Resolving Conflicts Over End-Of-Life Care: Mayo Clinic Experts Offer Tips

It’s one of the toughest questions patients and their loved ones can discuss with physicians: When is further medical treatment futile? The conversation can become even more difficult if patients or their families disagree with health care providers’ recommendations on end-of-life care. Early, clear communication between patients and their care teams, choosing objective surrogates to represent patients and involving third parties such as ethics committees can help avoid or resolve conflicts, Mayo Clinic experts Christopher Burkle, M.D., J.D., and Jeffre Benson, M.D., write in the November issue of Mayo Clinic Proceedings.

“Health care professionals in the United States have struggled with the importance of maintaining patient autonomy while attempting to practice under the guidance of treatments based on beneficial care,” Dr. Burkle, the study’s lead author, says.

Tips from Drs. Burkle and Benson to effectively discuss end-of-life care include:

Clear communication: Early and clear communication between health care providers and patients or their surrogates is the best way to avoid disagreement over whether medical care should continue. Recent studies show that more than 95 percent of such disputes are resolved through mediated meetings involving physicians and patients/surrogates.

Choose objective surrogates if patients cannot represent themselves: The surrogate’s role is to stand in the shoes of the patient and suppress his or her own judgment in favor of what the patient would have done. However, it is important to acknowledge that medical surrogates often struggle to balance their wishes for the patient with the patient’s own wishes. Studies have found that not only do many surrogates fail to accurately predict a patient’s treatment wishes, but when asked to resolve disputes, they are more likely to show bias by overestimating the patient’s desire for continued treatment.

Involve third parties when necessary: When health care providers and patients or their advocates cannot agree on end-of-life care, involving a third party becomes necessary. Beginning in 1992, the Joint Commission, the largest hospital accreditation organization in the United States, required hospitals to establish procedures for considering ethical issues. Hospital-based ethics committees have been the most common response to this requirement.

“End-of-life care will continue to be an ongoing discussion within the medical community; however, it is important that medical care providers and patients/medical surrogates continue to dialogue,” Dr. Burkle says. “Only then can experts continue to offer insight into the effectiveness of systems used in countries that have moved to a more patient-centrist approach to end-of-life care treatment choices.”

Source: Mayo Clinic, a nonprofit worldwide leader in medical care, research and education for people from all walks of life. For more information, visit

Dictionary of Eldercare Terminology: 95-Year-Old Attorney Releases Updated Edition of His Classic Compendium

Anyone in the field of aging knows that it has its own unique language.

Understanding all the shifting terms, however, can be a challenge.

Walter Feldesman, a prominent New York attorney for more than 65 years, recognized this need in 1997, when he published the first edition of his Dictionary of Eldercare Terminology .

It remains the first and only dictionary defining eldercare words and terms.

At 95, Feldesman recently released the third edition of the dictionary and is making it available online through the website of the National Council on Aging (NCOA).

“Walter is an incredible example of someone who continues to contribute to society well past the traditional retirement age,” says NCOA President Jim Firman. “That’s why we gave him the first NCOA Exemplar of Vital Aging Award in 2009. Now, we’re proud to offer his newly updated dictionary as a great online resource for anyone interested in aging.”

Feldesman entered the world of elder law informally in 1990 when his bedridden mother-in-law asked him who was paying for all of her care. He did not have an answer—so he started researching.

The result was a comprehensive dictionary that includes overviews of major eldercare fields, including home care, long-term care insurance, Medicaid, Medicare, Medicare supplemental insurance, and Social Security. The new, third edition includes a wide mix of gerontological terms, as well as financial, estate planning, and legal terms related to eldercare.

The first two editions were quoted, cited, and accredited by many sources, including Medicare’s consumer handbook Medicare and You and the official Medicare website,

Feldesman has served on numerous boards, including NCOA’s Leadership Council. He enjoyed a long and distinguished career as a corporate attorney, director of public companies, hospital and college trustee, philanthropist, and author.

Source: The National Council on Aging (, a nonprofit service and advocacy organization headquartered in Washington, DC. NCOA works with thousands of organizations across the country to help seniors find jobs and benefits, improve their health, live independently, and remain active in their communities.

