Many Power of Attorney and Health Care Proxy Documents Should be Revised in Massachusetts

If you’ve had legal documents drafted in Massachusetts pertaining to your health, financial, and long-term care wishes, you should have them reviewed and revised now! Massachusetts laws relating to powers of attorney and health care proxies have recently changed. This along with federal medical privacy laws can affect your already-created documents.

The federal law, known as the Health Insurance Portability and Accountability Act (HIPAA), generally prevents health care providers from disclosing your personal medical information to anyone other than you and someone you’ve named as your “personal representative.” Frequently you will sign medical releases at your physician’s office allowing them to communicate with any specialists you are seeing, like a podiatrist or a cardiologist. Protecting your medical privacy is very important but the law can create some complications.

Madelyn executed a Health Care Proxy that names her daughter, Stella, to make medical decisions when/if she is unable to make them herself. Unfortunately, her Health Care Proxy doesn’t include a HIPAA provision due to poor planning. Madelyn develops dementia and Stella feels that the doctor may be overlooking an undiagnosed mental illness. This is in addition to Madelyn’s cardiac issues. Since Stella isn’t the “personal representative” under HIPAA regulations, she has had a lot of difficulty speaking with her mom’s doctors and accessing written medical information. She is frustrated because she can’t make the best health decisions for her.

Madelyn also executed a Durable Power of Attorney which also named Stella to make her financial decisions if she would be unable to make them in the future. But, again, the document did not name Stella as her HIPAA “personal representative.” Stella cannot access Madelyn’s medical information and cannot prove to Madelyn’s financial institutions that she is indeed incapacitated. As a result the Power of Attorney document is of little value and may force Stella to seek out a costly Conservatorship in probate court.

To make sure your chosen agent(s) do not get caught up in this conundrum, your Power of Attorney and Health Care Proxy documents should contain HIPAA clauses. It is also highly recommended, and has long been the practice of this office, to sign separate HIPAA release forms.

Lacking HIPAA provisions isn’t the only reason why Health Care Proxy and/or Power of Attorney documents fail. Did you know that recent Massachusetts laws directly affect the way these documents should be drafted to be fully complete? Also easy to overlook items like lacking specific powers, or not having the document executed properly, can leave your family in a tough situation where they have to go to court to get the power you intended to grant them in the first place.

If you are concerned that your Health Care Proxy and/or Power of Attorney documents are lacking, please contact Vickstrom Law to make sure they are complete and comply with the new laws.

Photo credit, cyOFdevelin and used under a Creative Commons license.

Let Someone Know Your Medical Wishes For National Healthcare Decisions Day

National Healthcare Decisions Day is on April 16^th, and it’s an important reminder for every adult to let someone know their most private wishes about medial treatments and possible end-of-life care.

Far too many people assume that their families would make the choices they would want in an emergency.  Yet everyday we hear stories of adult children, siblings, or other relatives/friends battling during a health care crisis over “what their loved one would have wanted” in that situation.

The Terry Schiavo case is a great example of this. At the young age of 26, Shiavo suffered sudden cardiac arrest and slipped into a permanent a vegetative state.    She never documented her wishes about things like feeding tubes, life support, and long-term quality of life, leaving her spouse and parents to battle for years over these questions in court.

Her husband eventually had her feeding tube removed claiming, “That’s what she would have wanted.”  But was it really? Her parents certainly didn’t think so. But we’ll never know because Terry didn’t make her healthcare wishes known to her closest family and friends.

But it’s not enough to just tell someone about your wishes.  You need to clearly document your preferences, too.  Remember, emotions can run high during a health care crisis, and it might be hard for your loved ones to stop life support when they desperately want you around.  Having your wishes spelled out in writing helps make these types of decisions easier for your loved ones, especially in cases when family members don’t agree.

