An Aid in Dying Update: More Available, Yet Few Will Choose It

On August 1, New Jersey became the eighth state to allow doctors to prescribe lethal medication to terminally ill patients who want to end their lives. On Sept. 15, Maine will become the ninth. By October 2019, 22% of Americans will live in states where residents with six months or fewer to live can determine how and when they will die. (Oregon, Washington, Vermont, Montana, California, Colorado, Hawaii, District of Columbia) Oregon was the first state to pass the Death with Dignity Act in 1997. More than 20 years later, opposition groups remain wary of potential abuse. Hospitals with religious affiliations may refuse to allow their physicians to perform the procedure. Yet opposition is softening as support grows. Aid in dying is more available, yet few will choose it.

A look back on the EOLOA in California

California passed the End of Life Option Act (EOLOA) in 2015. Jerry Brown signed it into law in 2016. Four years and it remains controversial and problematic. While the campaign for aid in dying (or death with dignity) continues to make gains across the country, supporters are increasingly concerned about what happens after these laws are passed—on both sides of the issue.

• Some fear that the law forces the dying to navigate an overly complicated process of requests and waiting periods.
• There are op-out provisions that allow doctors to decline to participate and health care systems to forbid their participation—even in places where aid in dying is legal. In areas where there is a shortage of doctors, it can be difficult to complete the necessary process within the prescribed timeframes.
• Those who oppose the legislation fear that it sets up a slippery slope for abuse.

The New Jersey bill had neared passage several times, but derailed in 2014 when Governor Chris Christie threatened a veto. Legislators passed the Aid in Dying for the Terminally Ill Act in 2019 and the governor signed it in April. Governor Janet Mills: “I do believe it is a right that should be protected by law–the right to make ultimate decisions.”

So what’s changed? All states are required to track usage and publish stats

Data show that whether a state has six months or 20 years of experience (Oregon, the pioneer in aid in dying), the proportion of deaths involving aid in dying (also known as physician-assisted suicide) remains tiny.

California’s 2017 data show that 632 people made the necessary two verbal requests to physicians, after which 241 doctors wrote prescriptions for 577 patients. This out of 269,000 deaths that year. The law shows no evidence of widespread abuse or misuse of the law. Attitudes within the medical community are changing. A number of national organizations and a dozen state medical societies have gone from opposing the law to taking neutral stances.

Despite Catholic organizations and other opponents, polls show broad support

In March, an aid-in-dying bill passed the Maryland House of Delegates but failed after a tie vote in the Senate. Opponents are attempting a ballot initiative to repeal Maine’s new law and pursuing a slow-moving court case to invalidate California’s. Yet public opinion polls consistently show broad support for aid in dying.

The small number of users suggests most Americans would not choose this option

There’s enough data from a number of states now to identify trending. The low numbers of users show that most users would not choose this option. However, it may also reflect difficulty in actually using these laws.

A recent survey of 270 California hospitals, published in JAMA Internal Medicine, found that 18 months after implementation of the state’s EOLOA, more than 60% — many of them religiously affiliated — forbade affiliated physicians to participate. Compassion & Choices is intensifying efforts to persuade local health care systems, doctors and hospices to agree to consider patients’ requests.

Laws drawing scrutiny; many believe they’re too difficult with too many safeguards

The model has been the first-in-the-nation Oregon law, which took effect in 1997. The law requires that a terminally ill patient:

• Sees two doctors.
• Makes two oral requests for a lethal prescription, plus one in writing.
• Waits 15 days.

For a terminally ill patient who perhaps lives in a rural area where doctors are scarce or even in an urban area where they’re booked up for weeks in advance, this can become challenging. A Kaiser Permanente study shows that at least a third of those who inquire about the aid in dying measure become too ill to complete the process or die before they qualify. Hawaii’s law took effect in January. It requires a 20-day wait, and they’ve an additional mental-health consultation requirement.

Dementia, testamentary capacity and Aid in Dying

• Rural areas face physician shortages, and Compassion & Choices has urged that nurse-practitioners and physician assistants be allowed to provide aid in dying in states where they can legally write prescriptions.
• One legislator has introduced several bills that would permit those in the early stages of dementia and other neurodegenerative diseases to use aid in dying, securing prescriptions theycould then use later as their illnesses progressed. “You could make the request when you were cognitively able to do it,” he said.
• Yet every existing state law bars that. Those requesting aid in dying must be able to show mental capacity; dementia patients will have lost that ability by the time they’re within six months of dying.

