ElderCare is a critical and, at times, difficult subject The following are my list of questions which I would ask if I were in your position. ...but FIRST, let me say again, ask questions, questions and more questions...your purpose is to be able to come back home in a "peaceful" state of mind that all is being taken care of, or that you have a clear idea of how it WILL BE taken care of. There are several ways to approach the subject: Finances, Health, past history, legal, Estate planning, friends, parent's commitments, beliefs, attitudes, concern and safe keeping. ALL of these need to be considered - though my questions will center more on the Legal and financial aspects. I am getting to the direct questions I would ask, but let me say: Call me if you have ANY QUESTIONS (214 823-7000)(Dallas, TEXAS) 1. I apologize for the length of this email. As I was writing it I realized that I should provide you several "links" which you will find helpful (either while you are there or when you get back). 2. The following questions are presented and then explained (as to why I would ask them)...this will NOT be a complete list of questions for you to ask; however write down the answers you receive and who said it to you 3. The following questions may not need to be asked at all - you should decide whether the question has already been addressed or is clear by your presence at your parents. 4. By being there, I would probably ask MANY more on-point questions which I do not know about as I am writing this email. A CHECKLIST Use this checklist as a quick reference guide to help you locate important documents in the event of an emergency or unexpected medical situation. It is also a good way to help your elder get organized while they are still living independently. For a more detailed organizational tool, consider the Prism Personal Organizer, one tool in the Caregiver Education Series . In the blank space, describe the location of each document. Keep this checklist updated on a regular basis. Bank Statements for Checking Account:_________________________________________ Bank Statements for Savings Account/Passbook:_________________________________ Birth Certificate:___________________________________________________________ Passport:_________________________________________________________________ Marriage Certificate(s):_____________________________________________________ Last Will and Testament:___________________________________________________ Durable Power of Attorney:__________________________________________________ Living Will:_______________________________________________________________ Health Care Proxy (Medical Power of Attorney):_________________________________ Safe Deposit Box Key:______________________________________________________ Deed to Home:____________________________________________________________ Insurance Policy/Records:___________________________________________________ Vehicle Registration/Title/Lease:_____________________________________________ Stock Certificates/Records:__________________________________________________ Bond Certificate/Records:___________________________________________________ Mutual Fund Records:______________________________________________________ Military Papers/Records:____________________________________________________ Records of Debts Owed to You:______________________________________________ Mortgage/Home Equity Loan Statements/Papers:________________________________ Credit Card Statements:____________________________________________________ Loan Papers/Records:______________________________________________________ Post Office Box Key/Combination:____________________________________________ Social Security Card:_______________________________________________________ Cemetery Plot Papers/Records:_______________________________________________ Previous Income Tax Returns/Records:_________________________________________ +++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++ QUESTIONS -------- (and not necessarily in this order). I have presented these in the form YOU would ask someone. Therefore a statement of "I want to talk with him" means "YOU" want to talk with him...not me. LEGAL: 1. I need a copy of my parents WILL & TESTAMENT. Read it to make sure it is the LATEST one. Who is/are the executor. I want to talk with him/her. Talk with them to find out what your parents said to them. Does what they are saying to you SOUND like something your parents would say. If ANYTHING is questionable...ask your parents if this is what they wanted the executor to do. Correcting a misunderstanding is an option NOW...it may not be an option in a few more months. 2. Have any TRUSTS been established - I need copies of any such instruments 3. Do my parents - JOINTLY or SEVERALLY belong to any PARTNERSHIPS, JOINT VENTURES or CORPORATIONS 4. Have my parents ever been SUED or had to defend themselves in a COURT FINANCIAL 1. WHERE are all your bank accounts - I need copies of Bank account numbers, account registers (showing detail transactions), locations, officers you deal with (checking and savings). 2. WHERE are all your STOCK accounts - I need copies of account numbers, locations, phone numbers and brokers). 3. WHERE are all your INSURANCE policies - I need copies of the polices, policy numbers, Insurance company, Insurance Broker. 4. WHERE are the IMPORTANT papers kept. I need copies of all of them. 5. WHERE are the DEEDS to all the REAL ESTATE PROPERTY that is owned. I need copies of these as well as the loan documents for all loans paid off or still being paid on, to whom and a name and phone number of who you have dealt with. GO TO THE COUNTY RECORDS Building and ask someone there to explain to you whom and what "encumbrances" are on such property. If there are none - the property is CLEAR. 6. WHERE are the last 5 years of TAX RETURNS - FEDERAL and STATE - I need copies of all of these. 7. have the CURRENT returns been prepared - I need to have a copy of these. IF these have not been filed yet...I want to make it clear that NOTHING will be filed with the tax authorities until I say so. PRACTICAL - to be asked of any and everyone of your parents friends and associates 1. Do my parents have ANY arrangement with you 2. Have my parents EVER had any arrangement with you 3. If YES - do my parents owe you anything? If so - I want to see the documents they signed which support such an obligation. 4. Who are my parents friends and advisors - talk with anyone you hear of. Get phone numbers, names and addresses. OTHER - some of these repeat from above General Issues Who will be the principal caregiver? What involvement will siblings have? Which responsibilities can be shared? By whom? (Supervising medications, shopping, doctors, day care, etc.) Is communication open and honest between caregiver and elderly person? Do family members share feelings and information? Financial and Legal What is the person's financial situation? Is there a list of assets, their value, their locations? Is there a private pension? Is it mailed directly to a bank? Which one? What is the social security amount? Is it directly deposited? Where? Are there other sources of income? Annuities, stocks, interest, IRA's, CD's, safe deposit box? What are the debts? Mortgages, car payment? Is there a need to apply for SSI, Supplementary Security Income? Is medical coverage adequate? Is there a prescription plan? Long term care insurance? Medicare? Medicaid? Has anyone consulted an eldercare attorney? Has the elderly person transferred any assets? What is the "time frame" in your state for transferring assets before being qualified for Medicaid? Is there a will, a living will, a power of attorney, a durable power of attorney that lasts beyond incapacitation? Where are they kept? Is there an insurance policy? Where is it kept? Housing What housing options are possible? Can the elderly person live alone? What about an assisted living facility? Is a nursing facility or a personal care facility needed? Is senior housing or shared housing an option? Is a life care community feasible? Has the person or family any "up-front money" available for some period of personal pay in a nursing home? Physical Condition Has the person had a recent physical? Is there a family doctor? Has a geriatric assessment been ordered? What medications are being taken? By prescription? Over the counter? Ask the pharmacist or doctor if any medications interactions should be avoided. Ask if any meds should not be taken together. Any foods avoided? After Death Are there any pre-paid funeral expenses? Any specific funeral wishes? What funeral home? A viewing? A family plot? Cremation? Any specific desires? Can you discuss death with the person for whom you are caring? Why not? Most of the elderly do not fear discussion of death. +++++++++++++++++++++++++++++++++++++ TO BE OBSERVED WHILE YOU ARE WITH YOUR PARENTS - This relates to THEIR home...possibly YOURS should they com to live with you... Each year, many older Americans are injured in and around their homes. The U.S. Consumer Product Safety Commission (CPSC) estimates that in 1981, over 622,000 people over age 65 were treated in hospital emergency rooms for injuries associated with products they live with and use everyday. CPSC believes that many of these injuries result from hazards that are easy to overlook, but also easy to fix. By spotting these hazards and taking some simple steps to correct them, many injuries might be prevented. Use this checklist to spot possible safety problems which may be present in your home. Check YES or NO to answer each question. Then go back over the list and take action to correct those items which may need attention. Keep this checklist as a reminder of safe practices, and use it periodically to re-check your home. This checklist is organized by areas in the home. However, there are some potential hazards that need to be checked in more than just one area of your home. These are highlighted at the beginning of the checklist and short reminders are included in each other section of the checklist. ALL AREAS OF THE HOME In all areas of your home, check all electrical and telephone cords; rugs, runners and mats; telephone areas; smoke detectors; electrical outlets and switches; light bulbs; space heaters; wood-burning stoves; and your emergency exit plan. CHECK ALL CORDS QUESTION: Are lamp, extension, and phone cords placed out of the flow of traffic? YES ___ NO ___ RECOMMENDATION: Cords stretched across walkways may cause someone to trip. Arrange furniture so that outlets are available for lamps and appliances without the use of extension cords. If you must use an extension cord, place it on the floor against a wall where people can not trip over it. Move the phone so that telephone cords will not lie where people walk. QUESTION: Are cords out from beneath furniture and rugs or carpeting? YES ___ No ___ RECOMMENDATION: Furniture resting on cords can damage them, creating fire and shock hazards. Electric cords which run under carpeting may cause a fire. Remove cords from under furniture or carpeting. Replace damaged or frayed cords. QUESTION: Are cords attached to the walls, baseboards, etc., with nails or staples? YES ___ NO ___ RECOMMENDATION: Nails or staples can damage cords, presenting fire and shock hazards. Remove nails, staples, etc. Check wiring for damage. Use tape to attach cords to walls or floors. QUESTION: Are electrical cords in good condition, not frayed or cracked? YES ___ NO ___ RECOMMENDATION: Damaged cords may cause a shock or fire. Replace frayed or cracked cords. QUESTION: Do extension cords carry more than their proper load, as indicated by the ratings labeled on the cord and the appliance? YES ___ NO ___ RECOMMENDATION: Overloaded extension cords may cause fires. Standard 18 gauge extension cords can carry 1250 watts. If the rating on the cord is exceeded because of the power requirements of one or more appliances being used on the cord, change the cord to a higher rated one or unplug some appliances. If an extension cord is needed, use one having a sufficient amp or wattage rating. CHECK ALL RUGS, RUNNERS AND MATS QUESTION: Are all small rugs and runners slip-resistant? YES ___ NO ___ RECOMMENDATION: The Consumer Product Safety Commission (CPSC) estimates that in 1982, over 2,500 people 65 and over were treated in hospital emergency rooms for injuries that resulted from tripping over rugs and runners. Falls are also the most common cause of fatal injury for older people. Remove rugs and runners that tend to slide. Apply double-faced adhesive carpet tape or rubber matting to the backs of rugs and runners. Purchase rugs with slip-resistant backing. Check rugs and mats periodically to see if backing needs to be replaced. Place rubber matting under rugs. (Rubber matting that can be cut to size is available.) Purchase new rugs with slip-resistant backing. NOTE: Over time, adhesive on tape can wear away. Rugs with slip-resistant backing also become less effective as they are washed. Periodically, check rugs and mats to see if new tape or backing is needed. QUESTION: Are emergency numbers posted on or near the telephone? YES ___ NO ___ RECOMMENDATION: In case of emergency, telephone numbers for the Police, Fire Department, and local Poison Control Center, along with a neighbor's number, should be readily available. Write the numbers in large print and tape them to the phone, or place them near the phone where they can be seen easily. QUESTION: Do you have access to a telephone if you fall (or experience some other emergency which prevents you from standing and reaching a wall phone)? YES ___ NO ___ Have at least one telephone located where it would be accessible in the event of an accident which leaves you unable to stand. CHECK SMOKE DETECTORS QUESTION: Are smoke detectors properly located? YES ___ NO___ RECOMMENDATION: At least one smoke detector should be placed on every floor of your home. Read the instructions that come with the smoke detector for advice on the best place to install it. Make sure detectors are placed near bedrooms, either on the ceiling or 6-12 inches below the ceiling on the wall. Locate smoke detectors away from air vents. QUESTION: Do you have properly working smoke detectors? YES ___ NO ___ RECOMMENDATION: Many home fire injuries and deaths are caused by smoke and toxic gases, rather than the fire itself. Smoke detectors provide an early warning and can wake you in the event of a fire. Purchase a smoke detector if you do not have one. Check and replace batteries and bulbs according to the manufacturer's instructions. Vacuum the grillwork of your smoke detector. Replace any smoke detectors which can not be repaired. NOTE: Some fire departments or local governments will provide assistance in acquiring or installing smoke detectors. CHECK ELECTRICAL OUTLETS AND SWITCHES QUESTION: Are any outlets and switches unusually warm or hot to the touch? YES ___ NO ___ RECOMMENDATION: Unusually warm or hot outlets or switches may indicate that an unsafe wiring condition exists. Unplug cords from outlets and do not use the switches. Have an electrician check the wiring as soon as possible. QUESTION: Do all outlets and switches have cover plates, so that no wiring is exposed? YES ___ NO ___ RECOMMENDATION: Exposed wiring presents a shock hazard. Add a cover plate. QUESTION: Are light bulbs the appropriate size and