Tag Archives: elderly

America’s other drug problem: Copious prescriptions for hospitalized elderly

Dominick Bailey sat at his computer, scrutinizing the medication lists of patients in the geriatric unit.

A doctor had prescribed blood pressure medication for a 99-year-old woman at a dose that could cause her to faint or fall. An 84-year-old woman hospitalized for knee surgery was taking several drugs that were not meant for older patients because of their severe potential side effects.

And then there was 74-year-old Lola Cal. She had a long history of health problems, including high blood pressure and respiratory disease. She was in the hospital with pneumonia and had difficulty breathing. Her medical records showed she was on 36 medications.

“This is actually a little bit alarming,” Bailey said.

He was concerned about the sheer number of drugs, but even more worried that several of them — including ones to treat insomnia and pain — could suppress Cal’s breathing.

An increasing number of elderly patients nationwide are on multiple medications to treat chronic diseases, raising their chances of dangerous drug interactions and serious side effects. Often the drugs are prescribed by different specialists who don’t communicate with each other. If those patients are hospitalized, doctors making the rounds add to the list — and some of the drugs they prescribe may be unnecessary or unsuitable.

“This is America’s other drug problem — polypharmacy,” said Dr. Maristela Garcia, director of the inpatient geriatric unit at UCLA Medical Center in Santa Monica. “And the problem is huge.”

The medical center, where Bailey also works, is intended specifically for treating older people. One of its goals is to ensure that elderly patients are not harmed by drugs meant to heal them.

That work falls largely to Bailey, a clinical pharmacist specializing in geriatric care.

Some drugs can cause confusion, falling, excessive bleeding, low blood pressure and respiratory complications in older patients, according to research and experts.

Older adults account for about 35 percent of all hospital stays but more than half of the visits that are marred by drug-related complications, according to a 2014 action plan by the U.S. Department of Health and Human Services. Such complications add about three days to the average stay, the agency said.

Data on financial losses linked to medication problems among elderly hospital patients is limited. But the Institute of Medicine determined in 2006 that at least 400,000 preventable “adverse drug events” occur each year in American hospitals. Such events, which can result from the wrong prescription or the wrong dosage, push health care costs up annually by about $3.5 billion (in 2006 dollars).

And even if a drug doesn’t cause an adverse reaction, that doesn’t mean the patient necessarily needs it. A study of Veterans Affairs hospitals showed that 44 percent of frail elderly patients were given at least one unnecessary drug at discharge.

“There are a lot of souvenirs from being in the hospital: medicines they may not need,” said David Reuben, chief of the geriatrics division at UCLA School of Medicine.

Some drugs prescribed in the hospital are intended to treat the acute illnesses for which the patients were admitted; others are to prevent problems such as nausea or blood clots. Still others are meant to control side effects of the original medications.

University of California, San Francisco researcher and physician Ken Covinsky, said many doctors who prescribe drugs in hospitals don’t consider how long those medications might be needed. “There’s a tendency in medicine every time we start a medicine to never stop it,” Covinsky said.

When doctors in the hospital change or add to the list of medications, patients often return home uncertain about what to take. If patients have dementia or are unclear about their medications, and they don’t have a family member or a caregiver to help, the consequences can be disastrous.

One 2013 study found that nearly a fifth of patients discharged had prescription-related medical complications during their first 45 days at home. About 35 percent of those complications were preventable, and 5 percent were life-threatening.

UCLA hired Bailey about three years ago, after he completed a residency at University of California, Davis. The idea was to bring a pharmacist into the hospital’s geriatric unit to improve care and reduce readmissions among older patients.

Speaking from his hospital bed at UCLA’s Santa Monica hospital, 79-year-old Will Carter said that before he was admitted with intense leg pain, he had been taking about a dozen different drugs for diabetes, high blood pressure and arthritis.

Doctors in the hospital lowered the doses of his blood pressure and diabetes medications and added a drug to help him urinate. Bailey carefully explained the changes to him. Still, Carter said he was worried he might take the drugs incorrectly at home and end up back in the hospital.

“I’m very confused about it, to tell you the truth,” he said after talking to Bailey. “It’s complicated. And if the pills are not right, you are in trouble.”

Having a pharmacist like Bailey on the team caring for older patients can reduce drug complications and hospitalizations, according to a 2013 analysis of several studies published in the Journal of the American Geriatrics Society.

Over a six-month stretch after Bailey started working in UCLA’s Santa Monica geriatric unit, readmissions related to drug problems declined from 22 to three. At the time, patients on the unit were taking an average of about 14 different medications each.

Bailey is energetic and constantly on the go. He started one morning recently with a short lecture to medical residents in which he reminded them that many drugs act differently in older patients than in younger ones.

“As you know, our elderly are already at risk for an accumulation of drugs in their body,” he told the group. “If you put a drug that has a really long half-life, it is going to last even longer in our elderly.”

The geriatric unit has limited beds, so older patients are spread throughout the hospital. Bailey’s services are in demand. He gets paged throughout the day by doctors with questions about which medications are best for older patients or how different drugs interact. And he quickly moves from room to room, reviewing drug lists with patients.

Bailey said he tries to answer several questions in order to determine what’s best for a patient. Is the drug needed? Is the dose right? Is it going to cause a problem?

One of his go-to references is known as the Beers list — a compilation of medications that are potentially harmful for older patients. The list, named for the doctor who created it and produced by the American Geriatrics Society, includes dozens of medications, including some antidepressants and antipsychotics.

When he’s not talking to other doctors at the hospital, Bailey is often on the line with other pharmacists, physicians and relatives to make sure his patients’ medication lists are accurate and up to date. He also monitors patients’ new drugs, counsels patients about their prescriptions before they are discharged and calls them afterward to make sure they are taking the medications properly.