The support for aid in dying continues to gain momentum. The fact that very few people are actually using this measure may be tamping down the fears of those historically opposed to the measure.

Many of our clients are seniors who come in to our offices to create their Living Trusts

The result is numerous conversations on a wide range of topics related to health, healthcare and end-of-life planning. California Document Preparers assists our clients in the preparation of their Trusts, which include a Power of Attorney and Advance Healthcare Directive. Most are surprised at how easy it is. Schedule an appointment today by contacting us at one of our three Bay Area offices. Our dedicated team is helpful, compassionate and affordable.

A Brain Scan May Predict Alzheimer’s. Should You Get One?

Juli Engel was delighted when a neurologist recommended a PET scan to determine whether amyloid — the protein clumps associated with an increased risk of Alzheimer’s disease — was accumulating in her mother’s brain.

Her mother, Sue Engel, is 83 and lives in a retirement community in Florida. She’s been experiencing memory problems and the other signs of cognitive decline that her family could no longer ignore. There were, of course, the small things that drive us all crazy–losing our keys and wandering into rooms, then forgetting why we’re there. But for Juli, there were more serious indicators: Mom had been financially exploited, suffered an insurance scam and caused an auto accident. Time for an intervention.

PET scans can detect amyloid plaques that can indicate Alzheimer’s

PET scans can detect the amyloid plaques that occur commonly in older people’s brains that contribute to Alzheimer’s disease. Receiving an early diagnosis can be devastating to patients and their families, but it can help patients get their affairs in order and make the most of the time they have left. They can begin taking medications that may slow down the spread of the disease. Alzheimer’s can be a slow-moving illness, and early diagnosis gives patients time to join support groups, spend time with their families and learn how to live as fully as possible in their remaining years.

A PET scan’s downside

Amyloid plaques occur commonly in older people’s brains, but not everyone with amyloid will develop dementia. Nor does a negative PET scan mean someone won’t develop dementia. Medicare doesn’t cover the scans’ substantial costs of $5,000-$7,000.

The healthcare community debates PET scans: Few benefits at significant costs

• Brain damage from Alzheimer’sbegins years before people develop symptoms, and worried patients and their families may start turning to PET scans to learn if they have this biomarker.
• While scientists at Washington University in St. Louis have developed a blood test for amyloid that can predict the development of plaques in the brain, it is years away from everyday use in doctors’ offices.
• Some experts fear PET scans offer few benefits, at substantial costs. Currently the criteria developed by the Alzheimer’s Association and nuclear medicine experts call for PET scans only in cases of unexplained or unusual symptoms and unclear diagnoses.

Even with detection, we have no corresponding treatment for Alzheimer’s

Alzheimer’s rates climb steeply at older ages, when people grow more likely to die of other causes before they can develop symptoms. But older people also may be among the 30% or so of those with amyloid deposits who, for unexplained reasons, retain normal cognition. “If we start treating everyone with preclinical Alzheimer’s, what treatments would those be? Multiple trials have failed to find drugs that prevent, reverse or substantially slow Alzheimer’s disease, perhaps because these treatments were introduced too late in the disease’s course.

Concerns about broader acceptance

Some worry about “indication creep,” when a drug or test approved for patients with a particular condition becomes used for others. They also worry about crushing costs for Medicare. “Even if a scan cost zero dollars, I wouldn’t recommend it,” said Dr. Ken Covinsky, a geriatrician at the University of California, San Francisco. “Do you really want to know that you have amyloid in your brain, years ahead of cognitive problems that may never develop?”

PET scans can act as motivators

Proponents of making PET scans more widely available argue that knowing their amyloid status may motivate patients to make lifestyle changes. Stopping smoking, exercising and eating a healthier diet are all found to reduce dementia, even among those at higher genetic risk. Perhaps, too, patients will be more likely to begin advance care planning.

What the scan will mean for Juli Engel

For the Engels, the test delivers tangible results. Once the neurologist documents her mother’s incapacity, Juli can take steps to prevent her mother from driving; she’ll be able to move her into assisted living when needed. As a geriatric care manager, Juli thoroughly understands the trajectory of this disease. Because she also knows that both her maternal grandparents had Alzheimer’s, she is considering her own future, too. Does she have amyloid in her brain? Her family is full of scientists, and we tend to want to know these things,” she said.

