The E-Therapy Revolution for Medicare Beneficiaries

One of the promises of the information technology revolution is disintermediation: basically the removal of middlemen from the supply chain, which reduces costs and increases convenience (which also adds tangible value) to a given transaction.

When it comes to psychotherapy or psychological testing services, middlemen abound. Office space isn’t cheap, and frequent no-shows add significantly to overhead. There’s often travel to and from the office for both the patient and the professional (unless the professional travels to the patient’s house, which is not uncommon in geropsychology).

Finally, there’s the issue of third-party-payors, such as HMOs, PPOs, and overwhelmingly in my field, Medicare. For psychologists and other mental health professionals, reimbursement rates for office visits continue to decline in markets across the U.S. (such has here, here, here, and here…. heck, it’s happening everywhere). Medicare also continues to threaten steep pay cuts for psychological services rendered to beneficiaries.  Over the past few years when raises have occurred, they are typically well below any rational cost of living increase (e.g., 1%).

So what is a psychologist to do? This is where so-called “e-therapy” comes in. As opposed to about 10 years ago, this is no longer a fringe idea. As the name implies, “e-therapy” is the act of delivering psychotherapy services over secure online communication, such as online chat, voice-over-IP, videoconferencing technology, email, discussion boards, or any combination of the above.

Naturally, there was much concern voiced about the ethics of such ventures; for example, how do you deal with all of the privacy concerns and regulations (e.g., HIPAA), or how do you address the issue of someone who presents for therapy if they are suicidal? Increasingly, answers to these questions are becoming clearer, although a consensual standard of ethical guidelines for “e-therapy” has yet to develop.

So again, one of the great promises of e-therapy, given the above, is that a therapist can maximize the shrinking reimbursement dollar by delivering services over the Internet. However, not all insurance companies reimburse for e-therapy services (although many do), which makes this a potentially complex move for a therapist to take if they are moving from a traditional “bricks and mortar” practice.

What about for a geropsychologist? Keep in mind that for us geropsychology professionals, because of how Medicare works, we have an enormous amount of difficulty providing any services outside of the Medicare reimbursement system (essentially Medicare monopolizes the funding of medical services for Americans over the age of 65).

But wait, will older adults even use the internet for therapy? Evidence says they do. In fact, they are one of the most rapidly-growing demographic group of internet users out there. Even better, unlike many insurance companies, Medicare does provide a reimbursement mechanism for provision of ‘e-therapy’ services. This is great – particularly considering the fact that many older adults are less mobile, and offering them the ability to access mental health services in their homes may be a particularly valuable service.

So here’s the problem – Medicare has designed the billing mechanism for e-therapy to be unfortunately rather complex and difficult for most sole practicioners (who often are the most energetic entrepreneurs in the mental health world) to take advantage of. First off, therapists can’t deliver psychotherapy services to their Medicare clients in their home, it has to be from an authorized ‘originating site,’ such as a doctor’s office, hospital, clinic, or nursing home. Second, these sites have to be located in predesignated Health Professional Shortage Area. So, for example, an older adult with mobility issues, living in a metropolitan center, who may have trouble going to a psychologists office, can not currently be offered e-therapy in his or her home as a Medicare beneficiary.

This seems like a shortcoming of the Medicare e-therapy codes that will need to be corrected. Again, Medicare reimbursements for practicioners are dropping, overhead is rising, and older adults are becoming more and more internet-savvy. This is an opportunity which needs to be capitalized on.

Psychotropics in Long-Term Care

There have been a variety of public policy initiatives designed to reduce the use of psychotropic medications in skilled nursing facilities, the most well-known is the so-called Omnibus Budget Reconciliation Act of 1987 (e.g., OBRA-87), which sets comprehensive guidelines for training nursing home staff and guidelines for prescribing psychotropic medications in nursing homes.

