These are Responsible for 40% of All Injury Deaths

Q. Recently, we got a call from the emergency room that my husband’s grandmother fell outside of a store and fractured her wrist. It was a rainy night and she slipped on the ramp walking out of the store.

Typically, when you hear about falls, you hear about instances where they occur on a rug that isn’t affixed to the floor in the living room or in the bathtub. You don’t hear a lot about outdoor falls, how often they occur, how they can be prevented, and how to make things safer for loved ones.

We are concerned about grandma, who is currently aging-in-place, and want to protect her as best as we can. Do you have any suggestions for us to better ensure her safety?

A. Falls can happen at any place and at any time, which is why it is so important to take extra precautions to ensure the utmost in fall prevention strategies.

While it is true that falls are most common inside the home, as you have experienced with your husband’s grandmother, it doesn’t mean they can’t happen outside the home, as well. In fact, falls (whether they are inside or outside the home) are the number one reason that seniors end up in the emergency room, accounting for over 50% of injury-related hospital admissions and 40% of all injury-related deaths

Organized efforts to prevent outdoor falls by older adults, sadly, have been somewhat neglected, as most research has focused on falls occurring in the home or hospital environment. However, outdoor falls are frequent with approximately half of falls among adults aged 65+ occurring in outdoor environments. Up to now, little research has been available about the contexts in which outdoor falls occur, how features of the external environment can present as risk factors for outdoor falls, and which outdoor falls are more likely to lead to injury and/or fear of falling.

However, a new study, conducted through New York University and published in the journal Archives of Gerontology and Geriatrics, focused solely on the outdoor fall experiences of older adults living in New York City. The findings are being used to develop and pilot an outdoor fall prevention program.

For the study, the researchers set out to investigate the experiences and fall prevention knowledge of older adults living in the community. Findings were as follows:

• Researchers surveyed 120 adults, ages 55 and older.
• Of those surveyed, 71% (85 people) had fallen outdoors in their adult years.
• Of those who had experienced an outdoor fall, 28 had minor injuries such as scrapes and bruises, 18 had moderate injuries with prolonged pain or soreness, and nine had severe injuries such as fractures, rotator cuff injuries, or injuries requiring stitches or surgery.
• Beyond physical injuries, respondents commonly described having an emotional response to the fall, including fear of falling again or embarrassment.
• A number of people surveyed reported their falls occurring during otherwise healthy activities such as exercising or walking a dog. For many participants, the falls were triggered by environmental factors, such as objects (metal post, branch, stones), surface conditions (slippery or uneven) or stairs, particularly at entranceways. Many participants attributed falls in part to their own practices, such as wearing ill-fitting or inappropriate shoes, not paying attention, or walking too fast.
• In addition, those surveyed frequently described multiple factors that contributed to their fall, such as rushing on an icy surface or being distracted on an uneven surface.

The study highlighted several aspects of the outdoor environment that may represent risk factors for outdoor falls and associated fear of falling. It also revealed a number of unmet education and training needs for outdoor fall prevention among older adults and caregivers.

What You Can Do

While many senior care providers have implemented safety tips and strategies in order to prevent seniors from falling inside the home, there are also additional steps that need to be taken by caregivers for when seniors leave the home, as well.

• Use your best judgement: If the weather looks bad and it isn’t an emergency, urge your loved one not to leave the house.
• Suggest that he or she pay close attention to curbs, ramps and elevation changes, as they are some of the main reasons that seniors tend to trip and fall. Make sure that you are looking out for drops in the pavement, uneven terrain or slippery surfaces (watch for holes, tree roots, and ice).
• Wear shoes that fit: Make sure that seniors are wearing properly-fitting shoes with plenty of traction on the bottom; this can help a great deal. There are also special accessories you can add to the bottom of the soles of your loved one’s shoes to lessen their chances of slipping.
• Walk on grass if sidewalks or roads appear to be slippery or uneven(grassy areas provide more traction and solid footing).
• Wear correct eyewear when walking(reading glasses or bifocals can distort the ability to see potential hazards). Consider wearing sunglasses (glare from the sun can hide areas, which can lead to falls).
• Walk in well-lit areas in the eveningto provide the most visibility for hazards.
• Walk hands-free using a fanny pack or an over-the-shoulder bag instead of a purse or hand-held bag.
• Wear hip pads or protectorswhile walking to ensure the protection of bones and to avoid hip fractures.
• Make sure your loved ones have their mobility aides, such as their canes, wheelchairs, or scooters, whenever they leave the home, even if you don’t think they will be travelling far.
• Accompany your loved one by holding on to his or her arm or hand while walking. This is one of the best ways to make sure an elder has the stability needed.

