Long-Term Care Planning

[moda0306]

Thought I'd bring up possibly the most morbid topic imaginable... I am very curious on people's thoughts on both the events themselves, including any stories they wish to share that they think are pertinent, as well as hit on how people think one should pre-plan for these events.

I'll start by pointing out that after hearing my sister's stories from working in a nursing home, I'm not left very pleased with the options our governments give us.  For instance, yes, if you require a feeding tube for an extended period of time you can have a health directive in place that allows you to "pull the plug," but most states don't allow physician assisted suicide.  We simply arent in a position where an alzheimers patient is going to be allowed to have pre-directed his/her own peaceful death on their terms.

So should we just give up and purchase long-term care insurance?  Should we tell our families to fly us to Montana (if we so wish) if we're not of sound mind to allow us to pass on our terms?

Any other things to consider?

[WiseOne]

Well-timed post.  Unfortunately my mother and I have been talking quite a lot about this with recent events.

The new 5-year spend-down rule says that the time-honored trick of hiding assets by giving them to family in order to protect them from from being drained by nursing home bills before Medicaid kicks in, will not work unless the assets have been out of your possession for at least 5 years.  I don't know more than this superficial level of detail, but I will soon because my mom is meeting with the estate planning attorney asap.  If anyone else knows more about this please do post!  My understanding now is that if my father ends up in a nursing home, my mother stands to lose everything except the house, one car, and $2,000 - including a family business that she shares with two sisters and that all of them rely on for income.

Regarding the feeding tube, the solution is simple:  refuse the peg (minor surgical procedure to get direct access to stomach/duodenum).  No peg, no long term feedings.  Putting one of those in a patient with advanced Alzheimer's or low quality of life with no hope of meaningful recovery is almost criminal, yet it happens every day.

[Benko]

No peg, no long term feedings.  Putting one of those in a patient with advanced Alzheimer's or low quality of life with no hope of meaningful recovery is almost criminal, yet it happens every day.

Our society is not ready to decide otherwise.

IF you ask the next of kin e.g. children what they want or don't want done for their parent who cannot decide for themselves, you will not infrequently be told they want everything done  (unless things have changed since I was involved in the process).

[MachineGhost]

So should we just give up and purchase long-term care insurance?  Should we tell our families to fly us to Montana (if we so wish) if we're not of sound mind to allow us to pass on our terms

I think you might be looking at this issue wrong.  The point of LTC is like any other insurance, to protect your assets, not guarantee a Health Care Directive.  You cannot wind-up on the state dole via Medicaid without having an earned/unearned income of less than $900 a month and assets of less than $2K (less a few exceptions for house, car, etc).  Even with a limit of $14K, it would take a while to gift all of your assets to your beneficiaries.  And why would you want to repudiate all your life's success just to be able to be taken care of in low-rung, shitty nursing homes which are for-profit businesses caring more about Medicaid compensation than patient's well-being?  Benign neglect is still neglect.  I have seen enough of them to be disgusted and sad.  Everything about the USA nowadays is an increasing crony capitalist corruption of one sort or another, most especially in the sick-care industry.

All of us should be buying LTC now, while its cheap.  But denial is a powerful block.  Obama torpedoed their public LTC plan because it was financially unsustainable.  Well, I will guarantee you, some government program eventually will be providing LTC for Boobus Americanus.  And it won't be pretty.

[moda0306]

MG,

My comment about "giving up and purchasing LTC insurance" was probably a bit misstated.  I strongly believe in insuring away large economic exposures with a low likelihood of happening.  In fact, I think insuring the wrong things and not insuring things like disability and LTC is one of the biggest financial planning blunders our society is making.

I am almost thinking that those that scoff at LTC insurance should then take some other initiative towards limiting their potential liability.  If there is some option to do so then I think it would serve us all to know those avenues.  It just seems so unnecessary the way we do things now.

[MachineGhost]

I am almost thinking that those that scoff at LTC insurance should then take some other initiative towards limiting their potential liability.  If there is some option to do so then I think it would serve us all to know those avenues.  It just seems so unnecessary the way we do things now.

Other than life extension, I can't see another initiative.  And I bet you that area has even less support than LTC insurance.  It threatens a humungous largesse of crony profits.  Which is exactly why I support it.

[moda0306]

What's "life extension?"  That sounds like it implies actually trying to live longer... I thought the solution was the opposite...

