Thoughts | Updates | Events
New(er) Tool for End-of-Life Planning
Written by: Lisa Bayer, J.D., CCM
I recently attended a professional presentation on end-of-life care and questions arose regarding the procedure to follow when someone dies. A last will and testament typically speaks to this. But, what if there is no will? What if there is a will but is it not in the possession of someone available to interpret it? If not, who gets to decide what happens to a loved one’s body? What if one family member wants cremation and another wants a traditional chaplain service and cemetery burial?
I have been practicing care management for more than 17 years and while this has never come up, I can see instances where it might. Twice I had the honor and privilege of being with the family when my client passed away. In both instances, everyone was in agreement, and we knew who to call and what to do.
But what if there is no one? I have a client who is a solo ager with no family. So as not to burden his friends, he named his accountant as his power of attorney and health care representative. I know where he keeps a copy of his will in his home, but I have no authority myself to make any decisions—nor can I even enter his home without permission.
At the professional presentation mentioned above I learned about a new planning tool to help with this scenario and I have started sharing it with my New Jersey clients at onboarding when appropriate. It is called an “Appointment of Agent to Control the Funeral and Disposition of Remains” and it is in accordance with **N.J.S.A. 45:27-22. What is important here is that the client is in control of, and decides who will oversee, what happens to his or her body after death. The form does need to be witnessed and notarized so there could be some logistical challenges if it is necessary to bring a notary to the client and, of course, the client needs to have sufficient cognitive capacity to understand and sign such document.
While this form may not be right for everyone, it allows me as a professional an opportunity to provide support to, and promote autonomy of, choice, for my clients and their families which is a hallmark of my care management philosophy and practice.
If you would like to learn more about end-of-life planning or if you live in New Jersey and would like us to send you a link to this form please reach out to us at: Hello@LMReldercare.com or call us at: 973.533.0839.
**While the form mentioned above is specific to New Jersey, other states have similar forms and regulations.
End of Life Planning For Your Pets
By: Lisa Bayer, J.D., CCM
Over the years as a geriatric care manager, I have been in hundreds of client’s homes. I also think that I have seen everything! I recently encountered a situation that truly threw me for a loop.
I was engaged by the legal guardian of a client who lives out of state to be her “boots on the ground” with respect to her loved one, Margaret. Margaret had a catastrophic event and suffered a TBI (traumatic brain injury) which requires skilled, nursing home level care. Before the TBI she was living independently in her own home with her dogs. She had never married, has no children, and has no other local involved family members.
One of my responsibilities was to help coordinate the emptying and selling of her home. The (living) dogs were surrendered to a local rescue but nothing prepared me for the 16 boxes of cremated pet remains that we found all over the home.
Part of the issue is that Margaret’s sister could not relate and would have thrown them in the trash if it were up to her. However, as the court-appointed legal guardian she was required to respect Margaret’s wishes, known or unknown, to the best of her ability. So, what to do?
Margaret’s sister had engaged an amazing realtor who partnered with me throughout the process to find solutions to each scenario that we encountered. And there were many!! In this case, we contacted local pet cemeteries to inquire about process and cost for burial. One of them was sympathetic and worked with us to keep the cost down by offering to combine plots of more than one pet. This was the best way that the guardian could think of to respect what Margaret may have done, or directed, if she had been able to.
Personally, I learned from this experience something that I will bring to my practice in the future. While many wills address what happens to pets after a person passes, most power of attorney documents (especially older ones) that I have seen do not always address how the agent should care for the living pet(s). And I have never EVER seen one that addresses how to treat pet remains when your loved one loses capacity and cannot speak for themselves. I always ask clients as part of onboarding to share their planning documents with me. As a trained attorney, I am able to make meaningful suggestions when it comes to any updates to make sure that the documents will work if needed. After this recent experience I will be more cognizant of not just living pets but how to handle their remains if a client is no longer able to do so him or herself.
