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Thank You For Making our 13th Annual Special Needs Seminar our Best Yet

Gilfix and La Poll wishes to thank the hundreds of attendees, and wonderful nonprofit co-sponsors, for making our 13th annual Special Needs Seminar our best yet!

We were overwhelmed with the response, and with all of the kind comments we received from seminar attendees. We were also thrilled to see many attendees connecting with co-sponsor support organizations, including:

  • Center for Independence of San Mateo
  • Children's Health Council
  • Community Resources for Independent Living (CRIL)
  • Jewish Family and Children's Services
  • Life Services Alternatives, Inc.
  • National Alliance on Mental Illness (NAMI)
  • Pacific Autism Center for Education (PACE)
  • Parents Helping Parents and many more!

The seminars, lead by attorneys Michael Gilfix and Mark R. Gilfix, covered the importance and structure of special needs trusts, recent special needs legislative updates, including the Special Needs Trust Fairness and ABLE Acts, and an overview of how estate planning can incorporate these very important tools. Michael and Mark were thrilled with the quality of questions they received from audience members.

Gilfix and La Poll is proud to be one of the nation’s premiere special needs planning firms. We were overjoyed to connect with so many in the bay area community at our recent seminar.

We know many who signed up were unable to attend, and space and parking restraints meant we were unable to accommodate all who wanted to attend.

Because of this, we will be offering a special follow-up Special Needs Trust Seminar on June 22nd at the Bay Café (1875 Embarcadero Road) in Palo Alto. Space will be limited, and we anticipate a full house. If you hope to attend, we encourage you to register as soon as possible here.

Again, we thank you for making the Special Needs Trust seminar such a wonderful and successful event!

REGISTER NOW FOR OUR SPECIAL EVENT

Gilfix and La Poll invites families to attend 13th Annual Special Needs Trust Seminar

Let’s face it, everyone is worried about the future of government benefits and how individuals with special needs will be cared for. To address this attorneys Michael Gilfix and Mark Gilfix of Gilfix and La Poll Associates are offering a free special needs planning seminar on Wednesday, May 10, 2017 in Palo Alto, California. The 13th Annual Special Needs Trust Seminar will provide valuable information for those who have children or other family members with special needs. There will be two seminar sessions, each lasting two hours.

Both seminars will highlight new legislative developments and opportunities: The ABLE Act and the Special Needs Trust Fairness Act. Special needs trusts are crucial planning tools. Michael Gilfix and Mark Gilfix will explain how they work and why they are necessary to create for a child with a disability. They will also discuss housing for disabled individuals, the ABLE Act, the Special Needs Trust Fairness Act and the possible impact of Trump administration initiatives. Seminar attendees will learn how special needs trusts complement public benefits like Supplemental Security Income and Medi-Cal rather than disturbing eligibility for them.

Michael Gilfix and Mark Gilfix have decades of experience in the field of special needs planning. Michael Gilfix is a member of the Academy of the Special Needs Planners and author of the book “Special Needs Trust Creation and Management Guide.”

The seminar is being held with the support of nonprofit organizations including Autism Society San Francisco Bay Area, Community Resources for Independent Living, Jewish Family and Children Services, Pacific Autism Center for Education, Parents Helping Parents and others.

Space is limited, so please reserve a spot as soon as possible. To register, call 650-493-8070 or visit www.Gilfix.com.

13th Annual Special Needs Trust Seminar
Wednesday, May 10, 2017
2pm to 4pm & 6pm to 8pm
Elks Lodge
4249 El Camino Real
Palo Alto, California

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Autism costs rise dramatically with age: study

Caring for individuals with autism and other special needs tends to involve a lifetime of expenses, whether it is paying for caregivers, accommodation or daily necessities. A study from the University of California, Davis (UCD), shows California spends significantly more on adults with autism compared to children who have the disorder. Researchers found state expenditures soar as people with autism age.

Each individual under the age of 18 received an average of $10,500 in state funding annually. Meanwhile, costs for adults were two and a half times higher at around $26,500. The widest gap was between the youngest and oldest age groups with an average difference of nearly $38,000.

The UC Davis Health System study examined per-person spending on autism services for over 42,000 California residents with autism. Researchers analyzed the California Department of Developmental Services’ spending from 2012 to 2013. The department funds services for people with autism through 21 regional centers in California.

The data took into account costs for transportation, daycare, employment support and accommodation at community care facilities. It did not include medical expenses or school expenditure. The study found daycare and residential care were the sources of the highest costs.