Do Driver’s Tests Provide an Accurate Picture of a Senior’s Driving Ability?

The issue of seniors and driving is coming more to the forefront with the aging of the baby boomers. Families worry whether their older loved ones are safe behind the wheel—and when a senior is diagnosed with Alzheimer’s or other memory loss, family are especially concerned. Much research is underway to understand the decline in driving ability as people age. This is not a simple subject.

Researchers at the Rhode Island Hospital’s Alzheimer’s and Memory Disorders Center wanted to find out whether standardized road tests can determine whether older adults should continue to drive. The researchers installed cameras in the cars of 103 older adults, some of whom had mild cognitive impairment. They wanted to observe the drivers “in their natural state—in their own vehicles going about their daily routines.” They found that some cases, seniors were actually better drivers than their driver’s test would suggest.

Lead author Jennifer Davis, PhD, reports, “Many older people don’t like to drive far from their homes; they like to stay in their comfort zone. They don’t drive many miles, and they often avoid driving at night. Taking them out of that comfort zone and placing them in an environment of formal test-taking—one with carries with it potentially life-altering consequences (loss of their driver’s license)—may lead to significant anxiety, which in itself could impair their driving abilities.”

The study, which was published in the Journal of the American Geriatrics Society [optional link to:], showed that people with cognitive impairment made more errors both on the driving test and in day-to-day driving. However, the errors made during normal driving were less serious. The researchers say this study suggests that mild cognitive impairment shouldn’t result in an automatic revocation of a person’s driver’s license. Said Davis, “Rather, it should emphasize the importance of monitoring an older person’s driving so that he or she can safely maintain their mobility and independence for as long as possible.” She added, “It’s natural to worry about older adults behind the wheel, even more so if they appear to have memory or cognitive issues, or have been formally diagnosed as such. But many of the people in our study drove safely.”

Copyright © AgeWise, 2013 reporting on study from Rhode Island Hospital’s Alzheimer’s and Memory Disorders Center

Is Assisted Living the Right Choice for My Loved One?

Checklist: Is Assisted Living the Right Choice for My Loved One?

Approximately one million older Americans are living in assisted living facilities and communities today. Residents choose assisted living because it offers the combination of a private, home-like residence—often a studio or one-bedroom apartment—as well as support to meet personal care and some health care needs. According to the National Center for Assisted Living, the typical assisted living resident is an 86-year-old woman who is mobile but needs help with a few of the activities of daily living, such as bathing, dressing, grooming, using the bathroom and transferring from bed to chair. This assistance is provided in addition to the basic services that typically go with retirement housing, such as housekeeping, laundry, transportation and meal service.

Assisted living is an important middle option for seniors who are concerned about their present or future ability to live independently, but who are also not in need of the skilled nursing care provided at a nursing home.

Families should be alert for signs that an older relative is no longer safe and healthy living at home. Is your loved one ready for assisted living? Here are some questions to ask:

  • My loved one’s home is as clean, tidy and in good repair as ever.   YES   NO
  • My loved one eats well and is able to prepare nutritious meals.   YES   NO
  • My loved one’s home is convenient and safe for a person with his/her mobility level.   YES   NO
  • My loved one has plenty of opportunities for physical activity and socializing with others.   YES   NO
  • My loved one is able to manage medications and take them correctly.   YES   NO
  • My loved one is able to manage doctor’s appointments and other healthcare tasks.   YES   NO
  • My loved one drives, or has access to good alternate transportation.   YES   NO
  • Our family is confident that our loved one is well-off living at home.   YES   NO
  • My loved one could get help right away in the event of a fall or other emergency.   YES   NO

If you answered “no” to several of these questions, learn more about the ways the supportive environment of an assisted living community promotes independence, health and safety for senior residents. As you select a facility, investigate the services offered to be sure they are a good fit for your loved one’s needs. Remember that services vary widely. Some facilities provide only limited help with personal care, health care needs and medication management. Others include a broad range of health care services. More facilities today offer specialized care for residents who have Alzheimer’s disease or other dementia. Make sure you understand the maximum level of care available in each facility, and what procedures would be followed if the time were to come when your loved one’s needs were greater than could be met at the facility.

