Look for a family practitioner or general practice physician to be the primary care physician for your loved one. General and family practitioners are trained to treat all aspects of a person’s health and well-being even though they have not specialized in a specific field. They treat the elderly as well as newborns, children and adults for everything from a splinter to a more serious illness.

Health Insurance Coverage

Choosing a doctor can be based upon several factors. One of the first aspects to look at is whether or not the patient’s health coverage is accepted by the physician being considered.  Most physicians will accept Medicare but it’s important to determine whether or not they will accept Medicaid and/or the supplemental policy if one is available.  If the doctor will accept the health coverage, the next thing to look at is accessibility.

Location and Accessibility

It is important to choose a doctor whose office is located close enough to be easily accessed for routine care and emergencies. If the elderly loved one is homebound, a physician who understands this and is willing to work around this detail to provide care is ideal.

Physicians can order home health nurses to draw blood, administer injections, take vitals signs and other basic medical procedures then report to the doctor. These procedures would normally be done at the doctor’s office, but when dealing with a homebound patient, getting them into the office may be a problem.

In addition, when transporting an elderly homebound loved one, distance to the doctor’s office can play a part in the convenience of the location. Determine if the time spent driving and the distance to and from a doctor’s office makes the doctor in question an acceptable choice for your loved one’s needs. If the doctor requires that your loved one must been seen at the office frequently, then distance can be an important factor when choosing the physician.

Office Hours

When choosing a doctor there are a few important questions about the doctor’s schedule that you should ask. What kind of office hours does the doctor hold? Do they have evening or weekend hours? How can you get in touch with them when the office is closed? Are the physicians who cover the “on-call” hours acceptible to you?

Hospital Choices

Most doctors have privileges at specific hospitals. When choosing a doctor, it is important to find out which hospital or hospitals the doctor has privileges at. This is the same hospital the patient would go to for emergency care, tests and surgeries in most cases. The size, location and reputation of the hospital may play a large role in your decision to choose or not choose a specific doctor.  Some towns and cities have specialty hospitals for certain conditions.  If your loved one has a condition that is treated by one of these specialty hospitals, it is important to determine if the primary physician has priviledges there.

Personality

Even the most qualified and credentialed doctor may not be the best choice for your loved one’s personal physician if their personality clashes with yours. You’ll probably want to choose a doctor that you genuinely like and feel comfortable with. Remember that you will need to be working closely with this person to advocate for the best health care for your loved one.  Imagine my surprise when I asked my father’s physician if he might be discharged in the afternoon only to hear him say “What part of HE WILL BE DISCHARGED TOMORROW MORNING did you not understand?”  However, there are also surgeons that I have worked with in the past who had terrible bed-side manners yet they are the ones with whom I would have trusted my life.

Choose a doctor who will take the time to speak with you as you advocate for your loved one’s health care. The doctor should be willing to listen to your concerns and answer your questions to your satisfaction. Remember, you are hiring them and paying them for their time.  The days of the primadonna physician OUGHT to be over.

Another consideration is the physician’s staff.

Do you like the physician’s staff? Are the doctor’s employees personable, respectful and pleasant? If you find receptionists, nurses and other staff members to be rude, then perhaps you should consider other physicians. These are the people you will be working with to schedule appointments, update prescriptions and access patient information. If you find them difficult to work with initially, it might improve over time but don’t expect it to automatically occur.

Ask the doctor if they have a Family Nurse Practitioner or a Physician’s Assistant in practice with them. These medical professionals assist doctors in caring for patients in many private practices. Decide if this is acceptable to you for your loved one’s care. If not, then you may need to continue looking or specify in the patient records that care must be provided by the doctor.  Keep in mind though that Nurse Practitioners and Physician’s Assistants generally have more time to spend with the patient and are trained to be patient advocates.  They are also often more accessible.

Making the Choice

After taking all of these factors into consideration, decide which physician you would like to care for your loved one. Schedule a new patient appointment and commit to making the new relationship work.