[MediumTex]

A person who stays physically and mentally active, maintains a healthy body weight and avoids lifestyle risks like smoking, living next to a lead smelter and that sort of thing should be able to expect to die like an animal in the wild--i.e., with good health late into old age followed by a brief final illness.  That's how I hope it turns out for me, anyway.

This business of hanging on when quality of life is near zero is a strange tendency that modern people have.

I think that every person should have the opportunity to die a heroic death, and the slow process of a bag of bones expiring in an assisted living facility is hardly heroic.  It's quite pathetic really.

Having seen a few of these old-people-dying-in-a-nursing-home scenarios, death often feels to the family and friends more like a relief than anything else.

[MachineGhost]

Having seen a few of these old-people-dying-in-a-nursing-home scenarios, death often feels to the family and friends more like a relief than anything else.

I feel exactly the same way but it appears that it still shocks people to keeping voicing it.  At some point its just not worth "fighting city hall" when the quality of life is horrid.  Appeasing guilt seems to be a bottomless pit of hell.

[Pointedstick]

Having seen a few of these old-people-dying-in-a-nursing-home scenarios, death often feels to the family and friends more like a relief than anything else.

I feel exactly the same way but it appears that it still shocks people to keeping voicing it.  At some point its just not worth "fighting city hall" when the quality of life is horrid.  Appeasing guilt seems to be a bottomless pit of hell.

Agree 100%. Watching my grandmother slowly waste away physically and mentally in one of those horrible places made me resolve to exercise every possible effort to keep anyone I care about out of the same situation.

I like MT's idea about a heroic death. Something outdoorsman-ish appeals to me. Maybe hunting boar or mountain climbing or something. Anything's better than rotting your body and mind away watching daytime television in a sterile room, hooked up to cold and unfeeling machines, far from friends or loved ones.

[moda0306]

MT,

Is there any evidence to suggest that living a healthy lifestyle will ward off dimensia in the form of MS and alzheimer's, or any one of a number of other debilitating diseases?

I agree with what you're trying to say, but as something like MS slowly eats away at someone, there is no plug to pull, and nobody's going to drive Grandpa out into the mountains to hunt a bear in his wheelchair with his old Army knife.

At this point, Grandpa can't legally ask someone to help end his life with dignity.  His only option might be to move to one of the few states out west that allow it and complete the procedure, but he better make damn clear to his family that this is what he wants before he falls into dimensia.

Also, sometimes people fall into a physical disability with their brain fully in-tact.  In that position, it might be more difficult for them to order a PAS because they still love seeing their Grandchildren and kids come to visit, even if they can't do some things themselves.

This is why I started this thread.  I think it would help to fully sort through this whole issue, because I think we could easily end up in a situation that we hadn't fully thought out and our attitudes towards nursing homes don't quite manifest themselves the way we thought they would.

Any one of us, healthy or not, could develop dimensia, or some physical condition, that requires help with ADL's (activities of daily living).  I think, as practicers of good risk-management planning, it's best to understand if we are leaving ourselves or our families exposed to any financial or "lifestyle" risk (the latter being my term for inadvertantly ending up being treated differently in a long-term care scenario than you would have liked to see youself).

[MediumTex]

MT,

Is there any evidence to suggest that living a healthy lifestyle will ward off dimensia in the form of MS and alzheimer's, or any one of a number of other debilitating diseases?

I agree with what you're trying to say, but as something like MS slowly eats away at someone, there is no plug to pull, and nobody's going to drive Grandpa out into the mountains to hunt a bear in his wheelchair with his old Army knife.

At this point, Grandpa can't legally ask someone to help end his life with dignity.  His only option might be to move to one of the few states out west that allow it and complete the procedure, but he better make damn clear to his family that this is what he wants before he falls into dimensia.

Also, sometimes people fall into a physical disability with their brain fully in-tact.  In that position, it might be more difficult for them to order a PAS because they still love seeing their Grandchildren and kids come to visit, even if they can't do some things themselves.

This is why I started this thread.  I think it would help to fully sort through this whole issue, because I think we could easily end up in a situation that we hadn't fully thought out and our attitudes towards nursing homes don't quite manifest themselves the way we thought they would.