“Medications only work if you take them,” Bailey said dryly. “If they sit on the shelf, they don’t work.”

That was one of his main worries about Cal, the 74-year old with chronic obstructive pulmonary disease. Standing at her bedside, Bailey pored over the list of 36 drugs. Cal told him she only took the medications that she thought seemed important.

Bailey explained to Cal that he and the doctors were going to make some changes. They would eliminate unnecessary and duplicate drugs, including some that could inhibit her breathing. Then she should take as prescribed all of the medications that remained on the list.

Bailey said he’s constantly weighing the risks versus the benefits of medications for elderly patients like Cal.

“It is figuring out what they need,” he said, “versus what they can survive without.”

This story was reported while its author, Anna Gorman, participated in a fellowship supported by New America Media, the Gerontological Society of America and The Commonwealth Fund.

KHN’s coverage of aging and long-term care issues is supported by a grant from The SCAN Foundation, and its coverage of late life and geriatric care is supported by The John A. Hartford Foundation. Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

Activists halt GOP scheme to exploit state’s disabled, elderly

Disability rights activists won a big victory in Wisconsin last week. On June 9, the Department of Health Services withdrew its plan to turn over programs for medical and long-term care for people with disabilities and the elderly to private, for-profit insurance companies.

While activists celebrated the victory, Tom Frazier, who led the coalition opposed to the changes, said he expects a new proposal to come next year.

Over the last 15 years, Wisconsin has become a leader in creating two innovative programs for helping people with disabilities receive care in their homes. Those two programs are called Family Care and IRIS, which stands for Include, Respect, I Self-Direct. At year’s end, there were about 40,000 people in Family Care and 13,000 in IRIS.

Although the programs are extremely popular and revenue neutral, meaning they cost taxpayers nothing, lobbyists representing for-private insurance companies persuaded Republican leaders to force recipients of such services into their care.

The switch to private, for-profit care, which was approved in April, would “not save money, but (would) disrupt the lives of people using IRIS and Family Care by forcing them into for-profit insurance companies,” said a May 16 press release from a group called Save IRIS, Wisconsin’s Self Direction Advocates.

Other disability rights groups also opposed the change, including Disability Rights Wisconsin and the Wisconsin Long-Term Care Coalition. Both of them urged the Health Services Department to scrap its plan.

On June 9, Health Services Secretary Kitty Rhoades did just that. She sent a letter to the heads of the Joint Finance Committee, Senator Alberta Darling and Representative John Nygren.

“We have received comments, feedback and questions from providers, advocates, legislators, and most importantly consumers,” she wrote. “Therefore, I am writing to withdraw the concept plan.”

One of the legislators she had heard from was Rep. Melissa Sargent, who wrote a commentary in the Capital Times on May 9, calling the plan “an attempt to make a profit off of Wisconsin’s most vulnerable citizens.” Sargent said that UnitedHealthcare was one company angling for such a state contract.

“Eric Schutt, Walker’s former chief of staff, is the vice president of external affairs for this company,” she wrote. “They have been aggressively lobbying the Legislature to ensure they receive the contract, and the profits that will come with it. Cronyism at its worst.”

UnitedHealthcare spent $124,000 on lobbying in Wisconsin last year, according to the Government Accountability Board’s website.

From 2009 through 2015, UnitedHealthcare of Wisconsin’s PAC gave $21,000 to candidates and campaign committees. The top two gifts were $6,000 to the Republican Assembly Campaign Committee and $2,500 to the Committee to Elect a Republican Senate. The PAC also gave $1,500 to the State Senate Democratic Committee.

During the same period, employees of UnitedHealthcare gave $30,035 to candidates for office. Scott Walker received the most, with $6,833. Senate Majority Leader Scott Fitzgerald was next, with $2,800.

Matthew Rothschild is the executive director of the Wisconsin Democracy Campaign. Visit www.wisdc.org.

Social Security must be preserved

Social Security, one of the most successful government programs in U.S. history, marked its 80th anniversary this year. As it enters its ninth decade of providing basic income security for older Americans, GOP presidential candidates are working to undermine faith in it.

They decry Social Security as an “entitlement” and warn of its insolvency. Using their favorite tactic of divide and conquer, they claim the money won’t be there for young people. They say Americans can get better returns from investing the same small sliver of their paychecks in private markets. So why should the government take the money?

Please don’t drink their Kool-Aid. 

Social Security is not an entitlement. Each of us pays for it through a deduction of 6.2 percent from every paycheck. Our employers match that 6.2 percent and send the total amount to the federal government monthly.

When we draw from Social Security in retirement, we receive money we have invested in the system our entire lives. The earliest age to claim Social Security is 62. The monthly check is larger if a person waits until full retirement age, which is 66 or 67, depending on your year of birth.

Social Security is not insolvent, and young people need only look at how the program benefits their grandparents to see what a valuable investment it is. All of my older relatives and friends rely on Social Security as an important part of their retirement income. They are not moochers. They have earned their benefits.

Social Security was championed by President Franklin D. Roosevelt and adopted by bipartisan Congressional majorities in 1935. Private charity had never fully met the needs of the poor and elderly poverty, a scourge that predated the Great Depression, grew more severe during the economic crisis.

The Social Security Act included old age insurance (the focus of this column), unemployment compensation, welfare benefits for the poor and survivor benefits for widows and orphans. Welfare — Aid to Families with Dependent Children — was abolished under Bill Clinton in 1996.

