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25 Mar 2013

San Diego Home Health Care: Final Things

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By: Cindy Hasz, Geriatric Care Manager

nurse care managersSAN DIEGO — One of the things that makes working with the frail elderly so different from other relationships is that you must help them face difficult issues without a lot of lead time.

Nurses generally get intimate with their patients quickly, needing to know about personal things like bowel habits and body fluids. But nurse care managers often function additionally as social workers or surrogate family members to help with even more difficult issues. Hard realities which may have been avoided all of a person’s life can come crowding into consciousness like noxious relatives in a one-room house. One of those realities is death.

Very early on in the relationship maybe even in the first few hours the question must be asked:

“Mr. Jones, if your heart were to stop and you were at peace, would you want us to try to start your heart again? Do you want CPR?” When put like that, most well aged or infirm people will signal an emphatic “No.”

San Diego home health care nurses can then fill out a “DNR” (Do Not Resuscitate) form both the doctor and patient must sign and post it in the home so that emergency personnel can assess immediately what level of intervention is appropriate.

The bottom line thus established, the difficult questions are not over. There is a wide continuum between health and cardiac arrest. What about when one becomes so sick that normal functions are hindered or interrupted and reestablishing them requires methods that are painful or highly distressing?

One of these gray areas regards the administration of food and fluids in a terminal state.

“If unable to feed yourself or swallow how would you feel about tube feedings?” “If you were in a “persistent vegetative state” would you want to be kept alive by artificial means?” Many if not most again say no.

Some people though will want everything possible done no matter what condition they are in. Sometimes the patient is ready to let go but the family is not. What many people do not realize is that their wishes must be stated clearly in a Durable Power of Attorney for Health Care and/or other advanced directives. Not only must one’s right to life be safeguarded but one’s right to die as well.

If there are no directives and a crisis presents itself to EMT’s, doctors and nurses, they are under an ethical obligation to do everything they can to save a life. That’s great if the patient wanted to be brought back but what if it means cracking the ribs of a 92 year old (not uncommon) while doing CPR who then will have to endure weeks or months of tortured experiences in the loneliness of a hospital ward only to die anyway?

What if it means having to place a nasogastric or stomach tube in an elderly person who has been suffering for years with some chronic degenerative disease and who really didn’t want to extend their life any further?

At every age there are many choices surrounding end of life issues. Those choices extend even to where one wants to die. Some people only feel secure in a hospital environment where high tech interventions are a call button away. Many people want to spend their last days and hours in the comfort of their own beds, in familiar surroundings and with the people they love. Thus the popularity of San Diego home care and the San Diego hospice movement.

It’s especially satisfying to empower patients and families by presenting them with the many choices that are available to them in both sickness and health, death as well as life. All of our processes are sacrosanct or should be. They don’t belong to nurses, physicians, hospitals or any medical priesthood who has some esoteric knowledge and power that they may or may not share with us if we are “good” patients.

We must own them ourselves. Being open and positive about some of the most powerful moments of our lives can help us and those who are close to us experience our transitions in wiser, more compassionate and more truly human ways.

Photo Credit

28 Feb 2013

What Does Dementia Mean?

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By: Cindy Hasz, Geriatric Care Manager

what does dementia meanSAN DIEGO — A large percentage of the elderly are afflicted with it, but what is dementia?

The dictionary defines it as “a severe mental deficiency or impairment.” Literally, out from (de) the mind (mens). Most of us will think immediately of Alzheimer’s. But there are assorted varieties of dementia – the Parkinson’s-related type and the generic dementias associated with aging and “hardening of the arteries.”

What I find as I visit the various outposts of severe mental deficiencies in and around San Diego – facilities that specialize in Dementia Care – is that they are very special places full of very special people. They are in a sense, aboriginal places. Patients there are who they are – having lost the capacity to hide or misrepresent themselves. Most often they cannot remember who they are well enough to sustain the artifice of manners or deception.

