Case studies #23/24

23.    A senior needs support: a 92 year old gentleman in a LTC home. Placed here, while his wife was in hospital, she died and he was not able to go home. He is very lonely.  His vision and auditory senses are poor.  He has locomotor issues due to a childhood disease.  He would welcome visitors anytime.  He loves to play cards.

24.   A 80-year-old husband is getting two hours a day respite. This is not enough time for him to get into town, do errands, and get back again, let alone having any down time. He is caring for his 78-year-old wife, who has had a stroke. She is frail, and in a wheelchair. She is often up in the night, disrupting his sleep. He sleeps in the day, and cannot keep her busy enough to sleep at night.
The husband has vision issues, and is facing day surgery. He is on a limited budget.
She is on a list for long-term care, but the list is long and slow-moving. Family is far away. Respite programs at near-by institutions are being cut back, although he has used them before for 10-day breaks.

NOTE: this are cases intended to assist those in healthcare to understand the issues rural residents face. Feel free to use them for non-profit purposes.

My concerns remain, that the Aging at Home programs fail to fulfill the needs of our seniors.
Money spent on Alternate Level of Care hospital residents, sending seniors home from hospital to free up hospital beds, does not work for those already at home. Such dilution of funds, without the proper PSW and nursing care required, has meant that many are lonely, isolated and suffering the indignities we wouldn't wish on our own family members.

Dealing with your depression

How big is your pain?

What does it taste, smell, feel like?

These are all ways to honour your grief, which honours your loved one.

You can draw your pain. Paint your pain. Sing your pain. Scream your pain. 

Green for jealousy
Black for fear, grief, terror,
Blue for sadness
Brown for guilt
Orange for nervousness
Yellow for happy

Mental health issues in seniors seem to be the most underdiagnosed issues.

Minneapolis Nursing Home Blamed in Resident Suicide

The Associated Press 
Posted Feb 25, 2011 @ 06:00 PM 

Minneapolis, Minn. — A state investigative report finds a Minneapolis nursing home could have prevented a 90-year-old resident's suicide. 
The woman was found Oct. 21 dead in her bed at the Jones-Harrison Residence. She had tied a bag over her head. 
According to a state Health Department report, the woman's suffocation followed a recent assessment in which she said she was "a failure, or let herself of her family down." 
The report says a nursing home employee said the woman's doctor was not notified about her depressed state of mind. 
Lowell Berggren, the home's president and CEO, tells the Star Tribune the home should have called the doctor. 
A state investigator's follow-up visit found the home had made necessary corrections.

Memory loss, dementia, high blood pressure

Ever wondered how the brain works and how Alzheimer's affects it? Take the interactive brain tour and see. 

These issues are incredibly difficult to deal with: and to change our eating behaviours in our 50s and onward, is very difficult.

High blood pressure, obesity linked to memory loss in elderly

Metabolic syndrome is defined as having three or more of the following risk factors.

Risk factors

-- High blood pressure
-- Excess belly fat
-- High triglycerides (a fat in the blood)
-- High blood sugar
-- Low levels of high-density lipoprotein (HDL) cholesterol ("good" cholesterol)

Volunteers in Hospice Palliative Healthcare

 I am a volunteer. I am wondering how we ensure that family members and volunteers are represented at the conferences in healthcare?

I find I can no longer belong to these provincial associations. I cannot afford the fees, nor can I afford to attend conferences. Between conference fees, and accommodation, it is a large amount of money to pay for someone who devotes 30 hours a week to volunteering. 

If only volunteers with disposable income can attend such conferences, we are doing our clients a disservice. Only those with money are fighting for a voice. Only those with money are able to advocate. The conference sponsors don't understand those who are impoverished, and are unable to ensure their loved ones have adequate pain management, home care, and professional support.

It is well and good to offer reduced fees to volunteers if they volunteer at such conferences and AGMs ($375 at the last one I applied), but these fees, on top of volunteering, are not manageable by any but those with large pensions. 

I believe that we are doing our clients a disservice by hosting exorbitant conferences. I find that many volunteers are the backbone of hospice/palliative care work. Yet, much misinformation abounds, and many volunteers, while trained, do not have the information that is freely disseminated at these conferences.

I continue to research on my own. But I am not the norm. Many people in my position are volunteering for several different organizations. Sometimes we fight misinformation from our supervisors. This is what I have found in various conferences at which I have presented.

We depend so deeply on volunteers in this stream of healthcare. I am concerned that we are not reaching people, like us, who are indeed front line, 

unpaid workers.