OBRA-87 required a number of changes to prescribing habits in nursing homes, all in the name of reducing the use of powerful medications as “chemical restraints.” It required prescribers to carefully document medications to be used for specific problems (e.g., as opposed to prescribing a resident Haldol for “dementia” it had to be for a specific behavioral issue). It asked providers to consider the use of shorter-acting medications rather than longer-acting ones, and to avoid other troublesome medications in older adults, such as cholinergic medications. The law also recommended providers regularly institute dose-reduction trials to see whether patients could function on less medications.

It appears OBRA-87 has had an effect on prescribing habits in nursing homes. According to research by Borson and Doane, prescribing habits have changed substantially over the years (Borson and Doane looked at ’89-’92), presumably due to the pressure brought to bear by the federal government’s purse:

  • Prescriptions for antipsychotics (e.g., Haldol, thorazine, etc.) in LTC fell by 34.8%.
  • Prescriptions for long-acting benzodiazepines (anxiolytics) fell by 70.1%.
  • Antihistamines, lithium, and psychostimulant prescriptions also fell significantly (40%, 24.1%, and 17.1%, respectively)

This all looks good. After all, antipsychotic use in the elderly, particularly the so-called “first generation” antipsychotics, poses particular dangers. Many, if not most of the older adults in nursing homes are prescribed antipsychotics for the purpose of controlling behavior issues secondary to dementia – I personally am very concerned about use of these agents with patients, given the issues related to tardive dyskinesia and how prone a demented older adult might be (particularly as their dementia advances in severity) to developing such issues. Avoiding long-acting benzodiazepines and antihistamines in older adults also seems like a good outcome, given the high risk of falls in the long-term care population.  Lithium, while effective, tends to have a very narrow therapeutic window (it tends to be toxic, particularly to the kidneys – which also are often compromised in older adults).

However, certain drug classes began to be prescribed more, apparently  – particularly short-acting anxiolytics like lorazepam and alprazolam (up by 7.9% and 11.5%, respectively) – and clonazepam prescriptions rose precipitously, up by 368%. While it’s an improvement over longer-acting benzodiazepine meds (like diazepam), in my opinion it’s never a good thing to be prescribing ‘benzos’ of any sort to patients who by their nature are prone to falls and mental confusion.

Prescriptions for buspirone, also known as Buspar, rose by a staggering 557.7%. Buspar is an interesting medication – typically when one wants to use medications to treat anxiety or agitation in anyone, older adult or no, a physician can use the benzodiazepine class of medications. While effective, these have the side effects of increasing confusion and fall risk (particularly in older adults, mentioned above) and of course, are also habit forming. In particularly difficult cases, one can use more powerful first or second-generation antipsychotic medications, but using those with older adults creates the risk of additional problems, such as metabolic side effects and even increased risk of death; this is why the FDA has issued one of it’s rare black box warnings for the entire class of drugs when used with older adult populations with dementia.

Buspar generated a lot of excitement when it was first released on the market in 1986 due to the fact it did not seem to lead to addiction or mental confusion in its users. However, anecdotally (just based on my experience) it doesn’t seem particularly effective, although to be fair it’s supposedly as effective as benzodiazepines for treating anxiety.

Finally, the antidepressant drugs doxepin and amitriptyline also dropped by 24.5 and 35.8 percent, respectively, presumably due to the fact that doxepin is contraindicated for use in people with so-called organic brain syndrome (of which most dementias would qualify).  Amitriptyline isn’t recommended for older folks because of its anticholinergic effects (older adults tend to produce less acetylcholine anyways – so they are more prone to unpleasant side effects from drugs with this tendency).

There continue to be periodic initiatives from governmental and regulatory bodies regarding psychotropic use in long-term care facilities, often with a focus on dementia patients. The latest is a push that began in March of 2012 and ended in December of 2012, which aimed to reduce the use of antipsychotic medications in dementia patients by 15% in all nursing homes.