So in honor of National Health Care Decisions Day, I encourage you to start tough conversations with loved ones about your personal medical preferences for medical and/or long-term care.  Here are some important questions to consider:

• What are your thoughts on feeding tubes, life support, and other artificial life saving devices?
• Is there any type of medical care you would NEVER want?
• If you were permanently disabled or incapacitated, what things would contribute or take away from your “quality of life?”
• Who do you trust to make important medical decisions if you are unable to speak for yourself?
• What are your thoughts on nursing home vs. in-home health care?  Who would you trust to manage your long-term care? your finances?

These are not the most fun conversations to have, but they will help to ensure that your most personal wishes are honored in a true medical emergency.  Talk them over with loved ones and have Attorney Kristina Vickstrom prepare important legal documents like a Health Care Proxy, a Living Will, and a Durable Power of Attorney. Getting documents in writing that spell out your wishes and the care you want if something happens to you is one of the best gifts you can give your family. It can avoid misunderstandings, family disagreements, and even court battles.

Get something in writing before an unforeseen emergency strikes. Do it early (age 18 and up) and check it often (with a major life event, or at least every 5 to 10 years) to make sure you have the most protection under the current Massachusetts laws and to make any changes to your wishes and/or decision makers.

Photo credit: Shoothead / cc by-nd 2.0

Worcester Estate Planning Attorney: How to Physically and Financially Protect Your Children If Something Happens To You

Parents in Worcester, Massachusetts rely on a lot of outside help when it comes to raising their children.  From family members to school systems to friends who pass on advice and hand-me-downs, it really does take a village to raise a child.  When it comes to estate planning, however, it is up to you to determine what is best for your minor children.

As an estate planning  and guardianship attorney, I recommend that all parents in Worcester who have children under 18 make planning a priority.  No one wants to consider the idea that they will not be able to raise their kids, but the unforeseen does happen.  By putting a plan into place while you are young and healthy, you can help determine your children’s future, even if you aren’t able to play the role in it that you had hoped.

For example, if you were to die or become somehow incapacitated, who would you choose to care for your child or children?  In many cases, the surviving parent is the obvious choice.  But, considering the fact that the family will be going through a particularly difficult time and that the parental responsibilities will now fall to one person, it may be beneficial to go a step further.  To do this, more central Massachusetts families are choosing to create an estate plan that provides for more financial support of both the children and the spouse.  In doing so, that caregiver can be relieved of some of the burden of working and raising the children.

In cases where both parents are killed or where one parent is already absent from the child’s life, setting up a guardianship is a must.  This allows you to determine who in your “village” will be responsible for the continued upbringing of your children.  Your estate plan may offer financial support to this person as well as trusts that the children can access when they reach a certain age.  That said, it is acceptable to place a different person than you named as guardian in charge of financial responsibilities.  An estate planning attorney will walk through the options with you in order to find a solution that best fits your situation.

When it comes to finances, it is also a good idea to consider what kinds of restrictions you might want to place on your children’s access to inheritance.  Some parents make access contingent upon certain goals such as age, education, and behavior.  Simply allowing access to a trust when a child reaches 18 may not always be the best approach due to inexperience and pressure from others.

Again, an estate planning attorney is well versed in the options available to parents who wish to plan for their minor children.  Choosing someone in the Worcester area, like Vickstrom Law, ensures that your estate plan is valid, complete, and meets the criteria of the local courts. For more information, please contact Attorney Kristina Vickstrom.

Photo Credit:  limaoscarjuliet / cc by 2.0

I Take Care of My Mother. Can I Legally Get Paid for That?

As the number of family members providing care for aging parents increases, the solutions to find help with loss of income because of time off from employment for caregiving has become a major concern for many. The demands on both the time and energy needed to provide the needed care can make it impossible to maintain both a full time job with full time caregiving.

Angela is a registered nurse. Her mother, Renee, has been experiencing a gradual decline in her health due to her Alzheimer’s and stroke and recently moved in with Angela. Angela is taking more and more time off from work to give Renee the care she needs. Sometimes she misses out on important overtime that her household finances depend on. Angela started paying herself out of her mother’s account for the care that she gives Renee. She pays herself some weeks, and doesn’t on others, even though she is providing the same care.