USA For-profit Hospices

For-profit hospices select patients who require less care, study shows

For-profit hospices were also shown to be more likely to have patients without cancer diagnoses and more dementia patients, which require fewer visits from hospice nurses and social workers.

Sixty-three percent of hospices restricted admission on at least one criterion. A significant minority of hospices would not admit patients lacking a caregiver (26%). Patients unwilling to forgo hospitalization could not be admitted to 29% of hospices. Receipt of complex medical care, including TPN (38%), tube feedings (3%), transfusions (25%), radiotherapy (36%), and chemotherapy (48%), precluded admission. Larger program size was significantly associated with a lower likelihood of all admission practices except restricting the admission of patients receiving TPN or tube feedings. Hospice programs that were part of a hospice chain were less likely to restrict the admission of patients using TPN, radiotherapy, or chemotherapy than were freestanding programs.

Conclusion: Patients who are receiving complex palliative treatments could face barriers to hospice enrollment. Policy makers should consider the clinical capacity of hospice providers in efforts to improve access to palliative care and more closely incorporate palliation with other healthcare services.

Journal of the American Geriatrics Society

Volume 52, Issue 5, pages 725–730, May 2004

Nonprofit Hospice Advocacy Group Urges Prompt Action to Address "Cherry Picking" of Patients by For-profit Hospices - bit.ly/hkA0yo

Lorenz, K. A., Asch, S. M., Rosenfeld, K. E., Liu, H. and Ettner, S. L. (2004), Hospice Admission Practices: Where Does Hospice Fit in the Continuum of Care?. Journal of the American Geriatrics Society, 52: 725–730. doi: 10.1111/j.1532-5415.2004.52209.x

Canadian hospitals charging ALC patients

Hospital bed charge illegal: Lawyer

Feb 22, 2011 03:00 am

Advocacy Centre for the Elderly lawyer Jane Meadus says it's illegal for hospitals to charge long-term care patients $600 per day, even if they refuse to leave for an available bed in a long-term care home. Some hospitals in the Windsor region are demanding the extra payment to cope with a shortage of beds.

The maximum a hospital can charge a patient waiting for LTC in Canada, is $53.23 per day. Some send an invoice, but family members are told to ignore it by the Advocacy Centre.

To cope with the bed shortage, the area's three hospitals also instituted a first-available bed policy, requiring long-term care patients to accept whatever's offered at any long-term care facility or face a $600-per day fee to stay at the hospital.


Ontario hospitals employ the same practice, some charging up to $1,800 per day.

Read more: http://www.windsorstar.com/health/Hospital+charge+illegal+Lawyer/4306611/story.html#ixzz1EjC6lQej

Home care, ALC patients

A man, sent home from a Toronto hospital to his Muskoka home, doesn't get the Home Care he is promised. I was in the same position - advocating for my parents, when Mom was discharged in 2003.
However, the discharge nurse kept us waiting for a couple of hours in Toronto until they found someone to provide home care for mom.

Home care consisted of a nurse who would check in on frail seniors, checking Mom's surgery site, changing the dressings.

On the way home, Dad had a petite mal seizure. Then, in his kitchen he had a gros mal seizure, and his brain tumour was identified. He had surgery later that spring, and that is when I began searching for a job closer to my parents home.

This family,
 http://www.thestar.com/news/article/941699--home-care-promised-by-hospital-never-arrives

Home care promised by hospital never arrives - thestar.com

should not have been forced to accept that their father was able to manage at home, with a catheter and just having had surgery. Adult children and caregivers have been taken advantage of by those who want to send Alternate Level of Care (ALC) patients home.
Who do we blame for this? For they ought to be held accountable. CCAC Case Managers who are pressured? Hospital staff, similarly pressured to send patients home?

Many cannot manage at home. Many couples are fighting chronic health issues, and one cannot be in charge of the other as both belong in long-term care. Home Care in places, like remote locations, like Central Ontario, Muskoka, do not have the nurses necessary for the Home Care services they need.

'Sunnybrook halted the practice late last year after the Advocacy Centre for the Elderly warned it contravened the Health Insurance Act.'
You cannot be forced to go to a long-term care home without your consent unless you are not mentally capable, at which time your substitute decision-maker will make the decision for you. Fortunately, the threats of 'paying $1800 day' have proven to be wrong, immoral and illegal.

Daughter copes at home with two ailing parents

Home care promised by hospital never arrives

When Harold Chamberlain was discharged from hospital last May, his son was concerned the 81-year-old was still too fragile to go home. Harold’s cancerous bladder and prostate had just been removed and his urine now collected in a pouch through an opening in his abdomen.