This may not sound like it’s related to caregiving at all, but indirectly, it is.  My father was a coffee drinker.  He probably went through about 2 pots a day up until his last year. He decreased his coffee intake due to “bathroom issues”.  I, on the other hand, will drink one cup, maybe one and a half cups per day (and I’m told I make weak coffee).  After my father died, it seemed wasteful to brew even half a pot of coffee when I would never finish it………..especially when it was Starbuck’s whole bean coffee that I brewed in the Grind-and-Brew system.

So when my kids asked me what I wanted for my birthday this year, I suggested the Keurig coffee system; you know, the one that comes with little pods of coffee ( Keurig’s are called K-Cups)  that brew one cup at a time AND in less than one minute!  There are a choice of coffees – for instance, Tully’s, Gloria Jeans, Newman’s Own, and several others.  There are also K-Cups of various teas and hot chocolate mixes.  I was SO excited !  THIS would be a great way not to waste money!  Or so I thought.

I was even more excited when I found a Keurig “commercial model” at the Food show.  The commercial had more stainless steel, I was told, and would “last longer”.  It was also less expensive that day (show special) and came with a display rack.  YES! I called my daughter and asked if I could go ahead and order it. 

But then it arrived and I tried my first cup.  YIKES…way too strong.  But fear not, it has a choice of brewing sizes so I then tried the 10 oz size thinking “more water/less strength”.  NO, not the case………it was still very strong.  My next attempt at coffee making was to brew a cup of coffee, dump half of it out, brew a cup of plain water, dump half of THAT out and mix the two together.  Ok, so now I’m using 2 cups and it takes 2 minutes to make coffee and I’m still not liking the taste of ANY of the coffees that came with it.  That’s okay; I’ll just go buy the Starbuck’s K-Cups.  Guess what?  They don’t MAKE Starbuck’s K-Cups.  UGH!

They do, however; make a little adapter K-Cup where you can add your own coffee and still make one cup at a time.  So things are looking up again. Another trip to the store for the adapter (at $14.95) and a pound of pre-ground Starbuck’s (pre-ground is not my fav; I prefer to grind my own beans, but the bean grinder would be another expense).  (And yes, I really do like Starbuck’s.) 

The next morning, I wake up excited for a cup of  ”not too strong” Starbuck’s, place the coffee into the adapter, place it into the machine and …………the lid won’t close !  OK, what did I do wrong?  I re-read the directions and can’t find the answer.  I rearrange everything and try it again………still, no go.  Grrrrrr

There’s a phone support number on the K-Cup adapter so I called and spoke to a nice lady who attempted to be helpful.  We went through the K-Cup adapter procedure and affirmed that it should work.  As an after-thought, she asked “what model coffee brewer do you own”.  When I told her, she said “Oooh, that’s why.  They don’t make K-Cup adapters for the commercial model”.  WHAT???? 

OK, as I’m getting ready to pack the whole thing up and sell it on eBay, she asks “what specifically did you not like about the K-Cup coffees that you’ve tried”?  When I told her that it was the strength of the coffee I didn’t like and which ones I tried,  she suggested some different K-Cup coffees that I could try for a “milder” cup of coffee. 

With renewed hope, BACK to the store I went……….but of course, they don’t carry the milder choices at the store; they’re available on-line though at Keurig.com.  Yesterday I ordered the “milder” choices on-line.  The on-line prices are more expensive and of course, they weren’t having a sale, but thankfully shipping was free with a “code”. 

While I wait for the (hopefully) “more to my taste” K-Cups of coffee, I have almost perfected my morning cup of coffee by following these steps: Brew a cup of coffee; dump one-third of it out; microwave 1/2 cup milk with an added  dash of vanilla caramel creamer to it; Combine the two.  It now takes 4 minutes to make the one-minute cup of coffee (PLUS an additional amount of time to pry open the K-Cup and place the grounds in the compost container).