type for the lamp or fixture? YES ___ NO ___ RECOMMENDATION: A bulb of too high wattage or the wrong type may lead to fire through overheating. Ceiling fixtures, recessed lights, and "hooded" lamps will trap heat. Replace with a bulb of the correct type and wattage. (If you do not know the correct wattage, use a bulb no larger than 60 watts.) CHECK SPACE HEATERS QUESTION: Are heaters which come with a 3-prong plug being used in a 3-hole outlet or with a properly attached adapter? YES ___ NO ___ RECOMMENDATION: The grounding feature provided by a 3-hole receptacle or an adapter for a 2-hole receptacle is a safety feature designed to lessen the risk of shock. Never defeat the grounding feature. If you do not have a 3-hole outlet, use an adapter to connect the heater's 3-prong plug. Make sure the adapter ground wire or tab is attached to the outlet. QUESTION: Are small stoves and heaters placed where they can not be knocked over, and away from furnishings and flammable materials, such as curtains or rugs? YES ___ NO ___ RECOMMENDATION: Heaters can cause fires or serious burns if they cause you to trip or if they are knocked over. Relocate heaters away from passageways and flammable materials such as curtains, rugs, furniture, etc. QUESTION: If your home has space heating equipment, such as a kerosene heater, a gas heater or an LP gas heater, do you understand the installation and operating instructions thoroughly? YES ___ NO ___ RECOMMENDATION: Unvented heaters should be used with room doors open or window slightly open to provide ventilation. The correct fuel, as recommended by the manufacturer, should always be used. Vented heaters should have proper venting, and the venting system should be checked frequently. Improper venting is the most frequent cause of carbon monoxide poisoning, and older persons are at special risk. Review the installation and operating instructions. Call your local fire department if you have additional questions. CHECK WOOD-BURNING HEATING EQUIPMENT QUESTION: Is wood-burning equipment installed properly? YES ___ NO ___ RECOMMENDATION: Wood-burning stoves should be installed by a qualified person according to local building codes. Local building code officials or fire marshals can provide requirements and recommendations for installation. NOTE: Some insurance companies will not cover fire losses if wood stoves are not installed according to local codes. CHECK THE EMERGENCY EXIT PLAN QUESTION: Do you have an emergency exit plan and an alternate emergency exit plan in case of a fire? YES ___ NO ___ RECOMMENDATION: Once a fire starts, it spreads rapidly. Since you may not have much time to get out and there may be a lot of confusion, it is important that everyone knows what to do. Develop an emergency exit plan. Choose a meeting place outside your home so you can be sure that everyone is capable of escape quickly and safely. Practice the plan from time to time to make sure everyone is capable of escape quickly and safely. Remember periodically to re-check your home. KITCHEN In the kitchen, check the range area, all electrical cords, lighting, the stool, all throw rugs and mats, and the telephone area. CHECK THE RANGE AREA QUESTION: Are towels, curtains, and other things that might catch fire located away from the range? YES ___ NO ___ RECOMMENDATION: Placing or storing non-cooking equipment like potholders, dish towels, or plastic utensils on or near the range may result in fires or burns. Store flammable and combustible items away from range and oven. Remove any towels hanging on oven handles. If towels hang close to a burner, change the location of the towel rack. If necessary, shorten or remove curtains which could brush against heat sources. QUESTION: Do you wear clothes with short or close-fitting sleeves while cooking? YES ___ NO ___ RECOMMENDATION: The CPSC estimates that 70% of all people who die from clothing fires are over 65 years of age. Long sleeves are more likely to catch fire than are short sleeves. Long sleeves are also more apt to catch on pot handles, overturning pots and pans and causing scalds. Roll back long, loose sleeves or fasten them with pins or elastic bands while you are cooking. QUESTION: Are kitchen ventilation systems or range exhausts functioning properly and are they in use while you are cooking? YES ___ NO ___ RECOMMENDATION: Indoor air pollutants may accumulate to unhealthful levels in a kitchen where gas or kerosene-fire appliances are in use. Use ventilation systems or open windows to clear air of vapors and smoke. QUESTION: Are all extension cords and appliance cords located away from the sink or range areas? YES ___ NO ___ RECOMMENDATION: Electrical appliances and power cords can cause shock or electrocution if they come in contact with water. Cords can also be damaged by excess heat. Move cords and appliances away from sink areas and hot surfaces. Move appliances closer to wall outlets or to different outlets so you won't need extension cords. If extension cords must be used, install wiring guides so that cords will not hang near sink, range, or working areas. Consider adding new outlets for convenience and safety; ask your electrician to install outlets equipped with ground fault circuit interrupters (GFCIs) to protect against electric shock. A GFCI is a shock-protection device that will detect electrical fault and shut off electricity before serious injury or death occurs. QUESTION: Does good, even lighting exist over the stove, sink, and countertop work areas, especially where food is sliced or cut? YES ___ NO ___ RECOMMENDATION: Low lighting and glare can contribute to burns or cuts. Improve lighting by: Opening curtains and blinds (unless this causes to much glare). Using the maximum wattage bulb allowed by the fixture. (If you do not know the correct wattage for the fixture, use a bulb no larger than 60 watts.) Reducing glare by using frosted bulbs, indirect lighting, shades or globes on light fixtures, or partially closing the blinds or curtains. Installing additional light fixtures, e.g. under cabinet/over countertop lighting. (Make sure that the bulbs you use are the right type and wattage for the light fixture.) QUESTION: Do you have a step stool which is stable and in good repair? YES ___ NO ___ RECOMMENDATION: Standing on chairs, boxes, or other makeshift items to reach high shelves can result in falls. The CPSC estimates that in 1982, 1500 people over 65 were treated in hospital emergency rooms when they fell from chairs on which they were standing. If you don't have a step stool, consider buying one. Choose one with a handrail that you can hold onto while standing on the top step. Before climbing on any step stool, make sure it is fully opened and stable. Tighten screws and braces on the step stool. Discard step stools with broken parts. Remember: Check all of the product areas mentioned at the beginning of the checklist. LIVING ROOM/FAMILY ROOM In the living room/family room, check all rugs and runners, electrical and telephone cords, lighting, the fireplace and chimney, the telephone area, and all passageways. QUESTION: Are chimneys clear from accumulations of leaves, and other debris that can clog them? YES ___ NO ___ RECOMMENDATION: A clogged chimney can cause a poorly-burning fire to result in poisonous fumes and smoke coming back into the house. Do not use the chimney until the blockage has been removed. Have the chimney checked and cleaned by a registered or licensed professional. QUESTION: Has the chimney been cleaned within the past year? YES ___ NO ___ RECOMMENDATION: Burning wood can cause a build up of a tarry substance (creosote) inside the chimney. This material can ignite and result in a serious chimney fire. Have the chimney checked and cleaned by a registered or licensed professional CHECK PASSAGEWAYS QUESTION: Are halls, passages between rooms and other heavy traffic areas well lit? YES ___NO ___ RECOMMENDATION: Shadowed or dark areas can hide tripping hazards. Use the maximum wattage bulb allowed by the fixture. (If you do not know the correct wattage, use a bulb no larger than 60 watts.) Install night lights. Reduce glare by using frosted bulbs, indirect lighting, shades or globes on light fixtures, or partially closing blinds or curtains. Consider using additional lamps or light fixtures. Make sure that the bulbs you use are the right type and wattage for the light fixture. QUESTION: Are exits and passageways kept clear? YES ___ NO ___ RECOMMENDATION: Furniture, boxes, or other items could be an obstruction or tripping hazard, especially in the event of an emergency or fire. Rearrange furniture to open passageways and walkways. Remove boxes and clutter. Remember: Check all of the product areas mentioned at the beginning of the checklist. BATHROOM In the bathroom, check bathtub and shower areas, water temperature, rugs and mats, lighting, small electrical appliances, and storage areas for medications. CHECK BATHTUB AND SHOWER AREAS QUESTION: Are bathtubs and showers equipped with non-skid mats, abrasive strips, or surfaces that are not slippery? YES ___ NO ___ RECOMMENDATION: Wet soapy tile or porcelain surfaces are especially slippery and may contribute to falls. Apply textured strips or appliques on the floors of tubs and showers. Use non-skid mats in the tub and shower, and on the bathroom floor. QUESTION: Do bathtubs and showers have at least one (preferably two) grab bars? YES ___ NO ___ RECOMMENDATION: Grab bars can help you get into and out of your tub or shower, and can help prevent falls. Check existing bars for strength and stability, and repair if necessary. Attach grab bars, through the tile, to structural supports in the wall, or install bars specifically designed to attach to the sides of the bathtub. If you are not sure how it is done, get someone who is qualified to assist you. QUESTION: Is the temperature 120 degrees or lower? YES ___ NO ___ RECOMMENDATION: Water temperature above 120 degrees can cause tap water scalds. Lower the setting on your hot water heater to "Low" or 120 degrees. If you are unfamiliar with the controls of your water heater, ask a qualified person to adjust it for you. If your hot water system is controlled by the landlord, ask the landlord to consider lowering the setting. NOTE: If the water heater does not have a temperature setting, you can use a thermometer to check the temperature of the water at the tap. Always check water temperature by hand before entering bath or shower. Taking baths, rather than showers, reduces the risk of a scald from suddenly changing water temperatures. CHECK LIGHTING QUESTION: Is a light switch located near the entrance to the bathroom? YES ___ NO ___ RECOMMENDATIONS: A light switch near the door will prevent you from walking through a dark area. Install a night light. Inexpensive lights that plug into outlets are available. Consider replacing the existing switch with a "glow switch" that can be seen in the dark. CHECK SMALL ELECTRICAL APPLIANCES QUESTION: Are small electrical appliances such as hair dryers, shavers, curling irons, etc., unplugged when not in use? YES ___ NO ___ RECOMMENDATION: Even an appliance that is not turned on, such as a hairdryer, can be potentially hazardous if it is left plugged in. If it falls into water in a sink or bathtub while plugged in, it could cause a lethal shock. Unplug all small appliances when not in use. Never reach into water to retrieve an appliance that has fallen in without being sure the appliance is unplugged. Install a ground fault circuit interrupter (GFCI) in your bathroom outlet to protect against electric shock. CHECK MEDICATIONS QUESTION: Are all medicines stored in the containers that they came in and are they clearly marked? YES ___ NO ___ RECOMMENDATION: Medications that are not clearly and accurately labeled can be easily mixed up. Taking he wrong medicine or missing a dosage of medicine you need can be dangerous. Be sure that all containers are clearly marked with the contents, doctor's instructions, expiration date, and patient's name. Dispose of outdated medicines properly. Request non-child-resistant closures from your pharmacist only when you cannot use child-resistant closures. NOTE: Many poisonings occur when children visiting grandparents go through the medicine cabinet or grandmother's purse. In homes where grandchildren or other youngsters are frequent visitors, medicines should be purchased in containers with child-resistant caps, and the caps properly closed after each use. Store medicines beyond the reach of children. Remember: Check all of the product areas mentioned at the beginning of the checklist. BEDROOMS In the bedroom, check all rugs and runners, electrical and telephone cords, and areas around beds. CHECK AREAS AROUND BEDS QUESTION: Are lamps or light switches within reach of each bed? YES ___ NO ___ RECOMMENDATION: Lamps or switches located close to each bed will enable people getting up at night to see where they are going. Rearrange furniture closer to switches or move lamps closer to beds. Install night lights. QUESTION: Are ash trays, smoking materials, or other fire sources (heaters, hot plates, teapots, etc.) located away from beds or bedding? YES ___ NO ___ RECOMMENDATION: Burns are a leading cause of accidental death among seniors. Smoking in bed is a major contributor to this problem. Among mattress and bedding fire related deaths in a recent year, 42% were to persons 65 or older. Remove sources of heat or flame from areas around beds. Don't smoke in bed. QUESTION: Is anything covering your electric blanket when in use? YES ___ NO ___ RECOMMENDATION: "Tucking in" electric blankets, or placing additional coverings on top of them can cause excessive heat buildup which can start a fire. Use electric blankets according to the manufacturer's instructions. Don't allow anything on top of the blanket while it is in use. (This includes other blankets or comforters, even pets sleeping on top of the blanket.) Don't set electric blankets so high that they could burn someone who falls asleep while they are on. QUESTION: Do you ever go to sleep with a heating pad which is turned on? YES ___ NO ___ RECOMMENDATION: Never go to sleep with a heating pad if it is turned on because it can cause serious burns even at relatively low settings. QUESTION: Is there a telephone close to your bed? YES ___ NO ___ RECOMMENDATION: In case of an emergency, it is important to be able to reach the telephone without getting out of bed. Remember: Check all of the product areas mentioned at the beginning of the checklist. BASEMENT/GARAGE/WORKSHOP/STORAGE AREAS In the basement, garage, workshop, and storage areas, check lighting, fuse boxes or circuit breakers, appliances and power tools, electrical cords, and flammable liquids. CHECK LIGHTING QUESTION: Are work areas, especially areas where power tools are used, well lit? YES ___ NO ___ RECOMMENDATION: Power tools were involved in over 5,200 injuries treated in hospital emergency rooms to people 65 and over in 1982. Three fourths of these were finger injuries. Good lighting can reduce the chance that you will accidentally cut your finger. Either install additional light, or avoid working with power tools in the area. QUESTION: Can you turn on lights without first having to walk through a dark area? YES ___ NO ___ RECOMMENDATION: Basement, garages, and storage areas can contain many tripping hazards and sharp or