Wrightsville Beach Magazine Aging Dinner

BY Bill Walsh & Pat Bradford

Andy Olsen is an attorney who specializes in estate planning and elder law but his insights into using money could easily open a second career as an investment counselor.

A baby boomer himself Olsen says that finding out what boomers want what they need and where they are headed then investing in the companies that supply those things is an investment strategy that is hard to fault. Such is the power of boomer numbers and the strength of the generation born in the late 1940s ’50s and early ’60s.

Boomers the 11 experts that we recently gathered for a round-table discussion of aging issues agreed are going to change the meaning of growing old just as they have changed the parameters of every other life stage through which they have passed. That’s a good thing; there is a lot that needs changing.

Pat Bradford: Our staff started having interest in aging because we had people in the office who had need of this type of knowledge and they didn’t know where to go. And we are finding that’s pretty much how everyone does it: They wait until there is a crisis — someone injured or a family member who needs care. With this aging series we’re trying to share with our readers what their options are.

Eleanor Krassen Covan: The issue that I raise is that there are many people in nursing homes whose needs are more social than medical but the staffing pattern in the health-care facilities is more medical than social. That’s the standard pattern.
There are not enough social workers and recreational therapists because the medical model of health care that we have accepted and endorsed in this society does not fund social workers.

Sandy McNeill: There are national and state standards. We would like to have one-on-one care — everybody would like to have one-on-one care. When you talk about it being cost efficient that sounds like a cold term but there is a reality about how much money there is to spend on anything.

Eleanor Krassen Covan: Our needs are social spiritual. They are that way when we are 20 they are that way when we are 30 they are that way when we are 57 as I am and I believe they are even that way when we are hooked up to IVs and are tube fed and on ventilators. But our system doesn’t fund that. It’s a matter of tax money but it’s also a matter of compassion and caring. We are more compassionate to our pets than we are to older people. We’ll pay for a ventilator and we’ll pay for tube feeding but we won’t pay for anyone to hold hands.

Betty Ann Sanders Sourwine: I agree with that but I also feel that one of the major problems that we’re facing in health care today… is the ratio of caregivers to patients within institutions.

Thomas R. Milam: I talked to a number of people before we came in to dinner tonight and I think there is no shortage of commitment to serving folks. I think the idea of providing care for the caregiver is important as well. But I draw a blank when I think of how to fund such things outside of private initiatives and donations. Where do you see funding streams coming from in terms of allowing respite care?

Betty Ann Sanders Sourwine: There are none — not in our category of care. There is no funding. Once in a while there are some grants available but of course the grant system literally dried up as everybody around this table knows and it’s tough it’s very tough. The funding that we have primarily comes from my own bank account. It’s just something that I am passionate about and so is my daughter.

Karen Gottovi: We were just able to get a small increase $5 a day in the daily rate in the last legislative session and there is ongoing work in trying to help adult daycare centers develop business plans so that they understand the difference that say a veteran can receive through his or her medical health system or somebody with developmental disabilities who may have another funding stream that could also help to fund the program.
    It’s very difficult but [daycare] is a totally essential service for people who are trying to keep their parents at home but who need to go to work. You cannot leave that demented or Alzheimer’s person at home alone.
    This is one of those issues that we will be faced with more and more as the society ages. About half of people over 85 will have some sort of dementia.

Annette Crumpton: This is not about the funding stream that you mentioned but just about the importance of a facility like Betty Ann’s with adult daycare [to help] caregivers. We have a very small family-caregiver grant that is able to provide respite care … to allow the caregiver to get out. It allows them to take their loved one either to an adult daycare center or to bring in-home health agents and that it is just so important.
    The importance of having a resource out there for caregivers is going to become more and more important as the baby boomers begin to grow and our population ages.

Kavita Persaud: It’s come to my understanding at this point that all the research is being done on things that can save money. But there are certain types of quality care that are not cost effective; that doesn’t mean that they’re not worthwhile. I wish that more research would be done on the quality outcomes not just cost effectiveness.