Though I am often shocked to find people so unrestrained (lying on floors, walking around naked or relieving themselves on the nearest green plant), it is also strangely refreshing to observe the freedom of the primitive.

They dance with us easily, tell you that they love you or need you or hate you as the case may be. They do more than tell the truth – they simply are the truth. Each personality stands out in stark relief. Like frescoes one finds oneself alternately drawn to and disturbed by.

There’s the woman who swings her hips as she walks in a bold, teasing way while clutching a tattered stuffed animal tightly under her bony right arm, like her bottom half and top half belong to very different people.

There’s the man who mutters to himself shuffling along in his stained polyester and Sinatra type hat. A man with a quick smile who moves furniture and the tiny wraithe of a woman with pale blue eyes who holds serious conversations with her “sister” in the mirror.

Then there’s Jackie, who whistles when she’s feeling awkward, and Faye, the piano teacher, who though she can’t remember much else remembers every piece of music she ever learned. We sat together one day while she played song after song.

Beethoven’s “Moonlight Sonata,” Bach’s “Intentions” – written for his children. A march by Franz Schubert and Chopin’s Prelude in A. Her face had grown translucent by this time and a group had gathered round.

She played Paderewski’s Minuet in G and then Tchaikovsky’s 6th Symphony, “Pathetique.” The Polish Madame began to dance with a little man with very sad eyes. Ruby sat and scowled as Ruby always does and the rest of us listened rapt as frail fingers flew over ivory transforming the very unremarkable room into a palace. There was no mistaking the crumpled royalty assembled.

When she finished we didn’t want to leave. We’d been together in a shaft of light so brilliant and devastatingly sweet that we wanted it to go on forever. I thought of the words, “Blessed are the poor in spirit for theirs is the kingdom of God.”

Lo and behold, is the kingdom of God to be found in the outbacks of dementia? Verily, the poor of memory and challenged of intellect have greater riches to share with us than we imagine if we have the wisdom to open our hearts to them.

Photo Credit

14 Jan 2013

Memorial Service at the Country Club

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By: Cindy Hasz, Geriatric Care Manager

Martini Glass

I don’t usually drink gin, but along with a lot of other people I tossed one back in her honor. No doubt she would’ve had several too, but our “Auntie Mame” had gone and left us bereaved of her winsome presence. So we dove into the gin for want of a good séance.

We gathered at her beloved country club after the memorial service in the small Episcopal Church in the pines. The priest was there, golf buddies, family members and business associates of diverse kinds. The table was filled with what she called “hearty hors d’oeuvres”; shrimp, deviled eggs, rumiaki, cheese, little salamis twisted cleverly in some back room by unseen fingers into tiny sombreros.

Sombreros, like the black and white sombrero she wore in my favorite picture of her; eyes bright like sunrise, mouth wide laughing, hands poised at the hat strings like leaves only partly uncurled to the light. Her fingers appeared shy and hesitant, lightly touching at the string below the knot under her chin. She’d been neither shy nor hesitant but she’d been reserved.

She had reservations about church ladies and today the church ladies were milling around. The same ones she kept from visiting her in her illness. She said they were always trying to “swoop down on her.” Once they got inside the house they gathered in her room and tended to hover over her bed. She hated few things more than hovering. Here they were out in force, swooping around the food table and in full hover mode for the sad celebration.

While coaxing a shrimp onto my plate an elderly gentleman in front of me dropped a deviled egg onto the carpet. It shot off the tray and spread its yellow devils all down the paper tablecloth before it hit the ground. I made little soothing comments meant to rescue him from embarrassment as he silently dabbed at the mustard putty like mixture, but he was having none of it. Not even a glance in my direction. Oh yes, I thought to myself, the stoicism and fortitude of the greatest generation. How silly of me to think he’d acknowledge defeat at the hands of an egg.

The place was buzzing with friends and family who’d emerged from obscurity for the party to bid her farewell. I could not help wondering where they had all been during the last six months of her life. Only her nephew and his wife and one friend made pilgrimage on a regular basis to see her. I think the rest of them just showed up for libations, victuals and of course, to do the expected homage to propriety as they got in line for their portion of her large estate.