Many studies confirm that in the second half of the 20th century, Social Security helped significantly to reduce poverty among the elderly. Without Social Security today, 48 percent of Wisconsin seniors would descend below the poverty line.

Concerns about the solvency of Social Security have been addressed over the years in several ways: raising the retirement age; increasing the percentage of contributions; and raising the amount of income subject to Social Security taxes.

Currently, individuals do not have to pay Social Security taxes on income above $118,500. Lifting the payroll cap to $250,000, which Bernie Sanders proposes, would secure Social Security for at least the next three generations.

Of course, the GOP opposes any new taxes — even for a successful program that keeps millions from destitution. The financial windfall for investment firms is the real motive behind those who want to privatize Social Security. 

Why should Americans hand over our one small reserve of secure savings to the banks and Wall Street, whose practices have become more secretive and whose history is full of reckless speculation? Have we forgotten the near crash that took place only seven years ago? They not only stole our money, we had to bail them out!

Social Security guarantees all of us a minimum retirement income when we grow old. It must be preserved.

St. John’s on the Lake makes room for residents’ furry friends

Anyone who’s ever had an animal companion knows just how much joy they bring. Our companion animals play an important and irreplaceable role in our lifestyles and emotions. They help to guide us through life’s many struggles and have been proven beneficial to our health and happiness. 

One challenge we all face is aging, particularly when the time comes to move into a retirement community. It’s a hard choice to leave one home for another, and many seniors must face the decision of whether to take a beloved furry friend with them. 

During such transitional times, having the love and support of a cherished pet can make more of a difference than ever. Just ask the resident pet owners who live at St. John’s on the Lake, 1840 N. Prospect Ave., Milwaukee. There, pets are welcomed with open hearts.

“Your pet sort of becomes everyone’s pet,” says resident pet owner Jack Ford, his curly coated tan pup Casper sitting beside him.

Residents walk freely through the halls with their dogs, take them outside to the outdoor doggie run, and socialize together at pet-themed events. 

“When I walk down the hall, usually people say, ‘Hi, Dexter,’” says Bill Lau, referring to his dog. “They say ‘hello’ to him before they even say ‘hello’ to me!” 

The cat owners also have their special place. One resident walks her sleek black cat Samantha in a lovely red harness during what would regularly be the dog hours.

For cat owner Mary McAndrews, whose cats all have been named after mystery authors, the decision to adopt Josephine was prompted by the hard choice the cat’s former “parent” had to face: Leave Josephine behind with a social worker when she entered senior living.

“Josephine was 8 years old,” explains McAndrews, “and the story that we heard was that she was brought in by a social worker. Her previous owner had two cats and was going into a senior facility that only allowed for her to keep one.” 

To celebrate the bonds between St. John’s residents and their pets, Lau conceived of a touching photography exhibit called the Pet Project. Resident photographers Dan Patrinos, Art Beaudry and Jim Ballard photographed 10 dogs, 14 cats and their owners in their homes at St. John’s. The display of black-and-white photographs features candid shots, portraits and group photographs of residents with their pets.

On a special side display titled Remembrance, photographs of pets who have passed are also included. This touching project is on display at St. John’s until mid-November and is free and open to the public.

The warmth that shines through each photograph evidences the power of pet companionship and the quality of life it adds to the residents and staff at St. John’s on the Lake. The photographs underscore the family atmosphere that St. John’s strives to create for everyone, including those for whom no family would be complete without an occasional “woof!” or “meow.”

Coalition rallies for Milwaukee ID card

A coalition on Nov. 2 rallied in support of a Milwaukee County budget amendment to create a work group to produce a Milwaukee ID card.

After the rally, about 20 people spoke in support of Milwaukee IDs during a hearing held by the Milwaukee County Board of Supervisors.

The ID would be available through a partnership between the city and the county.

The budget amendment creating a work group to produce the card passed the county board’s finance committee in late October and will come to a full vote before the county board on Nov. 9. Last week, the public safety committee of the Milwaukee Common Council unanimously backed legislation to include the program in the city’s budget, which was to be voted upon on Nov. 3.

Speakers at the rally included County Supervisors Khalif Rainey, Peggy Romo-West and Marina Dimitrijevic, transgender community members, undocumented immigrants, family members of incarcerated people, and representatives of St. Ben’s Community Meal Program.

“This is about is about giving everyone an opportunity to be included in society,” said Rainey. “You shouldn’t be a member of our community and go to the hospital and not be able to get the services you need. That’s why I’m standing with you in solidarity in support of local ID.”

“I need to have a way to identify myself, to show who I am,” said Guadalupe Romero, a member of Voces de la Frontera. “One of my sons broke his back in a work accident, and had to have a metal bar placed in his spine. You can imagine the pain he was in. The doctors gave him a prescription for pain medicine, but because he didn’t have a government-issued ID card the pharmacist would not give it to him.

“A little while later our pet dog got sick,” continued Romero. When we took him to the veterinarian, we were able to obtain medicine for the dog immediately, and I ask, why? Does my son not have more value than an animal?”

“In many cases, a lack of a government-issued ID is a barrier to domestic violence victims who are attempting to escape abusers,” said Tony Gibart, public policy director of End Domestic Abuse Wisconsin. “First, court documents, such as petitions for divorce, must be notarized, and notaries usually require the presentation of a government-issued ID. Second, applications for federal immigration protections for undocumented victims of domestic violence and their children require possessing a government-issued ID. Providing the opportunity for people to easily obtain a local ID would address these problems.”

“I had to deal through years of shame, and still continue to be shamed for simply declaring: this is who I am,” said transgender woman Livia Rowell-Ortiz. “When I leave my house I am making a conscious decision that I am placing myself in active danger — that it is likely that I be harassed increasingly depending on how visible I am that day, to the extent of fearing going outside at all. It is my hope that this local ID will pass and start the process of ending this shaming with the protection of the county and city of Milwaukee for myself and other transgender persons.”