Eleanor Krassen Covan: I agree with you because it’s obviously most cost effective to herd people as it’s most cost effective to herd animals.

Sandy McNeill: I think from the standpoint of some of the social-care issues there is an expectation on our part … that family and friends are a part of the team that gives some of those additional care requirements for the patient. You bring a professionally trained person in to do the nursing or medical care and you hope that you can get buy-in from the family and friends to help on some of the other issues. We do have a social worker who helps supervise activities but what we try to tell the families is that there’s a buying-in on their part to help us look after the patient. It’s a team effort to provide the care and we want their input and regular attendance there to help us.

Betty Ann Sanders Sourwine: It’s a great idea but it doesn’t always happen.

Pat Bradford: My church has just created a ministry called the Crossover Ministry. I’m on that team but I haven’t yet served. The idea is to go and sit with people in the final stage of life whose family resources are short. Maybe there is an outlet for volunteers through churches to volunteer more — to be that respite effort Sandy is talking about.

Thomas R. Milam: Some may call that a faith-based initiative but I think in terms of how some of these issues are going to be funded. The things that private people are doing are going to be more and more important for the baby boomers who are living with much greater wealth than their parents and that gets into the allocation of resources.

Betty Ann Sanders Sourwine: Good point.

Thomas R. Milam: More money is available but I find a sense of “somebody else is responsible for this. I did not create this Alzheimer’s I did not create this need for medical/mental-health care. This happened to a mother and father it’s not my responsibility. You the government the nursing home need to take care of them.”
There is a sense of divorcing ourselves from responsibilities and I think that is a particularly modern American phenomenon — to divorce ourselves from providing care for people as they get older.

Eleanor Krassen Covan: I have studied the other side of that. You said that you thought it might be peculiarly American for adult children to be rejecting the notion of responsibility for parents. In my research I have studied older adults who rejected the notion of their children serving as their caregivers. Many of the retirees who are moving to Wilmington fit that profile as would the people who live in the retirement communities who for the most part have planned their retirement and it’s not part of their plan to move back in with their children.
    They would much rather be cared for by a business something that they could pay for or get insurance for rather than have their children do this. I’m one of them. My father is 91years old my mother is 89 my stepmother is 90 and all of them are adamant about not wanting me to be their caregiver despite the fact that I built a house with a wing on it that’s handicapped equipped for the day when they’ll need it.

Thomas R. Milam: It’s very sad because a lot of these folks have rich lives rich stories. Their bodies may have failed them their minds may have failed them but they are as equally valuable now as they were the day they were born and equally deserving of respect. But I think too many people look to government and social services.

Eleanor Krassen Covan: We have moved so quickly at this dinner table on aging issues facing the frailest of the frail who are always going to be a very small percentage of those who really exist. Most older people are okay. And those who aren’t need the most help whether it’s provided by churches or whether it’s provided by businesses or whether it’s provided in some other way.
    Most of us are aging like Betty Ann — thriving and still giving back so much to the community until the very end of life. I wonder how many of us are anticipating being cared for by our kids.

Thomas R. Milam: It scares me it really does. It scares me for my children too in terms of what is going to be left. I don’t look to the government to provide. Being 40 now I really don’t count on there being any Social Security retirement or anything like that. I feel like I have to take care of myself.

Eleanor Krassen Covan: Particularly in Brunswick County and Pender County the influx is of older adults who are not coming with their adult children and they’re coming to make their last wonderful decision for where they’re going to live in their golden years. They’re not looking ahead at their tarnished years when they are no longer able to polish the gold and silver on their own. And they don’t have a family to do it and we still have a system that is expecting family to do it. When they reach 75 a third of all baby boomers are not going to have children to care for them because they didn’t have any or they had one who is not able to care for himself or herself let alone the parents.
    It’s a real difficult dilemma and it makes one think of other cultures and what people have done historically. We all want to be taken care of. There are lots of people who are in that baby-boomer group who have decided not to have any children at all or who have one child. Whatever money they have they might be willing to spend [on care] but maybe they would rather give it to some charity to care for people who have much more life to live.