What’s the alternative to using medications in long-term care facilities to treat behavior issues in dementia patients? In one of my next posts I’ll take that on (the subject of behavior management) – there’s actually lot that can be done, but it’s not as straightforward as giving people a pill or a shot – which is probably why it’s not as easy to do.

Dementia Definitions: A Brief(er) Post

Dementia, as readers of this blog are no doubt well aware, is a health problem which particularly (but not exclusively) strikes the older adult population and, because of the “greying of America” that’s been going on, will only increase in prevalence over the coming years. Increasing age, of course, is a major risk factor for developing dementia.

Let’s define dementia first. Probably one of the most influential definitions of dementia is in the American Psychiatric Associations’ Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text-Revision (DSM-IV-TR for short), which basically says that to have a dementia of any sort, you must have

1) the development of multiple cognitive deficits manifested by both:

a) memory impairment (impaired ability to learn new information or to recall previously learned information); and

b) one (or more) of the following cognitive disturbances:

i) aphasia (language disturbance),

ii) apraxia (impaired ability to carry out motor activities despite intact motor function),

iii) agnosia (failure to recognize or identify objects despite intact sensory function), or

iv) disturbance in executive functioning (i.e., planning, organizing, sequencing, abstracting).

2) The above cognitive deficits need to produce “significant impairment in social or occupational functioning and represent a significant decline from a previous level of functioning.” Which means that if the person has cognitive deficits as specified above (say, identifiable via neuropsychological testing) but seems to function well, miraculously, in their daily life, then they don’t have dementia and may instead have something milder, say, mild cognitive impairment.

Complexifying things further, the DSM-IV-TR is currently poised to be updated to DSM-V (just when we got comfortable with the mental disorders we already had!), and we already know that the diagnostic criteria for what is considered dementia will likely shift anyways. But we’ll go with the DSM-IV-TR definition, because it’s still current and it works and makes sense for me as a practitioner (except perhaps for the requirement that memory dysfunction always be central to having a dementia).

So what about Alzheimer’s Disease? One of the common misconceptions I run into when talking to people about what I do as a geropsychologist (aside from people constantly mistaking me for a psychiatrist) is that “dementia” and “Alzheimer’s” are synonymous. Alzheimer’s Disease, of course, is only one of many, many difference dementia subtypes – dementia is an umbrella category of which Alzheimer’s disease falls under. There are other dementias, such as vascular (stroke) dementia, Lewy Body dementia (which I plan on posting about in the near future), dementia due to alcohol, Frontotemporal dementia, and many, many others.

Dementia is what I do for a living, basically. Look for more posts about the subject down the line.

Sleep (and specifically Slow-Wave Sleep), Older Adults, and Memory

So wending it’s way through the news cycle about a week or two ago (briefly) was some neuroscience research from folks at UC Berkeley relating to older adulthood, memory retention, and so-called “slow wave sleep.”

What these researchers did is took two groups of ostensibly healthy young adults (in their 20s) and older adults (in their 70s), and subjected them to a word-pair matching memory task where English words and nonsense words were associated and subject to a subsequent forced-choice recognition memory test (they did administer a number of other neuropsychological tests, but the critical one was the word-pair matching task). They selected the word-pair task because it was found in previous research to be sensitive to the effects of sleep in subjects performing the task.

Subjects were assessed immediately after the task, and then after a typical nights sleep for them (if you call typical when you’re wired up in a sleep lab), they were tested again – but the testing the next morning was done with subjects’ brains being monitored via fMRI.