“We have homeless at St. Ben’s who constantly come to the doors saying they need help in trying to get an ID,” said Br. Rob Roemer, OFM Cap, director of St. Ben’s Community Meal Program. “Often they cannot get their birth certificate that is required to get a State ID. We encourage the county to start offering other forms of ID’s that help the homeless and poor to get the jobs and help they need to get out of their situations.”

The coalition supporting local IDs for Milwaukee includes St. Ben’s Community Meal, Project Return, Wisconsin Jobs Now, Milwaukee LGBT Community Center, End Domestic Abuse Wisconsin, the Jewish Community Relations Council of the Milwaukee Jewish Federation and Voces de la Frontera.

Walking with my mother in her heart-breaking decline

All life cycles have watershed moments, times when another bridge has been irrevocably crossed. In the life of a child, that moment is often a joyful one. But for an elderly parent, life proceeds in reverse, leading often to sorrowful conclusions. 

My mother Liz, who is 93 years old, reached one of those watershed moments one night three years ago. 

We had moved my mother from Milwaukee to a senior housing complex near our Madison home five years earlier. My wife Jean and I had visited her twice that Sunday to address various issues. She seemed strange, but we weren’t yet seasoned enough to understand what was wrong.

After her third call, we returned to find Mom sitting in her nightgown on her bed, with three television and cable system remotes and three cordless telephones alongside her. We realized that something was happening.

Jean began to remove the clutter, which snapped Mother out of her stupor,

“Don’t touch those,” she said anxiously. “Those are my phones!”

Some were her phones, and some weren’t. Due to their similar shape and color, she could no longer tell the difference. We bundled her up and took her to the nearest emergency room.

> > >

More than 10 million adult children over 50 care for aging parents, according to a 2011 study by the MetLife Mature Market Institute. Baby Boomers comprise the majority of caregivers. The number of parents cared for both physically and financially by their kids has more than tripled over the past 15 years.

Not surprisingly, daughters tend to provide more care than sons and suffer more financially because of it. On average, the amount of lost wages, pension dollars and Social Security benefits for women forced to leave the workforce early to provide care totals $324,044, according to the study. Men suffer less financially, but it still costs them an average of $283,716 in aggregate salary and benefit losses to care for elderly parents.

A disproportionate number of boomers caring for parents are gay and lesbian, according to John George, health care administrator for Saint John’s On The Lake, a retirement community of 330 residents on Milwaukee’s east side.

> > >

Upon reaching the hospital that Sunday night, my mother was diagnosed with dehydration and a urinary tract infection, both of which accounted for her confusion. But we would soon discover she also suffered from transient ischemic attacks, often called TIAs or “mini-strokes.” Those would lead to more dire consequences. 

TIAs are caused by blood clots that come and go in the brain. Some are relatively harmless, while others can be precursors to larger, fatal strokes. A series of TIAs followed by a large stroke killed Mom’s older brother Harold decades earlier. We felt that a similar outcome was possible, if not imminent, for her.

While doctors worked to get her situation under control, we made arrangements to move Mom temporarily to a nursing home for rehabilitation. A former RN, my mother had worked at Sunrise Care Center on Milwaukee’s south side until she was almost 86. We thought she’d be comfortable with the transition.

> > >

Transitions to some level of assisted living are often the most difficult things for families to cope with, according to Elaine Dyer, a registered nurse and administrator for the Jewish Home and Care Center, a 160-bed retirement community also on Milwaukee’s east side. Large families often have the hardest time agreeing on what should be done with an elderly parent.

“When there’s more than one child, there’s always more than one opinion,” Dyer says. “As caregivers, we need a point person whose guidance we can rely on, and that person needs to be the patient’s health care power of attorney in order to make the right decisions.”

Dyer’s own mother was a resident at the Jewish Home until she passed away from Alzheimer’s disease last October, and the administrator is acutely aware of how hard the “little losses” of cognitive decline can be on family members.

“Watching cognitive decline is harder than watching physical decline,” Dyer says. “The elderly begin to lose the abilities you gain as a child, including swallowing, talking, walking, bowl and bladder control.”

In terms of providing care, Wisconsin’s 323 nursing homes serve only about 5 percent of the state’s population over 65, Dyer says. The surprising statistic is mostly due to finances. Owing to the recent financial recession, admissions to skilled care facilities have declined over the past four to five years, because too many families need their parents’ Social Security checks to make ends meet.

And then there’s the cost of putting those parents in a skilled care facility.

“The cost for nursing home care is $8,000 to $10,000 a month, and even the wealthiest person who has saved for it could one day run out of money,” Dyer says.

But before that happens, adult children should make sure they understand what their aging parents want and then make those ultimate decisions based on that guidance, she adds.

> > >

Mom spent two weeks in the nursing home, eventually returning to a variant of her former self. But we knew that bridges had been crossed and things would never be the same again.

During my mother’s nursing home stay, we found her an assisted living facility on Madison’s west side. We moved her out of her senior apartment, disposing of furniture and other things she no longer needed. During the grueling two-week process, we discovered clues to her cognitive failure that weren’t previously apparent.

Dozens of unopened bottles of generic acetaminophen and countless file cards and paper scraps with duplicate addresses and phone numbers she didn’t want to forget filled nooks and crannies. We discovered boxes of junk mail — her “bills” as she called them — including some stored in the unused dishwasher. We found cash in the refrigerator.