Copyright © AgeWise, 2013

Help Older Loved Ones Beat the Heat

As we grow older, our bodies are less efficient at regulating temperature. Especially at risk are people with health problems such as cardiovascular disease, kidney or lung problems, unhealthy body weight, or those who take certain medications that interrupt the body’s ability to protect itself by perspiring.

Here are some tips for staying safe and comfortable during periods of higher heat:

  • Drink plenty of fluids, even if you don’t feel thirsty. On hot days, the body loses moisture more rapidly, so keep hydrated with water or fruit juice. Avoid caffeine and alcohol, which cause the body to lose more fluid.
  • Keep your home cool by letting in cool air during the early morning and evening hours. If you do not have air conditioning, create cross-ventilation by opening windows on two sides of the building. Use fans to circulate cooler air. Close curtains and blinds during the warmest hours.
  • Take a break at an air conditioned location during the hottest part of the day. Go to the mall, a movie, the library.
  • Dress for the weather. Wear short-sleeve, loose-fitting garments. Natural fibers and light colors are cooler than synthetic materials and dark colors. And don’t forget your sun hat!
  • Exercise and work outside only during the cooler hours of the day, and pace your activities.
  • Wear sunblock when you are outdoors. Sunburn reduces the body’s ability to regulate heat.
  • Be aware of the symptoms of heat exhaustion:  dizziness, weakness, nausea and perspiration.

If a loved one shows signs of heat-related illness, seek medical attention right away.

Copyright © AgeWise, 2013

Growing Good Garden Habits

Fresh air and fresh veggies! Delicious garden treats to nourish our bodies, and perhaps a bouquet of flowers to nourish the spirit! Experts in healthy aging have long known that gardening and yard work provide good exercise and a great mood boost as well. Seniors who garden also consume on average more vegetables and fruit in their diets.

Experts from Chicago’s Loyola University Health System remind us that just as with any form of exercise, it’s important to practice safe body mechanics while planting, pruning, weeding and raking.

“Working in your garden is a great way to exercise. Whether pulling weeds or spreading mulch, you are using major muscles all over your body and you’re sure to break a sweat,” said Kara Smith, special programs coordinator for the Loyola University Health System’s Center for Fitness.

The Center offers these gardening exercise tips:

  1. Don’t make it a marathon; keep a regular gardening routine. Schedule at least 30-60 minutes of yard work two to three times per week.
  2. Warm up your body by taking a brisk walk around the yard.
  3. When raking, change the movement and alternate the sides of your body to ensure you are working them equally.
  4. When digging, switch hands often so you are using both arms. This helps prevent muscle imbalances, repetitive motion injuries and blisters.

As with any good exercise program, be sure to cool down with stretches to help alleviate post-yardwork aches and pains:

  1. Hamstring stretch: Stand with feet shoulder width apart and slide one foot in front of the other. Gently sit your hips back and support your upper body on the leg you did not move. Hold for 15-30 seconds and switch legs.
  2. Lower back stretch: Stand with feet shoulder width apart. Bend knees slightly and bend at the hips. Support your upper body with your hands on your thighs. Gently round your back so it arches like a cat.
  3. Chest opening: Stand tall and relax your shoulders down your back. Reach hands back with thumbs pointing up. If this is uncomfortable, grasp hands behind back and lift your chest.
  4. Upper-back stretch: Stand with your feet shoulder width apart. Bring palms together and reach arms away from body. Feel the stretch between your shoulder blades.

To ensure a healthful experience, here are a few more tips to keep in mind while working in the yard:

  1. Wear sunscreen, long-sleeved shirts, pants and a wide-brimmed hat to limit sun exposure to your skin.
  2. Drink plenty of water.
  3. Bend at your knees and keep your back straight when lifting heavy items.
  4. Use a kneeling cushion to support your knees.
  5. Use gloves to help prevent blisters on your hands.
  6. As with any exercise program, be sure to check with your physician before you start and listen to your body for signs of stress and fatigue.

Based in the western suburbs of Chicago, Loyola University Health System is a quaternary care system including the main medical center campus, Gottlieb Memorial Hospital and 28 primary and specialty care facilities in Cook, Will and DuPage counties.