Before I get to the results – what is sleep? When I was starting graduate school, sleep was an activity subdivided into five distinct identifiable stages according to the so-called Rechtschaffen and Kales sleep scoring criteria – this had been the method for identifying sleep stages for approximately the last 40 years. In 2007 the American Academy of Sleep Medicine got into the mix and simplified matters somewhat and made the practice of polysomnography somewhat more straightforward, by collapsing seven sleep stages into four. Thus, a typical sleep cycle looks like this:

N1 → N2 → N3 → N2 → REM

In both methods for scoring sleep, there was little real change in the objective criteria for identifying so-called Rapid Eye Movement, or REM sleep. N1 and N2 (formerly 1 and 2) were the same across both staging methods (representing N1 / 1 being essentially just drowsing, and N2 / 2 being so-called “alpha wave” sleep – where conscious awareness of the environment disappears).

Slow-wave sleep went from being measured across multiple sleep stages (3 & 4) using the R&K criteria and now is now measured in a single sleep stage (N3).

Below is something called a hypnogram, where sleep can be visually represented across the various sleep stages – typically looks like this (peaks on this graph represent waking periods, with lower points representing increasingly deep sleep).hypnogram

The above hypnogram is a fairly typical looking representation of a young adult’s sleep pattern across an entire night. As is typical, there is more slow-wave sleep during the first ½ of the night and more REM sleep during the second half.

Now let’s look at a hypnogram depicting the same, typical young adults’ sleep with that of a typical older adult (from Lichstein & Morin, 2000; Treatment of Late-Life Insomnia – a great book).

(Note that the hypnograms here are scored using the older R&K criteria).

sleep stages

Note a difference? The term used by the sleep folks is that older adults, even ostensibly healthy ones, tend to show evidence of a “fractured sleep architecture,” characterized by more intrasleep arousals (those are the very highest points represented on the hypnogram), a generally shallower “sleep depth,” and significantly less time spent in NREM sleep (e.g., non-REM sleep). Lack of sleep depth and reductions in NREM sleep tend translate into lack of so-called slow-wave sleep.

Slow-wave sleep (SWS), is referred to as such due to the distinctive pattern of 75microvolt (0.5-2 Hz) waves observable on electroencephalogram (EEG) leads during a polysomnogram, and consist of stages 3 and 4 of the R&K criteria (now just stage N3). SWS is not dreaming sleep and typically when subjects are awoken from SWS they do not report dream activity (unlike REM sleep). It’s considered the most physically restorative sleep period, notable by the fact that production of human growth hormone (HGH) peaks during this time of night. Also, when SWS suffers in otherwise healthy young adults (as is the case in patients suffering from narcolepsy), the result is subjective reports of being physically exhausted, despite sleeping several hours a night, such as this person.

Back when I was a lowly predoctoral intern in psychology at UMDNJ in New Jersey, I did a rotation at the hospital’s sleep lab where we saw a number of patients and offered treatments. One of the “rules of thumb” I learned when I was first learning sleep medicine is that SWS is for resting the body, and REM sleep is for resting the mind.

Of course, sleep is an inordinately complex biological process and while it seems likely that REM sleep plays a role in consolidation of certain types of memories, it now seems clear that SWS plays a role in consolidation of memory, particularly declarative memory, as well.

So, back to Mander, Rao, and Lu et al. (2013; the Berkeley study referenced at the beginning of this post). What these researchers found is that SWS deficits observed in older adults were reliably related to performance deficits on the word pair matching task, and that this SWS deficit observed in older adults, moreover, was related to degeneration of a part of the brain called the medial prefrontal cortex (mPFC, part of the frontal lobes of the brain), and finally, was also related to overactivation of the hippocampus the next day.

The idea, of course, is SWS is the mechanism by which memories stored in the hippocampus (sort of a neurobiological memory buffer) are consolidated and shunted to the cerebral cortex for long-term storage, via the mPFC. If the mPFC is malfunctioning, the memories stay stranded in the hippocampal ‘buffer’ until they are overwritten. Which, of course, then provides us with a fascinating account of how those “senior moments” take place, or worse, how dementia begins to show itself in older adults.

The question is, how is this information of practical use? Interestingly, there are a number of ways to boost SWS. Exercise, hot baths, carbo-loading are some easy, drug-free methods. One of the active ingredients in cannabis, THC, is known to increase the duration of SWS. Transcranial stimulation (also known as EMG) is another method.

