Dad in Nursing Home, have questions about Power of Attorney & Benefits

[Caiyuo]

I appreciate it, man

[Weiing]

First, to clear some confusion: POLST is not the same as an advance health care directive. They are different in nature, although they basically talk about the same things (do you want your life prolonged if X happens?). Advance health care directives are more general in nature, and good to have at ANY time. POLST is more immediate and for individuals at the end of life. It's a physician's order, so what the POLST said must be executed/followed by all health care staff no matter what. Advance Directive can be more subjective, and is just a document, not a direct physician's order.

For instance, scenario A with a POLST - Person has a cardiac arrest, but everyone knows that he has a POLST. The nurse goes to check the POLST, and it says that the person only will accept injections to start the heart, but no intubation and chest compressions. With that information, the staff only inject the person with the medications for the heart.
Scenario B with advance health care directive with a DPOA - Person came to the ED, and was found down. Person had no POLST, so the paramedics typically default to full code and attempt resuscitation. They resuscitate the person by intubating, chest compressions, AED, injections, etc etc. Now this guy is intubated and all that jazz, but basically brain dead. Consulting the advance directive and the DPOA, the family and health staff decide that was not what the person wanted, so they extubate and remove everything that's sustaining the body.

ANYWAY...to go to your main content:
1) So they think he will eventually return to baseline or close to baseline? Are you sure he will ever be able to return to being somewhat functional? If not, then may have to look into other, more long term care options, whether at home or in an assisted living facility or something of the sort. But if he may actually be able to regain more of his strength even if it's slower progress for him, I guess you guys will need to set goals and dates to re-evaluate progress.

2) He may have had a psych eval at the beginning, but generally that gives a good idea of where he was at his possible "worst". From there, is there any sign of improvement? Or is it really still just fluctuating? Typically one can do a short mini-mental status exam daily to see how he's doing.

3) DPOA stuff - For Advance Health Care Directive (AHCD) and health care POA, you can do it yourself. HOWEVER, if you feel more confident if you had some legal person with you to concoct a document, then by all means.... because what will be contained is very sensitive. There are many AHCD templates online, and I'm sure there's a pretty generic one you could find for Florida. However, I think if you wanted to draft a financial document, it may be better to consult someone more well-versed in that respect. Also, "durable" power of attorney means that the POA status is maintained even if the person is incapacitated... From my understanding, general POA's power is terminated if the person is incapacitated. But I'm not so sure, it may actually be the same... Because honestly, I use both interchangeably in my work.

4) Your mother - So... You could apply for food stamps and other cash benefits for her as an individual. If you go to your local welfare office, you can ask to speak with a social worker who will be more well-versed than I am about your state-specific programs. If your father does pass away, whenever that may be, your mother may be able to receive his benefits. Also, if he is a veteran, perhaps she may receive something after his death from the VA as well. I'd encourage you to explore what the VA might have to offer.

Sorry if my responses are quite vague or just too broad... I am just not very familiar with Florida policies. I can only give broad advice from what I know about how things typically go.

Let me know if there's anything else. You can feel free to post on here. But if there comes a time when it becomes too personal and you rather not have it be shared to everyone, you can email me. I don't care either way.

[Caiyuo]

hey Weiing, thanks for responses, here's what I got:

1.) sorry I took baseline as a general meaning but I don't know what it means in this context; recently they've said he was beginning to decline what with getting pneumonia before and now dealing with a ton of congestion and also said there's a good chance that he may be moved to their long-term care wing over time since physical improvement has been scarce, essentially meaning he'd be there indefinitely and we've dealt with the costs surrounding that already.

2.) he's been on a medication for dementia for a few weeks now that he's taken steadily since it's all through his feeding tube and so they're noticing improvement. Talking to him seems a lot more normal now, so I'm hopeful in this regard.

3.) I spoke to the SW at the SNF and she said nothing could really be done until his was more aware of what he'd be signing and I was under the impression he was at that point, but she doesn't feel the same so POA hasn't been done yet. I'll speak to his nurses to get a general consensus to make sure since I don't want to waste any opportunities given how wavering his condition's been.

