Health caretaker services for patients with dementia

I must say that I have not enough knowledge to use the correct words for what I am going to ask and describe. I hope I nevertheless can describe a situation in plain words and may be some of you have some answers.

In the German health care system, you
1. have to be health insured mandatorily (can't stay without it - premiums are calculated on the basis of your income). If you are sick, physicians have to treat you and make decisions of the care and medication you may need at no costs to the patient.

2. while being health insured you automatically also pay with your premium an insurance that provides caretaker services for patients, who need assistance with their daily chores, like bathing, eating, clothing, accompanying patients to any places outside their homes and bedrooms etc.

There are two forms to ask for those personal caretaker assistance services.

One provided by the government of your town, whereby you do not have the choice of who comes to the home as a caretaker of the patient and the patient also may have no control anymore over his finances.

The other one is to use the caretaker services provided by your health insurer. Here the person, who is applying for it, can name caretaker person of his choice and the health care insurance pays a certain amount of money to the patient dependent on how the insurer has measured the patient's needs for a caretaker person. There are five or sixs grades of needs.

And independent association sends out professionals to your house and who interview the patient thoroughly to get and idea how much care the patient needs. They also evaluate the mental health of the patient.

Now take a case where the patient has been evaluated as being dement and needing a personal caretaker of the grade three.

The patient has an awful skin disease with open lesions on legs and arms and pustulas, severly itching. A professional private dermatological service center has done thorough diagnostics to try to find out where that skin disease is coming from and it looks as if part of the cause is a reaction of a medication the patient had to take last year in late summer for a thrombosis. In addition it also was said that there are other potential causes and that a final diagnosis can't be made without further tests.

As the patient never went to any physician deliberately, very few things are known about other diseases the patient might have without knowing it. So, the physician asked the patient to get all further diagnostic tests done as a patient in the dermatological department of a well-known university hospital, of which he was the former chief physician and head of the department. He managed to get a free bed in the hospital for the patient.
The patient is brought (with difficulties and the help of two persons) into the hsopital. Arriving there the patient refused verbally vehementally to be taken into stationary care for further tests to be done. The caretaking accompanying persons and the physicians in the hospital were not successful in convincing the patient to stay in the hospital (be aware that all of it would have been paid for by the health insurance and at no cost to the patient). Helplessly the caretaking accompanying persons had to take the patient home.

Because the reaction of the patient was so irrational, the health insurance provider was asked to evaluate the patients needs for care. During the interview that followed (as decribed in 2. above), the patient was categorized with dementia.

Another incidence where the patient complained of strong pain in the legs, let the caretaking persons believe, the patient might have a thrombosis for the second time. Emergency physicians came to the house and said, no there is no new thrombosis in the legs. But that physician too said the patient needs to be brought into a hospital for further tests to find the causes of the severe skin lesions of arms and legs.

My question now is:
If the patient would again refuse (drama queen-style theater) to accept to be treated and tested out in a hospital, this time now with an official diagnosis of dementia, would the hospital be allowed to enforce a stay in the hospital as requested by the physician, against the will of the patient? As the patient is diagnosed with dementia what is the legal obligation of the hospital? Enforcing a hospital stay to the benefit of the patient or not being allowed to enforce it against the will of the patient?

Strangely enough, though I tried to find out the answer to that, nobody knew. They say that is a legal question and they don't know the answer to that.

In my opinion the physicians in the hospital, who don't treat her, would work against the oath they have taken, but if they enforce treatment, they would also abuse the will of the patient. In how far is that situation changed now, as the patient was diagnosed with dementia?

I don't know how that would be seen in the US health care providing systems, but some here know a lot about it, so I thought I take a chance and would ask you. Thanks for any feed back.

From what I see out of the answers I got from diverse persons, it seems the individual will of the patient is to be respected, even if that will is against the oath a physicans has taken to do no harm. Not treating the patient would though do harm. What is it now?

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mimi's picture

gladly would hear your opinion later on.

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Centaurea's picture

I don't know anything about the laws in Germany. In the US, as a general rule, in order to override the patient's will, the person has to be incapable of making decisions for himself.

The incapacity can be because the person is unconscious or otherwise impaired by illness or injury, such that he can't express what he wants. In that case, the doctors usually consult with family members or whomever has the patient's medical power of attorney. If the patient has signed advance directives ("do not resuscitate", for instance), they'll take those into account.