Hot baths, exercise, and eating sweet treats sounds nice, but may not do the job on their own. Use of cannabis to boost SWS, while it might be effective and with few side effects (aside from perhaps an increased preference for the aforementioned sweet treats) isn’t a particularly practical treatment given its current legal status. EMG is interesting but even more impractical given the expensive and unwieldy equipment required.

Another treatment option for boosting SWS is a prescription medication called Zyrem, also known as sodium oxybate. Zyrem is basically a chemical analogue of gamma-hydroxy-butyrate, also known as GHB. GHB, of course, is a neurochemical that humans produce endogenously (in our brains) and is thought to be related to the maintenance of the human sleep cycle, particularly as it relates to SWS.

Even there, however, the practicality issue makes use of GHB and GHB analogues difficult – GHB is also an illegal drug, like cannabis, and Zyrem is a drug that is more tightly controlled than many narcotic pain medications, and is only approved for use in narcolepsy.

This is unfortunate. Barring the invention of a cheap and portable version of an EMG machine for use in older adults beginning to show signs of memory problems (or even showing signs of frank dementia), direct methods for stimulation of SWS production in older adults is difficult given the practical (legal) limitations on use of agents like cannabis or GHB.

Of course, we should back up for a moment. It’s certainly possible that boosting SWS in older adults may be a successful treatment for memory problems – but it may not be. Recall that in the Berkeley study (Mander et al.), the reduction in SWS was observed to be related to degeneration of the mPFC (part of the frontal lobes of the brain). Its possible (although it seems unlikely) that boosting SWS may not reverse memory problems in older adults because, after all, it’s unclear how boosting SWS would actually reverse the brain damage we know now is associated with dementia. However, this is interesting information and hopefully there will be research taking place.

Paying For Long-Term Care

As a nation, saving money just isn’t something we’re very good at. Causes could include stagnant wages, or possibly our love of shopping, but the result is undisputed: 45% of people age 46 to 64 have less than $25,000 saved for retirement. Between the decline of pensions and the housing crash, it is unlikely that number will improve in the future.

Despite this, about 70% of people age 65 or older will need long-term care services at some point in their lifetime, and the median annual rate for a private nursing home room was $81,030 in 2012. My math skills aren’t the greatest, but these figures tell me there’s a huge (and growing) gap between need and ability to pay when it comes to long-term care.

One solution, perhaps more popular ten years ago than today, is long-term care insurance.  However, the recent low-interest rate environment (combined with rapidly escalating long-term care costs) has resulted in premium hikes many older adults cannot afford to pay.

Unfortunately Medicare only covers the first 100 days of skilled nursing care per illness, provided various requirements are met; Medicare does not cover “custodial care,” designed to help with activities of daily living. Increasingly, even middle-income seniors are turning to Medicaid to cover the cost of long-term care.

Eligibility guidelines for Medicaid vary state by state. In California, Medicaid (known as “Medi-Cal“) covers nursing home care with prior authorization from a health care provider if you qualify.

Determining whether you qualify for Medicaid or Medi-Cal is an extremely complex task. As noted by Disability Benefits 101, there are over 90 eligibility categories, each with its own rules and requirements. An elder law attorney is the best person to contact if you or someone you know may need Medicaid assistance. The National Academy of Elder Law Attorneys (NAELA) has a “find an attorney” feature on its website; this is a very good place to start.

A person may be automatically eligible for Medi-Cal if he or she receives aid from one of the following programs:

  • SSI/SSP (Supplemental Security Income/State Supplemental Program)
  • CalWORKs (California Work Opportunity and Responsibility to Kids). Previously called Aid to Families with Dependent Children (AFDC).
  • Refugee Assistance
  • Foster Care or Adoption Assistance Program.