“As children with autism grow up and become adults and no longer receive public school-based assistance, their services transition to expensive independent living support and more of the cost burden shifts to the state,” said study author Paul Leigh, a public health sciences professor at UCD. “We hope our data can help justify earlier, expanded and equitable spending on younger children with autism. There is a great return on investment in high-quality early intervention services.”

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Military retirees can now use special needs trusts for SBP payments

Military families with special needs children face a number of difficulties when planning for their future financial security. However, a new law now allows military retirees more flexibility and peace of mind with the way their Survivor Benefit Plan (SBP) can be paid upon their passing.

The SBP allows retired military members to designate up to 55 percent of their retirement pay to eligible children, spouses or other beneficiaries. Under the Disabled Military Child Protection Act, military parents can now provide survivor benefits to a disabled child via a special needs trust. Although the Act was passed in December 2014, the Department of Defense did not issue a guidance on how to implement SBP payments to a legally established special needs trust until a year later.

Previously, military families faced the challenge of being unable to assign SBP payments to a trust. The funds had to be designated to an actual person, whether it was the beneficiary, a guardian or representative payee.

As a result, military retirees with special needs children were reluctant to select their child as the beneficiary. They feared the SBP payments could potentially affect the child’s eligibility for government benefit programs such as Medicaid or Supplemental Security Income. With the new policy, both SBP support and eligibility for government benefits can be protected with a special needs trust.

Military families need to think about the long-term impact when designating survivor benefits for a disabled child. When considering the use of a special needs trust for SBP payouts, families should consult a knowledgeable special needs planning attorney to ensure the correct type of trust is used in their plan and that it is in compliance with federal and state laws.

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Smartphone app helps nonverbal children communicate through symbols

Predictive typing firm SwiftKey has launched a smartphone app that aims to provide special needs children with an easier way to communicate.

SwiftKey Symbols is described as an assistive symbol-based communication app specially designed for children with autism and other learning difficulties. It can be used by other nonverbal individuals as well. The company’s contextual language prediction technology allows users to communicate with others by selecting images from various categories in order to create sentences.

Children with autism may face difficulties developing language skills and communicating effectively with others. Technological innovations such as this app help to remove communication barriers for special needs children by opening up opportunities for them to express themselves. SwiftKey Symbols includes an audio playback feature where a formed sentence is read aloud for children with verbal impairments. It also allows users to customize the app by adding their own categories and images.

The app gradually adapts to the user through its predictive sentence completion feature. SwiftKey technology suggests symbols based on factors such as time and day. For example, if the user has art lessons on Wednesday afternoons, the icons previously selected at that time will appear.

SwiftKey shared in a blog post that the inspiration for the new app came from the company’s employees whose nonverbal family members have autism. “We wanted to bring an accessible, free app to people with talking and learning difficulties so that they could communicate more easily with their friends and family,” wrote product manager Ryan Barnes.

The app is available for free download on Android devices.

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California caregiver law aims to prevent elder abuse

The law seeks to enhance the safety of elderly and disabled people who receive private home care services from a caregiver who assists them with daily tasks. Senior citizens can often be vulnerable to abuse, whether it is physical, sexual, mental or financial. Elder abuse can happen not just in a nursing home or other institutional care facility, but also in one’s own home.

Under the Home Care Services Consumer Protection Act, home care agencies in California are now required to be licensed with the state and provide their staff with mandatory training in first aid, CPR and emergency procedures. In addition, their caregivers must pass a criminal background check and register with the Department of Social Services.

Independent caregivers are also required to be licensed before providing any type of home care services. Elderly individuals or their families can then check the state's database to ensure the caregivers are registered. Prior to this law, only those providing medical services at home were subjected to certification requirements and background checks.

Agencies that are not licensed may incur fines of up to $900 per day. The legislation comes after reports of senior citizens in California suffering embezzlement, fraud and abuse at the hands of home caregivers. The hope is that the Act will help usher in stricter standards to the state’s home care industry, which has lacked oversight and regulation.

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Michael Gilfix, National Experts Form Trump Policy Analysis Group

THE TRUMP POLICY ANALYSIS GROUP (TPAG) – FOCUSING ON OLDER AMERICANS AND THOSE WITH SPECIAL NEEDS

The Trump Policy Analysis Group (TPAG)1 has convened to consider probable changes in law that will affect older Americans and those with special needs. Initial TPAG focus is on entitlements, public benefits, tax, special needs planning, and veterans’ benefits.