Health professionals, as well as caregivers, are recommended to consider outdoor environments as well as the home setting when working to prevent falls and increase mobility among older people. Adults could benefit from training on fall prevention strategies, including safety during routine activities such as carrying items on uneven surfaces, going up and down stairs, and opening or closing doors. Education around safe outdoor walking strategies (avoiding distractions, navigating sloped and uneven surfaces, and walking slower) would also be beneficial, and more opportunities for such education are much needed.

What Happens If a Loved One Falls and You Are Not Around?

Sensor-based home monitoring systems can alert a family member or caregiver of an emergency or when something unusual has happened. Some Personal Emergency Response Systems (PERS) also contain GPS technology. If in trouble, the wearer can press a button and be connected with a call center that can dispatch help and notify caregivers. Many PERS devices only work at home, but a few allow the wearer to get help wherever they are — on the golf course, in the car, or around the block. Examples of such technology include the GreatCall 5Star Urgent Response, MobileHelp, or Life Alert.

When Taking Preventative Measures Isn’t Enough

When taking preventative measures isn’t enough, assisted living or nursing home care may be needed for your loved one. Nursing homes in our area can cost as much as $150,000 per year. Life Care Planning and Medicaid Asset Protection is the process of protecting yourself or your loved ones from having to go broke to pay for nursing home care, while also helping ensure that you or your loved ones get the best possible care and maintain the highest possible quality of life, whether at home, in an assisted living facility, or in a nursing home. Please call us to make an appointment for a no-cost initial consultation:

Fairfax Elder Law Attorney: 703-691-1888

Fredericksburg Elder Law Attorney: 540-479-1435

Rockville Elder Law Attorney: 301-519-8041

DC Elder Law Attorney: 202-587-2797

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Who Gets to Control my Dead Body? Part 2

By Fredrick P. Niemann, Esq. of Hanlon Niemann & Wright, a Freehold, NJ Estate and Probate Attorney

In Part 1 of this series I introduced you to a court case involving who has decision making powers over funeral arrangements and payment obligations among family members. In Part 2 I will be discussing the appeal of this case.

The interment statute of New Jersey, creates a hierarchy as among survivors for purposes of determining which of them is authorized to control the disposition of a loved one’s remains. At the same time, however, the statute expresses a preference for carrying out the wishes of the decedent by referring to the right of the decedent to give directions and by authorizing others to act only in the absence of such directions. This enumeration is necessary to make clear “who may decide on burial…to avoid, or to end quickly,” disputes regarding burial.

In this appeal of the trail court decision there is nothing in the statute providing that the statutory hierarchy should be modified based on whether natural born children inherit or are disinherited under the will. Their exclusion from the Will could reflect decedent’s charitable nature, or that the children were provided for otherwise during the decedent’s lifetime, or that they did not require a bequest.

Under the will, the decedent directed that her “just debts and funeral expenses” be fully paid and satisfied. It was the Executor’s task to “settle and distribute the estate…in accordance with the terms of any…will” (N.J.S.A. 3B:10-23). This obligation included the payment of funeral expenses. With that said, however, when a third person makes funeral arrangements for a decedent at the expense of the estate, “all of the authorities uniformly hold that the expenses incurred must be reasonable.” In a reported decision a wife unilaterally made funeral arrangements for her husband, but the Estate refused to pay for the cost, stating it was unreasonable. The court held that the Estate was liable for reasonable funeral expenses and the wife was liable for anything above what was reasonable. The cost of the funeral expenses and burial of the decedent should take into account her “circumstances and social condition…and the value of her estate.”

The take away from this case is that all Last Wills should explicitly designate a funeral representative but in the absence of same, the law defines the priority of decision makers. And always remember, if conflict results, funeral expenses must be reasonable if the person who pays them seeks to be reimbursed from the estate.