A person with income above the eligibility levels of no-cost Medi-Cal programs may also qualify as “medically needy” if he or she is, for example, 65 or older, blind, or disabled. This program usually requires the person to pay a monthly share of cost, similar to a co-payment.

Physician Orders for Life-Sustaining Treatment (POLST)

POLST stands for “Physician Orders for Life-Sustaining Treatment.” Next to an advance health care directive (AHCD), a POLST is one of the most important documents you can have.

The POLST was developed in response to concerns that physicians were not honoring patients’ AHCDs. An AHCD expresses the patient’s wishes for end-of-life care; the POLST is a doctor’s order concerning end-of-life care.

The POLST is typically printed on ultra pink paper, although any color paper will do. The POLST program was first developed in Oregon, and California is one of a handful of other states that have adopted the paradigm. In California, the Coalition for Compassionate Care has taken the lead on educating the public; copies of the POLST are available on its website.

Studies have consistently shown that patients with POLST forms are more likely to have their wishes concerning end-of-life care honored than patients using traditional methods of conveying those wishes (e.g., AHCDs).

Patients and clients are becoming increasingly aware that traditional healthcare at the end of life is often invasive, expensive, and can result in unnecessary pain and suffering. Sometimes even a patient’s express wishes, written on paper aren’t enough. Sometimes the only way to save a client from the perils of western medicine is to find a doctor willing to issue the right prescription.


We Can Build It… We Have The Technology

One thing is certain – over the next 10-20 years, regardless of what other economic or political events sweep the USA, this country will have far more older adults, as a proportion of the overall population, than we do now. This is sometimes referred to in the media as the “graying of America” or the “demographic tsunami” which has already been sweeping Japan and Europe.

On the one hand (as the linked article above accurately reports), members of this newer generation of older adults tend to be in better shape than counterparts of previous generations – and it appears that this trend will continue in the forseeable future; consequently the older adult of the future will be less likely to depend on long-term care than the older adult of today or yesteryear.

However – here’s the rub: we will be utterly groaning, bursting at the seams with older adults as a nation within the next few decades. Within the next 15 years, the number of people over the age of 60 in the U.S. will nearly double. By 2050, the numbers will nearly triple. That means that regardless of how much healthier the “baby boom” generation may be than previous generations of older adults and how much less prone to physical debility (and that’s also debatable, apparently), there will be much greater numbers of older adults requiring long-term care (as in skilled nursing care and assisted living) and even more older adults will require some sort of assistance in their home with basic activities of daily living (ADLs). So, while the proportion of the total number of older adults requiring nursing homes and intensive personal care arrangements may go down in the next 10-20 years, the overall number of older adults demanding nursing care will be skyrocketing.

And nursing care is absurdly expensive and getting more so. In California, nursing home beds at minimum fetch $60,000 per year and costs can go far north of that into the six figures. Hyperinflation of healthcare costs, for whatever the reason, has not excepted nursing homes (we’ll cover the challenge of affording nursing home care in an upcoming post).

So, with the costs so high and the “demographic tsunami” so clearly poised to swamp our system, what can be done? It’s worth imagining what the nursing home of the future will be faced with, and what they’ll need to do to accommodate these changes. Nursing homes of the future will be faced with patients with far more complex needs than the past – and that includes behavioral needs. Patients who make it into nursing homes today will be “triaged” to home care tomorrow so that nursing home beds can be saved for the neediest of the needy.

Long term care nursing staff, already working for one of the most heavily-regulated sectors of the US economy, generally have little time to spend providing and caring for patients’ psychosocial needs; tasks generally relegated to Recreation Therapy (RT) staff, volunteers, and the few-and-far-between mental health consultants who serve community facilities. So what are nursing homes to do? Modern long-term care facilities now offer cable television, and increasing numbers of nursing homes are offering wireless Internet capabilities to allow their increasingly-savvy residents to communicate with the outside world, but these kinds of technological innovations are cold comfort.