pointed tools that can make a fall even more hazardous. Keep an operating flashlight handy. Have an electrician install switches at each entrance to a dark area. CHECK THE FUSE BOX OR CIRCUIT BREAKERS QUESTION: If fuses are used, are they the correct size for the circuit? YES ___ NO ___ RECOMMENDATION: Replacing a correct size fuse with a larger size fuse can present a serious fire hazard. If the fuse in the box is rater higher than that intended for the circuit, excessive current will be allowed to flow and possibly overload the outlet and house wiring to the point that a fire can begin. Be certain that correct-size fuses are used. (If you do not know the correct sizes, consider having an electrician identify and label the sizes to be used.) NOTE: If all, or nearly all, fuses used are 30-amp fuses, there is a chance that some of the fuses are rated too high for the circuit. CHECK APPLIANCES AND POWER TOOLS QUESTION: Are power tools equipped with a 3-prong plug or marked to show that they are double insulated? YES ___ NO ___ RECOMMENDATION: These safety features reduce the risk of an electric shock. Use a properly connected 3-prong adapter for connecting a 3- prong plug to a 2-hole receptacle. Consider replacing old tools that have neither a 3-prong plug nor are double insulated. QUESTION: Are power tools guards in place? YES ___ NO ___ RECOMMENDATION: Power tools used with guards removed pose a serious risk of injury from sharp edges or moving parts. Replace guards that have been removed from power tools. QUESTION: Has the grounding feature on any 3-prong plug been defeated by removal of the grounding pin or by improperly using an adapter? YES ___ NO ___ RECOMMENDATION: Improperly grounded appliances can lead to electric shock. Check with your service person or an electrician if you are in doubt. CHECK FLAMMABLE AND VOLATILE LIQUIDS QUESTION: Are containers of volatile liquids tightly capped? YES ___ NO ___ RECOMMENDATION: If not tightly closed, vapors may escape that may be toxic when inhaled. Check containers periodically to make sure they are tightly closed. NOTE: The CPSC has reports of several cases in which gasoline, stored as much as 10 feet from a gas water heater, exploded. Many people are unaware that gas fumes can travel that far. QUESTION: Are gasoline, paints, solvents, or other products that give off vapors or fumes stored away from ignition sources? YES ___ NO ___ RECOMMENDATION: Gasoline, kerosene, and other flammable liquids should be stored out of living areas in properly labeled, non-glass safety containers. Remove these products from the areas near heat or flame such as heaters, furnaces, water heaters, ranges, and other gas appliances. STAIRS For all stairways, check lighting, handrails, and the condition of the steps and coverings. CHECK LIGHTING QUESTION: Are stairs well lighted? YES ___ NO ___ RECOMMENDATION: Stairs should be lighted so that each step, particularly the step edges, can be clearly seen while going up and down stairs. The lighting should not produce glare or shadows along the stairway. Use the maximum wattage bulb allowed by the light fixture. (If you do not know the correct wattage, use a bulb no larger than 60 watts.) Reduce glare by using frosted bulbs, indirect lighting, shades or globes on light fixtures, or partially closing blinds and curtains. Have a qualified person add additional light fixtures. Make sure that the bulbs you use are the right type and wattage for the light fixture. QUESTION: Are light switches located at both the top and bottom of the stairs. YES ___ NO ___ RECOMMENDATION: Even if you are very familiar with the stairs, lighting is an important factor in preventing falls. You should be able to turn on the lights before you use the stairway from either end. If no other light is available, keep an operating flashlight in a convenient location at the top and bottom of the stairs. Install night lights at nearby outlets. Consider installing switches at the top and bottom of the stairs. QUESTION: Do the steps allow secure footing? YES ___ NO ___ RECOMMENDATION: Worn treads or worn or loose carpeting can lead to insecure footing, resulting in slips or falls. Try to avoid wearing only socks or smooth-soled shoes or slippers when using stairs. Make certain the carpet is firmly attached to the steps all along the stairs. Consider refinishing or replacing worn treads, or replacing worn carpeting. Paint outside steps with paint that has a rough texture, or use abrasive strips. QUESTION: Are steps even and of the same size and height? YES ___ NO ___ RECOMMENDATION: Even a small difference in step surfaces or riser heights can lead to falls. Mark any steps which are especially narrow or have risers that are higher or lower than the others. Be especially careful of these steps when using the stairs. QUESTION: Are the coverings on the steps in good condition? YES ___ NO ___ RECOMMENDATION: Worn or torn coverings or nails sticking out from coverings could snag your foot or cause you to trip. Repair coverings. Remove coverings. Replace coverings. QUESTION: Can you clearly see the edges of the steps? YES ___ NO ___ RECOMMENDATION: Falls may occur if the edges of the steps are blurred or hard to see. Paint edges of outdoor steps white to see them better at night. Add extra lighting. If you plan to carpet your stairs, avoid deep pile carpeting or patterned or dark colored carpeting that can make it difficult to see the edges of the steps clearly. QUESTION: Is anything stored on the stairway, even temporarily? YES ___ NO ___ RECOMMENDATION: People can trip over objects left on stairs, particularly in the event of an emergency or fire. Remove all objects from the stairway. REMEMBER PERIODICALLY TO RE-CHECK YOUR HOME +++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++ The core issues in Elder Law revolve around how you can control your financial, legal and health affairs in the event that you become incapacitated. If you want to "get your affairs into order," you should consider drafting some important legal documents with the guidance of a lawyer specialized in family or elder law matters. By preparing a set of documents, you can decide who will receive your assets when you die, and preserve your nest egg and make decisions if you become incapacitated. If you need long-term health care or suffer from a catastrophic illness, you may watch all of your savings "go out the window." These documents as a package will bring you a long way to protecting your assets from catastrophic loss and notifying your loved ones about your preferences regarding medical care. These four documents form the foundation of good estate planning: Last Will and Testament Durable Power of Attorney Living Will Health Care Proxy (or Medical Power of Attorney) 1. Last Will and Testament The Last Will and Testament is the only one of the four documents that you must prepare with the assistance of an attorney. The Last Will and Testament is your last opportunity to decide who gets your property when you pass away. It should be drawn up by a lawyer and reviewed at least once every five years. When you review it, make sure that the people mentioned in the Last Will and Testament are still alive, available and the people you want to be named. The key people are: your heirs; your executor; your alternate executor; and your two witnesses. You should know where these people are because when you die, they must be located to attest 1) that they were physically present when you signed the document and 2) you were competent when you signed it. Witness affidavits should be attached to the Last Will and Testament. The Last Will and Testament goes into effect when you die. That is, when the physician signs your death certificate. Until you are dead, your executor and heirs have no authority to act on your behalf. While you are alive, you make all of your financial, legal and medical decisions. But if something goes wrong and you are unable to make these decisions - you become incompetent - there are other legal documents that you can prepare to plan ahead. 2. Durable Power of Attorney A Durable Power of Attorney is a written document that designates another person to act on one's behalf when making legal or financial decisions. By designating someone to act in your behalf, you allow them to sign your name in the event you become incompetent. Your designee should be someone you closely trust and you should hold onto the document until it is necessary. However, you should tell your designee where the document is kept should it become necessary. Make sure that you provide for an alternate designee. The Durable Power of Attorney becomes especially important when planning asset transfers and when qualifying for Medicaid. A Durable Power of Attorney is a relatively simple 2-sided form. You sign it before a notary and have him/her notarize it. Most states have their own form, which can be purchased at most stationery stores. Make sure that you have a Durable Power of Attorney form for each state in which you hold property. The Last Will and Testament and Durable Power of Attorney documents deal with control over financial and legal matters. But how can you plan for (and help others plan for) your life, healthcare matters and destiny? You may have asked yourself this question: "If the only reason I am being kept alive is by machines, would I wish to continue to live that way?" You Last Will and Testament and Durable Power of Attorney can not help your loved ones decide that or act on it in the case you become incapacitated by a stroke, accident or Alzheimer's Disease. 3. Living Will A Living Will is another relatively simple 2-sided form that spells out how you feel about your medical destiny. The Living Will is limited to your wishes regarding life support systems only. A Living Will is important for another reason: in your state, your spouse may be legally and financially responsible for the cost of keeping you alive indefinitely with machines. Your Living Will should be signed by you and two witnesses (who may be family members). You should choose as your witnesses two people who are aware of your wishes and the quality of life issues that are important to you. Several people should be given copies of your Living Will: Your children: Be aware that your wishes may not necessarily be the same as their wishes - you should try to avoid disagreements among your children by carefully spelling out your wishes in a Living Will; Your physician and HMO (if applicable): Have original copies of your Living Will made a part of your medical record so that it is clear to your health care providers what your wishes are. But other types of medical issues that do not include life support may arise. For example, you also make decisions on which procedures or surgeries to have. Who will step in in those cases if you become incapacitated? 4. Health Care Proxy A Health Care Proxy is often called a "Medical Power of Attorney" because it is a way to delegate your health care decision-making to another person in the event you become unable to make those decisions yourself. You should choose someone who you trust and someone who knows your wishes with regard to medical treatment and concerns. A Health Care Proxy covers all types of medical decisions, including changing medications, experimental treatments, surgical procedures, changing physicians and transferring between facilities. One specific decision is not covered: tube feeding. You must specifically state that you do not want to be kept alive by artificial nutrition or hydration ("tube feeding"), or else you physician will make the decision for you. Legal Disclaimer This article is not intended to be legal advice. It provides an educational and informational background to the issues and documents involved in basic estate planning. As with all sensitive matters, you should consult your legal, financial and medical advisors whenever you make important decisions. Also be aware that laws may vary, sometimes considerably, from state to state and you should plan accordingly. ++++++++++++++++++++++++++++++++++ HELPFUL LINKS A crisis can bring a family closer together and illustrate strength and love; or it can drive a wedge of resentment between members. Whenever a loved one's heath, safety or wellbeing becomes a concern, it is important to be proactive and address your loved one's issues. If the issues come to a point of crisis, families - often spread out across several states - need to call themselves together to discuss the changes which are occurring and will occur in the future. Stephen Covey, author of The 7 Habits Of Highly Effective People, states: "Most families are managed on the basis of crisis, moods, quick fixes, and instant gratification - not on sound principles. Symptoms surface whenever stress and pressure mount: people become cynical, critical, or silent or they start yelling and overreacting." If this is how you perceive a family meeting may progress, it is important to understand that it doesn't have to. You can have family meetings that are under control and structured. Understand that you will never be able to please everyone all of the time, but that you are not meeting to meet your individual needs but those of your aging loved one. Your first two family meetings should be small - only siblings or close family members who are in direct contact with your aging loved one. Regardless of how you feel about your extended family members, it is imperative that everyone be involved in the meetings. If meeting all together in person is not possible due to separation by miles, arrange for a conference call through three-way or conference calling. This service is available through your local phone company for a nominal monthly fee. Whether you choose to have an informal meeting or a structured meeting depends on your family style and how your family best works together. The first meeting should take place without your loved one present, as topics may be discussed which could cause he/she to become upset. During the meeting, you need to take a hard look at the situation at hand. It is best if you all have prepared three or four concerns (and even possible solutions) to discuss beforehand. Together, you will need to begin planning for the future and, if needed, take responsibility for specific duties. The goal of the first meeting is to create a plan of action to work together as a team, or if nothing else, call a temporary truce to a family feud. Don't be discouraged if your first meeting doesn't run smoothly. Everyone involved views the situation from a different perspective. Human nature is rather egocentric, so do not be alarmed if most are concerned with how the changes will effect them. It is easier to be defensive than admit fear. If you will be discussing a topic that is going to be heated, it is best to hold that subject until another meeting where a neutral moderator can be present. The moderator should not be related to the family. It could be a family friend, a member of the clergy, a social worker or geriatric care manager, for example. For topics that will cause irrational responses, it is best to have all parties prepare, in private, why they feel so strongly. Many times, putting something in writing can make the "it" feel less abstract and frightening. You may find you all have a similar fear and are simply reacting in different ways. You