If the person is conscious and able to express their will, the doctors usually have to abide by what the patient says they want (or don't want), unless there is a court order declaring the person legally incompetent. The diagnosis of dementia, by itself, isn't sufficient for this purpose.

Like I said, though, I don't know what the laws are in Germany. I'm sorry your friend is having this trouble. I know from experience how frustrating and scary it can be, when you're the one trying to get help for someone in this kind of situation.

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"Don't go back to sleep ... Don't go back to sleep ... Don't go back to sleep."
~Rumi

"If you want revolution, be it."
~Caitlin Johnstone

speak with any authority whatever about either the German medical system or German law.

As you probably recall from your decades in the US, we don't even have the same sort of system of law as Germany has, having adopted English common law while we were still colonies (with the exception of Louisiana, which used the French Civil Code as its starting point). Most of us cannot even google for you effectively, an excellent knowledge of German being critical to reading German law.

Maybe one of your colleagues in Germany knows, like lotilizard? If not, your answer likely lies in German statutes, as interpreted by German courts. I'd at least start with using the search engine that works best for you in German.

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@HenryAWallace a lawyer there, and read the regs and case law there.

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dfarrah

that is similar to an emergency process here.
We can swear to facts in an affidavit which state that a person is a "danger to themselves and others", and if the presiding probate judge is convinced by the sworn affidavit, the person is taken against their will into custody at a mental health facility for testing. I haven't done one is so long, I can't remember the mandatory hold time. I think it is 4 days. If they are determined by the doctors to be a danger to themselves and others, the state can appoint a guardian to manage their person and their estate.

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mimi's picture

@on the cusp
yet a danger to herself, I would say her dementia is more of a cognitive dissonance she is not aware of. It can be a bit cumbersome, but luckily the kind of disease she has is not life threatening.

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mimi's picture

is the one that clears it up for me.

The incapacity can be because the person is unconscious or otherwise impaired by illness or injury, such that he can't express what he wants. In that case, the doctors usually consult with family members or whomever has the patient's medical power of attorney. If the patient has signed advance directives ("do not resuscitate", for instance), they'll take those into account.

If the person is conscious and able to express their will, the doctors usually have to abide by what the patient says they want (or don't want), unless there is a court order declaring the person legally incompetent. The diagnosis of dementia, by itself, isn't sufficient for this purpose.

I have a signed advance directive (I am the patient's medical 'attoreny, so to speak). There is no court order declaring the person legally incompetent. I would not want to pursue that venue and the patient is very well capable to express his/her will (in this case to not get treatment for the sickness in a hospital).

The fact that a diagnosis of dementia, by itself, is not sufficient as an incapacity for the physician to not abide the expressed will of the patient, is the answer I was looking for. I believe that answer is correct. Probably in both the US and the German legal systems.

I will still have to figure out if the dementia equals to a person's legal incompetence to contract or if that is only the case, when the court order for legal incompetence has been issued.

Thank you all, especially centaurea. I have no money to consult a lawyer for that. I try to avoid the courts to get involved and believe it is possible to be worked out over time.

Thank you for all your kindness and answers. What a great place we have here at C99p. Yes 3

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dkmich's picture

@mimi

Everytime mom went off her meds, she'd get paranoid and lose all touch with reality. When this happened, the daughter had to go to court to petition for custodianship due to mom being medically incompetent. The hospital should know. How else would they know when it was and wasn't ok to ignore the patient's will? Do you have patient advocates in the hospitals? They should be able to help you too.

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"Religion is what keeps the poor from murdering the rich."--Napoleon

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mimi's picture

@dkmich
either to herself or others, and the dementia is still in the beginning phase, I had not thought about going through a process asking for guardianship or a court-ordered transfer in a facility for the elderly with slight signs of dementia.

There are assisted living facilities and nursery homes and hospice services into which neither the patient, nor I, would like to have her transferred to, so far. Me and another persons are care givers in the house the patien lived in since at least 32 years and grew up in as a child. We both don't think it would be good to tear the patient out of the familiar surroundings. The patient doesn't need psychopharmaca to keep the mental health in a stable condition, as long as we respect the patient's will and can get a caretaker, when I or the other care taker are not there for several days.