DOWNLOAD THIS ARTICLE AS A PDF

We used a three-fold analysis:

  • Stated policy (declared Trump policies and those of the Republican Congressional Leadership);
  • “Realpolitik” (circumstances and factors rather than explicit ideology, often considered “pragmatism”); and
  • Educated speculation (based largely on experience and knowledge of TPAG members who have been leaders in these fields for decades).

STATEMENT OF PURPOSE

On January 20, 2017 both the White House and both houses of Congress will be in Republican hands, not seen since 2006. As president Obama said shortly after being elected in 2008, elections have consequences. We acknowledge this reality.

During the long and divisive campaign, differences in priorities and agendas between the major parties, particularly in social and health policy, were greater than in any recent election. In our opinion, the uncertainty and challenges now facing seniors, disabled, and medically needy Americans are unequaled and unsettling.

Our goals are twofold. First, to objectively analyze real and probable changes in government policies that directly impact older Americans and Americans with disabilities. Second, to identify planning and other steps these populations should take to preserve or, ideally, to increase quality of health care and quality of life.

SOCIAL SECURITY AND MEDICARE

President-elect Trump has consistently stated that the Social Security and Medicare programs are to remain intact and (presumably) solvent. How solvency would be achieved in light of impending bankruptcy of both programs (Medicare long before Social Security) remains to be seen.  Government and non-government economists only disagree about when insolvency will occur, not if it will occur. As one of their proposals to counter insolvency, Trump and Congressman Ryan (Speaker of the House) are promoting Social Security and Medicare privatization.

The Affordable Care Act took some steps designed to extend the solvency of Medicare. Trump, as President-elect, announced that he would keep parts of the Affordable Care Act but did not explain how he would pay for it. With so many members of younger generations convinced that Social Security will not be there for them, preservation of the fiscal health of both Social Security and Medicare is one of the main challenges facing this Administration.

MEDICAID

1. Rising Fears of Significant Restrictions

A significant majority of Americans are seriously worried about the cost of health care and long term care, in particular. Restrictions on benefits and legislative changes that restrict or limit access to government programs such as Medicaid can only heighten such fears.

2. The Trump and Ryan Block Grant Proposal

Currently, Medicaid is administered at the federal level by the Center for Medicare and Medicaid Services (CMS). While each state has its own state Medicaid Plan, there are mandates and there are constraints.

Block grants, which were first proposed by then Speaker of the House Newt Gingrich in 1995, presumably mean that each state would receive a certain number of Medicaid dollars. Each state would then decide how to utilize and spend those dollars.  In some states, little would change. In other states, changes could be profound. For individuals who may rely on Medicaid, this is a time of uncertainty and concern.  This means, in turn, that planning needs will vary from state to state.

TPAG is aware of some details and elements of proposed plans. Some are designed to restrict protective planning – to make it much more difficult for older Americans to protect their homes and other assets while qualifying for Medicaid, particularly in a long-term care setting. Planning challenges could therefore become dramatically more difficult. Increasingly, older Americans and their families will need up-to-date information and advice to understand and qualify for needed services. This will be particularly true for the majority of older Americans who will need home care services and who need to reside in skilled nursing facilities.

Americans with special needs and their families face as many worries, including concerns about possible reductions in protections and services.

TPAG believes that planning will increasingly involve multiple generations to enhance quality of life, quality of care, and asset protection.

3. Protection of Family Assets: Focus on Protecting the Family Residence

The vast majority of older homeowners will view protection of the residence as a core value, a legacy for future generations. Appropriate legislation must be preserved. Appropriate planning steps must be taken, particularly in light of possible changes in Medicaid, the only federal program that can subsidize or pay for the cost of skilled nursing care. No specific proposals to threaten existing tax and Medicaid protections for the residents have yet emerged.

TAX PROPOSALS – GIFT, ESTATE, INCOME, AND CAPITAL GAINS

1. Gift and Estate Tax

President-elect Trump calls for the elimination of gift and estate tax, perhaps replaced by a “mark to market” tax of capital gains at death. Perhaps a compromise package will not eliminate the tax but will significantly increase the level of estate and gift tax protection. Note that the current level of federal protection is historically high at $5,450,000 per person. If any estate tax remains, it would likely be reduced from the current 40% tax rate.