may ask your loved one's legal or religious advisor(s) the be present at a family meeting of the serve as facilitator or moderator. Geriatric care managers are usually skilled facilitators or social workers who can lend experience and balance to difficult family dynamics. Consult the National Association of Professional Geriatric Care Managers at for a directory of local care managers. It may be a good idea for the family members to chip in for the care manager's fees, rather than one member managing the relationship to avoid perceptions of "bringing in hired guns." Planning a Meeting We don't always have the luxury of meticulously planning family meetings due to sudden illness, medical emergencies or family squabbles. But we can maximize scarce time by sticking to a few rules of thumb. Establish a "goal" for every meeting that is agreed upon ahead of time by all (or almost all) participants; Plan to move incrementally, rather than address ALL issues in one marathon session; Select a comfortable and "neutral" location; Most meetings function smoothest with no more than seven participants; Invite close relatives only; Collect and share background information. For example, bring fact sheets on Alzheimer's Disease if your loved one is recently diagnosed, or legal documents if the topic relates to estate planning; Prepare - and stick to - a short agenda that includes adequate time for each member to participate; Allow the agenda to be slightly adjusted only at the beginning of the meeting; E-mail or snail mail all materials to all participants ahead of time. Conducting the Meeting All participants must remember that they are in a meeting. Every meeting should have rules and guidelines. Unfortunately, when it comes to family meetings, many do not recall this fact. In the beginning of each meeting, gently remind all parties to have respect for one another and follow some rules that you have all agreed upon. If your family works smoothly and in unison, then focus on exploring your loved ones concerns rather than your own. Here are some rules that you may want to include: No one is allowed to dominate the meeting. If you need to, use a timer and give each family member 10 minutes to state concerns and points of view; Create a list of all concerns and then as a group number them 1 through 5. 1 being the most urgent, 5 being the least urgent. Tackle each one in the order of urgency, not in the order of preference; When someone is talking, other must not interrupt. You wouldn't interrupt another co-worker in a board meeting. Give your family members the same respect. If you have a comment, write it down and discuss it either at the end of their turn, or the beginning of yours; The facilitator or leader should be fair, but firm, to ensure that the meeting follows the agenda and doesn't take too much time; Use only "I" statements. Avoid finger-pointing accusations that begin with "You..." This one is difficult to master; Remember that your loved one still has the right and responsibility to make his/her own decisions (unless incompetence or dementia is the issue); Stick to the topic. It is easy to get off topic and revisit old family arguments. Keep the topic of the meeting posted where all can see it, whether on a central board or on the top of everyone's note sheet. This is also difficult to master, but possible; Reach a sense of closure on each item of the agenda, or at least set an action item or next step. You may need to address issues that arise during the meeting and put them in a "Parking Lot" to be addressed at a later time; Agree on what to discuss at the next meeting and schedule a time and date before concluding to avoid confusion. Following Up on Meetings After your first one or two meetings, your family will have found a style that works best for those involved. It is now time to begin discussing possible solutions. Include your loved one in the meetings if they are able to comprehend what is happening. Make sure to listen to your loved one first. Allow your loved one the time s/he needs to express their concerns, wants, and desires. Do not degrade their concerns. Although their priorities may be different than yours, unless doing as they wish will put them in physical harm, do your best to accommodate their wishes. For example, the family might feel that it is best for Mom or Dad to move into a residential facility because there they will have meals provided, laundry done, and opportunities for socialization. Mom or Dad may wish to stay in their home for now because that is where they feel safe. Hiring in home care assistance for a few months may be the compromise for both sides. Your loved one has usually lost much control over their own life and even their body by the time you are holding a family meeting. Be gentle with them. It is upsetting for them to watch their world slip away and not have a say in what is happening, or to see discord in their family. Roles and Responsibilities Once solutions and duties have been agreed upon, you should discuss the possibility of having a family spokesperson. This is especially helpful for those families who are located in different areas of the country or world. It is less complicated when there is a single point of contact for information. Having a family spokesperson is also a way to encourage effective communication, avoiding the "operator game." The "operator game" is when one person passes an original message on to another and this person now sends what they heard onto the third person, etc. By the time the last person is reached, the original message is completely distorted. This can cause major problems within a family. The spokesperson will represent the family if your loved one is unable to confer with professionals. S/he will keep in touch with the doctors and relay the information to the other family members. Additionally, the spokesperson may have responsibility - or share responsibility - for health care and legal decision-making. Care management duties should also be divided up. Even if some live far away, they can contribute by calling your loved one, sending them cards, handling some paperwork, or even paying the bills. If someone else has small children and lives nearby, they could cook an extra serving of dinner and bring it by for a visit. Another family member could be responsible for coordinating the services needed while your loved one remains at home. It is inevitable that one person will shoulder the majority of the duties, but if all are participating as a team, the chance of resentment building are decreased. Talk to your family members and see about coordinating respite and vacation times so that you are not overburdened. When necessary, bring in the appropriate professionals, such as geriatric care managers, elder lawyers, financial planners, counselors or religious advisors and insurance or paperwork professionals. Consider having family members contribute to a fund to pay for in home care assistance and respite workers. Making It Work By conscientiously planning, conducting and following up on family meetings, members can assure themselves that they are working in the best interests of their loved one and minimizing unhealthy family dynamics. Remember that you are all working in the best interests of your loved one who has lost some capacity to handle their own affairs. Be a positive participant and rise to the occasion. Organizing a family meeting is a complex task. It involves coordinating the schedules of many to discuss a topic close to their heart. Having a predetermined time and date to meet will help all members be able to plan accordingly. You may find that it is convenient to keep in touch via the Internet. MyFamily.Com () offers families the ability to coordinate schedules through a calendar of events, post updates, and even post pictures on the site! For each topic included on the calendar, those listed in your database will be notified via email. This is excellent when coordinating multiple doctor appointments, family schedules, and keeping everyone updated. It is also a fun place to show off the grandkids new art work and to remind everyone that they are a family as a whole, not only during a crisis. Resources and Reading ElderCare Online () offers comprehensive and practical articles and tools on the range of caregiving issues. Family caregivers are welcome to print off a limited number of copies to share with family members in family meetings. Professionals should contact us for reprinting and copyright instructions. Take the time to read documents that specifically deal with the issue you are facing, such as Alzheimer's Disease, estate planning or residential options. The following resources belong in the arsenal of every caregiver: The Caregiver Education Series includes booklets, workbooks and multimedia tools to help you maintain quality of life. The Prism Personal Organizer helps you collect, store and quickly access your loved one's personal and financial records. This reduces time spent looking for information during emergencies and helps improve legal and financial decision-making. The Prism Medical Manager is an essential workbook to manage complicated care plans and busy schedules. This improves your ability to talk with your loved one's doctor, manage complicated medical regimens and avoid complications and medical errors. Financial Caregiving Article : Easy-to-follow checklist of issues to consider. ElderLaw Basics : Concise explanations of the different legal instruments that all adults should have - Durable Power of Attorney, Health Care Proxy, Will and Living Will. The Complete ElderCare Planner : Joy Loverde's acclaimed book is great tool for managing aloved one's affairs. It has recently been updated for 2000. Talking With Your Aging Parents: Mark Edinberg's comprehensive guide to talking with your loved one's about legal, financial, housing and health issues.(Out of print, but available in many libraries) ++++++++++++++++++++++++++++++++++ Some Ways of Handling Promises The first piece of food for thought is "Don't make the promise they ask for, make a promise you can sensibly keep." This is much easier to suggest than to do, however. It may take you some preparation to be able to reassure your older relative that their underlying concern(s) will be met, but that circumstances will have to dictate what you will and will not do. A second approach, if you failed to do the first one, is to revisit the promise and in essence change your unqualified "Yes" to a more specific statement of what you can promise. You will run the risk of the other getting angry, disinheriting you, or calling you names, but the price you would pay in guilt or in negative consequences for years if you didn't revise your previous "yes" may well be worth this risk. A third approach is to talk for a while with the relative about what is behind their need for the promise, then put on the table some values you both agree on, such as: We want to do what is best for the entire family We want to be sure to get the most out of these resources We want to be able to make decisions if things change dramatically The fourth aspect of talking about promises requested is to be sure you address the underlying concerns directly. You can promise not to violate these as long as the integrity of the family is upheld without determining a specific course of action. Look at how these strategies can be applied to the promises mentioned in the beginning of this article: Promising to "Never put me in a nursing home." An alternative approach is to say, "I can promise you certain things. The first is that I will make sure you have the best care we can afford. The second is that you will never go to any living situation that is not right for you. The third is that we will try to do what is best for the entire family if you are sick or need assistance. I will not allow you to be treated without respect and dignity. We will not, under any circumstance I can think of, abandon you emotionally." Promising never to sell the family business. An alternative approach to a blanket "Yes" is: "I understand your desire to keep the business going. I may or may not be able to do so. I will not lie to you about this. If we can keep the business going as a positive legacy for you, we will, provided it is in the best interest of the family. We would only want a legacy from you that is a positive one." Promising never to sell the family home. An alternative to a later regretted "Yes" is: "I understand the importance of the family home to you. We all have some strong feelings about the home and about you. We may or may not be able to keep the home in the family, we can try to do so as long as it is in the family's best interest. Either way, we can take the memories of the home and its personal value with use, no matter where we live." Promising to "take care" of a handicapped or incapacitated relative. Be sure to be specific by what you mean by "take care." You can, for example, promise to look out for their welfare, to be sure they get benefits they are entitled to. You can also get a promise back from your older relative to work with you to arrange for financial care. If the "incapacitated" individual has a history of drug and/or alcohol or mental disorders, the situation can become more complicated, especially if the older relative does not fully acknowledge the impairments of the impaired family member. You can get around this in part by indicating that the two of you (your older relative and you) have a difference of opinion about the situation of the other relative, but that you understand their position and will at least give "due diligence' to the other, even if you choose not to not to provide financial support or housing. Promising to continue a family feud (e.g. "Never talk to cousin Ned because of what he did in 1943, and promise me you will never forgive him or his children."). Alternatives to saying "Yes" vary considerably, depending in part on your impression of the nature of the feud and the people involved. For example, you may not like the "others" and be very willing not to have contact with them. Still, you would be best served by agreeing as to your dislike of these people, but not go so far as to dictate how you will act in the future. You may want to acknowledge the wish of the older relative, ask for a full explanation of why they want the feud continued, and still hold out to be able to make up your own mind. I know of one situation where a woman wanted a named executor of her estate to ensure that a minor child would not have contact with her older brother. She told this to the executor while preparing her will. At the same time, she would not disclose the nature of the brother's transgressions. The executor told her in advance he would not make this promise, but, if she wished to include a letter about the specifics and concerns in their will, the executor would take these concerns seriously. The woman did write such a letter, but is still alive, so the minor child has become an adult and the situation is no longer on the (future) executor's plate. Both sides seemed to be happy with the process and outcome. Promising to not take a specific course of action about a stock or investment (e.g. "Never invest my money in banks"). Here, the key seems to be to get the other person to reframe the promise in more general concerns: