End of Life Planning For Your Pets

By: Lisa Bayer, J.D., CCM

Over the years as a geriatric care manager, I have been in hundreds of client’s homes. I also think that I have seen everything! I recently encountered a situation that truly threw me for a loop.

I was engaged by the legal guardian of a client who lives out of state to be her “boots on the ground” with respect to her loved one, Margaret. Margaret had a catastrophic event and suffered a TBI (traumatic brain injury) which requires skilled, nursing home level care. Before the TBI she was living independently in her own home with her dogs. She had never married, has no children, and has no other local involved family members.

One of my responsibilities was to help coordinate the emptying and selling of her home. The (living) dogs were surrendered to a local rescue but nothing prepared me for the 16 boxes of cremated pet remains that we found all over the home.

Part of the issue is that Margaret’s sister could not relate and would have thrown them in the trash if it were up to her. However, as the court-appointed legal guardian she was required to respect Margaret’s wishes, known or unknown, to the best of her ability. So, what to do?

Margaret’s sister had engaged an amazing realtor who partnered with me throughout the process to find solutions to each scenario that we encountered. And there were many!! In this case, we contacted local pet cemeteries to inquire about process and cost for burial.  One of them was sympathetic and worked with us to keep the cost down by offering to combine plots of more than one pet. This was the best way that the guardian could think of to respect what Margaret may have done, or directed, if she had been able to.

Personally, I learned from this experience something that I will bring to my practice in the future. While many wills address what happens to pets after a person passes, most power of attorney documents (especially older ones) that I have seen do not always address how the agent should care for the living pet(s). And I have never EVER seen one that addresses how to treat pet remains when your loved one loses capacity and cannot speak for themselves. I always ask clients as part of onboarding to share their planning documents with me. As a trained attorney, I am able to make meaningful suggestions when it comes to any updates to make sure that the documents will work if needed. After this recent experience I will be more cognizant of not just living pets but how to handle their remains if a client is no longer able to do so him or herself.

PCR is Not Just a Covid test; A 21st Century Approach to Diagnosing and Treating Urinary Tract Infections

Written by: Lisa Bayer, J.D., CCM

Recently, I had the pleasure and privilege of sitting down with Dr. Joseph DiTrolio, and Ms. Pilar Vega, Senior Director of Business Development with Premier Medical Laboratory. By way of history, Ms. Vega and I were speaking one day and she alluded to a qPCR (Quantitative Polymerase Chain Reaction) test that her lab offers patients in multiple care settings. Ms. Vega explained that the results of this type of test is typically available within 24 hours and allows for more pinpoint targeted treatment, or in some cases non-treatment, than the traditional “scorched earth” approach of prescribing a generic antibiotic for urinary tract infections (“UTI”) while waiting 4-5 days for the culture results only to find out that a patient does not have a UTI or the prescribed antibiotic is the wrong one.

Over the past two (pandemic) years we have all become well accustomed to the term “PCR.” I for one did not realize that it is not a Covid-specific test but rather stands for “polymerase chain reaction” which is a type of testing that looks at a pathogen’s DNA profile to identify the organism(s). The qPCR can also detect the genetic makeup (the DNA or genes) of the pathogen to prevent and avoid antibiotic resistance. As a geriatric care manager, most, if not all, of my clients have suffered from at least one, usually multiple, UTIs. I was curious and so Ms. Vega graciously set up a meeting so that I could ask Dr. DiTrolio questions and learn more about this approach.

I asked Dr. DiTrolio to please explain why the qPCR test is preferable to the traditional urine culture and why, if it is not better, it is not the standard of care. At the outset, Dr. DiTrolio explained that 50% of people who present with a possible UTI do not actually have one. Yet, physicians often prescribe antibiotics before testing as the traditional culture takes 3-7 days to get back and they do not want the patient to have to wait. And, while Dr. DiTrolio was too polite to say it outright, I inferred that to do the less traditional qPCR while still a urine collection, may involve a bit more effort to arrange to have the right lab pick up the samples. Meaning, some providers do not take the time or make the effort to become educated and instead rely on 100-year-old protocols. The old “if it ain’t broke why fix it” adage. Yet, in the end it is the patient, our health systems and our children and grandchildren who suffer if we mistreat patients and create drug-resistant organisms in the process.

As Dr. DiTrolio explained, the longer a urine specimen is out of the body, the greater the chance that the results will be tainted. Furthermore, if two or more strains are present, using the traditional method of waiting for a culture gives the “dominant” bacteria strain a chance to destroy or mask the less dominant strain(s). This does not mean that the bacteria are all gone—just that it was not picked up on the traditional culture. And so, we see occurrence or reoccurrence of bacteria that were present but not picked up and therefore not treated properly the first time around.