2. Capital Gains Tax

Different proposals have been proffered by President-Elect Trump, Speaker Ryan and others regarding limitations on “stepped up basis” upon an individual’s passing. For some families, this could result in net tax increases.

For high-end practitioners, those who focus on avoiding estate tax, the challenges are obvious. The number of individuals requiring such sophisticated planning will, at best, dramatically diminish. For most older Americans, the avoidance of estate taxes will have little or no impact from a tax planning perspective and the focus will shift to income taxation. Further, the impacts on entitlements and family financial security could be profound.

3. Corporate and Individual Income Tax

Corporate and individual tax rates for higher earners, in particular, would be substantially reduced. The long-term impact – beyond the obvious increase in after tax income, is impossible to predict. As with most modeling and forecasting, projected outcomes depend on presumptions.

AMERICANS WITH SPECIAL NEEDS

No proposals have yet been made that would directly affect services for special needs children and adults.  Medicaid block grants could adversely affect special needs residents of states that decide – at the state level – to reallocate or otherwise restrict funding for both governmental and non-governmental providers. The reach of Medicaid block grants could significantly reduce or even eliminate the benefit of special needs trusts which maximize assets for the person with a disability.

Additionally, it is possible that support for expanded charter schools and school choice could expand options. This has become more probable than just possible what with Trump’s appointment of Betsy DeVos, as Secretary of Education, an outspoken advocate for charter schools and the dismantling of publicly funded schools. Many special education advocates fear these expanded options could come at a price of diminishing procedural and substantive protections of the Individual with Disabilities Education Act (IDEA), and even reduce or remove the funding formula that follows eligible individual students with special needs under IDEA).

VETERANS’ BENEFITS

President-elect Trump is presumably supportive of maintaining and perhaps expanding services for veterans. At the same time, proposals that predate the election have been introduced that could restrict access to needed programs, such as Aid and Attendance, which provides financial assistance for veterans and spouses of veterans who need higher levels of home care assistance. While new legislative and perhaps regulatory restrictions could make it more difficult for veterans and their spouses to obtain benefits, proactive planning will be an inevitable need across the nation.

LGBTQ PROTECTIONS

President-elect Trump has said that he accepts the United States Supreme Court decision effectively legalizing gay marriage. (His Vice President, Mike Pence, may have a different viewpoint.) The Supreme Court ruled that the U.S. Constitution guarantees the right for same-sex couples to marry in all 50 states creating uniformity across the nation in recognition of the rights of same-sex couples.

IN TIMES OF UNCERTAINTY, FAMILIES WILL PROTECT THEMSELVES

A core conclusion of TPAG is that families will become more insular, more protective of themselves, their assets, and future generations. They will be more focused on what they can control and truly value – their families – and less on public policies that are difficult to influence. This has myriad implications for attorneys, financial planners, and other professionals who work directly with America’s elders, those with special needs and their families. A premium will be placed on advance planning. Inevitably, this will increase involvement of younger generations.  The demand for multi-generational planning – planning that involves and relies on involvement of children and grandchildren – will expand dramatically.

WHAT SHOULD YOU DO?

TPAG thoroughly understands that most Americans, and older Americans in particular, are fearful at this point in time. Above all, do not panic. The stock market panicked at the end of Election Day but soon resolved and moved higher than ever. TPAG believes that the stock market’s response to the election is a lesson for everyone: Learn, watch, be advised, and protect yourself and your family. The changes in store will take time.

TPAG’s goal and its purpose is to turn fear into hope. This is what good planning does.

TPAG will continue to be a source of balanced, objective information about developments at the national level. TPAG is working hard to track initiatives by President-elect Trump, Republicans and responsive proposals of Democrats.

TPAG will work hard to be “one step ahead.”

**Members of the TPAG group include Michael Gilfix of Palo Alto, California, Vincent J. Russo of Garden City, New York, Harry S. Margolis of Boston, Massachusetts, Frank Johns of Greensboro, North Carolina, and Tim Nay of Portland, Oregon.

mike gilfix vincent russo harry margolis
frank johns timnay

Three mistakes parents of special needs children should avoid

Parents of special needs children hope to provide their offspring with financial security and the care they need. However, even with the best of intentions they risk making mistakes that could have costly, long-term consequences for their child.

