Can I refuse care for my Dad as POA?
My father on law is 90 in final stages of dementia various cardiac issues and now has breathing issues yet to be diagnosed. I am the dpoa for him and he has an active dnr and do not hospitalize active on file. The dr at the nursing home prescribed some nebulizer meds to help breathing issues. Well we got the bill for the meds and on was covered by insurance the other was not the one not covered was $1245 for one month!!!! Totally out of the budget so as the activated poi for both medical and financial I told the home to change the med to something covered by insurance or stop this treatment now!! I was told I couldn't stop treatment now we are really just waiting for him to hopefully pass away as there really isn't any quality of life left. It would a god send if he passed. So can I as poa say to stop treatment and or med and just let him pass and no longer receive meds or treatments
starting tomorrow 99% of the meds will be stopped, if the nebulizer is going to continue then the nurse has to be in the room with him for 100% of the treatment as he would pull off the mask and throw it on the ground when she would leave. Dr agreed no meds would be prescribed unless his staff called me and Ok'ed with me first and NO med would be prescribed that wasn't covered to where I only pay the $7 co pay.
He said with the swallowing issues that showed up last year and the breathing this year are both signs he isn't long for this world and told me he doesn't believe he will last through the end of the year. That truly would be a god send with the way he is now. So now the Dr and I are all on the same page and the Dr office will contact me with treatment or drug changes. Definitely a step in the right direction. Thanks everyone for all your support only those who are living this difficult or have lived through it know what its like. It's so great to have found you guys - I definitely don't feel like i'm the only one.
You gotta do what you gotta do, taking the whole picture into consideration (which his docs aren't doing). And you're doing just that. Hugs to you...and sorry that you have to push for the right answer for your FIL and MIL.
Now for me the ? is why there would be foot-dragging on hospice??? Hmmmm -so how is dad paying for his care? If he is Medicaid, the NH should be all over themselves in getting hospice benefit added into the mix as Medicare (which pays for hospice) doesn't cause the NH any extra fees as Medicare pays the hospice separately and then the NH has extra for no cost to them medically trained hands to help out with dad. So there must be something about his insurance that discourages hospice for this NH. Or is the facility more of a rehabilitation facility?
If its geared to rehab, it is probably not the place for your dad.
Now does this NH take Medicaid or is it a purely private pay/ LTC insurance facility?
You know there are some hospice groups that have an in-unit &/or freestanding hospice facility, that situation may just could be what you need to move dad into. Yeah I know the thought of moving him would not be easy, but would you want to be in this same situation for months & months. Like in my mom's city, there was an old Women's & Children's hospital at the medical center complex that is now a free-standing VITAS hospice. You kinda have to have some significant issues to go there (like a lot of them have Class 4 drug needs and most hospice workers do NOT carry Class 4 pain meds on them) or there are lots of co-morbidities with the patient. You know dad may qualify for a free standing hospice placement because he has so many possibly complex co-morbidities. My mom would never qualify to go to the freestanding hospice but my MIL went into one as she had post surgery sepsis with big bad bacteria, dementia, COPD, etc. MIL died maybe within 2 weeks there, they did a lovely job in weaning her off of meds and regulating pain, the RN called my DH every evening too. My aunt went to the VITAS one in my mom's city after a fall with a brain bleed and I think it was 5 weeks that she was there, most of the patients were younger, lots from cancer and almost all needing serious pain meds. For what it's worth going to see my aunt in her 90's there when so many others on the floor were young & dying from cancer or major trauma, made it a lot easier to be calm about my aunt's passing.
Igloo based on what you posted for hospice qualification he should qualify but so far hasn't since Sep they have been in 2 or 3 times and still hasn't. The bottom method he would be between 12 -16. The upper one he definitely has up to #6 with some of #7 seems to me he should qualify too. But still hasn't Think I need to do some leg work on this. I know it sounds awful to say out loud but its time to let him go and stop everything.
The FAST doesn't refer to time to do it, it stands for Functional Assessment Staging Test (FAST). Mitchell is a Mortality Risk Index & somewhat easier.