Having been to many death rituals over the years, it always strikes me how many friends one has once one is dead. How much everyone seems to care once you’re gone; the flowers, the cameo appearances… Like they just parachuted in doing dry runs for their own funerals. I lifted another glass of gin to my friend whose presence I felt keenly, whispering her dry comments about everything transpiring in her name.

Unlike all this, we’d been through some serious stuff together; Leukemia, kidney failure. She had done it with great dignity and humor. We kept her comfortable, at home. She was not one who would’ve tolerated a nursing home well. All the patronization. All the swoop and hover.

I kept thinking how much she would’ve enjoyed her party. Why couldn’t they have done this when she was alive? Why couldn’t have all these people sent her flowers when she could enjoy them? Why didn’t they send her cards or bring over chicken soup, a good joke or a drink? True, she had “No Trespassing” signs out to many but anyone who halfway knew her could read the fine print, “Please come in.”

She only wanted to give an excuse to those who secretly wanted one anyway.

Touching on this with a friend of mine later, he said an aunt of his held her own wake before she died and told everyone just what she thought of them as well as giving thorough instructions for her funeral. A grand idea and one I fully intend to emulate it if I am in any condition to do so.

I remembered the saying “A friend is someone who comes in when the whole world goes out.” Her real friends were those who’d been with her in the days and nights before she died. A single member of her golf sisterhood brave enough to trespass, two young women from the Philippines, an African American women, myself and a faithful nephew whom she taught to drink extra dry martinis.

We were the lucky ones.

29 Oct 2012

Getting Old in Hollywood

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Written by Gaby
When I look around most any restaurant in Hollywood, none of the ladies look old. They may look a little out of this world with the facelift, botox and sometimes breast enhancement but nobody, nobody has the appearance of what I would call an “older person.” Why this dread of aging? Dying, maybe, but what’s wrong with having a history? Beethoven, Willem de Kooning, Franklin Roosevelt, none of them made their mark as youngsters. In maturity, they became memorable.

I grew up in Amsterdam, Holland where aging was respected. Families often lived together, parents, grandparents and children. It worked; one generation helped the other. The young had their grandparents to dote on them, the parents had built in baby sitters, and the old felt appreciated and not isolated and lonely.

What can we do to bring this back? Fire the plastic surgeons with their beauty enhancements or teach children in school that Rembrandt was a star in his own time and not always young. An old Rembrandt is priceless. And so were many artist composers and writers. It was in their prime that they blossomed.

Especially in Hollywood this worship of youth and beauty takes place. When I was a performer, we dreaded getting older. No wrinkles, no white hair, no middle aged body fat— only, a large head of hair, sizeable boobs, white capped teeth, and the smile of a teenager, or at least, early twenties.

What price do we pay for this fear of aging and the lack of respect for the old?

First of all looking for a job at over 50 is almost hopeless. A friend of mine is doing it and not even being a salesclerk is available to him. He has to live on his meager social security or hope to find a well to do companion. Quite a choice, eh?

Can we educate our citizens to open their minds to aging? After all a salesperson over 50 still can do the job and must they look like a teenager? What IS this obsession with youth here in Hollywood? My memories of stars include elders from Spencer Tracy to Bette Davis. Even a droopy eyelid was acceptable; they were stars in spite of vintage years.

I pray that with time this rejection of aging will change. After all, leaders of our country start to get elected mostly in their mature years. Has there ever been a president in his teens or twenties? I admit that at 80 I am propagandizing for senior citizens. Open your minds and judge people by their character, skill and wisdom, not to mention compassion and kindness, the wise words of the Dali Llama.