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dkmich's picture

@mimi

All you want is temporary guardianship to get her the medical treatment she needs. If she isn't mentally impaired, then I think you need to just respect her decision no matter how poor a decision it might be.

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"Religion is what keeps the poor from murdering the rich."--Napoleon

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mhagle's picture

is a dyslexic genius who became schizophrenic after our oldest sister abruptly died at age 27. The family ultimately had to go to court to have her "committed" in the 80s. She was away for about nine months and came home heavily sedated. For about ten years we went through cycles where she would be on meds and pretty much OK, they would eventually take her off meds, she would slip back into paranoia, and family members would have to go through the process of getting her committed again. Eventually, they quit taking her off meds. In those days Iowa and pretty good mental health care. There was a person called an advocate who would come to visit, speak firmly but very lovingly and compassionately that my sister stay on meds. Eventually, both of our parents have passed away.

So it is left to my brothers and I to watch out for her. She eventually figured out that she could refuse meds. She lives in the family home and we use farm rent to pay bills.

Fortunately, schizophrenia fades with age in women. She is still stubborn and a bit delusional, but lives alone and mostly gets by OK. This is what she wants. So, Mimi . . . here is my answer. We have decided it is best to respect her choices. Even though she lives alone out in a farm house in the country. And she is not a very good housekeeper. If we would commit her now, we have no rights to her medical anything so they would take her off but not call any of us as to her whereabouts, etc. Some folks might judge us as to why we haven't put her in an apartment in town. If we did that, she would completely lose it.

It can be scary sometimes, but it is what she wants. And she seems happy enough.

Can there be some other way to treat her skin rash? Something she is OK with?

Glad this woman has a good friend like you.

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Marilyn

"Make dirt, not war." eyo

mimi's picture

@mhagle
signs of schizophrenia and so far I could be her only caregiver and manage that. The other person who helps is male and therefore not suitable for some of the care she needs considering her private hygiene etc. I just need a person, who can replace me, when "I come visit you and my son in the US for a longer time" without needing her to transfer into a mental health care facility for the elderlies.

I am confident I will find a solution and the detailed answers to my questions as well.

No, the skin diesease is more severe than just a rash. Medication so far has not had any effect, contrary it had worsened her overall condition.

Oh well, I wonder when I start having signs of cognitive dissonances. Just kidding. Thanks for your comment. Smile

Alles wird gut ... is my motto.

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Alligator Ed's picture

@mimi

, I wonder when I start having signs of cognitive dissonances. Just kidding.

It will be apparent to any that you have achieved cognitive dissonance if you believe either that Hillary is honest or Democrats are smart.

Signed,

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mhagle's picture

@mimi

Diet, herbs, all of that stuff. Eating differently? I don't know anything about it so I am speaking in ignorance. So her body went off balance while being treated for another condition. Is there a way to restore it's balance? Maybe someone else here has good ideas about that. StudentofEarth might know. And maybe there are things that would not feel threatening to her.

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Marilyn

"Make dirt, not war." eyo

Alligator Ed's picture

includes the legal ascertainment of mental competency since I am qualified to give such expert legal opinion, even in court (and have done so in involuntary competency trials). In addition to centaurea's excellent comment, regarding only US law, a court can order an involuntary determination of competency if it is suspected that the patient is incapable to give informed const. Coma obviously is the simplest case. Legal determination of competency based on medical testimony is best performed by a trained expert, such as a psychologist, psychiatrist, or neurologist. Any licensed physician may give such testimony but the weight of this testimony, especially when parties are contesting the declaration of incapacity, will be discounted usually when compared to a lesser educated/qualified individual.

In Germany I have no idea of what happens. Hope this helps.

Smile

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mimi's picture

@Alligator Ed
and I am glad you just gave me a correct diagnosis of my mental health status. I am a care-free dissenting cognitive mystery, and always detect all kind of deceiving lying political bodies due to my voodoo trained clair-voyance capabilities. Amen.

With regard to declaration of incapacities that is contested in court, I will not have any like those, but will talk to a person next week, who explains to me, what would happen, if such a situation should occur. That person is an official who offered me an advisory meeting without a court date. So, I guess he knows what courts want and accept and what not.

Thanks and Good Night.

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Alligator Ed's picture

@mimi

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mimi's picture

@Alligator Ed
I will have a boiled egg for breakfast ... and my sister too. Smile

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Alligator Ed's picture

@mimi Smile

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