Mom appeared to be settling in nicely to her assisted living facility, making new friends and regularly eating a healthy diet, something she had also stopped doing in her apartment. There were even activities and outings, but over the course of two years we could see that she had started slowing down.

When construction began on the facility’s new addition, we saw her confusion and anxiety increase. A series of three UTIs in as many months seemed to send her to the moon and back again — not to mention the hospital — on a regular basis. 

George notes that a change in a senior’s environment can result in “transfer trauma” and a large percentage of sufferers are usually dead within a year. When her strange behavior continued, we began to wonder just how long her future would be.

My mother called me on the telephone last week. 

“Mike? This is Grandma,” she said. “If you are out can you stop by? I haven’t had a working phone all day.”

And so, once again, it begins. I don’t want to spend Mothers’ Day at the hospital this year, but maybe just having one more Mother’s Day anywhere is the best I can hope for.

Fight against Walker budget cuts

The state Legislature’s Joint Finance Committee is vetting Gov. Scott Walker’s proposed budget cuts to the UW System, environmental protections and services for the elderly and disabled.

It’s not an exaggeration to say our futures are at stake: quality, affordable education for young people and returning students; the beautiful lands and streams we love but often take for granted; and the long-term care needs of our elderly and disabled family members and neighbors. 

I’m dismayed by people accepting Walker’s drastic changes as inevitable. Walker’s cuts are not inevitable and it’s self-defeating to assume that nothing can be done.

Public pressure already has succeeded in getting the Joint Finance Committee to nix the proposal that would have stripped policy-making powers from the Department of Natural Resources and Agriculture boards. Some Republican legislators are now saying they plan to reduce Walker’s $300 million cut to UW campuses and $127 million cut to K-12 schools.

Joint Finance co-chair Sen. Alberta Darling was rattled by UW chancellors using the media to announce huge cuts in personnel. “This is sort of a tactic to get people to lobby us,” she huffed. Yes, and an effective one! 

Corporations pay lobbyists to pursue their profit-making schemes, in many cases writing the laws they benefit from. Those hucksters are ubiquitous and made welcome in our state Capitol. But when average folks speak up to defend their public land and institutions, their opinions are considered an imposition.

I say let’s keep imposing ourselves. Activate your social network. Call, email or send letters to Walker, Joint Finance Committee co-chairs Sen. Darling and Rep. John Nygren and your state senator and representative.

Contact Walker at 115 E. Capitol, Madison, WI 53702 or at 608-266-1212. To find your legislators’ contact info, go to http://legis.wisconsin.gov and type in your address. 

Snail mail is slower but has greater impact. Postcards and letters have a physical presence, especially if politicians get a lot of them.

Written communications can be as short as “I am opposed to budget cuts in the university system so please vote against them” to longer letters that include facts and arguments against specific cuts. Supportive facts can be found on the websites of organizations such as the Wisconsin League of Conservation Voters, Disability Rights Wisconsin, Citizen Action of Wisconsin, Planned Parenthood, the Wisconsin AFL-CIO and UW Alumni groups.

Never be abusive but be firm and state that you vote in every election.

You can also take a personal approach and describe how the cuts will affect your education or your children’s education, the state parks you enjoy, or the care of your grandparents. If you have kids, nephews or nieces, throw a letter-writing party. Have them drop the letters in the mailbox with you. Doing it together sets an example and teaches them we all need to stand up for what we believe. 

In the longer term, we must prepare for voter ID and make sure everyone we know has proper ID and is registered. We need to support, through volunteer time and donations, the grassroots groups working their hearts out to protect our lands, schools and people. 

The fight to preserve public resources and oversight is the fight for Wisconsin’s future. Budget debate and floor votes only extend through May, so please act today.

Death Cafes allow end-of-life discussions

On a blazing afternoon, cars vie for the few shaded parking spots outside Radiance of Sarasota in Florida, a storefront in a small strip mall billed as a “wellness and inspiration center.”

Visitors, mostly aged 50-plus, enter the center’s cool, dimly lit quarters, where they’re invited to help themselves to tea, pastel-colored pastries, gluten-free brownies and a seat within a large circle of chairs.

They are not necessarily seeking radiance, wellness or inspiration. They are here to participate in a frank, open-ended discussion about life’s grand finale at the monthly Sarasota Death Cafe.

The idea? To provide a casual, comfortable space for people to discuss everything from the practical (legal documents and right to die legislation) to the ethereal (near-death experiences and the great “What’s next?”). The free gathering is based on the writings of a Swiss sociologist who believed talking openly about death could lead to a fuller, richer, more conscious life.

If that sounds a little morbid, a growing number of people would disagree. Death cafes are just one of the ways a subject once taboo — or at least uncomfortable — is coming out in the open.

Over the past year, Sarasota, Florida, with one of the oldest demographics in the country, has joined other communities across the nation in embracing frank discussions about the end of life — everything from how to avoid dying in the hospital to advancing legislation in favor of physician-assisted suicide.

A public lecture at the Selby Library by the president of the World Federation of Right to Die Societies in February drew a capacity crowd and went an hour overtime to accommodate questions.

Two panel discussions with end of life experts sponsored by the Herald-Tribune in March following its publication of “Dorothy’s Choice,” the story of one elderly woman’s choice to end life on her own terms, were standing-room only.

A 9 a.m. weekday screening in July of “Consider the Conversation,” an award-winning documentary that encourages people to plan ahead for their deaths, had to be moved to a bigger Lakewood Ranch theater to meet demand.

And the Sarasota Death Cafe, begun in May, tripled in size from the first meeting to the third.

Even parents and children are more frequently broaching the once-taboo subject, though Joelle Angsten, chief medical officer of Tidewell Hospice, doesn’t endorse the frequent suggestion to have “the conversation” over Thanksgiving dinner.