It is understandable that Angela would want to be paid for the care she is giving her mother, especially when it is interfering with her current job. Also if it wasn’t for this care, Renee would be in a nursing home. But, Angela must be sure to go about getting paid correctly.

The National Family Caregiver Support Program was created by the federal government to support family caregivers. While reviewing this site, Angela found out where she can get respite care for Renee, so she can take a much needed vacation with her husband. She also discovered how she may get paid, without feeling bad about her mother’s dwindling funds, and how these payments can continue after her mother runs out of money.

Often overlooked, the Veteran’s Aid and Attendance pension benefit is a great source of money to pay family caregivers to provide care at home. This money is available to veterans who served during a period of war. Pension money is also available to the widows of these veterans. This benefit, under the right circumstances, can provide up to $1,949 a month in additional income to pay family members to provide care at home. Luckily, Angela’s late husband was a WWII veteran and she qualifies for aid. However, she must have a professionally drafted caregiver contract in place, get a medical evaluation, meet income and asset qualifications, and have proof of medical expenses and care needed.  

Alternatively, or sometimes in addition to, a long term care insurance policy covers home care and payment to the care giver from this source could be arranged. Some policies require the care provider to be through a licensed home care agency, but others will pay for individual aides certified as such. This would require some training by the family member to become certified, unless they had a nursing background, like Angela. Renee did not have a long term care insurance policy in place. However, there are policies that pay a daily benefit amount to the insured to use as they want to pay for their care.

In some cases the elder has the funds to pay for their own care. If a family member is giving care it is very important that a professionally drafted caregiver contract be in place. Without one, any payments could disqualify the elder from certain MassHealth/Medicaid long-term care payments. Lump sum payments for care and/or retroactive payments are never a good idea.

A caregiver contract prepared by an elder law attorney like Attorney Kristina R. Vickstrom, will be a signed and dated agreement will outline the services provided as well as the amount of pay for these services. The contract will eliminate questions about what is expected from both parent and caregiver as well as providing a legitimate contract and a clear and consistent payment record of services to qualify for MassHealth/Medicaid. The contact will be treated as an employer/employee relationship and payroll records must be kept with taxes paid. Retroactive payments for care-giving are almost never allowed when applying for MassHealth/Medicaid.

The family member providing such care, like Angela, can not only save their loved one from needing nursing home services outside of the home, but also could protect assets in the event that long-term care is needed in the future. Please contact Vickstrom Law to set up a consultation if you are interested in learning more about the right way to get paid to take care of your loved one.

Grandparents Raising Grandchildren- Legal Options and Financial Support

With the decline of the traditional nuclear family, individuals over 50 are increasingly vested with responsibility for the caretaking of young children and adolescents. Financial problems are the primary cause of seniors having to assume more “traditional” child-rearing duties. Whether due to a divorce, military service, substance abuse, mental illness or other secondary issues, some adults may be unable or simply unwilling to be good parents themselves.

After suffering ten years of domestic abuse at the hands of her husband, Jennifer finally filed for divorce and moved herself and her daughter in with her parents, Gerry and Donna Daly. Although the relocation was supposed to be temporary, Jennifer has exhausted her bank accounts, refuses to obtain employment, and has sunk into a deep depression. Gerry and Donna are proud, retired grandparents who want to ensure that their grandchild is raised with love, discipline, and opportunity. They have been expensing the household’s grocery bills and clothing for the child, as well as toting her from play-dates to extracurricular activities. The Dalys’ other children have begun to voice concern over their parents’ spending, noting that their income is supposed to sufficiently cover a two-person household and not be stretched to support a four person family. While Gerry and Donna understand their concern, they don’t believe in asking Jennifer and her daughter to leave and have the utmost confidence that Jennifer will get back on her feet. What are their legal and financial options?

Many times, the child-rearing duties that grandparents assume will cause a real strain on seniors’ budgets. Child care costs can grow exponentially dependent on the length of time a grandparent will be asked to assist in raising his or her grandchild. Given this responsibility, these seniors might consider obtaining legal authority to make decisions for that child – on important issues such as healthcare and schooling – and financial assistance from the State.