Kavita Persaud: I think that there is a large group of elderly people who are very ready to die. They are not afraid of dying. They are afraid of disability of poverty of dependence. Dependence on other people is the thing I think they fear the most. That is what threatens their dignity and if we had an assisted suicide or euthanasia allowance in our community I think you would be shocked how many people would utilize it. And it’s very interesting that when you talk to the patients themselves they tell you these things and if they never talk to their families about what their values are then the families are the ones trying to keep them alive during extended illness.

Eleanor Krassen Covan: I raise difficult questions. Sometimes people altruistically say I don’t want to live that long I don’t want to be cared for that way and we don’t allow that either. We don’t allow it and it’s even difficult to talk about assisted suicide and euthanasia for humans. The more of us baby boomers there are those issues are going to get on the table for the wrong reason because we’re wondering how to pay for it rather than the right reason which is to manage it. If I were very very ill and at the end of my life and I had resources … I think I would rather leave my funds to some charity so that children could be helped.

Kavita Persaud: In the geriatric literature there is an article called “The Daughter-from-California Syndrome” and if you live in California I think you call it “The Daughter-from-New York Syndrome.” It’s really about the families that are trying to do intensive curative care at the end of life blame everybody else and complain. They’re the ones at the nursing-home desk complaining that mama’s peas are cold and they’re doing it out of guilt. They’re on the scene now at this final moment but they feel guilty because they were not involved up to that point. The families that are there every day they don’t have those types of issues.

Sandy McNeill: That’s the biggest problem group that we have the group you speak about. Hopefully people will begin to make choices in their wills about what they want done and not done.

Jane Jones: Choices and independence — those are very important to me. It’s important to my mother who is 84. She does not want to be cared for by her children. And folks want to retain dignity and that sense of independence that you have when you become an adult and that’s where a lot of the programs that are available in the community can meet some of those needs. We have to remember that older adults don’t always remain in long-term care don’t always remain at home; they transition from home to long-term care. It may be rehab aftera hip replacement then they transition back home. Five percent of your [elder] population is in nursing homes. You’ve got another 95percent who are living in the community successfully with the support systems. But we who are in the aging field have got to continue to advocate for those support systems because that’s what keeps people healthy and independent and they reduce social isolation.

Karen Gottovi: And those are cost effective?

Jane Jones: Very cost effective.

Eleanor Krassen Covan: But anywhere from eight to 10percent of adults in this county do not drive and there isn’t adequate public transportation for that population at all. I’m talking about those who can’t get somebody to take them for their medicine and within that group there is a smaller group who couldn’t afford it even if they could get somebody. But we have people who can afford it who can’t get to the store to get their medication or can’t get to the store sometimes to get food or clothing or to the doctor.

Betty Ann Sanders Sourwine: If we didn’t provide free transportation … I don’t know what would happen. The caregiver the family member sometimes they don’t even have an automobile.

Kavita Persaud: Let me tell you that since Medicare Part D came all of those companies sent a letter saying if you are a Medicare patient eligible for Part D whether or not you signed up or not they would no longer give you patient assistance. So basically the drug companies are out of the business of providing any patient assistance to Medicare.

Jane Jones: And they’re not providing samples to the physicians either.

Kavita Persaud: No samples have gone way down since Medicare.

Karen Gottovi: And they are on TV every night for what you should ask your doctor for.

Jane Jones: New Hanover County had a prescription-drug program that we provided through a grant from the Health and Wellness Trust Fund for three years to assist seniors who couldn’t afford their medications getting those medications from the pharmaceutical companies. Medicare Part D came along and senior care disappeared and we have had to help transition those people into Part D. Those folks who were getting medications at no cost suddenly could not afford their medications because of the Part D premium and the co-pay. Medications are still a big issue.

Annette Crumpton: Not only does it disturb me that the cost is continuing to increase but the complexities of this Medicare Part D prescription-drug plan and the difficulty of making a decision on which plan you think is going to work best for you which plan is going to cover your particular prescription drugs that you will need….