Functional Assessment Staging Test (FAST)
Stages:
1. No difficulties;
2. Subjective forgetfulness;
3. Decreased job functioning and organizational capacity;
4. Difficulty with complex tasks and instrumental ADLs;
5. Requires supervision with ADLs;
6. Impaired ADLs, with incontinence;
7. A. Ability to speak limited to six words & B. Ability to speak limited to single word
& C. Loss of ambulation
& D. Inability to sit & E. Inability to smile &
F. Inability to hold head up
. Some combination of the 7's mean hospice needed.
Mortality Risk Index Score (Mitchell)
Points & risk:
1.9 Complete dependence with ADLs;
1.9 Male gender;
1.7 Cancer; 1.6 Congestive heart failure; 1.5 Bowel incontinence; 1.6 O2 therapy needed w/in 14 days;
1.5 Shortness of breath; 1.5 less than 25% of food eaten at most meals;
1.5 Unstable medical condition; 1.5 Bedfast; 1.4 Age over 83 years;
1.4 Not awake most of the day. You add up the points and get a MRI score. The
risk estimate of death within 6 months
(Mitchell score):
Score Risk %
0 8.9
1-2 10.8
3-5 23.2
6-8 40.4
9-11 57.0
= 12 70.0
Mitchell can change over time. My mom was over a 12 her first month and now has lost points but still OK for hospice. Hospice gets approved at first on a 90 day period and thereafter every 60 days. Medicare has clamped down on allowing for years of at-home hospice and lots of those patients have had to be re-evaluated but that is not the case for your dad. Good luck and sometimes you have to just be a real pit bull to be an advocate for your elder!
Once he is on hospice (btw sounds like he should easily qualify), I bet almost all of his drugs will either be stopped or will be decreased to get him weaned off of those that require smaller & smaller doses to get off of. IF the expensive medication is a treatment, hospice will require it be stopped as all procedures or medications that "cure" or treat will no longer be allowed under hospice rules. I would be somewhat disturbed by a facility who refuses to look into stopping a medication or in changing the prescription to a generic - this just doesn't sound right.
Hospice is a MediCARE paid for benefit. As such, the Medicare recipient (your dad) can choose the hospice group. You as his MPOA can do this for him. Most NH have a group of several hospice that service the facility. If the NH tells you that they choose the hospice, that it total bs. Hospice is Medicare and Medicare is self-directed in choosing providers. There should be lots of hospice groups in your area. The two bigger ones are VITAS & Compassus. If they are in your area, I'd contact them to start with.
Dad will have to have an evaluation for hospice done. I will do a separate post of the 2 types of test done for hospice. But he sounds like he will pass. Now his MD will have to request a hospice evaluation. SO you will need to speak to his doctor about that. If his MD is the medical director of the NH, I would fax over a request for this to be done rather than trying to speak with them as they probably are limited in their time @ the NH.Faxes are considered a legal document and cannot be ignored like a verbal conversation can be….this is why you need to fax the request over, someone will HAVE TO DEAL WITH THE REQUEST. If his MD is still a doc with a private practice, then you can call the office to ask for orders to be written for getting the hospice evaluation. Those orders then go to the hospice provider so they can go to the NH to do the evaluation.
My mom is in a NH and in June fell and broke her hip, so she is now bedfast and is finally qualified for hospice. It has been just great and she really has never been cleaner or in better care. She gets a CNA 3 X a week and RN twice a week and once a month social worker & clergy, all this in addition to the daily care provided at the NH. Medicare pays right under 5K a month to the hospice group. Most good NH really like having hospice there to provide care & extra hands in tandem with the care they provide. For my mom, the hospice CNA works with the NH aide in doing mom's bathing in a portable geri-chair that the hospice group ordered for her. She really has never been cleaner and more moisturized. There are 5 different hospice groups that "work" my mom's NH. The first hospice group I had issues with as they would not provide the level of communication I wanted and were slow on ordering equipment, and so I discharged them from care and went to another hospice group within the first 90 days. Took 2 days to do the switch. Again, hospice is self-directed so I as my mom's MPOA could do this.
If I can stop some of the treatment for some of his symptoms I am sure he would once again qualify. Right now I need to stop or have them change meds to ones that. Are covered by insurance at a minimum. As poa can I force that?