Let me summarize for you the cost of “not wanting to waste money by brewing a whole pot of coffee with my former Grind and Brew system”: Keurig coffee system- $169.00; K-Cup adapter (that cannot be used) – $14.95; “milder” K-Cups purchased on-line-$68.00 for 72 cups of coffee !  Additional plastic empty K-Cups added to land-fill………..NOT priceless.

Now that I’ve written this out on “paper”, I think I’ll go back to my Grind and Brew.

Some of the best “heart healthy” foods are fatty fish such as samon, herring, lake trout and anchovies.  These fatty fish contain omega-3 fatty acids which are good for preventing and fighting heart disease,  maintaining a low blood pressure, helping to prevent dementia, increasing immunities and easing arthritis.  They are also high in protein and lower in calories.  But recently, many people have stopped eating fish because of concerns about mercury and other toxins.  Just how safe is it to eat fish?

Well, according to Newsweek magazine, two new studies bring a positive answer to that question.  Researchers at the Harvard School of Public Health and the National Academy of Sciences have both arrived at the same conclusion. The benefits  from eating fish outweigh the risks from the small amounts of mercury and other toxins that can be found in them.

One thing to note is that the levels of mercury vary from species to species.  The larger the fish, the larger amount of contaminants it might contain.  This is because the larger fish are higher on the food chain and have eaten the smaller fish who already have traces of mercury in them.  (Unfortunately, industrial pollution is to blame for most of the mercury that is contaminating the fish.)  So your best bet is to eat smaller fish such as salmon, anchovies, cod, flounder, and pollack (the fish that is usually used to make “faux crabmeat”) and shellfish such as scallops.

Also, try to eat fish that are from the wild as opposed to being farm-raised. 

An interesting side note (per AARP’s interview with Donald Hensrud, M.D., a nutritional specialist with the Mayo Clinic) is that older persons, whose brains and nervous systems are fully developed, can tolerate higher amounts of mercury than children. Of course, pregnant women should also be careful not to eat fish with the potential for high mercury levels. 

For a list of Mercury Levels in Commercial Fish and Shellfish from the U.S. Food and Drug Administration, go here: http://tinyurl.com/m7uhzb

The American Heart Association recommends consuming at least two servings of fish (especially those that contain omega-3 fatty acids) per week.  To keep the meal low in saturated fats, avoid frying them or adding rich buttery sauces.

Ironically, I know exactly what I didn’t know in my dream.  I know that I have a lot of guilt over the circumstances of his death .  He wasn’t treated well at the hospital; I HATED seeing him propped up in a chair.  I wasn’t there when he passed away in the middle of the night.  Nobody was.  I wish I could change that and therefore I go over and over it in my mind, trying to rewrite the past but realizing that it is impossible to do so. 

According to Dr. Vickie Rackner, author and keynote speaker, “Guilt is a pain that tells you there’s a mismatch between the person you’d like to be and the person you were in that moment.”  At “that moment”, I would have liked to have been the person who stayed at the bedside 24/7 and the person who KNEW to argue for hospice care and kept my father at home .  I regret that I wasn’t.

Dr. Rackner also states that regret and guilt are distant cousins.  Certainly they are related because regret often leads to guilt.

In the book, “The Emotional survival Guide for Caregivers” by Alexis Abramson, Barry J. Jacobs, PsyD states that when a loved one dies, guilt is the 2nd most predominant feeling in a former caregivers’ experience.  There is guilt that they didn’t do enough, guilt that they are now “free” of the burden of caregiving, guilt that they have their own life back.  This guilt can last 6 months or even longer. It comes and goes but is eventually replaced by the knowledge that the disease process and God’s plan were the biggest factors overall.

Guilt is a part of all aspects of caregiving.  Caregivers are often overburdened and torn between what they need to accomplish for their employer, their spouse, their family and their care recipient.  What was NOT accomplished often leads to feelings of guilt. ( I missed the soccer game; I missed spending quiet time with my spouse; I ran in, dropped off groceries, and ran out of my Mother’s house without stopping to chat at length.)  When I was caregiving for my father, I would often feel bad that I didn’t make the time to sit with him and play cribbage or watch T.V. as often as he wished I would.  There was just too much to do.  We DID play Cribbage at least 2 hours almost every night but as he always said “I have all day !”  He did; I didn’t.