In Massachusetts alone, 67,781 children reside in grandparent-headed households. Although the Daly’s granddaughter is physically living in their home and they are raising her, Gerry and Donna do not have any legal rights or authority to make decisions on behalf of the children. Jennifer could sign a form giving her parents ‘caregiver authorization.’  This is a caretaking option provided by the Massachusetts Uniform Probate code and allows parents to authorize a designated caregiver to exercise “concurrent parental rights” on healthcare and schooling matters. Provided that the caregiver lives with the child, the authorization is valid for two years and does not require court approval. Caregiver authorization is an alternative to filing for Guardianship of a Minor, a court decree effectively suspending the rights of the parents and transferring them to a guardian entrusted with caretaking responsibility. Depending on Jennifer’s state, this may be necessary for the Dalys.

If you are on a fixed income and unable to get help from a child’s parents, the child may be eligible for payments from Massachusetts’ Transitional Aid to Families with Dependent Children and medical coverage through MassHealth. For further information on assistance through these and similar programs, consider reviewing the Massachusetts “Resource Guide for Grandparents Raising their Children.”

While it may be your desire to become legally and financially responsible for your grandchildren, you are not required to as a matter of law. It is ultimately up to the Commonwealth to assign custody to a suitable individual. However, if circumstances have placed your grandchildren in your home, it is helpful and oftentimes necessary to review your present legal options and to adapt an existing estate plan to ensure that the unique challenges of caring for grandchildren are addressed. Contact Vickstrom Law to your situation and get informed on your options.

Parent-Child Role Reversal

Hoarding: How to Help a Loved One Declutter

The issue of hoarding has recently gathered a great deal of attention, particularly due to news reports and popular television shows.  However, hoarding is not a new or a small problem. The problem of hoarding has been documented since the turn of the century and is thought to significantly affect nearly 15 million Americans, many of them elderly. A great article recently appeared in the Boston Hearald dealing with the clinical aspects of Hoarding.  Unfortunately, research has been lacking in this area – until now.

On July 14, 2010, a Bellingham, Massachusetts couple and their dog were found dead in their home.  The ultimate factor in their deaths: hoarding.  Authorities deduced that 75-year-old Richard Lamphere tripped on a pile of trash, fell on top of his wife, 62-year-old Susan Abraham and one of their dogs.  Lamphere died instantly from head injuries; Abraham was severely injured in the fall and died later from her wounds.  Police confirmed that the couple were hoarders.  They had trash and belongings piled everywhere inside their home.  The conditions were uninhabitable and clearly unsafe. For the full story, see this article.

When assessing the severity of a loved one’s hoarding situation, several questions are important to remember:

• Can the occupant access doors in case of an emergency?
• Does he have access to the kitchen to prepare and store food?
• Can he access the bathroom facilities? Can the bathtub/shower be utilized?
• Can the resident safely reach their bed or have they made other sleeping arrangements?
• Are the home’s mechanical systems in working order (electrical, plumbing, heating)?
• Are pets being cared for?
• What health hazards are present (mold, decaying food, bodily waste, etc.)

If the basic needs of an occupant cannot be met, then it is time to consider intervention.

The difficulty with trying to help a hoarder is that most of them do not seek or want any “help”.  In fact, hoarders typically do not comprehend that they actually have a problem.  Thus, attempts to “clean out” or assist a loved one in “tidying up” his or her home should be done with care and patience.  And, although perhaps difficult, refrain from making judgments.

Tips to aiding someone who hoards include encouraging them and helping them establish new relationships.  Gently remind them that their grandchildren will be able to come and visit if they clean their house.  Perhaps it is time to participate in a local community activity for seniors.  If they are busy with other activities or plans, then getting rid of “stuff” may seem less consequential to them.  Many local companies specialize in professional, home organziation and cleanouts. Additionally, you may look into a hiring a certified home maker a few hours a week to keep up with housework and tackle clutter habits.