One such estate planning mistake involves disinheriting the child to ensure their eligibility for key government benefits such as Medi-Cal and Supplemental Security Income. A more valuable option is for parents to set up a special needs trust. The trust can hold assets for their child without jeopardizing eligibility for federal programs. Parents can use special needs trusts to provide their child a higher quality of life that goes beyond the basic needs delivered by government benefits.

Procrastinating is another mistake parents might make. Some parents might choose to wait until their child is between the ages of 18 to 21 in order to have a better sense of their long-term prospects, mental capacity and degree of financial independence. However, failure to plan in a timely manner can mean that the special needs child is left without financial security or a guardian in the event the parents become incapacitated. As a result, it is better to engage in special needs planning sooner rather than later.

Choosing a trustee to oversee a special needs trust when parents can no longer do so is an important decision. When the responsibility falls into the wrong hands, the child may see their wishes overlooked and the special needs plan fall apart. Parents must choose someone who is trustworthy, knows the child and who will act in their best interests. They must also be able to follow trust administration rules and manage the resources available to the beneficiary.

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Choosing Wisely: avoiding bad care and maximizing the chance of getting good care

By Myra Gerson Gilfix

The Choosing Wisely campaign, an initiative by the American Board of Internal Medicine Foundation in partnership with Consumer Reports (begun in 2012), is an attempt to alert both doctors and patients to problematic and commonly overused medical tests, procedures and treatments.

From their website:
 
“In 2012 the ABIM Foundation launched Choosing Wisely® with a goal of advancing a national dialogue on avoiding wasteful or unnecessary medical tests, treatments and procedures. http://www.abimfoundation.org/About-Us.aspx
 
“Choosing Wisely centers around conversations between providers and patients informed by the evidence-based recommendations of ‘Things Providers and Patients Should Question.’ More than 70 specialty society partners have released recommendations with the intention of facilitating wise decisions about the most appropriate care based on a patient’s individual situation.
 
“Consumer Reports is a partner in this effort and works with specialty societies to create patient-friendly materials to educate patients about what care is best for them and the right questions to ask their physicians. Through a coalition of consumer groups like AARP and the National Partnership for Women and Families, Consumer Reports is ensuring patients get the information they need just when they need it.”

Virtually every specialty has lists of procedures or tests to avoid doing
 
The collection of Choosing Wisely Lists can help a patient or patient advocate to resist recommendations of physicians — and nursing homes — which they are wary about, and allow them to make proactive choices. It’s nice to have the power of a major medical group to back up your concerns!
 
Working through professional organizations representing medical specialties, Choosing Wisely asked doctors to identify “Five Things Physicians and Patients Should Question.”
 
The idea was that doctors and their patients could agree on tests and treatments that are supported by evidence, that don’t duplicate what others do, that are “truly necessary” and “free from harm” — and avoid the rest. Needless to say, there are likely more tests and procedures that are not “wise,” but this is a great start. It also means that you should use our handout, “Suggested Questions to Ask Your Doctor” when any treatment or procedure is proposed … not just those on these lists.

For the elderly in particular to avoid

Although virtually every specialty has released lists, the recommendations from geriatricians and palliative care specialists may be of particular interest to you, since many are grappling with such issues in their own families.
 
Both the American Geriatrics Society and the American Academy of Hospice and Palliative Medicine agreed on one major “don’t.” Topping both lists was an admonition against feeding tubes for dementia patients. This is something most of you have already specified in your Advance Health Care Directive that you don’t want. This is important because many patients are still being tube fed by default — even without a conversation that would engender a good decision.
 
Feeding tubes
 
Research has shown that feeding tubes do not prevent aspiration pneumonia or prolong dementia patients’ lives, but they do exacerbate bedsores and cause such distress that people often try to pull them out and wind up in restraints. The doctors recommended hand-feeding dementia patients instead.
 
Antipsychotic medications

The geriatricians’ list goes on to warn against the routine prescribing of antipsychotic medications for dementia patients who become aggressive or disruptive. Though drugs like Haldol, Risperdal and Zyprexa remain widely used, “all of these have been shown to increase the risk of stroke and cardiovascular death,” Dr. Lee said. They should be last resorts, after behavioral interventions.
 
Meds to achieve ‘tight glycemic control’ for type 2 diabetes
 
Prescribing medications to achieve “tight glycemic control” (defined as below 7.5 on the A1c test) in elderly diabetics who need to control their blood sugar, but not as strictly as younger patients.
 