e.g. "Don't take extraordinary risks", or "Take a conservative path", or "Don't completely trust the stock market." Promises to the Departed So these ideas about how to handle promises are well and good, you might think, but what about a promise made to someone who is now deceased? How can we rescind the promise and the guilt when the other is no longer around to forgive us? If you are sure that the promise is an illegitimate one (i.e., one that had negative unintended consequences or has created great difficulties for the family), one method I use is to have an IMAGINARY conversation with the other, remembering where they or their "spirit" or "karma" may now reside (depending on your belief about afterlife, of course). Do you think that they, if they fully understood the current situation, would want you to continue the promise? If the answer is yes (if it is "no" you are off the hook), examine what their motives were for the promise and talk with them IN IMAGINATION about how to respect their motives while changing the form of the promised behavior or decision. Usually this can work very nicely, even if you do not believe in the spirit world and consider this merely a symbolic or psychological exercise. And, if you are really smart and lucky, you may even get them IN IMAGINATION to forgive you and bless your revision of the promise that should work to the benefit of the whole family, including you. +++++++++++++++++++++++++++++++++++ let us look at some of the areas in which empowerment is a factor. Where You Live The primary decisions for seniors are where they will live and how they will spend their free time. For most seniors their preference is to stay in their homes, independently throughout life. Some are fortunate in this regard but for others, they may reach a point where health and safety factors indicate that independent living is no longer possible. Except in cases of acute or sudden onset of a situation, there is usually a gradual increase in signs that an alternate arrangement is needed. Families who wait too long to solve the problems may not use all possible resources and may not involve the senior parent enough. To the extent that families plan long range, explore options and work collaboratively, the transition will work better. To the extent that a rapid emergency decision is made with little choice and input from the elderly, adjustment will be affected. The result may be feelings of malcontent, loss, abandonment and being misunderstood. Any change, be it arranging for help in the home or moving to a facility, is best done with the senior parent evaluating, and expressing their feelings, preferences and comfort level. There is a "goodness of fit" between a person and a place. All places tell you how fine they are and all the amenities they provide. In fact, facilities vary widely in their ambiance and the specific services that they offer. The person, who will be living there can best assess their comfort level in a given setting. The lack of opportunity to have input can result in the feeling of being "placed" or "put." This combines with feelings of abandonment and is a factor contributing to depression. What You Do Wherever the older adult lives they have an increase in available leisure time. The goal is to fill time in a rewarding way rather than to have time hang on one's hands. By the time seniors are 60 and older, they have a good sense of what brings them pleasure. If they haven't fully discovered it, they now have the time to explore it. To begin with it is important that senior adults stay mentally and physically active because this has been shown to improve health and longevity. Staying socially connected is important because isolation has been associated with poor health and depression. Families are a valuable resource here. If the senior adult lives alone, transportation should be set up to get them out. Families are a resource for getting the adult parent out of assisting living and nursing facilities for the day. Seniors rally when they get out. Sometimes getting out even one-week day is an anchor and gives seniors something to look forward to. Families should encourage their loved ones in assisted living and nursing facilities to participate in outings and activities and to be out of their room. Sometimes a family member going along and participating helps the parent begin to progress. In line with this, contact with the community through a religious or volunteer activity can provide a sense of being involved in something that goes beyond oneself and fosters a connection with the world. Families can be involved in finding these resources, setting them up and initially participating to get things going. Senior citizens possess a wealth of information. They have lived a long time and learned a lot. They need to be appreciated for that fact that what they think and say has value. Family members need to listen to the concerns and ideas of their loved one. Their transition issues are real, their observations valid and not just complaints. If family members minimize, ignore or deny what their loved one says, (i.e. "It's beautiful here. There's so much to do. How could you not like it?"), the loved one will feel more isolated, misunderstood and unsupported. Some older adults have excellent ability to adjust, transition, and keep busy, while others struggle more with change. Family involvement and support is a crucial factor in enhancing and facilitating adjustment and helping parents establish a fulfilling life in the senior years. ++++++++++++++++++++++++++++++++++ Do's for emotionally laden situations Think ahead of what you need to get (vs. what you hope to get) from discussions: That is, what is your bottom line? Do you need to get your parent(s) to tell you EVERYTHING about their possessions or do you really need to get them to confer with a competent attorney? Do you need to get your family member into a nursing home or do you need them to be evaluated by a competent agency, physician or other provider who may come up with options that may work for your older relative? Answer the following question (and it's a very important one): Are you doing this WITH the older adult or FOR them? That is, do they have both a say and veto power in the discussion? If the older relative has veto power, then he or she may disagree with you or even do something you are very uncomfortable with. At the same time, if it is really their decision, then you should not try to coerce or manipulate them into the decision. Think ahead as to when and where to have the conversation. Pick a place and time when older relatives can hear what you are saying without family and holiday distractions. I know of individuals who have actually made a special trip to another city to visit their parents just to have an important conversation. Use "I" statements. Literally, this means beginning any declarative sentence with the word "I". This means talking about "My view", "My perception", and especially "My feelings" rather than talking as if you have a corner on the truth and anything your parents says not only contradicts you but is wrong. "I" statements can lead to negotiation and sharing, "You" statements may lead to war. Consider having a mutual ally present when beginning important and emotionally laden discussions.- Having someone who is trusted by both parties may make things easier. Be clear about the topic of discussion with your family member. Give the others time to process and think about what you are presenting. Going too fast can lead to misunderstandings. You may have to have more than one conversation about an emotionally laden topic. Respect the rights of the others to agree and disagree. Stand your own ground. That is, you can be assertive and clear about your beliefs and your point of view without denying others their rights and own perspectives. Be aware of your own feelings and reactions to the situation and the others involved. Sometimes, this may mean taking time to go over your likely reactions and figuring out how to enhance reactions that might help the conversation move along and, at the same time, find ways to keep inflammatory reactions in check. Practice the conversation with a "coach", someone who can listen to you and let you know how you are coming across. A coach can be a spouse, significant other, family member or friend. If you practice, be sure to ask your coach what behaviors or actions you have that might give the wrong message to your older relative. Be prepared for the discussion to end before you want it to. Make every attempt to treat the discussion as a door opener, that is, an opportunity to get the ball rolling, rather than the time everything has to be decided upon. Don'ts for emotionally laden situations Don't blame others in either word or tone of voice. We often forget that our internal tension or concern may come across as judging others or being defensive, which in turn leads to their not paying attention to our care and thoughts about them. Don't do all the talking. A rule of thumb is to do occupy no more than « of the airtime. It is important to listen and acknowledge the others' concerns and questions. You don't have to answer each and every point when it is made. Don't go in with a fearful attitude, it will become your message. Being clear about your goals and having practiced what you want to say can help decrease anxiety. Don't overload the table with old issues and hurts. A major mistake made in these conversations is that once the initial point is agreed upon, too much is attempted too quickly. It helps some people to think of their old history as a museum, don't show all of the items at once, limit your exhibits. Don't believe that disagreement means someone does not love someone else. I would even go so far as to suggest that a parent's defensiveness (or our own) also does NOT mean that someone does not love someone else. Too often, people mistake defensiveness as a lack of love. Don't believe that a quick agreement means the others will agree with you after reflection. People may go away from an involved encounter and think things over again, be prepared to revisit tough issues several times. Don't go in with a "someone has to win" attitude, you are usually working together. People who are naturally competitive may find themselves competing with their aging parents rather than working together even with the best of intentions. One way around this is to be clear that the goal is for the "team" of both of you to figure out what is best for the ENTIRE family. While hardly a complete list of all the nuances of family communication, these guidelines may help you evaluate how you want to have discussions as well as be an informal checklist to evaluate how you did after a discussion about an emotionally laden topic. Let's take a look at an imaginary conversation (with some comments in parentheses about the dos and don'ts). Remember, these guidelines have to be applied by you in your situation. They will potentially take many forms, you have to be the final judge on how to apply these principles and ideas. Good luck! Simple scenario and dialogue An imaginary conversation about where mother is gong to live. Mother is 78, in fairly good health, but has had a few falls and has high blood pressure. She lives alone in the family home, a two story dwelling with all the bedrooms and the bathroom upstairs. The conversation is between daughter, age 45 (with grown children and a husband) and her mother. Daughter: Mom, there's something we need to talk about. Mother: What is it dear? Daughter: Well, I've been thinking about your house. Mother: Oh? Daughter: Well, the house is where we grew up and everything, but I was hoping we could sell it some time. (Not clear about the topic of discussion) Mother: What? Sell the house? Why would I do that? Where could I live? Daughter: (becoming a little nervous): Mom, you need to think about this before you say that. (blaming) Mother: What do you mean, I don't think? Daughter: No, mom, it's just that we want you to have what is best for you, you know. (defensive) Mother: Have you talked to your brother about this? Daughter: Of course not, I mean I should of, I hope he doesn't get too mad about this. (includes old issues) Mother: Now, now, dear, you two shouldn't fight. Daughter: We don't fight, we don't even talk. (brings up old topics) Mother: Well, I certainly won't sell the house if it makes you all upset. Daughter: Mom, I am not upset, it's just that I find it hard to talk with you about this. (is assertive) Mother: Why, what do you mean? Are you saying I am difficult? Can't I have my way? Daughter: I'd like to have my way, just for once. (blaming) Mother: You can, but not with my house. Daughter (takes a breath): Mom, I'm sorry, but I really want to talk with you about your home and where you live while things are going OK for you. I care for you, I do not want to fight with you or my brother, I want us to talk together about how you can handle yourself. (assertive, clear about topic) Mother: (reconsiders): OK, I believe you, what do you want to talk about? Daughter: I am concerned about what may happen to you in the future if you stay in the house. (shares real concerns) Mother: What do you mean? Daughter: I mean that the house is designed for younger people, with the bedrooms and bathroom upstairs. If you fell and had to walk with assistance for any period of time, the house would not be a good place to rehabilitate.