Ok Folks. Shall we older folks organize like the Weightwatchers or Alcoholics Anonymous? Let me know. I am eager to have YOUR input!  Please email me at

24 Aug 2012

Anne Had Her 93rd Birthday Today

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Anne had her 93rd birthday today. This feisty woman from Brooklyn didn’t look anything like the woman I first met five years ago. At that time she was about to be put on hospice since she had stopped eating and was wasting away in a nursing home. She was literally gray, rigid and staring at the ceiling. She had bedsores all over and was unable to communicate in anything like intelligible language. Although the doctors told her daughter she didn’t have a chance at recovery, her daughter simply didn’t believe that there was nothing more she could do.

She hired geriatric care managers to be her patient advocates and we went to work. Our first consult was with a wound specialist at Pomerado Wound Clinic who told us that in order to give Anne the chance she needed to heal her bedsores and recover her general health; she’d have to have a gastric tube placed to improve her nutritional status immediately. Low protein stores in the body had to be overcome so that her ulcers could heal. Her doctor gave the order and the G-tube was placed. Ann began to go to the wound clinic to get her wounds treated.

Within a short time Ann went home with home health care and private home care. She had her stomach tube in and was still primarily in bed but home health therapists and her caregivers started to get her up to a standing position on a daily basis. With her physician’s support, good therapy and a diligent home care team she soon was out of her bed and up in a chair. She began to eat again, talk again and walk again. Her wounds healed and eventually the G-tube was removed and Anne was back. Everyone was amazed but it was really very simple … this woman wanted to live. She has gone on from that rough time to enjoy her home and her family for several more years. Recently she was placed in a care facility where she continues to have a good quality of life.

Thank God for a daughter who cared enough to give her Mother another chance. Thank God for doctors and nurses who didn’t give up either simply because this woman was in her late eighties and down on her luck.  Thank God for geriatric care managers who aren’t satisfied with the status quo; who believe that every day of life is precious and worth fighting for.

Thank God for doctors who will give their elderly patients the benefit of the doubt when they are very ill and allow their families to try aggressive treatment.  It seems the majority opinion these days is that such patients should or even must go with hospice. Hospice would never have had a G-tube placed. Hospice would have never had engaged the wound clinic. Hospice would have never given the rehabilitation therapy that was necessary to get back to the former level of function.

I am a veteran hospice nurse and dearly love the hospice philosophy. There is certainly a time and place for hospice but it should never be the pathway of choice simply because of advanced age and chronic illness.

FOR SOME ELDERLY, HEAVEN'S JUST A HOT BATH AWAYI’d been diving for attractive artifacts on the ocean floor of my mind. As I rested in the shallow, warm waters off the coast of my bathroom tub, I mused on the absurdity ‑‑ indeed criminality ‑-of the elderly in nursing homes being denied the pleasures of a long soak in hot, steamy water.

For the most part, skilled nursing facilities have common showers where they wheel more than‑slightly embarrassed men and women on “shower chairs” ‑‑ which look like they’re made from PVC pipe ‑­through the hall to be hosed off, in a perfunctory ritual that usually happens twice a week.

That’s right: No tubs.

Well, one place I worked there was something like a tub, which was called a “whirlpool.” There was just one for over 60 people, and you had to have a special doctor’s order to use it. Using something akin to a small cherry picker, they hoisted them up and dropped them in and then fetched them back out again.

Flying through air at the end of a crane is not usually an 84‑year‑old’s idea of a good time.

Recently, while attending to a woman in an Alzheimer’s facility, I saw she had a severe problem with “neurogenic dermatitis,” a skin irritation of psychological origin. We found a cortisone injection that helped tremendously, but she was still terribly uncomfortable and kept scratching and tearing at her skin until it bled. I searched the facility for a tub so I could relieve her misery. I simply could not believe there was no tub on the premises. We improvised and eventually her she could live comfortably in her own skin again.

In my estimation, the absence of such amenities is inhumane. When you are old and aching with arthritis, frantic with dermatitis or have feet and hands numb with cold from poor circulation, a hot bath can be next to nirvana.

At very least it can be a reprieve from hell.