Avoid prescribing sleeping pills when possible. Dr. Sei Lee, a geriatrician at the University of California, San Francisco, and a member of the working group that narrowed more than 100 recommendations down to five, pointed out that doctors should not turn to sleeping pills as the first choice for older people who suffer from agitation, delirium or insomnia. Xanax, Ativan, Valium, Ambien and Lunesta “. . . don’t magically disappear from your body when you wake up in the morning,” Dr. Lee said. They continue to slow reaction times, resulting in falls and auto accidents. Other sleep therapies, such as cognitive therapy, are preferable.

Avoid prescribing antibiotics for many urinary tract infections (UTIs)
 
An informative case study:
 
Avoid prescribing antibiotics when tests indicate a urinary tract infection (the most common infection among nursing home residents) but the patient has no discomfort or other symptoms. Many older people have bacteria in their bladders but don’t suffer ill effects; repeated use of antibiotics just causes drug resistance, leaving them vulnerable to more dangerous infections. “Treat the patient, not the lab test,” Dr. Lee said.
 
Brown University geriatrician Dr. David Dosa observes, “As people get more frail and old, physicians tend to do more, when often we should do less.” This observation is so important that it should be a guiding principle in hospitals and nursing homes. DO MORE BY DOING LESS.
 
While younger people who get a positive test result almost always need antibiotics since it’s not normal for them to have bacteria in their urine, many older people are “colonized” with bacteria and thus don’t necessarily need treatment. Often they live in environments with more germs, and they’re subject to procedures — like catheterization — that can lead to infection. Yet even though they may have a positive urinalysis indicating the presence of bacteria, they’re not sick. “This is normal for them,” Dr. Dosa said. “Just because they’re colonized doesn’t mean they need to be treated.”
 
The McGeer criteria (named for the infectious disease specialist who published them) call for antibiotics only if an older patient has three of these five symptoms: a fever; increased frequency or urgency of urination, or burning associated with it; pain behind or near the bladder; a change in the smell or appearance of urine; or deteriorating function or mental state.
 
But in two Rhode Island nursing homes where Dr. Dosa and his colleagues reviewed the medical records of 172 residents with urinary tract infections, physicians routinely ignored those guidelines. As the researchers recently reported in The Archives of Internal Medicine, more than 40 percent of patients got antibiotics when the guidelines suggested no treatment was necessary. Even worse, not only are we treating people with antibiotics when they don’t need them,” Dr. Dosa said, “but we’re using the wrong drugs.” 

In the Rhode Island sample, 56 percent of patients who received antibiotics got the inappropriate medications, and almost half were taking the wrong doses. They were also taking the drugs for far too long. Women generally only need three days to treat a UTI, according to medical guidelines. Men, who get far fewer infections, need to take them for seven to 14 days. But in this Rhode Island sample, where the average age was 83, more than two-thirds of patients took antibiotics for far longer. And these are high-quality nursing homes.
 
Uncomplicated urinary tract infections should be treated first with narrow-spectrum drugs (Bactrim is an example), the guidelines say, rather than broad-spectrum ones like Cipro or Levaquin. Broad-spectrum antibiotics tend to wipe out all the bacteria in the gastrointestinal tract, including the helpful ones that help people digest food and ward off infection. “It’s like a nuclear bomb that takes out everything, as opposed to a sniper’s bullet that targets one bug,” Dr. Dosa said.
 
Some of us who have experienced uncomfortable UTIs may think, “Better safe than sorry.” But that really doesn’t apply here. It just isn’t safe for elderly folk to take unnecessary, unfocused antibiotics or to take them for longer than needed when they are actually appropriate.
 
“One of the most important findings, and other studies show similar results, is that under- treatment didn’t hurt anybody,” Dr. Dosa said. “Nobody in our sample who didn’t get an antibiotic had a bad outcome,” like a kidney infection, hospitalization or death.  But those patients who were over-treated — that is, given antibiotics when their symptoms didn’t fit the criteria — were far more likely to be struck by the virulent and dangerous C. difficile bacterium, which flourishes in the gut when patients’ own competing bacteria have been eliminated by potent drugs.
 
Palliative care
 
The palliative care doctors’ Five Things list cautions against delaying palliative care, which can relieve pain and control symptoms even as patients pursue treatments for their diseases.
 