Anger can also lead to feelings of guilt.  We feel badly about being angry that we are stressed, overwhelmed, over-worked, tired, etc., so then we feel guilty which leads to anger back to guilt and more anger….a never-ending circle.  Guilt will also cause us not to take care of ourselves, perhaps because we believe we don’t deserve the care  – which of course, will lead to anger, to guilt…and you get the picture.

In order to get rid of the guilt, it is important to acknowledge that feelings are JUST feelings, nothing more.  You must forgive yourself for your imperfections.  You are only human and no human is perfect.

While you cannot change events or all of the activities in your caregiving role, you CAN change your feelings about them and you may be able to change some of the actual activities themselves.  For instance, if you are finding it difficult to have any quality time with your care recipient because you are too busy doing chores, hire some of them out.  (If expense is a problem, The Area Agency on Aging has a scholarship program for a certain number of hours per month where caregivers can do light housework).  (Meals on Wheels may be available in your area to deliver some hot food to your loved one or perhaps your church may have a program.) When you are able to spend some time with your loved one, you can get to (RE)know them better, and enjoy them.

In the last couple of years, there has been a lot of talk surrounding the book The Secret and the laws of attraction.  Part of that philosophy involves a change in the way you look at the world and your role in it.  You CAN change the way you perceive your caregiving role from one of burden to one of gratitude for the experience.  Changing your perception will cause you to (consciously or subconsciously) change your actions in order to align the two with each other.

You must remember that it is absolutely imperative to take care of yourself and to continue to enjoy life.  Do not feel guilty about those things that you do just for yourself (I’m speaking in moderation, of course).  They will make you a happier person to be around. Do not become a matyr; it does nobody any good. 

So how does this all relate to my dream and my feelings of guilt ?  As I thought it through, I decided that I did the best that I could with the knowledge that I had at the time, so I forgave myself .  I had cared for my father in my home up until the last week and a half of his life and I am proud and grateful that I was able to do that.

With the holidays approaching, I wanted to mention something else that Dr. Vicky Rackner stated.  “Consider giving yourself a holiday gift.  Forgive yourself for one choice that brought you guilt.  Forgive one other person for one action that disappointed you.  Forgive the world for the bolt of unfairness that stood between you and an old dream.”

I hope that you can do that.

Gary’s article can be found immediately below.

“Coumadin^®, available generically as warfarin, has been widely used to reduce the risk of stroke for well over 50 years. Dwight Eisenhower, Richard Nixon and George Bush senior were all taking Coumadin during their active years of former Presidency. Despite millions of prescriptions written annually for this medication, practical, easy to use information remains a challenge.

One of the most common and historical needs of managing warfarin is diet, specifically, dietary vitamin K. Physicians use warfarin to increase the bleeding time in patients at risk for developing unwanted blood clots. The goal is to prolong the bleeding just time enough to prevent clot formation where it isn’t needed (the heart and lungs for example) but allow clotting to take place for normal blood vessel bleeding repair. While warfarin prolongs your bleeding time, dietary vitamin K increases the body’s natural ability to form clots.

The simple blood test called an INR test measures that active anti-clotting effect of warfarin. The higher the dose of warfarin, the more potent or longer the blood takes to clot. A diet high in vitamin K can reduce the effect of warfarin and lower the number of the blood test result. For this reason, it is important for patients to keep a consistent intake of dietary vitamin K to help maintain safe levels of protection warfarin provides without interfering too much.

It is difficult to monitor vitamin K intake when food and beverage labels do not provide this information and the FDA does not require it. While professionals teach vitamin K is abundant in leafy green vegetables – there are many hidden sources patients and their care givers need to know about. Salad dressings and some mayonnaise are good examples.