“I’d recommend while you’re in a car on a long trip,” she says, only half in jest. “That way you don’t have to look at each other but you can’t escape.”

As the aging but fiercely independent baby boomers effort to control their own destinies clashes with modern medicine’s ability to sustain life to extremes, a backlash is building. This generation is determined to rewrite the script on dying, much as they have altered social acceptance of living together without marriage, nursing babies in public or same-sex unions.

But it won’t happen, they say, unless we talk about it.

“No previous generations have had to figure this out,” Angsten says. “So there’s no role model. But we’ve adopted so many things that support social change _ like maternity leave, for example. Wouldn’t it be great if we could figure out how to do that at the other end of life?”

The first official “death cafe” was organized by a 40-ish father of two, Jon Underwood, who hosted the initial gathering at his home in East London in September 2011. Underwood’s “Mum,” a psychotherapist, helped to facilitate.

“They’re not being morbid,” Underwood said at the time of the original participants. “These are people who want to live more fully. The more we talk about dying and what it means about ego and self, the more we add to life.”

After he created a website, deathcafe.com, with instructions on how others could start their own chapters, the idea proliferated into a global movement. The first death cafe in the United States was held in Columbus, Ohio, in 2012; there are now hundreds of regular gatherings in this country and more than 1,000 meetings have taken place around the world.

The cafes _ which have no set objectives, agendas or themes, nor any profit motives _ reached Florida during the past year, with sessions held in Tampa, Naples, Gainesville and Ocala, as well as Sarasota.

The local group was started by Lori Marshall and her partner, Mark Sanders, who call themselves “spiritual mediums and life counselors.” It has drawn a diverse crowd: from psychics to educators, elders on oxygen to an 11-year-old girl who accompanied her mother and, at one point, burst into tears, protesting, “But I don’t want to die!”

Donna (who does not share her last name) says that when she first heard the term “death cafe,” she assumed it must be a party for Grateful Dead fans. Then she thought it was a joke. But as caregiver for both of her parents, who are in their 80s, she is looking for help with end of life planning.

Tobie DeSantis, who assists the elderly with end of life challenges _ her business card advertises help with household needs, doctors appointments and “special projects” _ came to learn more about Florida’s laws regarding deaths that take place at home.

Mark Tishman wants to help people through the dying process with a more natural approach than the one he was taught as a funeral director.

Susan Dana figured a birthday trip to the death cafe was a fitting follow-up to a stop at the Marie Selby Botanical Gardens for a glimpse of the Amorphophallu titanum or “corpse” plant, which blooms only once every few years and smells, so they say, like a decomposing mammal.

“Every month we’re not really sure what will happen,” says Marshall, who was motivated to start the group after the “amazing experience” of watching her father die in hospital hospice two years ago. “But everyone leaves feeling just a little more connected, a little more comfortable and little less fearful about the idea of death.”

Death and how we deal with it has changed dramatically over the past century, Marshall says. Before advances in medicine made it possible to sustain life beyond “natural” limits, a death at home was the logical bookend to a birth that also took place at home. Family members held vigils as a loved one expired and personally prepared the body for burial.

Now, with most people dying in the hospital, the process has become clinical and the intimacy desensitized, she says; the body becomes an object to be whisked away to a crematory or funeral parlor and the vigil agonizing or feared.

No one gathered here thinks being hooked up to a ventilator matches their idea of a graceful, dignified leave-taking. But they aren’t necessarily unified about what does. Over the course of two hours, the conversation veers from the inadequacy of living wills and “Do Not Resuscitate” orders to how to communicate with those “on the other side.” At one awkward moment, it even segues into someone’s tirade about drones, but that topic is quickly shut down. Organizers are emphatic that meetings are not meant for grief counseling nor political rants.

For the most part, the exchanges are sensitive, thoughtful and accepting of a diversity of opinion. In fact, were it not for the skeleton skull that decorates the refreshment table, you might think you’d stumbled on a friendly coffee klatch or a “Meet Up” group. Though there is plenty of solemnity and even the occasional tear _ Marshall has learned to have a box of tissues on hand _ humor surfaces just as readily.

In fact, it doesn’t take much more than the brief self-introductions that kick off the session, to demonstrate that, while death may be no laughing matter, it can elicit plenty of good-natured jokes.

One elderly man smiles endearingly at the woman seated next to him as he shares that on this very date 56 years earlier, they were in the middle of their wedding ceremony.

With perfect comic timing, John St. Clair, a retired probate attorney, quips:

“Well if that’s the case, no wonder you wanted to come to a death cafe today!”

Not every death cafe takes place in a public place.

In Ocala, monthly meetings that began last October were moved from Mojo’s Grill, which proved too hot, noisy and distracting, to the comfortably middle-class living room of Teddy Laury.

Jovial and direct, Laury is a native of the Netherlands, the first country to legalize physician-assisted suicide in 2001 and the catalyst for starting this first death cafe in Florida. She is not accustomed to holding back her opinions on death or anything else, for that matter; the back of her SUV bears bumper stickers with environmental, political and religious slogans.

“Holland has always been a refuge for people persecuted for every reason,” she says, with a gutteral accent. “In the Netherlands, we talk about everything.”

So does this group of eight people _ plus one dog and two cats _ who met on the last Monday evening of July in a cramped circle, perched on an assortment of overstuffed chairs and furniture dragged in from the nearby screened porch.

Donna Wright and her friend, Lee Hansen, arrive a few minutes late after the 30-minute drive from their home in Cross Creek. Wright promised her late husband she would not allow him to suffer during his death from cancer; Hansen worked for many years in hospice.