As a last resort, do not be afraid to contact the authorities or professional help.  Let someone else be the “bad guy”.  The story of a local hoarder who has made progress over the years can be found here.

Finally, a temporary or limited Guardianship may be necessary, at least until improvements can be made for the individual’s overall safety.   For more information and advice contact your local Elder Services or area Agency/Council on Aging.

More Protection Than a Health Care Proxy Alone?! MOLST- a Pilot Program in Worcester

Some people think that Elder Law and Estate Planning attorneys are only useful further down the road. They think, “I’m healthy. I don’t need to worry about those things now.” Even while you are healthy, there is one document that everyone over the age of 18 should have in place: a Health Care Proxy (HCP). A health care proxy is necessary to ensure that someone, a health care agent, will be available to make medical decisions for you if you are unable to make them on your own because you are incapacitated. Currently, in Worcester County, another form is also worth considering: the Medical Orders for Life-Sustaining Treatment (MOLST) form. This medical order works with the HCP to inform your health care agent and your doctors what you actually want to happen in various circumstances.

In April 2008, the Massachusetts Health Care Quality and Cost Council (MHCQCC) issued its annual report recommending that Massachusetts establish a pilot program to improve communication between patients and clinicians, and other interested parties, regarding end of life treatments. The MHCQCC found that many patients nearing the end of life were unaware of the treatment options available to them, or, if patients had been aware of such treatment options and had discussed them with their doctors previously, nothing was in place to ensure that their preferences were honored. Therefore, the Massachusetts legislature enacted legislation in August 2008 establishing a demonstrative program for the MOLST process in one community in Massachusetts: Worcester. (Yay, Worcester!)

The MOLST form is fairly simple and easy to read; the most difficult part is actually making the decisions and putting them down on paper. The form is only two pages long, and only two sections must be completed in order for the form to be honored. These two sections are Section D (patient information – specifically who is signing the document on behalf of the patient) and Section E (physician information). In   Section D, it is possible for the patient, the patient’s health care proxy, or the patient’s guardian to sign on his or her behalf. If a guardian is signing for the patient, the guardian must ensure that s/he has the legal authority under the guardian appointment to do so. This may require consultation with the patient or guardian’s Elder Law attorney.

If any other section of the form is not filled out, the health care agent is not limited in his or her decisions for life-sustaining treatment for the patient. Sections A, B, C, and F ask the difficult questions regarding resuscitation, intubation and ventilation, hospitalization, respiratory support, dialysis support, and artificial nutrition and hydration. It is critical that you speak with a physician before making these decisions so that you fully understand the meanings of the terms used and the potential consequences. Once these sections are filled out, they must be honored by all health care professions in Massachusetts, where clinically appropriate. The MOLST form is different from a Living Will or another document expressing your “final wishes” because it carries more authority and is more likely to be honored. A Living Will or final wishes document is only used by health care professionals to keep your wishes in mind when making decisions about treatment. While the MOLST form is not currently legally binding, health care professionals are strongly encouraged by the state to honor it.

Finally, Section G simply asks for the contact information of the health care agent. There is also room on the form for other treatment preferences, in which you can more clearly articulate your wishes. There is an expectation that the form will be reviewed throughout the patient’s life so that if his or her preferences change, those preferences will still be honored.

View a sample MOLST form here.

MOLST in Massachusetts from Commonwealth Medicine on Vimeo.

Antipsychotic Drug Use for Dementia Should be Closely Monitored by Doctors & Family Members

Are you a family member or guardian of someone that suffers from dementia? Is s/he living in a nursing home? Do you know what medications s/he is taking? Do you know what the dosages are? When was the last time those medications were reevaluated to determine if they are helping in any way, or if they are even necessary? These are all important questions to keep in mind and to continue asking the administrators of the nursing home and the physicians who care for your loved one.