The vitamin K registry

An easy to use, extensive vitamin K database is available for patients and their family. The vitamin K diary allows you to simply type the first few letters of a food or beverage you’re interested in and a menu of products is displayed listing the serving size and the amount of vitamin K. The vitamin K registry can help you keep balance and choice in your diet. A printable version is also available to assist in creating grocery lists for the Coumadin patient.

The vitamin K diary

The vitamin K diary is an interactive resource for patients or caregivers to keep track of vitamin K intake. While using of the vitamin K registry as a source guide, the vitamin K diary allows the user to record the vitamin K (listed in micrograms) consumed for each meal. The diary, offered as a word document, calculates the total daily and weekly intake of vitamin K. The vitamin K diary is best used 7 days prior to the patient’s blood test to best evaluate the effect of diet and shared with the patient’s healthcare provider.

For other helpful resources on maintaining your quality of life, visit www.PTINR.com  ”

Courtesy of Tena home health products are some tips to reduce stress during this busy season, written by Ann Cason, a caregiving expert and founder and director Circles of Care.

I also wanted to introduce you to the QAS website because they have some great teaching articles about vitamin K (a vitamin that should be limited when receiving Coumadin therapy) and also about some other medications that should be avoided during therapy.  He will discuss those more in later posts.

So without further adieu……

There is good news for patients taking Coumadin^® (warfarin)!

The good news for patients, family members and those who care for a loved-one taking Coumadin® (warfarin) came March 19, 2008 when Medicare announced coverage for patients to test their blood in the privacy of their home. The policy extends benefits to Medicare beneficiaries who have been taking warfarin for at least 90 days for any of the following reasons: atrial fibrillation, mechanical heart valve replacement, or venous thromboembolism (DVT/ PE).  

What is patient self-testing?

Patient self-testing allows patients taking warfarin to test their blood at home with a small finger-stick sample of blood – not too different for diabetic patients who check their blood for insulin levels.

Coumadin^® is a medication that requires a small sample of blood to measure the effect of prolonging the bleeding time designed to prevent dangerous blood clot development. Medicare and many private insurance company’s provide reimbursement for up to, but not more frequent, than weekly home testing to reduce bleeding risks.

Home INR testing however, requires a physician’s prescription for one of the FDA-approved, small, hand-held monitors and for testing supplies. The monitor and testing supplies are not available in retail pharmacies but can be obtained through specialty distributors such as Quality Assured Services, Inc. (QAS).  QAS is a Medicare and private insurance company that distributes, trains, and communicates patient’s home test results to the patient’s physicians.   

Who is a candidate for home INR testing?

Patients who are motivated, with a desire to improve their control of warfarin and reducing the risk of side effects are good candidates for home INR testing. The test is simple to perform by the patient or a caregiver.

How home INR testing works

Home INR testing enables patients to test more frequently than monthly, in the comfort of their home, resulting in better warfarin control and therefore improved safety. Home testing results may be phoned in through a secure 800# provided through the distributor of the monitor. Testing strips are shipped directly to the patient’s home at no additional charge.

Weekly testing is a testing frequency that has been proven superior in clinical studies. Testing weekly evaluates the effect of patients: diet, overall health, metabolism of Coumadin^® and interaction of other medications. Patients or care providers simply phone each home test result into their physician’s office or online service.

How to get started

Patients or caregivers can have many of their questions answered by visiting home INR testing. Specialty pharmacy providers such as QAS, Inc. provide full-service assistance including insurance, clinical and technical support at no charge to the patient.

We see them once in a while on birthdays or Easter or something like that but never aside from that.

If I lived in the same town as my grandparents I would not claim being busy as an excuse. You make some time when you want to. I would at least call or drop over to see them every couple of months. We did for our parents and grandparents. We never regret we did, we know we would regret it had we not have.

The are typical religious people. Big on talk, church going but not the best Christians in my mind. I know better Christians who never go near a church. Even if they weren’t the religious type, we always made time for our grandparents, it is the respectful, loving thing to do. No more we guess.