(Gives good reasons, is calm) Mother: And, I think, if I had to go into a nursing home, the house might have to go to pay for my care. Daughter: Unless you made plans in advance. Mother: Which I haven't done. Daughter: So, where should we go from here? (Includes mother in decision) Mother: Well, we should talk to your brother. Maybe I can talk to him first. Then we should talk to someone who knows about these things. Daughter: Thanks, mom, I love you. Mother: I hope so (laughs). I hope you can see how the dos and don'ts of communication can influence how a discussion goes. ++++++++++++++++++++++++++++++++++++++++++++ ++++++++++++++++++++++++++++++++++++++++++++++++ Elder Abuse: Definitions and Resources for Caregivers Each year hundreds of thousands of older persons are abused, neglected and exploited by family members and others. Many victims are people who are frail and vulnerable and cannot help themselves and depend on others to meet their most basic needs. Legislatures in all 50 states have passed some form of elder abuse prevention laws. Laws and definitions of terms vary considerably from one state to another, but all states have set up reporting systems. Generally, adult protective services (APS) agencies receive and investigate reports of suspected elder abuse. National Elder Abuse Incidence Study Reports to APS agencies of domestic elder abuse increased 150 percent between 1986 and 1996. This increase dramatically exceeded the 10 percent increase in the older population over the same period. A national incidence study conducted in 1996 found the following: 551,011 persons, aged 60 and over, experienced abuse, neglect and/or self-neglect in a one-year period; Almost four times as many new incidents of abuse, neglect and/or self-neglect were not reported as those that were reported to and substantiated by adult protective services agencies; Persons, aged 80 years and older, suffered abuse and neglect two to three times their proportion of the older population; and Among known perpetrators of abuse and neglect, the perpetrator was a family member in 90 percent of cases. Two-thirds of the perpetrators were adult children or spouses. Generally Accepted Definitions Physical Abuse Physical abuse is defined as the use of physical force that may result in bodily injury, physical pain, or impairment. Physical abuse may include but is not limited to such acts of violence as striking (with or without an object), hitting, beating, pushing, shoving, shaking, slapping, kicking, pinching and burning. In addition, the inappropriate use of drugs and physical restraints, force-feeding and physical punishment of any kind also are examples of physical abuse. Signs and symptoms of physical abuse include but are not limited to: bone fractures, broken bones and skull fractures; bruises, black eyes, welts, lacerations and rope marks; open wounds, cuts, punctures and untreated injuries in various stages of healing; sprains, dislocations and internal injuries/bleeding; broken eyeglasses/frames, physical signs of being subjected to punishment and signs of being restrained; laboratory findings of medication overdose or under utilization of prescribed drugs; an elder's report of being hit, slapped, kicked or mistreated; an elder's sudden change in behavior; and the caregiver's refusal to allow visitors to see an elder alone. Sexual Abuse Sexual abuse is defined as non-consensual sexual contact of any kind with an elderly person. Sexual contact with any person incapable of giving consent is also considered sexual abuse. It includes but is not limited to unwanted touching, all types of sexual assault or battery, such as rape, sodomy, coerced nudity and sexually explicit photographing. Signs and symptoms of sexual abuse include but are not limited to: bruises around the breasts or genital area; unexplained venereal disease or genital infections; unexplained vaginal or anal bleeding; torn, stained, or bloody underclothing; and an elder's report of being sexually assaulted or raped. Psychological Abuse Emotional or psychological abuse is defined as the infliction of anguish, pain or distress through verbal or nonverbal acts. Emotional/psychological abuse includes but is not limited to verbal assaults, insults, threats, intimidation, humiliation and harassment. In addition, treating an older person like an infant; isolating an elderly person from his/her family, friends, or regular activities; giving an older person the "silent treatment;" and enforced social isolation are examples of emotional/psychological abuse. Signs and symptoms of emotional/psychological abuse include but are not limited to: being emotionally upset or agitated; being extremely withdrawn and non-communicative or non-responsive; unusual behavior usually attributed to dementia (e.g., sucking, biting, rocking); and an elder's report of being verbally or emotionally mistreated. Financial or Material Exploitation Financial or material exploitation is defined as the illegal or improper use of an elder's funds, property, or assets. Examples include but are not limited to cashing an elderly person's checks without authorization/permission; forging an older person's signature; misusing or stealing an older person's money or possessions; coercing or deceiving an older person into signing any document (e.g., contracts or will); and improperly using conservatorship, guardianship, or power of attorney. Signs and symptoms of financial or material exploitation include but are not limited to: sudden changes in bank account or banking practice, including an unexplained withdrawal of large sums of money by a person accompanying the elder; the inclusion of additional names on an elder's bank signature card; unauthorized withdrawal of the elder's funds using the elder's ATM card; abrupt changes in a will or other financial documents; unexplained disappearance of funds or valuable possessions; substandard care being provided or bills unpaid despite the availability of adequate financial resources; discovery of an elder's signature being forged for financial transactions or for the titles of his/her possessions; sudden appearance of previously uninvolved relatives claiming their rights to an elder's affairs and possessions; unexplained sudden transfer of assets to a family member or someone outside the family; the provision of services that are not necessary; and an elder's report of financial exploitation. Neglect Neglect is defined as the refusal or failure to fulfill any part of a person's obligations or duties to an elder. Neglect may also include failure of a person who has fiduciary responsibilities to provide care for an elder (e.g., pay for necessary home care services) or the failure on the part of an in-home service provider to provide necessary care. Neglect typically means the refusal or failure to provide an elderly person with such life necessities as food, water, clothing, shelter, personal hygiene, medicine, comfort, personal safety, and other essentials included in an implied or agreed-upon responsibility to an elder. Signs and symptoms of neglect include but are not limited to: dehydration, malnutrition, untreated bed sores, and poor personal hygiene; unattended or untreated health problems; hazardous or unsafe living condition/arrangements (e.g., improper wiring, no heat, or no running water); unsanitary and unclean living conditions (e.g. dirt, fleas, lice on person, soiled bedding, fecal/urine smell, inadequate clothing); and an elder's report of being mistreated. Abandonment Abandonment is defined as the desertion of an elderly person by an individual who has assumed responsibility for providing care for an elder, or by a person with physical custody of an elder. Signs and symptoms of abandonment include but are not limited to: the desertion of an elder at a hospital, a nursing facility, or other similar institution; the desertion of an elder at a shopping center or other public location; and an elder's own report of being abandoned. Self-neglect Self-neglect is characterized as the behavior of an elderly person that threatens his/her own health or safety. Self-neglect generally manifests itself in an older person as a refusal or failure to provide himself/herself with adequate food, water, clothing, shelter, personal hygiene, medication (when indicated), and safety precautions. The definition of self-neglect excludes a situation in which a mentally competent older person, who understands the consequences of his/her decisions, makes a conscious and voluntary decision to engage in acts that threaten his/her health or safety as a matter of personal choice. Signs and symptoms of self-neglect include but are not limited to: dehydration, malnutrition, untreated or improperly attended medical conditions, and poor personal hygiene; hazardous or unsafe living conditions/arrangements (e.g., improper wiring, no indoor plumbing, no heat, no running water); unsanitary or unclean living quarters (e.g., animal/insect infestation, no functioning toilet, fecal/urine smell); inappropriate and/or inadequate clothing, lack of the necessary medical aids (e.g., eyeglasses, hearing aids, dentures); and grossly inadequate housing or homelessness. Why Does Elder Abuse Occur and Who are the Perpetrators? Elder abuse, like other types of domestic violence, is extremely complex. Generally a combination of psychological, social, and economic factors, along with the mental and physical conditions of the victim and the perpetrator, contribute to the occurrence of elder maltreatment. Although the factors listed below cannot explain all types of elder maltreatment because it is likely that different types (as well as each single incident) involve different casual factors, they are some of the causes researchers say are important. Caregiver Stress Caring for frail older people is a very difficult and stress-provoking task. This is particularly true when older people are mentally or physically impaired, when the caregiver is ill-prepared for the task, or when the needed resources are lacking. Under these circumstances, the increased stress and frustration of a caregiver may lead to abuse or willful neglect. Impairment of Dependent Elder Some researchers have found that elders in poor health are more likely to be abused than those in good health. They have also found that abuse tends to occur when the stress level of the caregiver is heightened as a result of a worsening of the elder's impairment. Cycle of Violence Some families are more prone to violence than others because violence is a learned behavior and is transmitted from one generation to another. In these families, abusive behavior is the normal response to tension or conflict because they have not learned any other ways to respond. Personal Problems of Abusers Researchers have found that abusers of the elderly (typically adult children) tend to have more personal problems than do non-abusers. Adult children who abuse their parents frequently suffer from such problems as mental and emotional disorders, alcoholism, drug addiction, and financial difficulty. Because of these problems, these adult children are often dependent on the elders for their support. Abuse in these cases may be an inappropriate response by the children to the sense of their own inadequacies. Who Are the Abusers? More than two-thirds of elder abuse perpetrators are family members of the victims, typically serving in a caregiving role. Is Elder Abuse a Crime? Depending on the statute of a given state, elder abuse may or may not be a crime. However, most physical, sexual and financial/material abuses are considered crimes in all states. In addition, depending on the type of the perpetrator's conduct and its consequences for the victims, certain emotional abuse and neglect cases are subject to criminal prosecution. However, self-neglect is not a crime in all jurisdictions, and, in fact, elder abuse laws of some states do not address self-neglect. For Help Regarding Elder Abuse When domestic elder abuse occurs, it can be addressed if it comes to the attention of authorities. Although each state has a different system to address elder abuse, the following are some of the agencies that have been established by federal, state and local governments to help: Which State and Local Agencies are Helping Victims and Their Families Involved in Elder Abuse? In most states, the APS (Adult Protective Services) agency, typically located within the human service agency, is the principal public agency responsible for both investigating reported cases of elder abuse and for providing victims and their families with treatment and protective services. In most jurisdictions, the county departments of social services maintain an APS unit that serves the need of local communities. However, many other public and private agencies and organizations are actively involved in efforts to protect vulnerable older persons from abuse, neglect, and exploitation. Some of these agencies include: the state unit on aging; the law enforcement agency (e.g., the police department, the district attorney's office, the court system, the sheriff's department); the medical examiner/coroner's office; hospitals and medical clinics; the state long-term care ombudsman's office; the public health agency; the area agency on aging; the mental health agency; and the facility licensing/certification agency. Depending on the state law governing elder abuse, the exact roles and functions of these agencies vary widely from one jurisdiction to another. Although most APS agencies also handle adult abuse cases (where clients are between 18 and 59 years of age), nearly 70 percent of their caseloads involve elder abuse. The APS community is relatively small compared with the groups working for other human service programs, but it is composed of a few thousand professionals, nationwide. Adult Protective Services In most jurisdictions, either APS, the Area Agency on Aging, or the county Department of Social Services is designated as the agency to receive and investigate allegations of elder abuse and neglect. If the investigators find abuse or neglect, they make arrangements for services to help protect the victim. State Elder Abuse Hotlines Many states have instituted a 24-hour toll-free number for receiving reports of abuse. Calls are confidential. Phone Directory for reporting abuse: Law Enforcement Local police, sheriff's offices, and prosecuting attorneys may investigate and prosecute abuse, particularly in cases involving sexual abuse or assault. In states whose statutes make elder abuse a crime, there may be a requirement to report suspected abuse to a law enforcement agency. Long Term Care Ombudsman Program Since passage of the 1975 Older Americans Act, every state has had a long term care ombudsman program to investigate and resolve nursing home complaints. The program has also been working toward extension of services to board and care facilities and, in some areas, to those who receive professional care at home. Check with your State Unit on Aging or Area Agency on Aging to see if the long term care ombudsman program in your area can help in any given instance. Information and Referral Every Area Agency on Aging operates an information and referral (I & R) line that can refer people to a wide range of services for people 60 and older. I & R services can be particularly helpful in locating services that can help prevent abuse and neglect. National and State Information Often people who want to help older relatives or friends don't live near them. Long-distance caregivers can call a nationwide toll-free Eldercare Locator number (1-800-677-1116) to locate services in the community in which the elder lives. In addition, some states have established a statewide toll-free number to provide centralized aging services information for residents of their states. Medicaid Fraud Control Units (MFCU) Every State Attorney General's Office is required by Federal law to have a MFCU to investigate and prosecute Medicaid provider fraud and patient abuse or neglect in health care programs which participate in Medicaid, including home health care services. What Happens After You Report? The APS agency screens calls for potential seriousness. The agency keeps the information it receives confidential. If the agency decides the situation possibly violates state elder abuse laws, the agency assigns a caseworker to conduct an investigation (in cases of an emergency, usually within 24 hours). If the victim needs crisis intervention, services are available. If elder abuse is not substantiated, most APS agencies will work as necessary with other community agencies to obtain any social and health services that the older person needs. The older person has the right to refuse services offered by APS. The APS agency provides services only if the older person agrees or has been declared incapacitated by the court and a guardian has been appointed. The APS agency only takes such action as a last resort. Sources: National Center on Elder Abuse, Administration on Aging Internet Resources - National Center on Elder Abuse - Phone Numbers to Report Abuse - The Elderly Place - Elder Abuse and Neglect - Comprehensive information and resources by Linda Woolf, Webster University - Elder Abuse Links from The Elderly Place