Kavita Persaud: And the doctors’ offices are getting hundreds of pre-authorizations to complete. I’m actually thinking that as of January 2007 if your prescription doesn’t go through Part D immediately that means it’s not covered and we’re not going to complete any paperwork. I can’t afford to pay a staff person just to do Medicare Part D paperwork.

Betty Ann Sanders Sourwine: You’re the legal eagle here tonight Andy. What kind of questions do you get? What’s the age group? Can they afford to come to you for help?

Andy Olsen: Well I get two kinds of folks mostly in regard to senior issues. One is the children of seniors and the other is the seniors themselves. Chronological age doesn’t have much to do with the health planning of my clients.
    But one thing that is common now is the increasing scarcity or difficulty with resources of the Medicaid system — qualifying people for nursing homes and the complexities of it.
    It’s getting to be more like the tax code where Medicaid administrators in an attempt to save money ratchet down on people who are applying to nursing homes. They ratchet down … and in doing that they pass regulations that affect a lot of other people generally and make it difficult for a lot of folks who are just trying to figure out how to qualify to get somebody into the nursing home and survive financially themselves in their home. There have been a lot of negative changes to that population just in the last 12months with the change of Medicaid regulations on the federal level.

Thomas R. Milam: Are you talking in terms of protecting assets for children and grandchildren?

Andy Olsen: Regulations now in effect have been ratcheted down because of concerns the regulators have had to save money. I certainly think the Deficit Reduction Act passed by Congress that came into effect in February was an attempt to cut down the total dollars that went out for Medicaid and I don’t think many congressmen really understand … how the Act is going to catch a lot of basically innocent people in a vise grip.
    That’s an area where advocacy with the legislature and with Congress needs to try to roll back some of these changes. There are certain changes that would have been appropriate … but I think bottom-line budget numbers got their day.

Pat Bradford: Before we leave the legal topic one of the things I wanted to know about is living wills. Are they working? Are they being honored?

Andy Olsen: We draft one with every will. We use the standard form that’s currently in the statute. It’s a very simplistic form. Currently there is legislation proposed to make some changes in some of the healthcare power of attorney and living-will documents. And that’s being worked on by various sections of the state bar association and I think some other organizations and we should see that fairly soon.

Thomas R. Milam: It’s sort of like the organ-donor program and there needs to be something to identify it because a lot of times people are brought into the emergency room or they’re short of breath come in by ambulance and you don’t know where these documents are. You have family members saying I think they wanted to do this or that. You don’t care about any of that as a physician. They’re in the E.R. and you’re going to do anything you need to do.

Kavita Persaud: The living will is probably the most useless document I have ever encountered in all of medicine because the patients think it’s going to protect them and give them something that they want but it doesn’t do that.
    Nobody has time to read five-page forms and most of the time they are still drafted with standard language that says if I am in a terminal condition or persistent vegetative state then I don’t want these things. The difficulties that arise in stating that somebody is terminal within the medical community are just huge outside of a cancer diagnosis. There is enormous reluctance to say that somebody is terminal with Alzheimer’s disease or heart failure or kidney failure.
    I try to focus a lot of my energy on helping people get a do-not-resuscitate document when that is what they want. I give them the living-will paperwork but I also tell them I think that the health-care proxy is more relevant and it needs to be coupled with lots of conversation with the person you appoint as your health-care proxy. Many people have filled out these papers with their attorneys but they haven’t talked to their healthcare proxy or their families.

Andy Olsen: I couldn’t agree with that more. When we have people come in one of the things we do is give them a[n extra] copy to send to the health-care proxy to at least engender the conversation. We do talk about the need for conversation.
    In a little bit of defense for the living will I think it’s a basis for two things: One is the do-not-resuscitate order that is much more practically useful and also for the health-care proxy because the two should be consistent and the health-care proxy generally contains language that is consistent with the living will. That at least gives some indication … of what a person’s desires are. But as far as the document being of much use in the real world it doesn’tgive much guidance.