It makes us so very sad. Actions not words are what count.

They never stop by.  We assume we are hopeless/worthless to them anyway.

This is why Olive and I do not want a church service or anything “if” we die. We don’t want people showing up after we are dead that would never take the time to visit while we are alive. I am sure our granddaughter and husband would be at the funeral if we had one. No thank you. That won’t be when we needed them, we need them now.”

There are two main types of blood thinners:  anti-coagulants and anti-platelet drugs.  Oral anti-coagulants are drugs that interfere with the biochemical effects of Vitamin K that are essential for blood clotting.  Anti-platelet drugs prevent small blood cells called platelets from aggregating, which is one of the first steps in forming a blood clot.

The most commonly used anti-coagulant in the US is warfarin (also known as Coumadin), which can be taken orally.  However, it takes 2 or 3 days for warfarin to become fully effective, so if immediate anticoagulation is required, intravenous heparin is usually administered in addition.  Warfarin also requires that blood levels be drawn in order to determine the effectiveness of the medication.  These are drawn more frequently at the beginning of therapy and less often thereafter. 

The best-known anti-platelet drug is aspirin.  In addition to its common use as a pain-killer, aspirin is often prescribed for long-term use at low doses to prevent formation of blood clots which can cause strokes or heart attacks.

Obviously, blood thinners must be used carefully since blood clotting is an important physiological safety system that protects us after injuries.  Doctors, patients and caregivers must work together to achieve the right balance between preventing harmful blood clots and permitting beneficial clotting after cuts or other injuries.

All patients receiving blood thinners should take certain precautions.  Elderly patients should observe the same precautions even more scrupulously, which often requires assistance and input from family members and caregivers at home.  Fortunately, most of these precautions are basic common sense.

1.  Take drugs exactly as directed.  Elderly patients may need help remembering to take their medications on schedule.  Make sure the doctor and pharmacist know what other drugs are being taken – some medications may cause an adverse reaction when taken with blood-thinners.  Antibiotics can lessen the effectiveness of Warfarin (Coumadin) and so blood must be tested to determine if adjustments in medication need to be made during antibiotic therapy.

2.  Do not take any other drugs, vitamins, cold medicines, herbal remedies, etc – even common over-the-counter products – without consulting the doctor first.  Aspirin in particular MUST NOT be used without a doctor’s advice, because it is also an anti-platelet drug and may inhibit blood clotting beyond what’s actually good for the patient.  You might be surprised by some of the things that can interfere with blood thinners:  according to the Los Angeles Times (“Booster Shots”, Sept 24, 2008),  Pepto-Bismol may also cause an adverse reaction.  The bottom line is to talk to the doctor before taking anything.

3.  Tell all health care providers about the blood thinners because they may need to modify their usual procedures to prevent or reduce bleeding.

4.  The American Heart Association recommends carrying an emergency medical ID card that lists the drugs being taken; the patient’s name, address and phone number, and their doctor’s name, address and phone number.

5.  Minimize activities that might cause cuts or abrasions.  Most elderly patients probably won’t be playing contact sports, but there are less dramatic ways to start bleeding:  shaving and brushing teeth.  To avoid razor nicks use an electric shaver, and switch to a soft toothbrush to go easy on the gums.  Also, be sure to talk to the dentist before any dental work, even routine cleanings.

6.  Geriatric massage, which is sometimes used to improve circulation and increase joint mobility in the elderly, is not recommended for patients taking blood thinners, because of the risk of damaging delicate blood vessels  resulting in subcutaneous bleeding.

7.  Vitamin K, which is found in leafy green vegetables (lettuces, spinach, brusel sprouts)  and other foods, can interfere with warfarin therapy.  Caregivers who provide food should talk to the doctor about how much of these foods you should prepare for your elderly loved one.

8. Of course, every precaution should be taken to reduce the risk of falls and their subsequent injuries.