Many of our clients are seniors who come in to our offices to create their Living Trusts

The result is numerous conversations on a wide range of topics related to health, healthcare and end-of-life planning. California Document Preparers assists our clients in the preparation of their Trusts, which include a Power of Attorneyand Advance Healthcare Directive. Most are surprised at how easy it is. Schedule an appointment today by contacting us at one of our three Bay Area offices. Our dedicated team is helpful, compassionate and affordable.

Drug Prices: Finally. Something Everyone Agrees On

Anyone who relies on prescription drugs or cares for someone who does knows that drug prices are soaring. The average annual cost of a brand-name drug has more than tripled in the past decade. Older adults take an average of 4.5 medications each month, which can add up to a total retail cost of more than $30,000 a year for brand-name drugs.

Strong patent laws plus limited pricing regulation over for-profit pharmaceutical companies mean these companies are pretty much free to charge whatever they want for the medicines they offer.

So why is it different now?

• Prices are so out of control that even in our historically divided Congress, Democrats and Republicans actually have found something to agree on.
• Several bipartisan bills have been introduced to attack the problem.
• The AARP believes that a combination of tactics can bring drug prices under control, including giving the federal government the ability to negotiate when buying drugs.
• It also includes legalizing the safe importation of drugs sold at lower prices in other countries and capping patients’ out-of-pocket costs.
• A final approach is to change patent rules in place now and allow manufacturers of brand-name pharmaceuticals to freeze out competition from generic alternatives that could lower prices.

AARP has launched Stop Rx Greed

• This is a national campaign to persuade federal and state lawmakers to take action on the issue. The campaign includes lobbying efforts, consumer-information programs and the release of new research about drug prices.
• We’re the only nation in the world that doesn’t negotiate the price of drugs
• The U.S. has the highest prescriptions drug costs in the world. One reason is that we’re the only industrialized nation whose government doesn’t bargain with drugmakers over pricing.
• Australia, Japan and most European nations have some form of a national health program with drug review boards that negotiate with manufacturers. They analyze whether a new drug is more effective than its previous incarnations, or simply a slightly modified version. They’re often able to negotiate significant discounts because they can walk away if companies won’t cooperate.
• A quick example: The asthma medication Advair costs $310/month in the US; it’s $38 in Germany. The list is endless and it breaks your heart. Especially when you read about people who are dying because they can’t afford their medications.

Proposed solutions to lowering drug prices 

• Let Medicare negotiate directly with drugmakers.
• Give Medicare Part D plans more flexibility in creating their lists of covered drugs.
• Leverage a drug’s price in other countries to identify the price here.

Let’s keep this in mind: Even as Advair’s $38 pricetag in Germany is a fraction of what it costs here at home, the drugmakers are still making money.

Prices are lower elsewhere, specifically Canada. Why not import those?

Tempting, but there’s a very good reason why we can’t just import all of our drugs from Canada, where prescription drugs cost 33% less than in the U.S. It’s illegal, though you likely know someone who gets his/her meds from Canada and has been doing it for years.

Proposed legislation would let patients buy lower-priced medicines from Canadian pharmacies for personal use. Critics say this would lead to harmful counterfeits. But there are ways to institute safeguards. The FDA has already safely imported drugs to address critical shortages. And more than 40% of drugs, both brand-name and generic, are made overseas.

The problem: 20 years of patents before generics can hit the marketplace

At the bottom of all of this is the long, expensive development cycle to get a drug on the market. To encourage innovation and allow pharmaceutical companies to recoup their expenses, the federal government grants 20-year patents on new drugs that give companies the exclusive right to market the medication.

Because it takes years to get the drug to market, manufacturers end up with a monopoly

They do everything they can, including making insignificant tweaks to the meds to extend those patents and prevent generics from entering the market. In 2012, the GAO estimated that generics had saved the U.S. health care system $1 trillion during the previous decade. By extending these patents, big pharma is preventing consumers from accessing affordable healthcare.

So whom should we believe?