To discuss your NJ Estate and Probate matter, please contact Fredrick P. Niemann, Esq. toll-free at (855) 376-5291 or email him at fniemann@hnlawfirm.com.  Please ask us about our video conferencing consultations if you are unable to come to our office.

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Who Gets to Control my Dead Body? Part 1

By Fredrick P. Niemann, Esq. of Hanlon Niemann & Wright, a Freehold, NJ Estate and Probate Attorney

Here is another recent court case involving priority of decision making for funeral arrangements and the payment obligations for that funeral among family members and the estate executor when a conflict on reimbursement costs comes up.

N.J.S.A. 45:27-22(a) provides that if a testator (creator of the will) appoints a person “to control the funeral and disposition of human remains, the funeral and disposition shall be in accordance with the instructions of the person so appointed.” However, if no such person has been appointed, and no other direction has been given by a court, then the statute sets forth a hierarchy of individuals allowed to control the funeral and disposition of remains. Specifically, the statute cites:

If the decedent has not left a will appointing a person to control the funeral and disposition of the remains, the right to control the funeral and disposition of the human remains shall be in the following order, unless other direction has been given by a court of competent jurisdiction:

1) The surviving spouse of the decedent of the surviving domestic partner.

2) A majority of the surviving adult children of the decedent.

3) The surviving parent or parents of the decedent.

4) A majority of the brothers and sisters of the decedent.

5) Other next of kin of the decedent according to the degree of consanguinity.

6) If there are no known living relatives, a cemetery may rely on the written authorization of any other person acting on behalf of the decedent.

Here, the court found that “because the children of the decedent were explicitly written out of the will…the statute clearly indicates that the brother had the legal authority to direct the funeral.” Thus the issue was taken up on appeal.

To discuss your NJ Estate and Probate matter, please contact Fredrick P. Niemann, Esq. toll-free at (855) 376-5291 or email him at fniemann@hnlawfirm.com.  Please ask us about our video conferencing consultations if you are unable to come to our office.

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Are Faith Leaders Trained to Talk to About End-of-Life Topics?

My wife and I are over 65, and are both ready to discuss the topic of death and end-of-life planning. We spoke about it amongst ourselves, but need some guidance. We are religious, and would like our religious leader’s advice in this area before we make any decisions, but are concerned that he may not be trained to discuss the medical aspects of end-of-life topics, and may only be trained to provide a religious perspective. We hope he can lead us in the right direction, but may need more than he can provide. Since they often sit with those who are sick, and pray for them, do you know if clergy members are typically trained in end-of-life topics? Thank you in advance for your guidance.

What will be most important to you at the end of your life? It’s a tough question, and one that many of us avoid discussing. You and your husband, however, are wise in your intent to address it with someone you rely on for advice, such as your pastor. Your concern about whether clergy members are experienced in discussing these topics is a good one, however. Let’s explore what is happening with faith leaders in their experience with discussing death and dying.

Training on End-of-Life Topics for Religious Leaders is Much Needed

Confronting sickness and death is part of a faith leader’s job description. We often see members of the clergy sitting with congregants during chemotherapy treatments and other life or death medical situations, and praying with them in the midst of pain. Faith leaders often prepare for this work at school, spending a semester working as a hospital chaplain or volunteering at a nursing home. However, some still enter professional ministry unprepared to sit at someone’s bedside and offer advice, according to recent research on religion and end-of-life care.

The research included two new studies, which are both part of Harvard University’s “National Clergy Project for End-of-life Care,” and the findings were that many clergy are both ill-prepared and reluctant to fully engage in end-of-life conversations with congregation members and their families.

One of the studies was a national survey of more than 1,000 clergy. The other involved in-depth interviews with 35 ministers from five states. The research raises four critical areas of concern:

• Too much faith in miracles: More than 3 in 10 clergy said they would strongly agree with a congregant who said, “I believe God will cure me of this cancer.” Only 18% affirmed the belief that every medical treatment should be accepted “because my faith says to do everything I can to stay alive.”
• Lack of knowledge: Spiritual leaders showed little knowledge of end-of-life care, including the benefits of palliative care and potential harms associated with invasive interventions. “Many grossly overestimated the benefits of aggressive medical procedures at the end-of-life,” researchers reported in the Journal of Palliative Medicine. Three-quarters said they would like more training in end-of-life issues.
• Fear of overstepping boundaries: The default position of many clergy, even those who personally believed it was against God’s will to suffer unnecessarily, was to merely support the decisions of dying congregants and their family members.
• Conflicting principles: Spiritual principles, such as the sacredness of life and the capacity for divine healing may come into conflict with other religious principles to comfort the suffering and place faith that God will care for individuals after this life.