Instead of spending the money to install some bathtubs and hire the extra staff it would take to stay with the patients for a few minutes while they steamed away their pain and weariness, corporate marketing spends lavishly on things they consider essential ‑‑ new wallpaper and carpet, tacky furniture and cheap art. When will those CEO’s care more about how their patients feel than looking good on paper? When will those marketing and PR types figure out that their residents don’t give a flying, furry fig if the place looks like an Ethan Allen showroom?

All they want is a few precious moments of being unworried and pain‑free.

Is a bath once in a while too much to ask for when you are paying so much for care? In most nursing homes in this country, apparently it is.

18 Jul 2012

The Conductor

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Toy TrainGeorge loved trains, music, and women — mostly women.

Age and disability notwithstanding he was always wanting to make love.

It never occurred to him that being nearly immobile presented some difficulties in that regard. For the most part he sublimated quite nicely into fervent hand holding and conducting his imaginary orchestra. He had a silver shock of hair that flopped around on his forehead like Leonard Bernstein when he got carried away. He was once a very powerful man and bitterly missed being important.

When I met him he lived in an exclusive residential facility on top of a hill with a million-dollar view he never saw. He sat in the middle of a huge room where he was enthroned amongst the trappings of a life gone by. A more lonely man I think there never was.

He’d been an executive with the FAA; awards were plastered all over the walls. He had plaques and memorials to service and leadership, and all the accoutrements of wealth and refined taste. Rosewood, and Chinese black lacquer furniture; high level trinkets interspersed with family pictures.

Ah, the family who rarely came.

An unfaithful wife had dumped him when he got older and lost his good looks and influence. He still roared like a wounded beast when he talked about her. But I could soothe him with the magic of trains.

Around Christmas I decided to get him a train set to fill up his cavernous room and got the big kind – H.O., I think — and the track and set them up in front of his recliner. The train set was red and gold and had a lovely whistle.

He was beside himself the first time they made their circle around the little village. I was on the carpet, of course, assembling it, and before we knew it George had slipped out of his chair and onto his knees and crawled over to join me next to the track. He was seven years old all over again and life was grand. He ran that train around and around and around, engineer’s cap on his hoary head.

Even better than the trains, we’d had a good laugh because the witch of a house manager had gone by the window and seen us all on the floor and thrown a fit. She “couldn’t understand,” “never thought,” and “just didn’t see how” for about five minutes, and after she’d huffed and puffed and we were still unimpressed, she simply shrugged and walked away. We exchanged purely wicked glances as delightful as 80-proof plum pudding. When George got tired we pushed and pulled to get all 200-plus pounds of him back up into his Barcolounger and tucked up nice and warm under his blanket with the remote in his hand. He fell asleep, blissfully exhausted.

He was recently moved to a nursing home where he continued to have poor impulse control; a hand up a dress, a fist in someone’s face, food flying at someone who bothered him. He’s got roommates; two unfortunate blokes who have to share a small room with his imperial highness of the ionosphere.

I try to soften the strain on everyone while waiting for a private room. I sing and clown to ease the tension, and scold when I need to.

I wanted to bring his trains and suggested we could set them up somewhere in the hospital where everyone could enjoy them. George could be station master.

It might even keep him out of trouble thought I, but for reasons inexplicable to me, management thought differently. The only nod to the needs of a troubled soul was permission to have a stuffed animal, so I got him a gorilla. He named him – of course, Georgie. The last time I saw him he was holding the black gorilla in his lap, explaining to him in confidential fashion that the food there was lousy.

Then he surprised me. He used Georgie to talk to the woman next to him who had a bear of her own sitting on her lap. She smiled, delighted. The sweetness of it nearly slayed me. Two lonely people in wheelchairs stuck in a nursing home found a way to connect.

Maybe they even became sweethearts – God, I hope so.

20 Jun 2012

San Diego Caregivers Gone Wild!

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Upset WomanOne of the most difficult things that Geriatric Care Managers have to endure is when one of their trusted San Diego Caregivers turns on them. We try not to take this personally as there are a certain number of caregivers in any home care agency who will act unethically and take the company’s elderly client “private.” It is one of the risks we have to accept that the people who we’ve trained and invested in on many levels may, given the right circumstances, decide to steal our clients and begin providing care for them on their own. There are measures put in place on the client side to discourage this but no real mechanisms on the caregiver side other than loss of job to discourage this behavior.