The qPCR test is covered by Medicare so it is not a payor or reimbursement issue. In fact, by procuring a reliable, quick test it can actually save money and produce better outcomes. This is because if the antibiotic is wrong then the patient does not only not get better, but he/she will need another course of treatment. Overuse and inappropriate use of antibiotics can lead to additional morbidities such as Cdiff recurrence, gastrointestinal disturbances and yeast infections. A severe, untreated UTI in a patient with multiple health problems is also more likely to end up in the hospital. In the worst case it can lead to death.   

In sum, it is important for caregivers, patients and their advocates, such as geriatric care managers, to ask questions of physicians and other providers and to insist on meaningful explanations and answers so that the care recipient has the opportunity to make informed and educated decisions on his or her care.

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*Joseph DiTrolio, MD, is Urologist in private practice in Roseland, NJ. He serves as Professor and Chairman of the Board for the New Jersey Medical School Alumni Association, his alma mater. He holds numerous patents and has authored and presented on hundreds of papers and articles all over the world. Dr. DiTrolio is committed to the care and support of our beloved veterans. Since graduating medical school in 1979 he has been affiliated with the East Orange Veterans Administration focusing on injuries and illnesses related to the urological system. 

*Pilar Vega’s background is in business and the life sciences.  She has over twenty years of experience in healthcare with a focus on diagnostics, pharmaceuticals and medical equipment. branches of the industry.  Pilar is a committed advocate of optimal care for every patient regardless of means or life circumstance.

Hope For a Sharper Mind

By Guest Blogger: Lisa Feiner

Until recently, it was thought that we were born with all the brain cells we would ever have, and they were slowly lost over time as we aged. Research shows, however, that the brain is neuroplastic and neurogenerative, able to continue learning and growing new connections. When the brain receives the right nutrition, enough mental stimulation, nourishing friendships, exercise, and sound sleep, and is also protected from trauma, prolonged stress, toxins and infection, it thrives. And we now have a good idea about how to keep it thriving throughout our lifespans.

According to the CDC, dementia is not an inevitable part of aging[1], and yet Alzheimer’s and other types of dementia cases continue to rise, even in younger age groups. A recent Blue Cross Blue Shield study reported a 373% increase in diagnoses of early onset dementia and Alzheimer’s disease among 30 to 44 year-olds, and an overall 200% increase in those aged 30-64.[2] How can this be? The nonprofit, Sharp Again Naturally (SAN), has identified more than 10 reasons our cognition can start to falter, and the seeds are often sown decades before symptoms appear. Reasons may include poor diet, a sedentary lifestyle, low hormone levels, heavy metals, prescription drugs, emotional and physical trauma, and more.

Some people, including doctors, will tell patients that nothing can be done to treat Alzheimer’s disease or mild cognitive impairment, and to go home and get their affairs in order. A prescription may be offered to help slow the disease for a few months. There is more that we can do. There are now protocols that for many people can preserve and/or restore partial, if not full, cognition. Studies are ongoing and several books have been written about this new multi-modal approach: instead of one drug, a combination of lifestyle changes, supplements, and other interventions are used.

Family members, close friends, co-workers and even neighbors are often in the best position to notice when someone is having memory issues. For example, they see that bills aren’t being paid or past experiences and conversations are not being recalled. There may be a change in personal habits, such as more frequent purchases from a home shopping network or lists being posted throughout the home.  Memory problems usually appear slowly and worsen gradually, but often the person him or herself starts to realize that they are having frequent lapses. It is at this stage that interventions can be most helpful.

A professional case manager, such as LMR Elder Care, works with families and individuals and often sees people who are at various stages along the dementia journey. In fact, it is not uncommon for the caregiver of someone with dementia to begin to suffer memory issues too. We know that caregivers who are caring for someone with dementia are six times more likely to develop dementia themselves.[3] The objective professional is in a unique position to holistically evaluate what is happening and refer the family to appropriate resources. That is why it’s essential for all of us to understand that memory loss should be addressed as it may be treatable, and to seek help as early as possible. We all deserve to live a full life with our minds intact.

Lisa Feiner, MBA, M.Ed. is a Board Certified Health and Wellness Coach and a founder of Sharp Again Naturally. SAN educates people about the causes of memory loss and offers tools to preserve brain health (sharpagain.org).

Citations:

[1] www.cdc.gov/aging/publications/features/dementia-not-normal-aging.html

[2] https://www.bcbs.com/the-health-of-america/reports/early-onset-dementia-alzheimers-disease-affecting-younger-american-adults

[3] https://www.sciencenews.org/article/caring-spouse-dementia-leaves-caregiver-risk