The more recent thing to happen is that on Friday the SNF contacted me and said his doctor was pushing for a DNR to be signed because of how frail he is. I was pretty shocked and put-off at the thought, but multiple people there contacted me about it to talk about why it was a good idea so I've been mulling that over. They expressed the difficulty of explaining it to someone who has never had to deal with it before since they see it frequently and it makes sense, I'm just hesitating over the decision. Should I even be making this decision if he were fully cognizant? I'm only signed on as a healthcare proxy such that I've agreed to make his healthcare decisions for him within the scope of the nursing home, but I don't really know how to even begin talking to him about this or how I'd go about it.

Again, thanks so much, you've been invaluable.

[Acturus]

Since you're in Florida, have you considered contacting a professional geriatric care manager? It's a self-pay service, but a good GCM will take care of everything from clinical assessment to perscription evaluation to benefits coordination.

My masters degree research project was on GCMs, and I interviewed a company in Orlando. I don't know the financial resources at your disposal, but in terms of total care for persons such as yourself, it could be a valuabe investment.

http://fgcma.org/

*edit* I'm less sure of the value of my suggestion, given your last response. It sounds like (forgive me) your dad is on a shorter timetable than I thought.

[Weiing]

@ Acturus - That would be a good option. However, I'm not sure how possible it would be given the current monetary burden on his family... But I do agree that having an overall care manager is helpful if it was affordable. I don't imagine that service is cheap.

@ Caiyuo -
I'm glad that it seems your father is improving some with the medications. If the SW told you that they don't feel your father is competent/aware enough to sign POA, then I'm sure the SW has already spoken with the MDs and RNs. HOWEVER, that does not mean that you shouldn't also consult with them yourself and have them tell you exactly what they are thinking or seeing from your father.

With regards to DNR status. Yes. That is, and will always be, a very difficult decision to make. Is he cognizant enough to talk about it? Because if he is alert and oriented enough--and not too demented (i.e. too much dementia/memory loss/confusion)--it should be his decision. However, I have an inkling if that the staff are coming to you with this matter, they might be thinking that no, he isn't in a state of mind to make this decision.

Herein lies the stress for you -- because it is a difficult decision, and possibly an ethically conflicting decision for you. First, even though you may be the health DPOA, does your mother and the rest of your family know about this DNR talk? Do they know the process of actual resuscitation? Do they know what your father would have wanted?

If his MD is suggesting a DNR because your father may not be able to physically sustain resuscitation attempts, just remember it's a suggestion. There's also the option of having limited DNR, if you would rather try the medication-route rather than chest compressions. The whole resuscitation process can be brutal, especially for an elderly individual. Ribs may break, throats may have tears due to stuffing the tube down the throat forceably, and sometimes people even puke all over in the process. Those are the main reasons I've heard for going with a DNR for elderly people. It comes down to "Will they come out at least the same as before they had their cardiac/respiratory arrest?" If you feel like a DNR is the best option, then you can defer to your MD and agree that DNR, or limited DNR, is the best option. However, it's understandable if you want your father to be full code, and if you believe he would be able to sustain resuscitation in all its forms.

Having actively participated in "code status" talks with patients and families, many think suggestions of DNR that come from the medical staff equates to giving up on the patient and family. However, it's more of what would be more "realistic", doing the least "harm", while also minimizing the chances of liability for them. I will admit that I do have my own biases and sometimes secretly get frustrated with patients/family members... Not to say I'm frustrated with your case, because I don't know the situation too well nor have I seen him before... It's only with the extreme cases that I get frustrated about. But honestly, no matter how frustrated one can become, health staff will NEVER go against a patient's or his/her family's known wishes.

Think it through, and speak with your family, too. However, just know that whatever code status you determine is not definitive. It can be changed at any time. They cannot say "NOPE. You said DNR, can't change your mind now."