Aging, to begin with, isn't easy for everyone. It can sometimes seem like an endless series of adjustments to new circumstances- none which were asked for, and many of which are unexpected. Changes in physical health, social circles, functional abilities, new medicines, new living situations, loss of independence: These are things that can come out of nowhere, throwing your world upside down.

The difficulties adjusting to these changes throw another wrinkle into the equation. For example, as a geriatric care manager and aging lifecare consultant, I've worked with many clients who have been in denial of their need to accept changes to the way they do things. Specifically, some life changes warrant new interventions and forms of help, e.g. home health aides, medicine, walkers.

So often I've seen that the people with the best eventual outcomes are the ones who are open to accepting help from others- be it family or hired professionals. When a client and their family are on the same page, safety can be more-easily assured.

But what should families do when an elder is help rejecting? Here's some advice:

1. If you know in advance of your loved one's actually needing help that they are likely to reject help later, start the conversation with them about their wishes now. That way, you leave them the opportunity to handle things on their own terms.
2. If you've reached the point at which help is needed, but your loved one is help rejecting, it helps to sometimes involve a third party to help mediate. Geriatric care managers, in particular, are often able to be the person who says some sort of intervention is needed, while you can concentrate instead on providing the emotional support that your loved one would probably prefer from you instead of doting, demands, or ultimatums.
3. Change tacks. Concentrate less on your loved one's deficits and more on their abilities, hobbies, and talents. Ask them what specific things you can do to help them continue to do the things that remain important to them.
4. In cases where someone has lost the capacity to agree or not agree to accept help (through dementia or other illnesses), certain legal options are available to help ensure the safety of their loved one. Feel free to contact Scott to learn more about some of these options.
   

A final note: Above all, it's important that family members of help-rejecting people in need of help try to accept the fact that there may be limitations to their ability to set up care. Clearly, this is far from an ideal option. Nonetheless, it remains a major part of many of the cases I see every day. Setting reasonable expectations is perhaps the most crucial element of this process, and should not be overlooked.

I'd like to start this blog post with a personal story. Last week, a family member of mine was admitted to the hospital for a small but serious procedure. Without getting into details, it was more serious a procedure than cataract removal and less invasive than, say, bypass surgery. It was serious enough that I took a day off from work, so that I could act as healthcare proxy, as they requested.

I'll kill the suspense by saying in advance that everything went perfectly (Thank you, NY Presbyterian!). Though I've discussed healthcare proxy before on this blog, and though as an elder care social worker and geriatric care manager in NYC, it's something I've discussed with countless clients, this was my first time ACTING as a healthcare proxy for someone I know. 

A day before the procedure, I realized I was going to make a very poor healthcare proxy for this person. Why? Because that piece of paper with my name on it meant absolutely nothing, zilch, nada, unless I knew specifically what the wishes were of the person designating me. They did not have a living will, which would have outlined the type of care they would like to receive should they become incapacitated. I didn't know if they were a DNR or so-called "full code". I didn't know what sort of heroic measures they might or might not want taken. I didn't know their hydration or nutrition wishes should they become incapacitated. In short, filling out a healthcare proxy form is a nice start, but in the absence of an executed living will, it is not enough.

So I pulled this person aside and had that conversation. Amazingly, it wasn't something they even put much thought into. They assumed (incorrectly, and perhaps dangerously) that I was some sort of mind reader, and would just know the right thing to do. The truth is, there is no right or wrong way to handle these things. It's all a matter of opinions and values. A good healthcare proxy asks these sorts of specific questions. A great healthcare proxy knows about the values and personality of the person they might have to represent. 

Here are some examples of specific questions to ask of the person appointing you healthcare proxy:

• Do you want to be resuscitated should you stop breathing or if your heart stops ("full code") or do you want to be listed as do-not-resucitate (DNR)? The default option at hospitals, unless you specify otherwise, is full-code.
• Do you want to be hydrated and fed if you have a catastrophic outcome and have little chance of recovery?
• How important is pain management to you? 
• Would you want to be kept alive "artificially" with a respirator, for example?

Of course, it can be difficult to ask questions like these. If you are a healthcare proxy and haven't asked these specific healthcare scenario questions, at least find out what sorts of things matter to the individual you're representing. Ask what they like to do. Ask what sorts of things they don't like to do. Ask their opinion about things like death and dying, or aging, or healthcare in general. Ask about a time in the past in which they've been in great physical pain and how they handled it. What worked? What didn't? To not have these answers as a healthcare proxy can result in decisions being made that the patient never would have wanted for themselves.

Luckily, I didn't have to enact my authority as healthcare proxy this past week. But I am so glad I'm prepared should I have to fulfill this role in the future. I also feel like I know this person even better than I did before, which is a real gift.