Some nursing homes have active “therapy dog” programs where residents are regularly exposed to animals for their well-recognized therapeutic purposes. Some nursing homes (particularly ones that subscribe to the “Eden Alternative” philosophy) even have animals that live in-house with the residents. Unfortunately, there are a number of issues with animals that make them impractical for use in many nursing homes in any widespread manner. First, there are the ever-present concerns about zoonoses (animal-to-human infection) and bites – no matter how vigilant a handler may be or how carefully veterinarian visits are documented, human error and the unpredictability of animals are always at play. Also, dogs and other animals need to be fed, toileted, cleaned, and with visitation therapy dogs need handlers to manage them – which make them a labor-intensive affair for an environment that tends to be starved for labor.

Meet the Paro Robot.


What is the Paro? Specifically, it’s what the developer has called a “mental commit robot” – a robot designed to elicit feelings of relaxation and happiness in the user (as opposed to the more traditional use of robots; e.g., for accomplishing specific tasks). Initially, the developers attempted to create these therapeutic robots using cats and dogs as models. However, they found that despite the cat and dog ‘paros’ being sophisticated machines, people were much too familiar with dogs and cats – they had far too well-developed prototypes of these animals in their heads to be fooled by a robotic cat or dog simulacrum.  So the developers hit upon using the ever-so-cute baby harp seal as their model – and it worked, simply because average consumers in the industrialized world have never encountered harp seals in their lives (and so had no prototypes in their minds to compare to).

I first discovered the Paro Robot approximately two-and-half years ago after I had spent some time struggling with a difficult case of an older woman in my VA nursing home who had severe dementia. This woman was in her 80s, had severe chronic pain (from arthritis), some previous issues with depression and anxiety that predated her dementia, and now spent much of her day in her bed screaming inconsolably. As the staff psychologist at my VA nursing home, they looked to me to address this issue (psychiatric medications were also being tried). The only thing I noticed about her is that she quieted only when the therapy dog volunteers visited her – unfortunately these visits were few and far between. The Paro Robot seemed an ideal solution.

Although this woman died before I was able to make full use of the Paro Robot with her, I have since used it on multiple patients and have encouraged other staff to use it at our neighboring geropsychiatric facility in Menlo Park. Since then we have collected data that suggest the Paro Robot is indeed an effective intervention for use with agitated and distressed older adults. When offered to these (frequently demented) older adult VA nursing home patients, we found that they significantly calmed and brightened in their demeanor, and that use of the Paro Robot often resulted in psychotropic medications not being used with our patients – which is an outcome of enormous value in and of itself.

The most important document you will never write

An advance health care directive (AHCD) is a legal document designed to tell your doctors and your loved ones exactly how you want your health to be managed at the end of your life. In California, the Office of the Attorney General has put together a very helpful website that explains what an AHCD is, and even provides sample forms you can fill out and distribute to your health care providers and family members, no lawyer required.

Although it is relatively easy to complete an AHCD, a vast majority of people fail to do so. The great mystery is why. Certainly, many people find it uncomfortable to think about end-of-life issues. People who propose the government educate people about AHCDs are accused of wanting to create “death panels.” Also, we commonly segregate the elderly, so that choices concerning death and dying remain on the periphery. As a result, the importance of clearly spelling out end-of-life decisions fades into the hum and buzz of everyday life. Sometimes, it’s just hard to find the time to get your sh*! together.

The importance of completing an AHCD is particularly acute given the standard approach to end-of-life care in our culture. Absent an AHCD, an older adult is likely to be subjected to heroic measures when the adult might consider comfort care more appropriate, instead.

Certainly, the AHCD has its critics, and the form does not always communicate effectively the wishes of the patient at issue. However, the best way to make sure your end-of-life health care wishes are followed is to communicate what you want to those you love. A written document, such as an AHCD, is the best way to make those wishes clear.