Long-term care

[EdwardjK]

A few comments on long-term care (LTC) posted on the "PP Safe Withdrawal Rate?" thread causes me to start this discussion.  I will let the moderator decide whether this is the best placement of this thread.

My wife and I are both 55 years old and have no children.  No children and two decent careers have enabled us to save enough to fund 30 years of estimated retirement spending, assuming no inflation, and to retire within the next year.  So my long-term investment return objective is to at least earn the rate of inflation.

While having no children enabled us to build our wealth, one day we talked about who would care for us when we are too old to care for ourselves.  We did not come up with a good answer.  I am the youngest of 5 children, and my father is alive, well and living on his own at 95 (and still driving!). My wife is the oldest of 4 children, and both her parents have or had major health issues.  Although we have lots of nieces and nephews, we are not especially confident that they will be available to care for us.

So, we recently purchased long-term care insiurance from Genworth Financial.  It will be paid off in 9 years and provide a 5% inflation growth rate every year.  We purchased a reasonable amount of coverage, thinking if one of us needed coverage we didn't want to bankrupt the other.

I am interested in learning others plans and thoughts on how they intend to handle LTC in their later lives.

Thanks.

[Reub]

The problem with LTC, in my opinion, is that it may still land you and/or your wife in a facility where you will be at the mercy of the local staff and give up your humanity and your rights. There has to be a better way.

[notsheigetz]

I think I started the Long-term care subject in the other thread.

My plan of owning a retirement home in a foreign country obviously isn't for everybody so I'll tell you what my parents would do if they had it to do over again. Actually, it was what they were planning on doing all along but they waited too long. I am told this is a very common mistake that the elderly make in over-estimating how long they will be able to take care of themselves. I find this very understandable as it must be a very difficult thing to come to grips with.

My parents planned on following the lead of my dad's brother in checking into a retirement home where they provide you with a nice apartment to begin with and the assistance you receive is based on what you need as the years go by. My aunt and uncle were well pleased with it.  My uncle has since passed on but my aunt is still living there getting by with minimal assistance.

Unfortunately, the bottom line was that you had to pay a large up-front fee to enter the facility and you had to be in reasonably good health when you checked in. My parents balked at the up-front fee as it would have been more than 1/3 of their life savings although they intended to do it eventually. Well, eventually is never going to come now because my dad is no longer acceptable.

I don't know how many facilities like this there are but it seemed like a lot better way to manage things than what my parents have ended up with.

[moda0306]

A good long-term care insurance policy bought when you're in your 40's or 50's makes so much sense.  Everything's a financial-planning nightmare if you don't know what your LTC situation's going to be.  You could be sitting on millions when you croak or lose all your wealth over a few year span.

I don't like that huge of an outcome spread.

[notsheigetz]

A good long-term care insurance policy bought when you're in your 40's or 50's makes so much sense.  Everything's a financial-planning nightmare if you don't know what your LTC situation's going to be.  You could be sitting on millions when you croak or lose all your wealth over a few year span.

I don't like that huge of an outcome spread.

Somebody selling LTC insurance came to my company a few years back and tried to market it to the younger people with the sales pitch that you will get all the money you paid in premiums back if you end up never needing LTC. They all just sat and stared off into space.

Can't say as I really blame them. You can get some people to think about saving for retirement but make plans for LTC? Very hard, I think. Not many people even want to think about it.

[moda0306]

LTC for a young person is a little much, but if I had $15 per month to apply to insurance policies I'd put that towards long-term care insurance (I'm 28) before wedding ring insurance or cell phone insurance... maybe even comprehensive auto if on a <$15k car.

[sophie]

I think people are talking about a couple of different types of long term care...

Assisted living or "aging in place" is a great plan to help you keep your independence as long as possible.  I've jokingly called Manhattan "the world's largest assisted living center", because you don't need a car (a real consideration as you age), there are neighbors and building staff to help you, and anything and everything can be delivered.  A senior community that provides all those services, plus makes it easy to get visiting nurses, home health aides etc, can make it a lot easier to stay out of nursing homes until the last split second.

Terminally ill patients (defined as < 6 months prognosis) can elect hospice care, either at home or in a facility.  This is usually very humane and well done, by people who truly care about what they're doing.

In between we have the nightmare scenario:  in a nursing home or SNF with advanced dementia or in a vegetative state, pretty much just waiting endlessly for the exit, Terry Schiavo or Karen Quinlan style.  No one ever wants this to happen, but unfortunately it may be in the cards for some of us.  Long term care insurance can keep you out of Medicaid facilities and preserve your nest egg, but take care to read the fine print.