Families are desperate for help!

When Sou Ping Tsoi fell and fractured her cheekbone, her family decided it was time to call for help. The 90-year-old suffers from dementia.

CCAC, who controls access to home care, could not come up with more support. With politicians promising 'AGING AT HOME' strategies, there simply isn't the budget for those who cannot afford to pay for it. Those with money purchase services from home care for-profit agencies. 

Adult day programs, for seniors with dementia, exist in the big cities, but not in the country. 

It is a community support group, one of 750 not-for-profit agencies across Ontario, that operate using volunteers, client co-payments and a shoestring budget to provide care for 750,000 seniors and their families.

Of Ontario’s $43.5 billion in health care spending last year, only 1 per cent, or $540 million, was spent on community support groups. Yet, for those who must work, it is the rural areas whose residents suffer from lack of home support. Leaving ill family members home alone is not an option.

A time to care

In Canada, with 618 long-term care homes, about 514 of these 'for-profit', our seniors are receiving better care than in many other countries. But is this good enough?

Many do not understand the difference between a retirement home and a LTC home.

Retirement homes, where those with money can purchase services, and are designated officially as  'tenants'. Those in long-term care (LTC) are protected by the Ministry of Health and LTC, and are residents with a Bill of Rights.
For those in long-term care many are subsidized in for-profit care, by government dollars.

'Nursing homes' are a term of the past. There aren't as many nurses as there used to be. PSWs do the heavy work, serving intimate needs (ADLs) of residents.

Christian Labour Association of Canada (CLAC) launched its "A Time to Care" campaign. 
In my opinion many already care. They are hampered by the system, however, and a for-profit model of healthcare in Canada.


You can find out more about the petition by visiting www.atimetocare.ca.

More time with residents needed: union

At a CLAC convention in 2008, a resolution was passed calling for the government to allocate a minimum of 3.5 hours of hands-on care per resident per day in nursing homes. The ministry has not responded to the request, and workers say they are becoming increasingly frustrated with the lack of time to care for seniors. In 2006, a CLAC survey found that in some cases, caregivers had as little as six minutes per resident to get seniors out of bed and ready for breakfast.

Select links of note

Before you look at my links, remember that you cannot believe all you read. Below is a guide.
When look for internet-based resources there are a number of things to look out for to ensure that the links are reliable, based in fact not fiction, myths or rumours, and that you can depend upon what you are reading. Unfortunately, some studies do not research enough of a population to come to conclusions. Other studies, many paid for by pharmaceuticals, do not report the truth. All studies do not include seniors over a certain age (65?) in their studies, or those with comorbidities. Most seniors have multiple issues and each patient is different. Journals do not publish studies that do not prove a hypothesis. There is a fight over journal space.

1. Check the source of the information. Often a webpage will have a button, "All About Us".  Universities are the most reputable, as well as  'Institute, Society, Association' and .net or .org. 

 e.g., Alzheimer Society, Cancer Society. Especially those who depend upon funding, with a responsible Board of Directors to manage the group.  I would avoid a union piece of research, as they have their own biases: their funding is based on membership, and position papers have hidden agendas for the members. CUPE, for example. Even CARP/AARP Canadian/American Associations for Retired Persons, are motivated by members who fit specific demographics, they do not legally represent all of us. They are lobby groups. Avoid About.com, as there is no way we can determine if the authors wrote the piece, or hold the credentials they purport to hold.

2. Check the credentials of the writer, if it is an individual. Ensure that writers are experienced professionals, who write from expertise. Look for M.Sc.N, in a nurse, as well as doctors credentials. Obviously, registered accredited professional groups, Canadian Medical Association, Nurses Associations, often publish excellent reference-based journals. A refereed journal is your guarantee that peers have reviewed the information, and several people have read it for content, accuracy, sources. (I used to do this for AACE.org)

3. Check for the date of publication. Anything older than ten years needs to be reviewed. We do more research in the world, and we ignore much of it, as well. 

4. Determine if the site is selling something. Many have a vested interest in particular products, and are selling something. You can spot these, in that the author recommends a particular product to solve the problem, a certain drug to make your disease go away! 

People, like myself, who have done research for a book, have had editors check for accuracy. Check a site for their qualifications and resume. I have an M.Ed., and this means that I know something specific about doing research. It also means that I have been trained to weed myths, and have discipline in my writing. Weeding facts from fiction, for civilians is a tricky prospect on the web. Many volunteers write blogs, but have only personal experiences to show for credentials. This is not to say that autobiographies are to be discounted, but carefully perused. The recent research on the Autism/innoculation scandal illustrates this. Actor/comedian Jenny McCarthy wrote a whole book on this topic.

