As Cognition Slips, Financial Skills Are Often the First to Go, New York Times

Dear Mom and Dad: Are Your Finances Ready for Retirement?, New York Times

Medical care in the United States is extremely expensive, even for patients with insurance coverage.  Here are a few tips that may save you or family members money on medical bills:

• Request a shared hospital room. Many insurance plans do not cover a private room.  If you request a shared room, you may end up in a private room but you should be charged the lower price of a shared room.
• Add language to the consent forms that you sign for treatment stating that your consent is limited only to in network care and that you are not consenting to care by out of network providers.
• If you are in the emergency department for many hours and anticipate you will need to stay in the hospital for over 24 hours, ask to be admitted to the hospital and not be on “observation” status. Many insurance plans require a qualified hospital admission for coverage of rehabilitation care in a skilled nursing facility afterwards.
• Write down the identification of all healthcare providers that appear at the bedside of the patient, and document what they do and who sent them. Decline all extraneous services.
• Do not take home any equipment that you don’t need.

For additional tips, read An American Sickness: How Healthcare Became Big Business and How You Can Take it Back by Dr. Elisabeth Rosenthal.

Medical directives are documents in which patients specify their wishes for end of life care. Typically, patients express their desire to decline artificial respiration, nutrition and hydration and other medical procedures where such treatment would only serve to prolong the process of dying and not result in a cure for a terminal illness or where there is a permanent unconscious condition. Having a medical directive helps avoid family disputes about the level of care to give a patient in such a situation.

Perhaps the most recent publicized example of a family dispute involving end of life care was Terri Schiavo, a Florida woman in a persistent vegetative state. Terri had not signed a medical directive before she had a cardiac arrest and resulting brain damage in 1990. Eight years later, having given up hope that Terri’s condition would ever improve and believing that Terri would not want to be kept alive in such a situation, her husband Michael petitioned the court to remove the feeding tube (medically assisted nutrition) keeping Terri alive. Terri’s parents intervened as did government officials and after seven years of extensive litigation Terri’s feeding tube was finally removed and she allowed to die in 2005.

Hospitals and other care facilities affiliated with the Catholic Church are required to follow the Ethical and Religious Directives for Catholic Health Services published by the United States Conference of Catholic Bishops. Unsurprisingly, such facilities will not readily provide information about Washington’s Death with Dignity Act. However, surprisingly to many people, such facilities will also not necessarily follow patients’ medical directives for end of life care.

For example, Directive No. 24 specifically states that medical facilities “will not honor an advance directive that is contrary to Catholic teaching.” Directive No. 58 states that “medically assisted nutrition and hydration should be provided for patients in chronic and presumably irreversible conditions” who can “reasonably be expected to live indefinitely if given such care” [the Terri Schiavo example]. Medically assisted nutrition and hydration become “morally optional” when they cannot “reasonably be expected to prolong life” or when they would be “excessively burdensome for the patient or would cause significant physical discomfort .” Since these issues require subjective judgment on the part of health care providers, family members may find themselves at odds with such providers in such situations.

Patients and their families may not even realize that a hospital is affiliated with the Catholic church as facility names may not appear to be of a religious nature and information is often not readily accessible on the facility’s website. In order to be sure that a patient’s end of life care wishes are followed, patients and their families should double check before admission that their medical directives will be followed. For further information about hospital policies, see endoflifewa.org and links to the policies of specific health care facilities in Washington.

Here’s a link to an interesting article in the New York Times about advance directives.  Much like birthing plans, it is difficult to know in advance exactly what care you will want to have when the time comes.  Better to designate a person you know and trust to make health care decisions for you if you are unable to make such decisions for yourself.  Make time to discuss at length your thoughts on quality of life with that person on a regular basis so he or she feels comfortable in the decision making.  Be sure your health care providers have the documentation in your medical records with current contact information for your designated agent.