Kavita Persaud: You see a lot of documents trying to encourage people to say yea or nay whether they would not do this procedure or that procedure but it’s really about a loved one understanding what your values are. They need to be able to be on the spot get the information and be able to make a decision.
    You might make a document that said I never want tube feeding — if they ever say ‘I need it I don’t want it don’t ever let them do it to me.’ You document that then break your jaw and are unconscious from a car accident. They need to do it temporarily. Well okay in that situation then I would want it. You need to explain to your proxy what your values are.

Pat Bradford: Where should the older people keep these documents?

Eleanor Krassen Covan: How about on a microchip? I’m not kidding. My dogs have microchips so if somebody scans them they know who they belong to they know some of their history. We’re so worried about privacy that we don’t have these things. And the reason why I said living wills are not worth the paper they’re written on is because usually we can’t find them at the moment of the emergency.

Kavita Persaud: I tell people to put the do-not-resuscitate documents in a plastic sleeve with a magnet and put it on their refrigerator so the EMS can see it if they come or they can grab it on their way to the emergency room.

Jason Clamme: The state of North Carolina also offers a chance to put it online through the Secretary of State’s office.

Andy Olsen: There are depositories with the Secretary of State’s office; I suppose if you had time you could find it there. I don’t expect doctors EMTs or doctors in emergency rooms to be concerned with those issues so much. Certainly you don’t know if someone is in a persistent vegetative state until they have been in the hospital for a while and you probably have made a judgment whether or not they have an incurable disease.

Jason Clamme: The living will and healthcare power of attorney as I understand don’t really apply to any kind of emergency situation to begin with so they are not going to ask if there is a living will before rushing in. It is going to be once a stabilization has occurred that those decisions can be talked about.

Kavita Persaud: Well the very act of calling 911 is stating to the public that you want emergencycare.

Jason Clamme: But people don’t necessarily understand this because I’ve had people many times come up to me saying ‘I’m telling you about a living will and my neighbor had one of those and EMTs rushed right in and did all this stuff.’ She very well might [have a living will] but that’s not how they’re used.

Eleanor Krassen Covan: That’s the other reason why they’re not worth the paper they’re written on. But let’s say you have given someone healthcare power of attorney and it’s not your spouse because you don’t think your spouse will be able to carry out your wishes. That’s all well and good but it’s your spouse who is likely to be there if you collapse; it’s your spouse who is going to pick up the phone and call 911 — not your healthcare agent. We don’t necessarily live with our healthcare agents.
    I shudder quite often because I am a healthcare agent for my father who lives in Florida and my mother who lives in Philadelphia. I’m not in real great shape to operate under those conditions. Granted I’ll be on the next plane but I’m not there. These are things that people don’t understand. I don’t know what percentage of your clients name people who aren’t in the same city nearby. You say that’s possible you can consult by telephone but I don’t know very many physicians who are going to call an adult child that is in another state to make a decision about life support.

Thomas R. Milam: It’s part of the medical model but I think it becomes an ethical issue and will become a financial issue. Just because we have resources just because we can do these things to prolong life does that mean that we have to do them? As physicians right now it’s yes we have to do it because that’s what we’re committed to. The cases where people just want to die are few and far between. Those are the easy cases and those are where living wills are helpful.

Jason Clamme: I think the benefit of a living will is that it gives the proxy or whoever ends up making that decision at least a little bit of peace of mind that at one point or another they signed this and they said it and at least now I can go home and sleep at night.

Karen Gottovi: The physician I think has to talk with the family and be very realistic about what’s going on and say ‘Now what is it you want if we bring her back? What are you bringing her back to?’

Thomas R. Milam: And my fear too is the next step of that is in another 20years we’re going to have to say ‘Do you know how much this is going to cost you to bring this person back? Do you want to pay for that?’

Pat Bradford: That’s how it is in veterinary medicine now.

Jason Clamme: And you might see that actually happening with the baby-boomer generation because as they moved through the child-bearing age it all changed. They drove the different kinds of things that they wanted. And as they get to the end of life … I’ve heard it joked that they’re going to want personal death trainers they’re going to want death latte. They are going to get what they want and need and they’re going to pay for it.