The study found that some religious leaders do not offer guidance out of respect for the “free will” of congregants, but researchers indicated a lack of knowledge of the medical consequences also played a role.

Around 3 in 4 faith leaders are open to training on end-of-life care, the research showed. For those who are willing to discuss end-of-life topics, The Clergy Project program leaders are working on a free end-of-life care curriculum to empower faith leaders, highlighting the important role religion often plays at the end of people’s lives. “What clergy say — and what they do not say — can make a major difference in whether believers experience a ‘good death,’” the Association of Religion Data Archives reported in its overview of the research.

Be sure to check with your religious leader to see if he or she feels comfortable sitting down with you and your husband to discuss your end-of-life wishes.

Medicare Recipients Can Consult a Doctor on End-of-life Topics at No-Cost

Whether or not you meet with your pastor, it is a smart idea to take advantage of Medicare’s coverage of end-of-life discussions with a doctor, as well. Last year, in the first year end-of-life conversations with doctors were covered by Medicare, 14,000 providers billed almost $35 million — including nearly $16 million paid by Medicare — for advance care planning conversations for about 223,000 patients from January through June.

The rule requires no specific diagnosis and sets no guidelines for the end-of-life discussions. Conversations center on medical directives and treatment preferences, including hospice enrollment and the desire for care if patients lose the ability to make their own decisions. The conversations may occur during annual wellness exams, in separate office visits or in hospitals. Nurse practitioners and physicians’ assistants may also seek payment for end-of-life talks.

Make sure your end-of-life plans are followed with an Advance Medical Directive

It is commendable that you are taking the steps to discuss your end-of-life planning. After doing so, it’s a good time to make sure your wishes are spelled out and available for your loved ones in your legal documents. If you have not done Long-Term Care Planning, Estate Planning, and Incapacity Planning (or had your Planning documents reviewed in the past several years), or if you have a loved one who is nearing the need for long-term care or already receiving long-term care, call us to make an appointment for a no-cost consultation:

Fairfax Elder Law: 703-691-1888

Fredericksburg Elder Law: 540-479-1435

Rockville Elder Law: 301-519-8041

DC Elder Law: 202-587-2797

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Critter Corner: Talking About Death Over Dinner

Dear Angel

My wife and I have most of our important conversations while we are sharing a meal. We are beginning to see the importance of planning for our future and for our loved ones. We have two young children to think about and recently witnessed a loved one on her side of the family passing away without her documents in place. I read about something called, “Death Over Dinner.” Do you know anything about it and how we can set it up in our home?

Thanks,

Dean Errtox

—-

Dear Dean,

I am sorry for your loss.

Conversations about End of Life Care often take place at a hospital during a crisis. Many people die in a way they wouldn’t choose, with loved ones left feeling guilty, bereaved, and anxious.

The Death Over Dinner movement was created by Michael Hebb to enable people to share end of life wishes and plan a dinner to help others share theirs.

In a TEDMED talk about the project, Hebb says he was inspired after coming across two startling statistics: “The vast majority of American bankruptcies are related to medical expenses, especially those related to end-of-life care;” and “(w)hile 75% of Americans say they want to die at home, only 25% actually do.” How we end our lives, he says in the talk, is the most important and costly conversation we aren’t having.

“The dinner table is the most forgiving place for difficult conversation,” the project’s website notes. “The ritual of breaking bread creates warmth and connection, and puts us in touch with our humanity.”

For those who want to host a dinner, the project’s website offers suggested reading for guests to peruse before they gather.

Since the Death Over Dinner project was founded two years ago, more than 70,000 people in over 20 countries have gathered to dine and discuss their views on a “good” death, and the issues that will matter to them in their senior years. If you decide to share a discussion about death and a delicious dinner with friends, we hope it goes well, and please be sure to share your experiences with us in the comment section below!

Hope this is helpful,

Angel

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