Big Pharma justifies high drug prices to cover the costs of research and development at $2.6B/ drug. But wait. Virtually all of today’s new drugs, such as blockbuster immunotherapies for cancer, have roots in government-funded research at the National Institutes of Health or leading academic centers across the country. Every one of the 210 new drugs approved by the FDA between 2010 and 2016 began life in NIH-funded labs, representing grant funding totaling more than $100B, a 2018 report by researchers at Bentley University reveals. That’s right. This is publicly funded research—it’s not coming out of the pockets of the drug companies.

Drug companies rarely, if ever, pursue these fishing expeditions of basic research, the stuff that might one day lead to a breakthrough drug but doesn’t have an immediate payoff. That work is increasingly funded by taxpayers.

Policy makers are considering a variety of options, such as demanding a higher return on investment for taxpayer-funded research that is ultimately commercialized, or allowing the government to control the patents of drugmakers that charge unreasonably high prices.

What to do: Increase generic competition

• Increase the availability of generics. Pending bills would beef up FDA budgets for reviewing generic applications to accelerate approvals of generic drugs.
• Limits on out-of-pocket costs. Cap out-of-pocket drug costs for Medicare Part D enrollees.
• Value-based pricing. Right now, a drug’s pricetag often bears no relationship to its clinical benefits. How do you distinguish a genuine advance from a mild improvement?

More enlightened consumer education 

As part of its drug-pricing blueprint, HHS is calling for increased price transparencyso consumers can make more informed decisions.

• Medicare and Medicaid have updated their pricing dashboards.
• Congress passed an anti-gag clause allowing pharmacists to tell consumers about drugs that are more affordable than ones they’ve been prescribed.
• Drugmakers are being encouraged to include list prices in their direct-to-consumer advertising.

The bottom line:“Real people suffering from real diseases should not have to beg, borrow or steal to control their diseases,” says Rena Conti, associate research director of biopharma and public policy for the Institute for Health System Innovation and Policy at Boston University.

Many of our clients are seniors who come in to our offices to create their Living Trust

The result is numerous conversations on a wide range of topics related to health, healthcare and end-of-life planning. The rising cost of medications is a frequent topic. California Document Preparers assists our clients in the preparation of their Trusts, which include a Power of Attorney and Advance Healthcare Directive. Most are surprised at how easy it is. Schedule an appointment today by contacting us at one of our three Bay Area offices. Our dedicated team is helpful, compassionate and affordable.

When You Know It’s Time to Move to a Retirement Home

A New York Times article regarding one couple’s discussions about moving to a retirement home brought back memories of my own parents’ ongoing dialog. My folks were in their mid-eighties, still healthy and active, but their three-bedroom home on a Florida lakeshore was becoming a burden. After a lifetime of shopping for groceries, planning and preparing meals, my mother had run out of steam. More important, she was feeling increasingly isolated and lonely. Her friends were either dead or living out their final days in nursing homes with dementia. My stepfather, of course, was completely comfortable having my mother cook and care for him. The subject of time to move to a retirement home was not something he entertained.

I don’t remember the catalyst, but they finally put their house on the market

My folks finally sold their house and moved to a retirement community overlooking a little lake. They had their own little unit, with a provision to move to assisted care and the nursing facility when/if it became necessary. My mother was thrilled. A very social person, she immediately made friends, played bridge three-four times/week, helped out in the library one day each week. There was always something going on and the staff were wonderful. My mother had cooked her last meal. This was exactly where she needed to be at this point in her life.

In the Times article, John and Dawn Strumsky had the same debate as my folks did. Dawn’s ready to pack it in. After a lifetime of caring for others, it’s time to be a “princess”, unburdened by the demands of cooking, cleaning and gardening. Her husband hated the idea of a leaving their longtime home and being surrounded by a bunch of strangers—a bunch of old strangers. He finally relented and they moved to a senior community outside Baltimore. He learned to embrace his new environment and subsequently wrote a 365-page history of the facility that they use in their marketing.

Dealing with seniors’ resistance to moving to a retirement home: It’s a journey

Seniors fear giving up their independence. It’s difficult to leave the home where they’ve raised their families. They don’t like confronting their own mortality. The key to convincing a parent to move to a retirement community is to be patient, said Tom Neubauer, executive vice president at Erickson Living, which operates 19 retirement communities. “Inherently there’s a sense of denial, particularly as it relates to aging, and you’re trying to defeat that.”He likened the process to helping a high school student choose a college: “You can’t just hand them a brochure and say, ‘This is where you’re going.’ It’s a journey.”