PCR is Not Just a Covid test; A 21st Century Approach to Diagnosing and Treating Urinary Tract Infections
Written by: Lisa Bayer, J.D., CCM
Recently, I had the pleasure and privilege of sitting down with Dr. Joseph DiTrolio, and Ms. Pilar Vega, Senior Director of Business Development with Premier Medical Laboratory. By way of history, Ms. Vega and I were speaking one day and she alluded to a qPCR (Quantitative Polymerase Chain Reaction) test that her lab offers patients in multiple care settings. Ms. Vega explained that the results of this type of test is typically available within 24 hours and allows for more pinpoint targeted treatment, or in some cases non-treatment, than the traditional “scorched earth” approach of prescribing a generic antibiotic for urinary tract infections (“UTI”) while waiting 4-5 days for the culture results only to find out that a patient does not have a UTI or the prescribed antibiotic is the wrong one.
Over the past two (pandemic) years we have all become well accustomed to the term “PCR.” I for one did not realize that it is not a Covid-specific test but rather stands for “polymerase chain reaction” which is a type of testing that looks at a pathogen’s DNA profile to identify the organism(s). The qPCR can also detect the genetic makeup (the DNA or genes) of the pathogen to prevent and avoid antibiotic resistance. As a geriatric care manager, most, if not all, of my clients have suffered from at least one, usually multiple, UTIs. I was curious and so Ms. Vega graciously set up a meeting so that I could ask Dr. DiTrolio questions and learn more about this approach.
I asked Dr. DiTrolio to please explain why the qPCR test is preferable to the traditional urine culture and why, if it is not better, it is not the standard of care. At the outset, Dr. DiTrolio explained that 50% of people who present with a possible UTI do not actually have one. Yet, physicians often prescribe antibiotics before testing as the traditional culture takes 3-7 days to get back and they do not want the patient to have to wait. And, while Dr. DiTrolio was too polite to say it outright, I inferred that to do the less traditional qPCR while still a urine collection, may involve a bit more effort to arrange to have the right lab pick up the samples. Meaning, some providers do not take the time or make the effort to become educated and instead rely on 100-year-old protocols. The old “if it ain’t broke why fix it” adage. Yet, in the end it is the patient, our health systems and our children and grandchildren who suffer if we mistreat patients and create drug-resistant organisms in the process.
As Dr. DiTrolio explained, the longer a urine specimen is out of the body, the greater the chance that the results will be tainted. Furthermore, if two or more strains are present, using the traditional method of waiting for a culture gives the “dominant” bacteria strain a chance to destroy or mask the less dominant strain(s). This does not mean that the bacteria are all gone—just that it was not picked up on the traditional culture. And so, we see occurrence or reoccurrence of bacteria that were present but not picked up and therefore not treated properly the first time around.
The qPCR test is covered by Medicare so it is not a payor or reimbursement issue. In fact, by procuring a reliable, quick test it can actually save money and produce better outcomes. This is because if the antibiotic is wrong then the patient does not only not get better, but he/she will need another course of treatment. Overuse and inappropriate use of antibiotics can lead to additional morbidities such as Cdiff recurrence, gastrointestinal disturbances and yeast infections. A severe, untreated UTI in a patient with multiple health problems is also more likely to end up in the hospital. In the worst case it can lead to death.
In sum, it is important for caregivers, patients and their advocates, such as geriatric care managers, to ask questions of physicians and other providers and to insist on meaningful explanations and answers so that the care recipient has the opportunity to make informed and educated decisions on his or her care.
*Joseph DiTrolio, MD, is Urologist in private practice in Roseland, NJ. He serves as Professor and Chairman of the Board for the New Jersey Medical School Alumni Association, his alma mater. He holds numerous patents and has authored and presented on hundreds of papers and articles all over the world. Dr. DiTrolio is committed to the care and support of our beloved veterans. Since graduating medical school in 1979 he has been affiliated with the East Orange Veterans Administration focusing on injuries and illnesses related to the urological system.
*Pilar Vega’s background is in business and the life sciences. She has over twenty years of experience in healthcare with a focus on diagnostics, pharmaceuticals and medical equipment. branches of the industry. Pilar is a committed advocate of optimal care for every patient regardless of means or life circumstance.