Other specifics:
 
Implantable defibrillators
 
It also urges discussion about deactivating implantable cardioverter defibrillators, or ICDs, in patients with irreversible diseases. “Being shocked is like being kicked in the chest by a mule,” said Eric Widera, a palliative care specialist at the San Francisco VA Medical Center who served on the American Academy of Hospice and Palliative Medicine working group. “As someone gets close to the end of life, these ICDs can’t prolong life and they cause a lot of pain.” Turning the devices off — an option many patients don’t realize they have — requires simple computer reprogramming or a magnet, not the surgery that installed them in the first place.
 
Topical anti-nausea gels
 
The palliative care list also warned that topical gels to control nausea don’t work because they aren’t absorbed through the skin. Dr. Widera noted, “We have lots of other ways to give anti-nausea drugs.”  Evidence also shows patients suffering pain as cancer spreads to their bones get as much relief from a single dose of radiation than from 10 daily doses that require travel to hospitals or treatment centers.
 
Ways of applying ‘Choosing Wisely’
 
My hope is that this initiative will have far-reaching positive effects the more it is discovered and embraced by patients and professionals alike. I found an interesting example of how this might look from an article from “Choosing Wisely – Canada” written by medical students. By seeing their list, we can tailor our own questions of medical professionals. Here are their six ways “medical students and trainees can avoid unnecessary or inappropriate tests, treatments and procedures . . .” My comments follow the quotes.
 

• “Do not suggest ordering the most invasive test before considering other less invasive options.” 
A good rule in any situation. Always start with the least invasive, most helpful intervention or test possible to get what is needed for the patient.

• “Do not suggest a test, treatment or procedure that will not change the patient’s clinical course.”
Fundamental. In other words, if it won’t make a difference to the patient’s treatment plan, don’t do it!

• “Do not hesitate to ask for clarification on tests, treatments or procedures that you believe may be ordered inappropriately.”
SPEAK UP — whether you’re a medical student, trainee or an “advocate” for the patient.

• “Do not miss the opportunity to initiate conversations with patients about whether a test, treatment or procedure is necessary.”
This is a nice corollary to my admonition in our handout, “Suggested Questions to Ask Your Doctor,” always to ask these questions.

• “Do not suggest ordering tests or treatments preemptively for the sole purpose of anticipating what your supervisor would want.”
Don’t do what may be unnecessary and counterproductive with the hope of sucking up to your supervisor.

• “Do not suggest ordering tests or performing procedures for the sole purpose of gaining personal clinical experience.”

IMPORTANT. Many will justify that in a teaching hospital, this is appropriate. However, a teaching hospital should emphasize teaching that the patient comes first. Students should be learning that it is the patient’s welfare that trumps their learning how to do something that their own patient doesn’t need. That is the most important learning for medical students and trainees. No rationalization about training being important should trump the welfare of the patient first.

Stay well, people. But if you need medical help, do what you need to do to ensure it is best for you or your loved ones. 

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Home Care and Financial Abuse

Over 8 million older Americans receive care at home or in facilities by strangers. Some caregivers are trained and managed by home health care agencies. Others are hired privately in an effort to save money. Privately hired caregivers may charge as little as $12 or $14 per hour. Caregivers hired through an agency may be as much as $18 to $30 per hour. The difference is very real.

Even more real is the danger posed by many caregivers who seek to take financial advantage. Retired emeritus professor John Wilson (not his real name) needed supplemental care in his life care community. He came to rely upon and trust a caregiver who was with him 40 hours per week. His trust was misplaced.

Over the period of two months, she used his credit card, had him sign checks made out to her for thousands of dollars, and forged his signature on other checks to pay for items that she purchased. In a short time, losses exceeded $60,000.

Professor Wilson was fortunate in that his care and finances were being monitored. The caregiver was fired, the agency reimbursed a portion of the funds, and other funds were recovered by other means. All estimates are that millions of dependent older Americans are victimized by this form of financial abuse every year.

To address, to reduce the possibility of financial elder abuse, much greater care must be taken when older Americans identify “attorneys in fact” when they sign Durable Powers of Attorney and when they choose successor trustees for their revocable trusts. Too few understand that individuals given such powers are in a position to misappropriate finances and otherwise take financial advantage. “A great disservice is done by online trust creators, such as LegalZoom,” warns Palo Alto attorney Mark Gerson Gilfix, “because they offer no counseling or effectively conveyed warnings about the need for an extremely conscientious and responsible person to serve in these roles.

Financial elder abuse is a plague that shows no signs of abating. Great care must be taken in choosing private caregivers, in particular, and carefully monitoring the financial affairs of vulnerable elders.

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