Neubauer’s strategy was to get his mother to recognize that the stairs in her house were steep, that cold weather affected her ability to get out and do things. That she was limiting herself because she wasn’t driving at night. It ended up being very easy. Collectively, all of these arguments persuaded his mother that it was time to move.

Go for a visit; stay for a meal or an overnight

Experts advise visiting retirement communities and trying to get a feel for what the experience would be like. Meet the residents, talk to the staff, stay for a meal. Some facilities will allow potential residents to spend a few nights.

Specialists in senior moving help seniors recreate their lives in smaller environments

We all love our stuff. Seniors may have spent decades in the same home, and it can be very difficult to leave all that is comfortable and familiar. A cottage industry of specialists in senior moving has sprung up, and the National Association of Senior Move Managers has more than 1,000 members.

These consultants do more than move boxes. They create digital floor plans to show clients how everything will look and fit in a smaller environment. They’ll ship leftover items to relatives or to auctions. As much as possible, they recreate the old space to make the transition as seamless as possible.

My folks lived in their retirement community for nearly ten years

As with many seniors, a health crisis necessitated my parents’ move into assisted living, then nursing care. They both died there within six months of each other. My mom was 94. In the end, we enlisted the support of Hospice, and the women who cared for her were wonderful. I think of my mom so often, and it’s generally while she was surrounded by her many friends in that retirement community where she happily lived out the last decade of her life.

California Document Preparers assists our clients with creating Living Trusts. A Power of Attorney and Advance Healthcare Directive are included as part of this legal document. Make an appointment today at one of our three Bay Area offices. Our dedicated team is helpful, compassionate and affordable.

You’re Having a Stroke: Could You Identify the Symptoms?

Kara Swisher is a business technology journalist and contributor to The New York Times. In a recent article, she describes her own symptoms that led to her rush to the ER with a stroke. What saved her life? It well may have been a long-distance consult with her doctor brother who recognized the symptoms. His words: “You’re Having a Stroke” could have saved her life. Could you identify the symptoms?

“Get to a hospital now. You’re having a stroke”

Swisher had flown to Hong Kong to run a conference. She was 49, healthy and didn’t have any of the conditions normally associated with a stroke—no high blood pressure, neither a smoker nor overweight. She had begun to feel odd symptoms, but associated them with the normal migraines with which she struggled. She felt a slight tingle on the side of her mouth and hand, and her words came out garbled. Odd, but certainly not alarming.

When she tried to eat a strawberry, it slowly dropped from the side of her mouth onto her shirt. As she’d been doing for years, she texted her symptoms to her brother, Jeff, a doctor. By the time she’d showered, dressed and headed to the restaurant for breakfast, her symptoms were largely gone, and she moved on to her day. By the time Jeff called to tell her she was having a stroke, she laughed it off.

But he was insistent. In an increasingly urgent tone he insisted that she drop everything and go to the hospital immediately. Getting the blood flowing back to the part of the brain that is affected is critical. So Swisher took a car to the Hong Kong ER.

A screen clearly showed a stroke

The stroke showed up on a screen: Evidence of a transient ischemic attack, a mini-stroke, was clearly visible. There was a small hole in her heart through which the clot traveled, plus Swisher had a type of blood that is more prone to clotting. Combined with not hydrating or walking around enough on the long flight to Hong Kong, it created what the doctor called a hole in one. He immediately started the treatment of anticoagulant drugs and medication. The doctor, who told her that had she not moved faster it would have been much worse.

Swisher was lucky to have had a brother who saved her life—or at least the quality of her life.

Strokes in younger people are very rare

• About seven in one million Americans under age 50 die annually from strokes caused by a blocked blood vessel, and nine per million die from a brain hemorrhage, the two main types of strokes.
• Arterial dissection. The lining of an artery tears and separates from the vessel wall. A blood clot forms at the site of the tear and travels to the brain, eventually blocking the flow of blood to brain tissue.