On March 10, 2010, Massachusetts joined a federal suit against Johnson & Johnson for paying millions of dollars in kickbacks to Omnicare, Inc., the largest pharmacy in the US that specializes in providing drugs to nursing home facilities. United States Attorney Carmen Ortiz argues in the complaint that substantial monetary kickbacks can be especially harmful in the nursing home context because nursing home patients have little to no control over the medical care they receive. He states: “Nursing home doctors should be able to rely on the integrity of the recommendations they receive from pharmacists, and those recommendations should not be a product of money that a drug company is paying to the pharmacy.”

The primary drug at issue in this case is Risperdal, an antipsychotic drug that is usually prescribed for patients with severe mental illnesses, such as schizophrenia. It is legal to prescribe antipsychotics for “off label” uses to treat people with dementia, but these drugs may also raise the risk of death among such patients. At the same time, antipsychotics can help patients with dementia suffering from extreme agitation and sleeplessness. When prescribed in small doses, these drugs can actually have amazing effects on making the lives of patients with dementia more bearable. However, it is important that the prescriptions and dosages be reevaluated regularly to determine their effectiveness and potential harm to the patient.

On March 8, 2010, the Boston Globe reported that 2,483 nursing home residents in Massachusetts were treated with powerful antipsychotic drugs in 2009. This data was collected by the federal Centers for Medicare and Medical Services, and Massachusetts has the 12^th highest rate in the nation for nursing home patients on antipsychotic drugs. While these statistics may appear alarming at first glance, any good researcher knows they don’t paint the whole picture. Many patients with dementia are only put on small doses that do not harm them in order to lower their agitation and improve their sleeping habits, but it is also critical not to simply overlook these statistics. As noted earlier, two after the data was published in the Boston Globe, Massachusetts joined an important federal suit against one of the drug companies that promotes these potentially harmful practices.

It is extremely important to be educated and informed regularly about the drugs your loved one is taking, especially if s/he is in a nursing home. While issues concerning antipsychotic drugs are currently making headlines, it will take individual conversations to ensure that your loved ones are being treated appropriately. Sometimes antipsychotic drugs are extremely beneficial for a patient with dementia, but if not administered properly, they can also be very damaging. Open communications between you, the patient, the patient’s guardian (if that is not you), the patient’s primary care physician, and the administrators at the nursing home s/he lives at, will make it possible to ensure that your loved one is on the right medication so that s/he is safe and comfortable.

Astor Matter Reminds Us that Trustworthiness is Essential When Nominating Substitute Decision Makers

Lately, the matter of Brooke Astor’s estate has been covered in the media. Like many people she had an estate plan in place which included a Durable Power of Attorney and Health Care Proxy, which nominated subsituted decision makers in the event she would lose the capacity to make important financial and/or medical decisions at some point during her elder years. She did not want to burden her family with obtaining a Guardianship and/or Conservatorship through the courts. She did end up suffering from Alzheimer’s disease and her son took over her financial powers. He just didn’t do a very good job…

The following is an exerpt from this week’s AZCentral.

Anyone who has signed a financial document has to be squirming a bit over Brooke Astor’s estate case.

Her son, Anthony Marshall, recently was convicted of stealing millions of dollars from Astor while she suffered from Alzheimer’s disease before her death. Although the case largely centered on a contested will purportedly signed by Astor, other estate-planning issues also came into play.

One was a financial power of attorney signed by Astor that gave Marshall authority to direct her affairs if she became incapacitated – and the means to steal from her.

The episode provides a wake-up call for people who use financial powers of attorney. These legal documents can be highly effective in ensuring that someone else will be around to handle financial matters for you if you’re alive but unable to do so – as in the case of mental incapacity.

A power of attorney can be as short as a page or much longer, depending on the detail desired. They’re often included with a trust, will, health power of attorney (addressing medical issues) and other estate-planning documents.

For all the benefits of using a power of attorney to avoid a potential court-supervised conservator situation, there are pitfalls, too.

In particular, you need to trust the person whom you designate to act on your behalf. And you should make sure he or she is responsible, diligent and reasonably astute.

“They really are documents that people should pay attention to,” said Denise McClain, a financial principal and attorney at wealth-management firm Lowry Hill in Scottsdale. “You’re potentially passing along a lot of power.”