after purchase of a home or a car, many families simply must find a less expensive way to provide final arrangements for loved ones. Some don't have the money for expensive services but still want to provide respect for a decedent and not simply put them in a pine box and place them in the ground. For these reasons and many others cremation is becoming more popular. Estimates are that 20% to 30% of all last arrangements use cremation.

It is interesting to note that legally in more than half of the states; the deceased person has no postmortem rights to what happens with his body. In those states, the family does what it wants, although many times the wishes of the departed are respected if that person made his or her wishes known before death or has created some binding condition in a will that forces the family to comply. If the decedent wanted a traditional burial, the family may choose cremation. If the decedent wanted cremation, the family may choose a traditional burial.

What is often not understood about cremation is that it does not prevent having a funeral or graveside service or even burying the remains in a grave. The body is still there, it is just in another form. In fact a traditional viewing and funeral service can even be arranged before the cremation takes place. If the family does not want to purchase an expensive casket for a pre-cremation, traditional service, a casket can be rented. Family may also view the cremation process. In most states there must be a waiting period before cremation can occur, for legal purposes, since there is no way to identify cause of death after cremation. Also some states require permission from a medical examiner or corner for the same reason. If it is a suspicious death, obviously cremation will not be allowed.

The process consists of first removing a possible heart pacemaker and external metal objects from the body and then it's common to place it an inexpensive wooden or cardboard coffin. But needing a coffin for cremation is not always required and simply adds to the expense. The body and or coffin are placed in a very hot furnace until everything is reduced to ash. This takes several hours. There may be remnants of metal parts such as artificial joints and there may remain a few pieces of bone. The metal parts are removed and the ashes and bone are processed to a very fine powder. The family has chosen beforehand a suitable receptacle or urn and the ashes are placed in it. The family can choose to have a funeral, a memorial service, or nothing at all. The ashes can be placed in a mausoleum in a cemetery, they can be buried in a cemetery plot, they can be kept in someone's home or they might be scattered in a suitable location.

Services centered around a cremation can be considerably less expensive than traditional funeral services. It is estimated that the average cost of a funeral in the United States is about $8,000. Interment using cremation can cost anywhere from $500 to $2,000. The less expensive version would entail only a cremation and a scattering of the ashes in an appropriate location. This would also mean no services and no memorialization and no urn. The more expensive version might entail a funeral service or memorial service, an expensive urn and memorialization in a cemetery.

Cremation is forbidden by Orthodox Judaism, the Eastern Orthodox Church and Islam. The Roman Catholic Church has allowed cremation since 1963 as long as traditional ceremonies respecting the body for purposes of resurrection are maintained. The ashes cannot be scattered or kept in the home but must be buried or entombed. Some Protestants allow cremation, some discourage it and others take no position.

Funeral Services and Funeral Service Providers

Probably the most common arrangement for closing out the life of a loved one is to have a funeral service and a burial in a local cemetery. Ostensibly funerals are touted as a way to honor the person who has passed away but in reality funerals are for the surviving family. The funeral is part of the mourning process. If the family has been proud of their loved one or if the loved one has had some standing in the community such as being a scholar, a doctor, a lawyer, a politician, a church leader or someone famous, the family wants the community to recognize their family member. They want to "show off" the deceased. As a general rule, the greater the status the more lavish the funeral. This recognition from the community and the emotional support from those who attend, in turn, help the family cope with the loss of their loved one. Here's an excerpt from the national Funeral Directors Association about funerals.

"Funerals fill an important role for those mourning the loss of a loved one. By providing surviving family members and friends a caring, supportive environment in which to share thoughts and feelings about the death, funerals are the first step in the healing process.

The ritual of attending a funeral service provides many benefits including:

•  Providing a social support system for the bereaved.

•  Helping the bereaved understand death is final and that death is part of life.

•  Integrating the bereaved back into the community.

•  Easing the transition to a new life after the death of a loved one.

•  Providing a safe haven for embracing and expressing pain.

•  Reaffirming one's relationship with the person who died.

•  Providing a time to say good-bye."

If the deceased person was not respected by the community or the family, it is less likely that a formal funeral service will be held. But it is also possible that regardless of the status of the person who has died, the family may not want a public viewing and service because they do not want the attention of the community. Oftentimes they will simply have a burial service at the grave site for a very select number of people. Or they may choose cremation and scatter the ashes in a private ceremony somewhere that would have been special to the person who died.

Concerns from consumer groups that funeral homes or undertakers were taking advantage of family and asking them to make purchase decisions when they were most vulnerable to manipulation, after the death of a loved one, led to the Federal Trade Commission publishing rules for the sale of funeral services.

The Funeral Rule prohibits specific misrepresentations in six areas (FTC 1997):

1. Embalming - Funeral homes may not tell consumers that embalming is required unless a specific state or local law requires it. In MOST STATES, embalming is not required by law.
2. Casket for Direct Cremation - Funeral homes cannot tell consumers that state or local law requires them to buy a casket if they are arranging a direct cremation for the cremation itself or for any other reason. An alternative container must also be made available.
3. Outer Burial Container - Funeral homes cannot tell consumers that they are required to buy an outer burial container, unless a specific state or local law requires it. They also must tell consumers that state law does not require them to purchase an outer burial container.
4. Legal and Cemetery Requirements - Funeral homes cannot tell consumers that any federal, state, or local law or particular cemetery or crematory requires them to buy a particular good or service, if that is not true.
5. Preservative and Protective Value Claims - Funeral homes cannot make any representations to consumers that funeral goods or services will delay the natural decomposition of human remains for a long term or an indefinite time.
6. Cash Advance Items - If funeral homes mark-up the charge on cash advance items or receive a commission, discount, or rebate that is not passed on to the consumer, they cannot state that the price charged for the cash advance item is the same as its true cost. This rule, however, does not prevent them from adding a service charge, nor does it require them to disclose the amount of that charge to the consumer.

Other Misrepresentations--other kinds of misrepresentations, though not specifically prohibited by the Funeral Rule, are nonetheless illegal. The FTC Act prohibits deceptive acts or practices. Likewise, the consumer protection laws of each state prohibit deceptive practices. The federal rule does not apply to businesses that sell funeral services only (cremation as an example) or goods only (caskets or grave markers as an example).