Knowing the symptoms can help prevent serious damage

Unlike Kara Swisher, not all of us have a doctor brother who can provide virtual medical advice. Nerve cellsin the brain tissue communicate with other cells to control body functions, including memory, speech and movement.When you have a stroke, your brain isn’t getting the blood it needs, so your memory, speech and movement are affected. You need treatment as soon as possible to lower your chances of brain damage, disability or even death.

Recognize stroke symptoms

If you feel the kinds of symptoms that Kara Swisher did—numbness and tingling—be aware that you could be experiencing the initial symptoms of a stroke. This easy test will help determine if you need to immediately get to the emergency room.

• Face: Smile and see if one side of the face droops.
• Raise both arms. Does one arm drop down?
• Speech: Say a short phrase and check for slurred or strange speech.
• Time: If the answer to any of these is yes, call 911 right away and write down the time when symptoms started.

How to lower the risk of stroke? Adopt healthy habits

• Lower blood pressure and cholesterol.
• Eat a healthy diet.
• Lose weight.
• Exercise more.
• If you drink, do it in moderation.
• Treat atrial fibrillation.
• Treat diabetes.
• Quit smoking.
• Have regular medical checkups.

Many of our clients are seniors who come in to our offices to create their Living Trusts

The result is numerous conversations on a wide range of topics related to health, healthcare and end-of-life planning. California Document Preparers assists our clients in the preparation of their Trusts, which include a Power of Attorney and Advance Healthcare Directive. Most are surprised at how easy it is. Schedule an appointment today by contacting us at one of our three Bay Area offices. Our dedicated team is helpful, compassionate and affordable.

Seniors in the Workplace: Is 60 the New 40?

The employment landscape for those 60 and older

According to Inc. Magazine, there are now more than 76,000,000 Americans reaching the age of 60 and beyond, “and it seems they either can’t or don’t want to stop working.” An article in The Atlantic points out that employment in America of those aged 65 and older doubled between 1977 and 2007 and continues to climb. The employment landscape for those 60 and older has changed dramatically over the last decade. Employers are finding a lot of good reasons to hire older workers.

Seniors in the Workplace: Is 60 the New 40?

Another factor in the growth of seniors in the workplace is the changing nature of work; we can be productive far longer than in earlier eras. Sixty may be the new 40. Some jobs require cognitive skills that actually improve with age. According to a research paper entitled “Population Aging and Comparative Advantage,” these skills include technical writing, human resources management and numerous other disciplines.

The economics of retirement

The fabled retirement that Americans worked for and enjoyed decades ago may no longer be an option for today’s seniors. It’s increasingly rare to find an organization, even a union company, which offers a pension on which it is sufficient to live. Improved healthcare means that people are living longer. They’re taking care of themselves, eating better diets, exercising and remaining physically and mentally engaged. This longer lifespan requires more money.

Many seniors want to continue working

Also consider that an older person who may have enough money to live comfortably may want to work. Older people may be just as eager to contribute as they were when they were twenty. For many seniors, retirement just doesn’t work. They like the structure of having a place to go every day. They like the relationships, the sense of belonging. The mental stimulation that’s part of sharing ideas and problem-solving.

Consider the numerous benefits an older employee may provide. They:

• Are a steady and reliable source of skilled labor.
• Offer decades of relevant experience and, if they enjoy health coverage, may offer the experience you require for less money than a younger candidate requiring full benefits.
• Offer your younger employees valuable mentoring at no cost.
• Are more comfortable than younger candidates with flexible hours. Many seniors are happy to work part-time.
• Are not aggressively seeking to advance their careers at this point in their lives. You probably won’t have to worry about their playing political games that can spoil office environments.
• Offer stability. Turnover is expensive for every company.
• Are experienced problem solvers, seasoned and more engaged – they want to be involved, focused on tasks.
• More technological savvy than you think. Boomers are comfortable using computers. Where there are skill gaps, they can learn.
• Will appreciate an opportunity to work. Loyalty is a valuable commodity.
• Represent a large segment of the buying public and know that market better than the rest of your team.
• Already know what they’re good at.

Remember that many veterans are in this age group, and hiring those who have served in the military may contribute to your company’s ethos and brand.

California Document Preparers assists our clients in creating Living Trusts. A Power of Attorney and Advance Healthcare Directive are included as part of our Trust portfolio. Make an appointment today at one of our three Bay Area offices. Our dedicated team is helpful, compassionate and affordable.