If you want to try to minimize the chances of ending up in that situation, you can elect to forgo heroic measures or aggressive care.  Advance directives, unfortunately, are nearly useless because in real life, there are always nuances that make it impossible to apply them.  They're also going to be overruled by any family member who steps in and expresses an opinion.  The best way is to choose a short list of trusted health care proxies from among your family and friends, and discuss your wishes with them ahead of time.

Whew, what a bummer of a post...but excellent and very brave topic to bring up in an online forum.  Good for all of you.

[MachineGhost]

Whew, what a bummer of a post...but excellent and very brave topic to bring up in an online forum.  Good for all of you.

Although I don't believe in it, setting a little aside every month for cryopreservation could be a good move too.  I just don't see the point in freezing my head or body after I'm already dead.  Why not before?

[notsheigetz]

If you want to try to minimize the chances of ending up in that situation, you can elect to forgo heroic measures or aggressive care.  Advance directives, unfortunately, are nearly useless because in real life, there are always nuances that make it impossible to apply them.

I think the problem with advance directives is that you can ask to forgo "heroic measures" and "aggressive care" but you can't ask for benign neglect of normal treatment. Well, maybe you can ask but I doubt if any medical professional would take the chance of honoring the request. In my dad's case I suspect he would have expired by now if they weren't constantly monitoring his blood pressure and insulin levels. And that, to me, is the big problem with checking into the system. Leaving aside the profit motive, you can't ask professionals to not be professionals. I don't really fault the doctors in this scenario. Seems to me like they are being put between a rock and a hard place - damned if they do and damned if they don't. 

[BearBones]

The ideal LTC would be family and community, IMO. Pay in early, then be taken care of by loved ones when you are infirm. When there is little quality of life left, have documents in force to stay out of the hospital so that you can die a dignified death. Any of the Early Retirement Extremers have any thoughts?

[Xan]

There's a great essay from not too long ago called "How Doctors Die":
http://zocalopublicsquare.org/thepublic ... ead/nexus/

And a follow-up:
http://zocalopublicsquare.org/thepublic ... ead/nexus/

Neither are long, and they are really important to read.

[sophie]

There's a great essay from not too long ago called "How Doctors Die":
http://zocalopublicsquare.org/thepublic ... ead/nexus/

And a follow-up:
http://zocalopublicsquare.org/thepublic ... ead/nexus/

Neither are long, and they are really important to read.

Thank you, Xan, for that link.  Everyone else, if you haven't read it yet, please do.  It's absolutely true.

I could tell story after story of hospital cases that absolutely horrified me, just like the ones in the article, and had me and all the other physicians around saying the same thing:  "That will never happen to me, or to anyone I care about."

Fear of the legal consequences are definitely a big reason why we end up going against our better judgment - like the story in the article about the nurse who reported a doctor for turning off a ventilator on a patient who clearly had a grim prognosis.  A bigger factor, though, is that people's idea of prognosis comes mainly from TV and movies.  Patients who are comatose, for example, always manage to recover, sometimes jumping right up and shooting the bad guy, and manage to stay looking tanned and fit throughout ("sleeping beauty syndrome").  So of course the family is going to say "do everything."  In real life, it's not so pretty and meaningful recoveries are almost unheard of.

Medical culture is another big difference.  We have physicians who come from Canada for specialty training, who shake their heads in disbelief at the prevalence of futile care here in the U.S.  One of them told me a story about "room 52".  It's a quiet, pleasantly furnished room near the ER at his training hospital in Newfoundland that they reserved for, say, a 70 year old with large brain hemorrhage.  We of course had no such room - instead, that patient would end up in an intensive care unit on a vent with an ICP bolt and microdialysis bundle, central line, arterial line, multiple drips, etc, for usually 1-2 weeks before the inevitable happened - usually multiorgan failure, sepsis or ARDS.  Which is why an infectious disease attending that I remember from internship called pneumonia "the friend of the elderly".

So now our secret is out.  And by the way...you or a health care proxy can refuse all the medical care you want.  Even if it's "normal treatment."  There's such a thing as "comfort care only", and that is not applied nearly as often as it should be.

[MachineGhost]

So now our secret is out.  And by the way...you or a health care proxy can refuse all the medical care you want.  Even if it's "normal treatment."  There's such a thing as "comfort care only", and that is not applied nearly as often as it should be.

So why is POLST better than an advanced care directive?

[stone]

There's a great essay from not too long ago called "How Doctors Die":
http://zocalopublicsquare.org/thepublic ... ead/nexus/
And a follow-up:
http://zocalopublicsquare.org/thepublic ... ead/nexus/
Neither are long, and they are really important to read.

What I find totally perplexing in the UK is that we have endless debates about euthanasia with people traveling to Switzerland with a press pack in tow and yet commonsense stuff like this doesn't get that coverage.