Additional Articles - Sometimes a Bruise Is Just a Bruse: Abuse and Alzheimer's Disease - Financial Caregiving - Legal & Financial Matters Channel +++++++++++++++++++++++++++++++++++++++++++++++++++++ When loved ones are ill, your first thought is to take care of them and that often includes assisting with their finances. Here's advice on how to prevent and deal with potential money problems, even from a distance. When it comes to finances, the typical caregiver helps with or arranges bill paying, deposits, insurance and benefit claims, savings and investment decisions, housing and adult day-care, tax preparation and countless other financial duties. The job is especially tough if a caregiver lives far away or has the usual demands on his or her time. And the stakes can be high. Among the potential financial pitfalls: bad investment decisions that can reduce a relative's assets or standard of living. These, in turn, can lead to disputes with family members or other people, which can result in estrangement or even lawsuits. Preventive Measures Consider taking these steps before an older relative becomes ill or disabled. Make sure the family knows where to find personal and financial documents in an emergency. These include bank and brokerage statements, wills, insurance policies and pension records. Explain to an older relative that you don't want to handle his or her finances or pry into personal financial information. Your main concern is that you know what documents to look for, and where to find them, in an emergency. By having this knowledge, you can help protect this person's assets, including dividends, interest, insurance, pensions, Social Security payments, rental income and the contents of safe deposit boxes. Obtain access to bank and brokerage accounts in an emergency. To write checks or withdraw funds, you or someone else your relative trusts should become a joint owner of a bank account or simply make arrangements through the bank to be authorized to conduct transactions. Also, to have access to a safe deposit box in a crisis, the owner of the box can have a joint renter or appoint a "deputy" or "agent." Because of the possible pitfalls or complications of giving someone else access to an account, advice should be obtained from a banker, attorney or other qualified professional. Consider automatic payment of important, recurring bills. You can arrange for water, electric and other utility bills, along with health insurance, mortgage and other regular commitments, to be paid electronically out of your loved one's checking account. This makes bill paying easier and prevents hassles and interruptions in service if required payments aren't made. You also may be able to arrange to be notified if your relative misses a payment. Consider the direct deposit of pay and benefit checks into bank and brokerage accounts. Many consumers are leery of direct deposit and other forms of electronic banking. Among their reasons: paper checks and pay stubs are easy to verify and photocopy. But most experts believe direct deposit is safer and more convenient than paper checks. There are no delays in getting funds deposited, no checks are lost in the mail or forgotten at home, and notices about each payment and deposit can be obtained. Also be aware that a 1996 law, with certain exceptions, requires that federal wage and retirement payments be sent electronically starting in 1999. (Final rules clarifying those exceptions are expected soon from the U.S. Treasury Department.) So, before ruling out direct deposit, consider talking to the Social Security Administration, bankers and others involved in the process to try to clear up problems or misconceptions. Try to make sure your relatives are properly insured. Some people have too little life, health, disability (loss of income), long-term care (for nursing home and home health care) or other insurance to be protected in a catastrophe. Others, especially some elderly people, are so concerned about potential medical expenses that they buy too much insurance or the wrong kind (such as cancer insurance that probably is adequately covered under traditional medical insurance). If you have doubts about someone's insurance coverage or ability to pay for long-term care, try to get a second opinion from a financial planner or an insurance agent you trust. Encourage saving, investing and prudent spending. If your loved ones don't already have financial goals and working relationships with professionals they trust (bankers, accountants, financial planners and so on), urge them to start. These relationships may prove especially beneficial in a crisis. Discuss the importance of wills and estate planning. The goal of estate planning is to distribute a person's assets and minimize taxes at death. For most of us, that means making and periodically updating a will. Also, various types of "trusts" or "gifts" can be arranged to help preserve assets for heirs. In general, trusts should be set up with the help of an attorney experienced in estate tax issues and estate planning. Consider a "durable power of attorney." This is a legal document giving one or more people the authority to handle finances, property or other personal matters if the individual granting the authority becomes mentally or physically incompetent. The durable power of attorney is considered a better tool for caregivers than a basic power of attorney because it remains in effect even if the person granting the power becomes incompetent. A durable power of attorney may not neatly address all cases, so check with your lawyer about what's suitable for your family's situation. Suggest a "living will" or other instructions about future medical care. If permitted by state law, most people should have a living will specifying the type of medical care they want or don't want if they become hopelessly ill and are unable to communicate their wishes. Experts also recommend a "health care power of attorney" or "health care proxy" designating a family member to make decisions about medical treatment. Among the reasons for living wills and health care proxies: they can prevent unwanted, unnecessary, and costly medical procedures. Try to get an accurate assessment of your loved one's financial situation. That's especially true if your relative is secretive about his or her finances. Speak frankly with your relative about their financial situation. After a Crisis The following should be on any family's checklist if a relative becomes ill or disabled. Get solid financial and legal advice from professionals you know and trust. Contact bankers, lawyers, accountants, insurance agents or financial planners your family has dealt with in the past. Let them know of your situation and your problems. Ask how they'd recommend you deal with matters, and find out how they can assist. Consider working with lawyers and financial advisors who specialize in helping the ill or elderly. Examples: "Elder law attorneys" regularly handle estate planning, Medicare and Medicaid issues, insurance disputes, fraud cases and other legal affairs affecting the elderly. "Daily money managers" are professionals who pay bills, balance checkbooks, monitor insurance claims and handle other daily financial responsibilities for other people. And "geriatric care managers" typically are nurses or social workers trained to help, or find help, with various tasks, including money management and evaluating housing options. Work only with professionals you believe are reputable and ethical. If friends or relatives can't give you a referral, talk to your doctor or your doctor's bookkeeper, or a social worker at a hospital or nursing home Take advantage of free or low-cost assistance programs. Many lawyers, financial advisors and other professionals offer free initial consultations. But for ongoing assistance at little or no cost, consider the services available from private organizations and government agencies in your city or state. Examples: financial counseling that employers make available to workers and their families; "social service agencies" sponsored by state or county government agencies and private organizations, including those affiliated with certain religious groups but available to people of any faith; the local or national offices of disease-specific organizations (such as the American Cancer Society or the Alzheimer's Association); and other membership groups (such as the AARP). Closely review your relative's insurance coverage and government benefits. You may be surprised, for example, to find a disability insurance policy covers more than just wages; it also could pay for physical therapy or other services. Similarly, a life insurance policy might have cash value or, in dire situations, an option to receive an advance payment of some of the policy's death benefit. You or someone knowledgeable should check out your relative's rights and benefits under Social Security, Medicare, Medicaid, private insurance and employee benefits. Respect your relative's opinions and desire for autonomy. While you may mean well by stepping in and helping with your relative's financial matters, be wary of becoming too protective. Your elder may still be able to make financial decisions even though they are physically incapacitated. Autonomy is very important to an elder - help them make decisions rather than make decisions for them. If the relative becomes mentally incapacitated, you may have to step into a more active role. Share financial decisions with the family. You might want to consider family meetings to discuss finances, just to keep everyone current on spending and income. It's generally also wise to keep good notes about significant discussions you have with family members and the actions taken as a result. Think about sharing duties with family and friends. Some regular responsibilities, such as bill paying or deposit making, might be done most efficiently by one person. But don't be shy about asking family, neighbors and old friends to help out where appropriate, from occasional banking matters to basic errands, phone calls and letters. Those with legal, health-care or financial training can be particularly helpful with certain tasks. If help is available on a regular basis, that's even better. You'll need a break periodically. Be aware of your potential liability. A caregiver may become a joint owner of a checking or savings account, serve as a legal representative (through a power of attorney) or become someone's trustee or guardian. Any time you agree to share responsibility with or for someone else you may be taking on unexpected risks and liabilities. It's a good idea to get a second opinion from a lawyer who is loyal only to you, the caregiver, when you sign a durable power of attorney or other legal document. Here's another pitfall worth considering: If a relative adds your name to a joint account at a bank where you already have deposits, this unintentionally could put some of your money over the $100,000 federal insurance limit. This is because, for example, under the FDIC's insurance rules your share in all joint accounts at that institution would not be insured for more than $100,000. Be prepared for out-of-pocket expenses. Caregivers don't get paid, often don't get thanked, and frequently don't get reimbursed for long-distance phone calls, travel, groceries, medications, personal care items or other purchases. Of course, as a caregiver your main concerns are to help someone who's helped you in the past, and to know that this person is being well cared for. Even so, the costs of caregiving can be substantial. The recent survey by the National Alliance for Caregiving and the AARP found that families caring for an elderly relative spend an average of $171 of their own money each month. This doesn't include "hidden" costs, such as unpaid leave from work. Take advantage of the many housing options available. It's likely that your ill or elderly relative would prefer to live at home than move in with you or others. That's more possible than ever, thanks to an increasing number of housing options and services available in most communities. Someone wanting to stay at home can benefit from in-home nursing care and housekeeping services, as well as adult day-care centers where ill or elderly people can spend a large part of their day. There also are retirement communities and apartment buildings where some form of health care or assistance with daily tasks is available. Costs of housing assistance can be considerable, but many services may be covered by Medicare, Medicaid or other insurance. Make frequent visits to your relative... and to the workers around them. You'll want to know that your loved one is getting good care from a hospital, nursing home, retirement community, day-care facility or any other institution or service you use. Caregivers say that one of the best ways to ensure quality service and to prevent neglect or abuse (including charging for services that aren't provided) is to make frequent, unscheduled visits, at different times of the day or night. You can see for yourself what's going on and send a message to workers that "someone on the outside is watching." Be on guard against financial scams targeting the sick or the elderly. Fraud artists know that ill or elderly people tend to be lonely and willing to listen to and trust strangers who call on them-- ideal candidates for telemarketing fraud, bogus home repairs, get-rich-quick schemes and other cons. If you discover a problem, the National Fraud Information Center (NFIC), part of the National Consumers League in Washington, says: "Don't be critical. Don't embarrass or humiliate the victim. Don't get angry." Instead, calmly explain that the friendly person supposedly offering great deals may indeed be a crook. If you think a crime has been committed, contact the NFIC toll-free at 800-876-7060 or through its Internet site ( ) and it will provide the information to the appropriate law enforcement authorities. Be smart about borrowing money. Your relative might need extra help to pay for medical or other expenses. In some cases, it might make sense to use a credit card or go to a financial institution for a loan. Seniors who own a home may be able to borrow against the built-up equity, using a second mortgage, home equity loan or reverse mortgage. Some banks also have loan programs just for the disabled, such as loans to buy specially equipped vans, or to make homes and businesses more accessible to the handicapped. Before agreeing to any loan, make sure the debt would be manageable, and thoroughly research and discuss the pros and cons. Also remember that under the Equal Credit Opportunity Act, a creditor cannot deny or terminate a loan because of someone's age or a disability. Final Thoughts As a caregiver, it's easy to feel overwhelmed and to forget to take time for yourself. That can lead to burnout, which isn't good for you or for the relatives who depend on you. But with the many resources available nowadays, a caregiver doesn't have to be alone when making or carrying out decisions. Get help and guidance from family, friends and professional advisors. Take advantage of the many government agencies and religious and private organizations that provide services to the caregivers as well as the ill and the elderly. Support like this could be just what the doctor