5. Who is paying for the site? Is there someone checking sources? Nothing is free, and most have an agenda of some sort.

Some sites are simply reposting information, with nothing new to add. They may not have ensured that the information is credible. You can spot these by the Google Ads, intended to make them a buck to two.
On the other hand, some sites are 'self-help', and this can be dangerous. Many of us, as caregivers as well as care recipients, need professional help and should not avoid those who have been trained to help.

6. If the site has spelling mistakes, grammatical errors, avoid it! There is no excuse for this.

7. Check references for specific articles and issues. No one should be publishing without including support for the topic from credible sources. 

8. Ensure that content represents your healthcare system; Canadian healthcare is vastly different than USA, and variances exist from province-to-province. For example, 500+ out of 640 or so long-term care (LTC) homes in Ontario are for-profit. It means that you must watch how you use the information you find. Ontario LTC are governed by the Ministry of Health and LTC, and have reporting rules, and rules, requirements and legislation that supports the healthcare recipient.

• 10 Min. Geriatric Assessment
• 10 Warning Signs of Dementia - Alzheimer's Society
• About Loss, Change and Grief - Education, Information, Resources.

Advocacy Centre for the Elderly - Elder Abuse, Long-Term Care homes (you cannot be forced into one),

• Aging Care Chat Site - US, but great Chat room, and good articles.

Altzheimer Society of Canada
Bereaved Families of Ontario.net
Bereavement Self Help Resources -stories, autobiographies, and book excerpts by husband/wife volunteers in Victoria, B.C.
Canadian Institutes of Health Research

Caregiver Network
Careguide Source for Seniors

CCAC - home care support
Checklist for LTC home selection (.PDF)
Children and Grief Resources - RobertsPress.ca newsletter and PDF resource list on the site.
CLEO.net, Community Legal Education of Ontario, on Power of Attorney, Archived Webinars on Substitute Decision Making, Elder Abuse.
(The) Compassionate Friends of Canada - Ottawa Valley/Outaouais Chapter, Library
Concerned Friends

• Dementia Symptoms

Dying With Dignity.ca
Eldercare Home Health (Tor.)
End-of-Life Care Info

• Family Caregiving Site

Family Councils: required in LTC homes
Family Health Teams (Ont.)
Freedom of Information Protection of Privacy Act (FIPPA)
Health Care Consent Act
Health Services for South West Ontario End-of-Life Care
Hospice Association of Ontario - Publications: manuals, setting up a hospice

• Hospice Foundation of America Products - USA based, books, brochures, DVDs

LTC Performance Reports (Ont.)
LTC Standards

• Medline Plus (US Gov't based info)
• Minding Our Elders Blog (US)

Ministry of Health LTC
My Reading List: grief and grieving
Nat'l Initiative for Care Elderly
Ontario Community Support Association
Ontario 211.ca
Ontario Seniors Secretariat
Ontario Palliative Care.org
Ottawa Seniors

• Pain Terminology
• Personal Health Information Protection Act (PHIPA)
• Personal Support Workers
• Provincial Gov't link: seniors
• PSW Canada
• PSW Network of Ontario
• Public Health Agency of Canada
• Public Health-Seniors Division (Can.)
• Questions for your physician
• Regional Geriatric Program (uToronto) - great resources
• Seniors in Canada the stats
• Senior Drivers -safety tips
  
• Social Research on Seniors (Can.)
• When Someone You Care About Dies - a pricey book, but articles and book excerpts, by Dr. Bill Webster.

Virtual Hospice When Death is Near - Health Care Decisions, Considerations for a Home Death, Advance Care Planning, Wills, Planning a Funeral

Visiting a resident

What else can you do for a client or care recipient?
Visit, but phone first! You don't want to be there when they are receiving care. Keep your visit SHORT, e.g., 10 min. to half hour, to an hour, depending upon their situation.

Wash your hands before and after your visit.

Talk to them...

• Talk to them about the past
• Listen to them
• Talk to them about what you are doing
• Take in photos that show their impact on your life, e.g., things you did together
  
• Ask them about family photos
• Read to them from a magazine or articles they may be interested in
• Take in YOUR family photos to show them what they are up to
• Talk to them about what is going on in the world
• Tell them how much they mean to you
• Talk about how proud they are of their family
• Tell them how proud they family is of them
• Ask about their early life
• Ask about grandparents, extended family members

What else?