For More Information

The Centers for Disease Control and Prevention (CDC) offer more health and safety suggestions for gardeners, including tips for people with disabilities.

Seniors, Families Can Help Prevent a Return Trip to the Hospital

The Agency for Healthcare Research and Quality (AHRQ) offers information to help patients safely transition after hospital care.

According to the U.S. government, one-fifth of patients covered by Medicare return to the hospital within 30 days. The AHRQ tells us that these readmissions cost about $17 billion each year. Readmissions can also slow down a patient’s recovery.

As of October, Medicare’s reimbursement rate will reflect the ability of hospitals to prevent unnecessary rehospitalizations. Hospitals with high readmission rates for heart attack, pneumonia and heart failure are now paid less than those with fewer readmissions.

Older patients are at higher risk of returning to the hospital because they are more likely to be frail and have chronic conditions. Other reasons are more avoidable: Older patients may need help with transportation to follow-up appointments. And they may need extra support when leaving the hospital for home, or when transitioning to a skilled nursing facility.

AHRQ has developed a new guide for patients: Taking Care of Myself: A Guide for When I Leave the Hospital, an easy-to-understand plan for what to do when you or a loved one leaves the hospital. The guide can be used by both hospital staff and patients during the discharge process, and provides a way for patients to track their medication schedules, upcoming medical appointments, and important phone numbers. You can download a free copy of the guide on the AHRQ website or order a copy to be sent to your home.

The AHRQ’s Dr. Carolyn Clancy says, “Helping patients improve their health once they leave the hospital is not easy or automatic. The new effort by hospitals to prevent readmissions is a big step in the right direction. You can help by learning what you should do when you or your loved ones are in the hospital.”

© IlluminAge AgeWise 2012

Everyone in the Pool! Water Workouts Compare Favorably to Dry Land Exercise

Canadian researchers find the same aerobic benefits to water exercise, with less wear and tear

Biking, running and walking are all good for you. But the strain can be tough if you’re overweight, have arthritis or suffer from other joint problems or injuries. What to do? Just add water.

A study presented at this year’s Canadian Cardiovascular Congress found that people who used an immersible ergocycle—basically an exercise bike in a pool—had just about the equivalent workout to using a typical stationary bike.

“If you can’t train on land, you can train in the water and have the same benefits in terms of improving aerobic fitness,” says Dr. Martin Juneau, director of prevention at the Montreal Heart Institute.

Juneau says people might assume that exercising in the water can’t be as valuable as exercising on land. Because of the resistance of the water when you move, it doesn’t seem like you can work as hard. This new study indicates otherwise.

Healthy participants did exercise tests on both the land and water cycling machines (with water up to chest level). They increased their intensity minute by minute until exhaustion.

Dr. Juneau reports that the maximal oxygen consumption – which tells you whether it was a good workout – was almost the same using both types of cycles.

His study colleague Dr. Mathieu Gayda, a clinical exercise physiologist at the Montreal Heart Institute, adds, “Exercise during water immersion may be even more efficient from a cardiorespiratory standpoint.”

Another finding, says Dr. Juneau, is that the heart rate of the participants was a little lower in the water. He says, “You pump more blood for each beat, so you don’t need as many heartbeats, because the pressure of the water on your legs and lower body makes the blood return more effectively to the heart. That’s interesting data that hasn’t been studied thoroughly before.”

Considering the number of people who can find it difficult to exercise on land, the water option is promising, says Dr. Juneau. He says that swimming may be the best exercise of all but not everyone can swim. With the workout benefits, the low stress of moving in the water and the reduced chance of injury, “this is a great alternative,” he says.

“Inactive people who become physically active can reduce their risk of heart attack risk by 35 to 55 per cent, plus lower their chance of developing several other conditions, cut stress levels and increase energy,” says Heart and Stroke Foundation spokesperson Dr. Beth Abramson. “Even if you have difficulty moving more, there are always solutions, as this study shows. This is encouraging given the aging population – it’s never too late or too difficult to make a lifestyle change.”

The Heart and Stroke Foundation (, a volunteer-based health charity, leads in eliminating heart disease and stroke and reducing their impact through the advancement of research and its application, the promotion of healthy living and advocacy.