Any one of us, healthy or not, could develop dimensia, or some physical condition, that requires help with ADL's (activities of daily living).  I think, as practicers of good risk-management planning, it's best to understand if we are leaving ourselves or our families exposed to any financial or "lifestyle" risk (the latter being my term for inadvertantly ending up being treated differently in a long-term care scenario than you would have liked to see youself).

I'm not saying that long term care insurance isn't a good idea.

I'm just saying that I think it's important to be realistic about what the point is of long term care beyond a certain point.

[moda0306]

MT,

I totally agree.

I started this thread as a space for brainstorming a solution to these issues, because left to their own devices, our families will probably default to keeping us alive, and even if we wanted to at some points, ending our life with dignity may or may not be illegal.

Just curious if anyone's developed a framework with how to plan around these types of events for the highest possible chances of having happen what you want to have happen.

[notsheigetz]

Just curious if anyone's developed a framework with how to plan around these types of events for the highest possible chances of having happen what you want to have happen.

I shared my plan on another thread but it won't work for every one. My wife is from the Philippines. When I retire in a few years we will start looking for a house there and then we will probably be splitting our time between the two countries. If/when my health begins to deteriorate we will make the permanent move to the Philippines. They don't have these kinds of issues there. I think it is something unique to affluent countries like ours.

I am currently watching my mother endure the situation that WiseOne is looking at with her mother, with my Dad using up their life-savings in a nursing home at an alarming rate. He's currently in hospice care but it still costs $7k/month. It's a very weird situation when we get a report from the hospice nurse that there is no change in his condition and this is actually depressing news but that is the reality of the situation. Better for everyone if he would go gently into that good night.

[MachineGhost]

Just curious if anyone's developed a framework with how to plan around these types of events for the highest possible chances of having happen what you want to have happen.

I have a Health Care Directive that says no to everything, although from the OP it now sounds like its not all that effective? 

Seriously, I'm not one that is worried about "dying in a socially acceptable manner" as the vast majority of Boobus Americanus are, so if I decide that I have some kind of horrible degenerative disease that is not amenable to fixing via "extreme" natural or vanguard medicine, then I will just simply off myself.  Problem solved.

Still, I am curious what exactly LTC is useful for other than upgrading your nursing home accomodations.  From what I recall, the average age of death is about 2 years after you go to a nursing home.  The new situation alone is an effective killer.

BTW, all hyperbole aside, there has been Federal pressure since at last the early 90's to maintain independent living and in-home care, because there is simply not enough nursing homes for all of the baby boomers.  So it won't be a dystopian situation with us all institutionalized in massvely-sized dormity nursing homes in the future.

[moda0306]

MG,

Well the "average" disability isn't that long, and the "average" house doesn't burn down... we still get disability and homeowners coverage .

In MN we have a Partnership plan that allows you to protect yourself (or moreso your spouse) from the medicaid spend-down rules (allowing the other spouse to have some assets while medicaid kicks in) so LTC planning is a bit different here.

Here's an article around the statistics of LTC: http://www.cbsnews.com/8301-505146_162- ... eal-risks/

There is currently a 16% chance that a 65 year old will have a LTC event costing them $100,000 or more.  Even if you pick a bare-bones facility, LTC events can be huge losses for an individual before medicaid kicks in.

To me, a risk of that size you either take off the table, if possible, through directives (I think that's pretty impossible in most states for events that don't leave you with massive medical assistance to stay alive) or your "off yourself" method, or you insure the risk away.  I'm not about to expose my wife & kids to the tune of $100k plus AND all the anguish associated with the intrinsic awfulness of the event itself.

What I don't like, and I see with my dad, is a kind of lazily thought-out combination of saying you'll off yourself (but having no means or plan to do so), but in reality simply exposing yourself to massive potential liabilities.  I see it with others, too.  If they read one article that tells them "Don't buy LTC," they stop there but don't have a very well-thought-out "exit strategy."

I've heard horror stories of sons bathing their mothers to help shoulder some of the burden of a LTC event.  To me that's an insurable risk if I've ever seen one.

[Pointedstick]

Still, I am curious what exactly LTC is useful for other than upgrading your nursing home accomodations.  From what I recall, the average age of death is about 2 years after you go to a nursing home.

From the department of coincidences:

2 years in a nursing home @ 7k/mo = $168,000
Average net worth of someone aged over 65: $235,000 (likely most of it home equity)

If Social Security is a vast inter-generational money transfer scheme, perhaps nursing homes are an attempt by the younger generations to siphon some of it back.