There are so many interesting dynamics in the caregiver/client relationship that lend themselves to an inappropriate working relationship. Indeed without diligent supervision this very close, even personal relationship can morph easily into the classic “undue influence” situation. What’s the profile? A lonely, confused elder without proper family and/or professional support becomes overly dependent on their caregiver and the caregiver responds by crossing professional boundaries. These types of caregivers usually justify this by thinking that they are the only ones that really “care,” and thus is the classic start to a potentially abusive relationship. It is usually financial abuse that ensues, not physical abuse. It is not unusual for checks to be given to the caregiver to “help” with their emergencies and family problems and then develop into more substantial agreements including getting themselves mentioned in wills etc. Though usual financial indiscretions are most common, it does escalate on occasion to something more serious and life threatening. San Diego elder abuse units could give you more details than you’d ever want to have on exactly how often this happens.

I am limiting myself in this blog only to those seemingly innocent and well intentioned caregivers who encourage their agency’s clients to hire them privately. The motivations for “going private” are clear. These caregivers can make more money without the middle man. By avoiding taxes, worker’s compensation and insurances and all the protections that bona fide home care companies provide their clients, they put themselves and their clients at risk.

Of course they never see it this way and neither do the clients or their families… until it is too late.

Our San Diego Caregivers are one of the most important aspects of our elder care services and it is heartbreaking when they betray the trust placed in them. Our caregivers are our friends, our students, our pride and joy. Often, they are our heroes. They provide the very best care in our communities and most of the times do this as humble, grateful and proud members of a dedicated elder care team.

As far as the bad apples go, what can anyone do? What you can do is report any questionable or potentially dangerous to Adult Protective Services.

an elder blowing bubblesGeriatric Care Management provides rich opportunities to meet very special individuals, both other health care providers and of course clients and their families.

Recently, I met a wonderful woman at the monthly support group for the San Diego Brain Injury Foundation. Her name is Rachel Downing. Rachel is an LCSW with a background of pioneering work with the first Adult Day Health Program in the country. Rachel worked at the USC Andrus Gerontology Center doing early research on elder care management and also worked at John’s Hopkins Hospital as a member of their Geriatric Assessment Team. But here’s the most special thing about Rachel and her gift to give the brain injury community, she is a traumatic brain injury survivor and a stroke survivor herself.

In 2008 and 2010 Rachel suffered TBI (traumatic brain injury) from a fall and two years later, a CVA and has come back from both of these devastating blows with wisdom, skill and passion to help others. She has developed a specialized program for recovery from brain injury and is making it available to Grace Care’s clients and to anyone who is looking to maximize their rehabilitation using the same techniques that helped her regain her function and live a full and satisfactory life.

She says “Recovery from a brain injury is a long process. After official intervention of speech, occupational and physical therapy, much more can be done to continue recovery.  Individuals need the stimulation of new activities to support brain recovery. Every opportunity to socialize and chat makes a difference. The brain needs both physical activity and mental exercises to build new neural pathways.”

Rachel shares just a few of her techniques:

1. Coloring in coloring books using both hands.
2. Writing with the non-dominant hand.
3. Reading out loud, forwards and backwards. Summarizing what you read.
4. Listening to books or educational material on CD.
5. Playing with blocks and other building materials.
6. Imagining achieving your goals.
7. Playing word games.
8. Playing ball, playing catch with friends and family.
9. Prayer, meditation, listening to music and singing.
10. Celebrating small victories.

These are just a few of Rachel’s techniques and the very things that helped bring her back. She is anxious to share her talents, vast clinical background and her personal journey overcoming the unique obstacles encountered in recovery from brain injury and stroke.

Thank you Rachel for all you are doing!! You are a blessing and we look forward to working together to serve the brain injury community in San Diego.

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