Be in touch if you have questions about this topic, or need help discussing these issues with your loved one.

If you've been following this blog, following me on Facebook or Twitter, or if you've chatted with me in person, by now you've learned some of the issues I feel are especially important to focus on, what issues I feel have become cliche, and my general musings on caregiving, aging, and elder care as a geriatric care manager in NYC. 

Sometimes, the resources and advice I give take on different levels of importance for different people. That's especially true for LGBT seniors, and I think it's worth writing about here.

This has been written about before, so I'll try to be concise with this blog. My aim is to give concrete and specific resources and tips to LGBT seniors and those caring for them. This blog will be far from exhaustive, but I hope it helps spark a conversation or two, or inspire you to learn more. Here are 3 of many examples of things I feel are important for LGBT adults to consider as they age.

• Advance Directives: This is the issue that jumps at me first when I think about aging and LGBT partners. According to the Washington Post, "In most states, an estranged sister would be appointed proxy before a same sex partner" in the absence of a written healthcare proxy. Heterosexual married partners, in contrast, are usually considered the default healthcare proxy. Even in states where same-sex marriage is legal, there have been reports of hospitals not honoring next-of-kin laws. While that obviously needs to change, it cannot hurt for anyone to be overly-prepared. For unmarried LGBT partners, there is an obvious need. Check out my blog on healthcare proxy to learn more. 
• Financial Support & Caregiving: Older LGBT adults are twice as likely to be single and 3-4 times more likely to be without children than their heterosexual peers. The risks of social isolation and poverty are subsequently higher. Ensuring a social support network is important for all elders, but perhaps is more acute for the LGBT community.
• Medicaid: By far and away, Medicaid is the best long term care insurance policy anybody could have- provided you meet the qualifications for it. It also provides certain spousal impoverishment protections, which help prevent spouses from depleting their home or nest egg in order to qualify for Medicaid. Unfortunately, these protections do not always apply to same-sex couples. Same-sex couples are subsequently strongly encouraged to meet with an elder law attorney or consider purchasing long term care insurance policies to better prepare for potential long-term care needs.   

The real and significant impact of discrimination, unique health care challenges (40% of elderly LGBT adults say their primary care doctor isn't aware of their sexual orientation), and unequal laws unquestionably puts LGBT elders at a disadvantage. We must work to improve this, and in the meantime, we should prepare accordingly. If you are an LGBT elder or family member considering working with a geriatric care manager, be sure they are sensitive to these unique needs from the get-go.

The experts on the issues affecting LGBT seniors is SAGE, and they're based right here in NYC. Visit SAGE's website to learn more, and to get involved on their great advocacy efforts. 

If I've left anything out (and I'm sure I have), please leave a comment. Let's keep the conversation going.

It's a recurring theme. I'm sitting down with a new acquaintance, making small talk, trying to explain to them what a geriatric care manager is and does. The conversation feels a little foreign to them. That's not for me, they'll think. None of this is part of my life right now. And that's OK. Most of the time they're 100% right. I'm not in the business of telling 30 year-olds they should think about buying a long term care insurance policy, or start vigorous estate planning (thank goodness). Talk too much about senior housing options at a wedding and you start to get funny looks.

But once in a while, something clicks. Something applies to them.  So let me inaugurate this blog with something most people associate with aging, but probably shouldn't exclusively. 

NYS Healthcare Proxy

That hyperlink I placed right above this sentence? Go ahead, click it. I promise it won't mess up your new iPhone. What it will do, though, is potentially improve your experience as a hospital patient. I say this not exclusively as a geriatric care manager, but also as a hospital employee. It's a standard healthcare proxy form for New York State residents, provided by the NYS Department of Health, and it's something you should fill out now. Literally, now.

If you lose the capacity to make medical decisions for yourself, you can use this form to appoint another person to make them for you. The trick is, you won't be able to fill this form out after you've lost that capacity, which is obviously a tough thing to predict.

Ideally, the person you designate is someone you trust, to whom you've made your general medical wishes known. Short of that, it should be someone who knows you as a person, and has a sense of what your values are.

The file itself has an excellent FAQ, so I won't go overboard with more information, but please know the following before you decide to click away and check basketball scores:

• You don't need a lawyer for this;
• It's free;
• It doubles as an organ donation directive;

Take 10 minutes. Fill this out. Get two witnesses to sign it. Give a copy to the people you've designated. That's it. Done. Go back to your regularly scheduled programming. 

I'll take some time in other blog posts to cover items I feel are applicable to people of all ages. This one deserved my first post, though. I hope you'll agree.