Weight Loss Found to Improve Incontinence

Urinary incontinence is a problem that plagues over 13 million American women today. Left untreated, incontinence usually worsens, and can be the first step in a debilitating withdrawal from life. Common treatments include bladder training, pelvic muscle exercises, medication, avoiding food irritants, and in some cases, surgery. Incontinence may be caused by weakening of the muscles which control bladder outflow, disorders of the nervous system or obstruction to the bladder. New studies show that being overweight also contributes to incontinence—and losing weight may help the problem.

Researchers from the University of California, San Francisco and University of Alabama at Birmingham worked with volunteer participants in the Program to Reduce Incontinence by Diet and Exercise (PRIDE). The study subjects were all overweight or obese, and experienced up to 10 episodes of incontinence per week. They went on a six-month program of diet, exercise and behavior modification. At the end of the six month period, participants had lost on average 17 pounds, and had cut their incontinence episodes in half.

Study author Dr. Leslee Subak said that weight loss should be a first-line treatment for incontinence when patients are significantly overweight. Co-author Dr. Frank Franklin said, “Earlier research has shown that behavioral weight loss programs have many benefits, including decreasing blood pressure and helping to fight off diabetes. Here we’ve shown that weight loss has measurable impact on reduced incontinence.”

Copyright © AgeWise, 2013 reporting on University of Alabama Birmingham news release

Most Americans Will Need Long-Term Care, But Few Plan for It

The Associated Press-NORC Center for Public Affairs Research recently announced the publication and availability of a major survey that provides a new baseline of understanding about what Americans 40 years or older believe about their need for long-term care services, what such care would cost, and how such issues fit into their concerns about growing older. The survey reveals that while there is widespread concern among this population about the need for long-term care, little is being done to plan for it.

“It is estimated that 70 percent of Americans who reach the age of 65 will need some form of long-term care for an average of three years each,” said Trevor Tompson, director of the AP-NORC Center. “The rapidly aging population brings with it important social and public policy questions about preparing for and providing quality long-term care. This survey establishes what Americans 40 and over understand about the need for long-term care and reveals troubling facts about what is being done to prepare for it.”

Statistics about the aging of America are compelling. Population projections for 2030 show that older Americans—the classic Baby Boom generation—will make up 19 percent of the population, up from 12 percent today and totaling 72 million people. To deepen understanding and to provide accurate information about long-term care issues, the AP-NORC Center carried out its survey by conducting 1,019 interviews with a nationally representative sample of adults who are at least 40 years old.

Critical issues revealed by the survey include:

  • There are widespread misperceptions of the cost of long-term care, with most underestimating the cost of nursing home care and overestimating what Medicare will cover.
  • Nearly one-third of older Americans would rather not think about getting older at all, and when prompted, a majority worry about losing their independence. Significant majorities prioritize factors that promote independence as they age such as homes with no stairs; and living close to family members, health care services, and stores.
  • While few are setting aside funds to deal with long-term care issues, there is broad concern about key issues of aging such as loss of mental ability, being a burden to family, leaving unpaid debts, and being alone without family or friends.
  • Though Americans 40 years or older are concerned about issues of aging, only 41 percent have taken the step of talking about long term care preferences with their families, and only 35 percent have set aside money to pay for long term care needs.
  • There is faith in family, with 68 percent of Americans age 40 or older feeling they can rely on their family a great deal or quite a bit in time of need, with another 15 percent saying they can rely on their family for at least a moderate level of support.
  • There is majority support for public policy options for financing long-term care, with more than 75 percent in favor of tax incentives to encourage saving for long-term care expenses and 51 percent in favor of a government administered plan.

The Associated Press-NORC Center for Public Affairs Research survey of perceptions, experiences, and attitudes of Americans about long-term care was conducted from February 21 through March 27, 2013 with 1,019 adults age 40 or older. AP and NORC staff collaborated on all aspects of the study, with input from NORC’s Health Care Department and AP’s subject matter experts. Additional information, including the Associated Press stories and the survey’s complete topline findings, can be found on the AP-NORC Center’s website ( Funding for the survey was provided by The SCAN Foundation (

Source: Associated Press-NORC Center (