Diane Podkomorski is an administrator at an assisted-living center looking to “open people’s eyes to the fact that you can’t wait until the last minute to make your plans.”

Don and Dave Laury, Teddy’s brothers-in-law sit mutely on the couch; they are here because they are Laury’s health care surrogates.

Whether because of its seniority, make up or location, this meeting has a different feel than the one in Sarasota. There are salty snacks and beer on the refreshment table as well as coffee and cookies and the conversation is less New Age and more topical, occasionally getting sidetracked by current events.

At a previous meeting the group watched a Dutch documentary about assisted suicide. But at this one, like most, there is no visual or verbal “prompt,” just friendly, like-minded chat about what Hansen calls “our death-denying, death-defying” world.” Laury sees that attitude as particularly American.

“This country is all about winning and American doctors feel like they have to win the fight,” she says. “Whereas our doctors in Holland look much more at the quality of life.”

For example, she says, when she recently refused a mammogram based on her conviction that, even if she had cancer, she wouldn’t choose to treat it, her doctor responded with: “I did not hear you say that.” When she speaks of her late husband’s choice to refuse chemotherapy after a diagnosis of stage four lung cancer _ he loved food and enjoyed a steak and potatoes dinner the night before he died _ it comes with a warning about the difficulty of charting a course that defies the medical model.

“When I asked for a referral to hospice after his diagnosis, the nurse gave me the dirtiest look, like, ‘So, you’re trying to get rid of him?”” Laury recalls. “And even as on top of it as I was, I let the oncologist talk us into a test that put him in the hospital for two days. He died at home, but I had a hard time getting him back out.”

Agrees Hansen: “Once that 911 call goes in, it’s out of your control.”

When the talk turns toward physicians’ inability to discuss end of life with their patients, Lila Ivey, the outreach coordinator for Marion County Hospice, is sympathetic, but pragmatic.

“Our doctors don’t want to go to jail,” she says. “They’re trained to meet people where they are, but people are uncomfortable talking about this with their own families. They’re certainly not going to talk to their doctors.”

Leslie Robertson, who is working on a graduate degree in suicidology — she’s careful to clarify that means counseling people who are suicidal, not advocating for it — wants to be part of altering attitudes about what constitutes a “good death.” She represents the youngest edge of the boomer generation, and believes a tidal shift is coming.

“Older folks might have wanted to go to the hospital to die, but baby boomers don’t,” says Robertson. “I feel like we need to let the community know there’s a better way.”

An AP member exchange.

Not so golden: Wealth gap lasting into retirement

William Kistler views retirement like someone tied to the tracks and watching a train coming. It’s looming and threatening, but there’s little he can do.

Kistler, a 63-year-old resident of Golden, Colorado, has been unable to build up a nest egg for himself and his wife with his modest salary at a nonprofit. He has saved little in a 401(k) over the past decade, after spending most of his working life self-employed. That puts him far behind many wealthier Americans approaching retirement.

“There is not enough to retire with,” he said. “It’s completely frightening, to tell you the truth. And I, like a lot of people, try not to think about it too much, which is actually a problem.”

With traditional pensions becoming rarer in the private sector, and lower-paid workers less likely to have access to an employer-provided retirement plan, there is a growing gulf in the retirement savings of the wealthy and people with lower incomes. That, experts say, could exacerbate an already widening wealth gap across America, as more than 70 million baby boomers head into retirement — many of them with skimpy reserves.

Because retirement savings are ever more closely tied to income, the widening gulf between the rich and those with less promises to continue — and perhaps worsen — after workers reach retirement age. That is likely to put pressure on government services and lead even more Americans to work well into what is supposed to be their golden years.

Increasingly, financial security for retirees reflects how much they have accumulated during their working career — things like 401(k) accounts, other savings and home equity.

Highly educated, dual income couples tend to do better under this system. The future looks bleaker for people with less education, lower incomes or health issues, as well as for single parents, said Karen Smith, a senior fellow at the Urban Institute, a Washington think tank.

“We do find rising inequality,” said Smith, who added that it’s a problem if those at the top are seeing disproportionate gains from economic growth.

Incomes for the highest-earning 1 percent of Americans soared 31 percent from 2009 through 2012, after adjusting for inflation, according to data compiled by Emmanuel Saez, an economist at University of California, Berkeley. For everyone else, it inched up an average of 0.4 percent.

Researchers at the liberal Economic Policy Institute say households in the top fifth of income saw median retirement savings increase from $45,539 in 1989 to $160,000 in 2010 in inflation-adjusted dollars. For households in the bottom fifth, median retirement savings were down from $8,433 in 1989 to $8,000 in 2010, adjusted for inflation. The calculations did not include households without retirement savings.

Employment Benefit Research Institute research director Jack VanDerhei found that in households where annual income is less than $25,000, nine in 10 saved less than $10,000, up slightly from 2009. For households with six-figure incomes, 42 percent saved at least $250,000, up from 34 percent five years earlier.

The days of retirees being able to count on set monthly payments from pensions continue to fade among non-government workers. Only 13 percent of private-sector workers now participate in “defined benefit” plans, compared with a third of such workers in 1985. They’ve been eclipsed by “defined contribution” plans, often 401(k)s, in which employers match a portion of employee contributions.

Americans know they need to save for retirement. The trick for many is actually doing it. It’s estimated that about half of private-sector workers don’t take part in a retirement plan at their current job.

“Over the years, all I’ve been able to do, especially as a single parent, is just pay your bills every month,” said Susan McNamara, a 62-year-old adjunct professor from the Boston area. “Anything that’s left over is used up when your car breaks down or when the furnace breaks down. … There’s never anything left over, ever.”