Andy Olsen: The baby boomers have generally been good about volunteering. What segment of elder care is most in need of volunteers? And conversely what are the best of opportunities for seniors to volunteer?

Annette Crumpton: The senior center and all the programs we offer are still there for volunteers. Home-delivered meals — we always get down on our hands and knees and beg for volunteers there. We constantly need drivers and people to pack the meals. Somebody has to pack those meals I don’t have a paid staff to pack those meals.

Betty Ann Sanders Sourwine: We could not operate without the volunteer program. We’ve got churches. God bless Carolina Canines and their dogs because they are the highlight of our patients every day when they come in. The Arboretum going over there for gardening is wonderful. We have the Wilmington Art Association coming in once a week teaching art. We have people off the street who just ask ‘can we do anything?’ I mean the volunteerism heartbeat that we experience on a daily basis is incredible. We couldn’t even open our doors without our volunteers.

Annette Crumpton: We have three high school students who come in and work our transportation program. This is the first year that it has really been an active opportunity for the high school students to volunteer. During the summer we will get students that are out of school to come in and help with the meals program. I was really pleased to see Hoggard High School allowing its students to come in.

Jason Clamme: I’ll just do a little shameless plug for volunteerism. In the hospice arena we often have elderly people who volunteer with us and I would say close to a third of our volunteers are there because of the loss of a loved one under hospice. They wanted to give back something to the organization and to the idea. So we do have several who do volunteer with us and part of the reason they are very effective at it is that they have that experience they have suffered that loss and they know what the people they’re helping are going through.

Kavita Persaud: The real advantage to both the volunteer and the patient and the resident in a facility I think hinges on continuity. It’s wonderful when church groups descend upon the facility and they’ve got a choir and they do some kind of activity and then they leave. But I wish we could get one-on-one friendships started where volunteers would commit to coming once a week or even once every two weeks to sit with the same patient and do something with them so that relationships can be formed. That’s really where the rewards come to the volunteer and that’s where the patient can also feel that somebody cares about them.

Eleanor Krassen Covan: I think you’re right. The V.A. has done a really good job with that kind of thing. If you go into the V.A. medical center or a V.A. nursing home they have no problems with volunteers because there is a plethora of veterans and they sort of use their shared experience and their shared history and they develop one-on-one relationships.

Jane Jones: In a lot of the school system some of the high schools actually have classes on volunteerism in the long-term care facilities.

Jason Clamme: Cape Fear Academy requires 400 and some hours of community service for graduation.

Jane Jones: This is the way we can get younger folks engaged with the older population which is a problem in such a mobile society. Most of us grew up with our grandparents very close by. Children do not usually have that option anymore.
    Let’s remember that it works in the reverse too. We have senior groups for example The Rocking Chair Players which is a senior theatrical group. They go into the schools and provide educational skits and plays to elementary and middle school children. So we have this exchange happening in both directions. I just don’t think we always realize that.

Thomas R. Milam: What people see now is that it is a negative thing to be old and particularly if you feel like you are going to be a burden on somebody. And that’s so sad because I’m not old but I can say it seems like a wonderful thing.

Kavita Persaud: But that’s the culture.

Thomas R Milam: Yes as a society age is something we fight against rather than something we see developmentally as part of human existence. We don’t accept it.

Jane Jones: We value youth and all of the hallmarks that normally go along with youth.

Thomas R. Milam: And if all the money that went into keeping us young went into providing some of these services we’re talking about we wouldn’t be here tonight talking about the problems; they’d be solved.

Eleanor Krassen Covan: I’m optimistic about what baby boomers are going to do maybe because I was a spoiled kid. I lived in developments that were designed around me and in neighborhoods where there was a neighborhood school. We grew up and there were a plethora of colleges built just for us state schools expanding from one campus to 16 in order to take care of us. I think that’s going to happen as we age but not necessarily for assisted living where we are warehoused because we don’t want to be warehoused. We’re going to want to be in the community. We have been a politically active generation; we’re going to stay that way. We’re going to want to do some good and I think we’re going to see new options.