ordered...for you and your family. Source: Federal Deposit Insurance Corporation ++++++++++++++++++++++++++++++++++++++++++ What happens to your hard-earned savings when you need long-term care? How are you going to protect your house, your doll collection, and your heirlooms when you or your spouse has to move into a costly nursing home? People of modest means find out, sometimes painfully, that they are required to foot the bill for long-term healthcare. Medicare only pays a very limited amount of nursing home expenses. And Medicaid is difficult to qualify for since you have to already have spent away your hard-earned savings. Most people assume that either they will not have to enter a nursing facility, or that once they do, "The Government" (i.e., Medicare or Medicaid) will pick up the tab. The first assumption is a form of denial, and the second assumption is only true in the worst scenarios. The fact is, as people age, they have a greater and greater probability of requiring some form of skilled care. Fortunately, more and more skilled care can be provided in the home, but nursing homes are still a reality for millions of elderly, especially those with dementia. The Government helps to pay for short-term care through Medicare, but only pays for people with very limited finances through Medicaid. In some states, nursing home costs can exceed $8,000 per month (not a typo!). That means that if you are paying for it yourself, it can run to almost $100,000 per year out of your own savings. If you have even modest assets of about $4,000 in the bank, you will NOT be able to receive Medicaid. There are some exceptions, but the vast majority of people are not eligible for Medicaid due to existing assets (such as bank accounts and property) and monthly income (such as pensions and Social Security benefits). "Estate planning" includes techniques and considerations that individuals and families use to make sure that their assets are disposed of in the way they desire near and at the time of their death. Proper estate planning uses legal methods to assess the value of one's estate, acquire insurance (such as life insurance and long-term care insurance), prepare the appropriate legal documents (such as wills, healthcare proxies and powers of attorney), provide gifts to family members and charities, and minimize taxes. The proper coordination and execution of all of these matters should be conducted with the guidance of a qualified (and specialized) elder law attorney and other financial and care management professionals. Options for Financing Long-Term Care So what is the vast Middle Class to do about paying for long-term care expenses? Our health insurance system in the US is a patchwork of private, federal and state programs. But as with any "patchwork," there are areas where the stitching has come apart, or where the seams were never sewn properly. We have serious gaps that often turn into gaping holes for many people. This article provides a very brief overview of the primary options for paying for long-term care. More detailed articles and resources are available at the end of this article. Private Pay This is generally the first line of defense for healthcare expenses. People pay out of pocket for prescription drugs, co-payments, deductibles, additional services, and non-healthcare expenses (such as respite, housekeeping, care management, and companion services). Most caregivers become acutely aware of how expensive many services are once they start paying for them out of their own checkbook. When faced with the prospect of these expenses for years on end, then the awareness turns to fear and loathing. Increasingly, people are purchasing healthcare benefit cards that provide discounts for prescription drugs, some services, eyeglasses, and some other eldercare expenses, but these provide some modest savings, not the kind of relief that most are seeking. Medicare Medicare is the federal government-run health insurance program for those over age 65. It covers hospital and doctor expenses, as well as some preventive procedures such as mammograms. Medicare also covers home healthcare and hospice services when ordered by a doctor. Individuals may purchase private "Medigap" insurance to help pay for those services that Medicare does not cover. Medicare will only pay for short-term skilled nursing such as when you are recovering after a hospital stay or surgery. Medicaid Medicaid is a federal-state program that is run a little bit differently by each county in the country. It is designed to provide healthcare to the medically and financially needy. It is not politically correct to call it a program for "poor" people, but the key eligibility requirement is that you have very limited financial resources and income. It is primarily for women with children and the elderly in nursing homes. Unlike Medicare (which everyone over 65 gets), Medicaid requires that you apply for benefits. Long-Term Care Insurance While long-term care insurance is gaining popularity, the rules and fine print can often be confusing, the policies prohibitively expensive, and/or your pre-existing conditions limiting. However, for many people, this form of insurance can provide the financial means to stay at home when illness leaves them debilitated or in need of skilled nursing care. When shopping for long-term care insurance, it is best for you to speak with an impartial third-party (such as a lawyer) to help explain things - not because insurance salespeople are dishonest, but because you should see how the policy fits in with your other plans and what some of the fine print really means. Issues and Techniques in Estate Planning Individuals and families wishing to plan for possible long-term care expenses and the dissolution of their estates at death should understand and explore several areas with qualified legal and financial professionals. Estate planning is not just for "The Rich" - people with a lot of property, warring children (a la Dynasty), mansions, and yachts. The Middle Class should consider many of these techniques and use the appropriate ones that help them achieve their goals of minimizing taxes and leaving an inheritance to their family. Families should always consult with trusted legal advisors. It's no secret that many unscrupulous people are out there, waiting to prey on concerned Baby Boomers and seniors. Use your best judgment and NEVER allow someone to pressure you into buying anything (be it insurance, legal assistance or management services). You are well-advised to get a second opinion when making your estate plan. A few hours with another lawyer (helping you understand some documents or legal issues) may cost a few hundred dollars, but when you are dealing with tens or hundreds of thousands of dollars, that will be money well spent. Trusts A trust is a legal device that gives a person (or group of people) the right to hold and manage specific financial assets. This is a very simple definition that avoids a lot of legal language. Be aware that trusts are usually quite complicated. Some trusts can be thought of as a new legal entity (much like a corporation or another person) that is required to spend its assets for specific purposes that the creator spells out ahead of time. People often establish trusts to avoid the costs and delays that can be associated with probate, to minimize or avoid taxation, to provide resources for individuals determined to be incompetent, to control how and when assets are distributed, as well as many other uses. There are several different types of trusts that people use for estate planning. While most fall into specific categories, it is important to understand that trusts are highly individual creations - one size does not fit all. Be wary of firms who offer a cookie cutter approach or a "kit" to create your own. Any trust (indeed all estate planning activities) should be designed with careful consideration and thoughtful legal consultation. Be aware that when establishing some trusts, you may limit your options in the future. A "revocable trust" may be established to set aside certain assets in the event that the individual becomes incapacitated. These assets never technically leave the person's ownership, so the assets are still considered part of one's estate when one applies to Medicaid for benefits. The value of a revocable trust is that you can designate a professional to manage your finances, receive income from the trust, and potentially reduce expenses associated with settling your estate at death. With a revocable trust the individual can change the terms of the trust at any time. An "irrevocable trust" is also referred to as a "Medicaid Trust." Assets are transferred into a new legal entity that then owns those assets. These assets are then no longer considered part of your taxable estate. By shifting assets into the trust, you may now be eligible for Medicaid benefits, but subject to the specific "look-back" rules of your county (see below). When setting up the trust, you determine who will receive the assets, regular payments, and income from the assets. Irrevocable trusts may also be used as an entity to own one's life insurance policy. This is a simplification of the process, so keep in mind that estate planning involves a lot of "moving parts" that should all be considered. Some types of transfers may result in tax liabilities and future financial limitations. Irrevocable trusts require that the individual give up some degree of flexibility with the assets and may be expensive to prepare. Once the trust is established, the individual gives up all rights to the assets that are included in the trust. You can not change the terms once it is finalized. A "credit shelter trust" is used to help an individual and her spouse maximize the federal tax credits they have when they die. This type of trust is also called a "bypass trust," "A-B trust," or "credit shelter trust plan." Each individual is permitted to transfer a large (but limited) amount of assets to his/her heirs free of taxation. For a married couple, the tax credit is essentially doubled (since it is the credits of two people). When the first spouse dies, the estate passes to the other, but when the second spouse dies, only one credit is remaining. This trust allows the two tax credits to be used instead of just one. Be aware that the U.S. Congress may make changes to the estate tax laws, raising the credit, or eliminating it all together. You should consult with legal and financial advisors who have up-to-date knowledge of federal and state tax laws. Medicaid Planning Since most people are concerned about spending down all of their assets to pay for long-term care, they will establish certain types of entities like trusts, give cash gifts to children, spend money on exempt assets, or engage in other legal financial maneuvers. You should make sure that your financial activities are legal as well as the smartest use of your assets. Even with perfectly legal activities, you may compromise or delay some of your potential benefits from Medicaid. Look-back periods. The application required to collect Medicaid benefits includes extensive questions about financial assets going back from three to five years. Medicaid will "look back" to see whether assets had been illegally sheltered to qualify a person for coverage. Moving assets through legal means is permitted. (All of the general approaches discussed in this article are legal at the time of writing 6/2001). However, transfers within the look-back period will be scrutinized, and even if they are legal, may incur some penalties. For example, if the person applying for Medicaid made an asset transfer (a gift, transfer into a trust, or other large transaction) within the look-back period, it does not necessarily disqualify them from receiving benefits, but it may delay the date when nursing home benefits begin. Currently, homecare benefits are not affected by the look-back period. There are many strategies for legally moving assets and timing the submission of a Medicaid application. A person skilled in the rules of your particular county, with knowledge of your larger estate plan, and with an understanding of your loved one's health condition can assist you in managing the process of applying for Medicaid. Spousal refusal. Married people have a legal obligation to pay for the healthcare costs incurred by their spouse if they are admitted into a nursing home (with some exceptions). If your spouse has been admitted to a nursing home, you may file a form with Medicaid and state that you refuse to pay for your spouse's care. This does not mean that you are getting a divorce! It is a legal bureaucratic loophole that allows individuals to retain additional resources than they normally would be able to. The county Medicaid office has the right to seek reimbursement from the spouse who is not in the nursing home (referred to as the "community spouse"), but such lawsuits are rare. It is unwise to assume that the county never will decide to sue you for the funds it has spent on your spouse's nursing home bills. In some cases, when individuals were sued, the county has settled for less than the full dollar amount spent on the care. Final Things to Remember Nothing is as simple as it sounds when it comes to "The Law." This article is not intended to be legal advice, nor does it cover all issues associated with estate planning. It provides an educational and informational background to the issues and documents involved in basic estate planning. We hope that you will use this article to give yourself a foundation with which to have intelligent discussions with your legal, financial, and care management advisors. As with all sensitive matters, you should consult your legal, financial and medical advisors whenever you make important decisions. Some of the concepts have been simplified and stripped of extensive legalese in the interest of readability and length. Furthermore, we have limited specific information on eligibility criteria, tax rules, and asset amounts since they vary considerably from state to state and county to county. We hope that this does not limit the value of the article, but recognize that it is a limitation. Laws and rules vary from state to state (and from county to county) and change constantly, so you should consult with advisors before making and firm decisions. Related Articles - Elder Law: The Basics - Medicaid Eligibility - Medicaid Benefits - Medicare Overview - Discrimination Against Medicaid Recipients - Tips for Choosing a Financial Planner - Life Insurance Trusts Resources - Long-Term Care Analyzer (interactive assistant) - Medicaid Long-Term Care Services (US federal government website) - ElderCare Online Insurance Coverage Channel - ElderCare Online's Legal & Financial Matters Channel Additional Reading - Health Care Without Medicare by Joseph Jackson - Beat the Nursing Home Trap: A Consumer's Guide to Assited Living and Long-Term Care by Joseph Matthews - ElderCare Online's Legal & Financial Matters Bookshelf Related Websites - Crash Course in Wills and Trusts - ElderLaw Answers - Seniorlaw.com - National Academy of Elder Law Attorneys - Pierro & Associates Law Firm (New York) - Estateplanning.com +++++++++++++++++++++++++++++ This is not all...but it is enough. ...lets talk when you get back. W. O. 214 823-7000 800 827-3923 wom@womills.com