McNamara is divorced and her son is now grown. But she has had heart issues linked to cancer in 2004 and related financial worries. She sold her home to meet expenses. McNamara has a defined contribution plan from past stints as a full-time professor, but its balance is under $50,000.

Or consider Kistler, who makes $41,000 a year working as a benefits counselor for a nonprofit health care provider. He has no substantial savings beyond the 401(k) worth roughly $19,000, and he has debt. He plans to keep working.

Kistler is philosophical about being on the short end of a retirement gap, though he wonders what will happen when boomers in his financial situation begin retiring by the millions.

“This next 10 to 15 years is going to be quite interesting,” he said.

EBRI, a Washington-based nonpartisan research group, projects that more than 55 percent of baby boomers and the generation that follows them, Generation X, will have enough money to last through retirement.

But EBRI also found the least wealthy boomer and Gen X households are far more likely to run short of money in retirement. Under some models, 43 percent of those in the lowest quarter run short of money in the first year of retirement.

VanDerhei, EBRI’s research director, said members of that group are relying mostly on Social Security and lacked consistent access to retirement plans over their careers.

Many of those retirees will find that it won’t be enough, David John of AARP’s Public Policy Institute said, noting the average monthly Social Security retiree benefit last year was about $1,300.

“In the long run, if we have significant numbers of people retiring on Social Security and very little else, there’s going to be a tremendous pressure on state and local governments for additional services, ranging from health to housing to libraries,” John said. “There’s going to be significant pressure on the national government to provide additional support.”

John said a good first step would be to ensure more workers have the ability to save through employer-sponsored retirement plans.

For many, it will mean working to a later age and cutting back.

In Brooklyn, 60-year-old Madeline Smith is already thinking about a modest future. While she has no illusions about living the “little fairy tale” of a cushy retirement, she also is confident she can get by, maybe working part-time, living simply or even renting out her house.

“Sometimes you have to learn to be a little bit more conservative,” she said. “I think a lot of people are learning that now as they get older.”

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ACLU sues Arkansas over voter photo ID law

A civil liberties group filed suit this week to block a new Arkansas law requiring voters to show photo identification at the polls before it is enforced for the first time statewide in the primary election next month.

The American Civil Liberties Union of Arkansas filed the suit in Pulaski County court on behalf of four voters it says will be harmed by the law, which was approved by the Republican-led Legislature last year. Democratic Gov. Mike Beebe vetoed the measure, but lawmakers overrode his objection with simple majority votes in the House and Senate.

“This puts more burdens on the voter than the Arkansas constitution permits…It only creates more trouble for people who have been voting all their lives,” Rita Sklar, executive director of ACLU of Arkansas, told reporters after the lawsuit was filed. “It throws hurdles in front of them instead of making it easier for them to participate in the democratic process.”

The new law is being challenged when the state is in the national political spotlight because of a hotly contested race that could tip the majority in the U.S. Senate. Democratic U.S. Sen. Mark Pryor is being challenged by Republican U.S. Rep. Tom Cotton. Neither faces an opponent in the primary but outside money is pouring into Arkansas for advertising months before the general election in November.

The lawsuit, which names Secretary of State Mark Martin and the state Board of Election Commissioners as defendants, says the voter ID law violates Arkansas’ constitution. The lawsuit, which also was backed by civil rights advocacy group Arkansas Public Law Center, says the requirement “placed additional qualifications and impairments on Arkansas citizens before they can exercise their state constitutional right to vote.”

A spokesman for Martin said his office was reviewing the lawsuit and would respond in court. The senator who sponsored the law said he was confident it would be upheld.

“The ACLU does what the ACLU does. To me they’re trying to be an obstacle in ensuring voter integrity at the polls,” said Sen. Bryan King, R-Green Forest.

The voters cited by the lawsuit include Barry Haas, a Pulaski County resident who refused to show ID when casting a ballot in a March 11 special election. According to the suit, Haas cast a provisional ballot that wasn’t counted since he didn’t show ID. Another voter, 78-year-old Joe Flakes, doesn’t have a photo ID because he was never issued a birth certificate by the state. The ACLU said Flakes was delivered by a midwife who did not properly record his birth.

While the law was used in some local elections earlier this year it will be used statewide for the first time during early voting beginning May 5 and on primary election day, May 20.

The ACLU said it planned to later ask for a preliminary injunction blocking the law’s enforcement while the challenge is being considered.

Thirty-one states have laws in effect requiring voters to show some form of identification, according to the National Conference of State Legislatures. Seven states have strict photo ID requirements similar to Arkansas. Voter ID laws have been put on hold in Wisconsin and Pennsylvania because of court challenges.

The lawsuit asks the court to prevent the state from enforcing the ID requirement, which took effect on Jan. 1, in the primary.

Under previous law, election workers were required to ask for photo ID but voters don’t have to show it to cast a ballot. Under the new law, voters who don’t show photo identification can cast provisional ballots. Those ballots would be counted only if voters provide ID to county election officials before noon on the Monday following an election, sign an affidavit stating they are indigent or have a religious objection to being photographed.

Arkansas Republicans had pushed for voter ID requirements for years, but the measure failed to reach the governor’s desk under Democratic majorities. Republicans in 2012 won control of the Legislature for the first time in 138 years and have enjoyed a number of successes, including the passage of stricter anti-abortion laws and broader gun rights.

The lawsuit is the second related to the new ID requirements although the challenge Wednesday is the first challenging the law directly. The Pulaski County Election Commission has sued the state Board of Election Commissioners for adopting a rule that gives absentee voters additional time to show proof of ID.