• Read them poetry, prayers, or psalms
• Bring in an order of service from a spiritual institution
  
• Sing them their favourite hymns (I take in my hymn book!)
• Offer to do small tasks- it means a lot. I changed a light bulb for a client!
• Take in meals for family members
• Bake cookies or muffins, with ingredients (e.g., nuts) listed
  
• Offer to provide respite care while a caregiver goes to the store or does an errand
• Answer questions truthfully
• Listen to their worries
• Rub their hands or feet (wash throughly first- ask if it is alright to touch them)
  
• Take photos of visitors so that family members know who has been there
• Leave a written note so that family knows who was there and/or brought what (Many are comforted by knowing, often residents cannot remember who visited.)
  
• Refrain from leaving plants that must be repotted or cared for in some way, or flowers that may cause allergic reactions (i.e., lilies)
  

Case Study #19 Elder Abuse or fraud?

Personal support worker steals from seniors' home resident
Court hears worker's credentials will be revoked

A personal support worker has lost her career for going on a $2,000 shopping spree using a credit card she stole from a resident at a North Bay long-term care home where she was working.

Court heard Rose was caught twice on security surveillance at two of the stores.

Rose has no criminal record and claimed she was in an abusive relationship at the time, but she didn't offer any reason for what she did.


She's currently living in Courtright, near Sarnia, is going back to school and expects to have her personal support worker credentials revoked.

Dementia and reality

Antipsychotics for Dementia Drops After FDA Warning (CME/CE)

A decrease in prescriptions for atypical antipsychotics accelerated after the FDA issued a black box warning about the risks of using the drugs to soothe behavioral problems in dementia patients, according to an analysis of VA system prescribing... full story

• The Seven Warning Signs of Alzheimer’s Disease
• Learn the 10 Warning Signs of Alzheimer’s
• 10 Signs of Alzheimer’s
• 'How to Handle a Loved With Dementia Who Lies.'
• Puzzles for Alzheimer's patients.

Antipsychotics for Dementia Drops After FDA Warning (CME/CE)

A decrease in prescriptions for atypical antipsychotics accelerated after the FDA issued a black box warning about the risks of using the drugs to soothe behavioral problems in dementia patients, according to an analysis of VA system prescribing... full story

Everyday EMS geriatric assessment tips for any geriatric patient:

• Introduce yourself
• Explain your actions before and as you do them
• Ask a single question at a time
• Wait for the patient to think through their answer before interrupting with a new question or re-asking the same question
• Listen to the patient’s answer
• Only raise your voice volume if the patient has a hearing impairment

Also, body language is important. Dementia clients don't always recognize friends and family, let alone recognizing that you are a stranger.

I would suggest being as unthreatening as possible. Smiling. Nodding. Being positive.
Sometimes a touch on the arm is important, others cannot bear to be touched!
Telling them everything will be alright, and making sure this appears in your visage. They know if you are tired, frustrated, impatient, and you need to let them think they are the most important person in the world, even if they cannot understand your words, they understand your demeanour.
 Asking them questions that are simple with let you know if, firstly, they hear you, and secondly, if they are processing.
My clients tend not to want to admit they have pain. (British stiff upper lip!)
Some cannot process the language, either expressive (I have pain in my leg!) or receptive, and do not process complex, abstract language. Pain is not always perceived, and can appear in the form of agitation, picking at their clothes, and facial features.

Pet peeves of the ER

From my friend, the emergency room charge nurse: “Epiphany”
~~~~~
Went to work the other day, found my assignment was in the treatment rooms, walked in and found I had five admitted patients: two fractured hips, a stabilized DKA (diabetic), and a couple of  FTCs/FTTs². All but one were over 80 and more or less unable to walk. 


Then I had an epiphany:  Acme Regional Health Centre doesn’t actually provide emergency services in the space they call the Emergency Department.  What we provide is Outpatient Day Surgery, Home Care Evaluation and Ongoing Treatment, a medical/surgical ward, ICU/CCU services, Pre-op Clinic, Fracture Clinic, Ambulatory Care, Office space for Consultants, Psychiatric counselling and Inpatient Services, and a very special place for GPs (and Telehealth Ontario and nursing homes³) to dump patients.

²Failure to Cope/Failure to Thrive: a sort of catchall diagnosis, describing frail elderly patients, who can’t go home, usually because they (or their caregivers) have become physically or mentally incapable.
³One of my most petest of pet peeves are nursing homes who call EMS for their obviously failing patients despite utterly clear, written advance directives that state “No Patient Transfer to Hospital. Comfort measures only to be provided at nursing home.”  And lo! They come anyway.

Yes, blame the physicians who seem unable to meet and treat patients in their offices.