Addressing Medical, Legal, & Financial Advance Care Planning:
The Healthy Aging Checklist Part 6

This is the sixth and final post covering the Healthy Aging Checklist, a set of six core activities that will help any older adult maintain the best possible health while aging.

They are:

• Promote brain health and emotional well-being.
• Promote physical health.
• Check for and address common aging health problems (such as falls, memory concerns, depression, incontinence, pain, isolation, polypharmacy).
• Learn to optimize the management of any chronic conditions.
• Get recommended preventive health services for older adults.
• Address medical, legal, and financial advance care planning.

In this post, I’ll address the last item on the list: advance planning for medical, legal, and financial issues. This includes power of attorney documents, plus much more.

This is a big topic, and it’s not possible to cover everything you could or should do in a single article. You would need a book for that — I suggest three down below — plus it’s best to work with qualified professionals (healthcare providers, eldercare attorneys, and financial planners) before completing any legally binding paperwork.

But every day as I work, I see older adults and families whose health and well-being is being affected by the consequences of their planning — or lack of planning, as the case often is.

So in this post, I will share some practical information that should make it easier for you to address planning that covers some common age-related challenges:

• The three key steps involved in all advance planning for aging
• 5 common problems every older adult and family should consider planning for
• What research has revealed about older adults and planning for the future (hint: that they are counting on their kids even though they usually don’t talk much to their families about this)
• 5 key steps for advanced planning in healthcare
• 4 key steps for advance planning for legal and financial issues
• What to know about durable power of attorney for healthcare and durable power of attorney for finances
• Tips for adult children, including what to do if you’re concerned about mental capacity or undue influence

3 Key Steps for All Advance Planning for Aging

Whether you are planning ahead for medical, financial, or legal issues – and they are often interrelated — there are three components that are part of all aging-related advance planning:

1. Anticipating common aging-related life challenges, either because they are very likely to happen (e.g. eventual advanced dementia in someone recently diagnosed with mild dementia) or are common and significant (e.g. a serious fall while at home alone).
2. Planning ahead in order to minimize the stress, financial problems, family strife, and health harms that people often experience when these challenges come along and no planning ahead has been done. All planning should involve conversation with family members, and others likely to be involved in a person’s age-related life challenges.
3. Completing necessary legal documents, and documenting one’s plans, preferences, and values. Legal documentation is required for certain things, such as enabling a family member or other trusted individual to act on one’s behalf if one becomes incapacitated by illness or injury. Additional documentation of preferences and values isn’t legally required, but can provide valuable guidance to surrogate decision-makers, clinicians, family members, and others who might be later involved in an older person’s care.

5 Common Problems to Anticipate & Plan For

It’s essential to do more than plan for what should be done if death seems imminent. Planning for “end-of-life” situations is important, but it’s probably even more useful to plan for the last years of life.

Specifically, you should plan for the “advanced life events” and decreases in abilities that often disrupt or otherwise profoundly influence the last few years of a person’s life.

Are these guaranteed to happen? Of course not. But planning ahead in case they happen – and these are all likely to happen to many or most people – is smart, because it will enable you and your family to navigate these with less stress and harm.

Remember: we want to hope for the best, but still plan for the likely and quite possible.

Here are five challenges that I recommend every older adult and family plan for:

1. Sudden decline in decision-making ability during hospitalization or due to injury. Many older adults and families don’t realize that this situation is fairly common, but it is. A study published in 2014 found that within 48 hours of hospitalization, 47% of older adults required decision help from surrogates.

Such sudden loss of mental abilities can be due to an event such as a bad fall, a head injury, or a stroke. It is also sometimes caused by delirium, a state of worse-than-usual mental function that is often brought on by illness, and affects about 30% of older adults during hospitalization. (Rates are much higher after surgery or in the intensive care unit.) After delirium, it can take weeks or even months for older adults to recover their usual mental abilities, and some actually never do.

Advance planning can equip an older person’s family or other trusted associates to step in and assist, if there is a sudden illness or other unexpected quick decline in mental abilities.

2. Difficulty managing driving and transportation. This is often related to developing cognitive impairment, but can also affect older adults who do not have Alzheimer’s or a related dementia. This is because vision problems and mobility problems become common in older age. The phenomenon of “normal cognitive aging” can also affect driving ability, because cognitive processing speed and reaction times become slower as people age.

Certain forms of advance planning can enable an older person’s care circle to arrange for and pay for alternative ways to manage transportation needs, especially if the problem is related to cognitive impairment and a loss of mental capacities.

3. Difficulty managing home tasks and home safety. Home tasks include things like maintaining the home, preparing meals, and grocery shopping. Problems doing these activities can be due to cognitive difficulties, mobility difficulties, or both. Home safety can be an issue if a person with dementia wanders, or leaves the stove on. Many older adults are also vulnerable to falls, which can especially problematic for older adults who live alone and may unable to get up or get help after a fall, especially if an injury is involved.

Research has shown that 70% of older adults will need a high level of supportive services for some period of time in late-life. (This research found that on average, the time is 1.5 years for men and 2.5 years for women, but 10-20% of people need a lot of help for five years or more.)

Advance planning can enable an older person to consider ahead of time what kinds of monitoring and supports would be preferred, in the event that he or she later develops difficulty managing at home. Certain types of advance planning can also enable a person’s family or trusted representatives to address safety monitoring, or pay for additional help in the home.

4. Difficulty managing finances and vulnerability to financial abuse. Like the problems listed above, these are especially common when an older adult develops cognitive problems. Research has found that financial difficulties is often the first sign of emerging Alzheimer’s or another dementia.

However, our recently improved understanding of “normal cognitive aging” suggests that all older adults experience some decline in their abilities to manage finances as they age.

Research also indicates that financial abuse of older adults is extremely common, with billions of dollars lost every year. This may involve strangers attempting “scams” or other actions meant to take financial advantage of a vulnerable older person. But it also often involves questionable or frankly illegal activities committed by family members, friends, or others in the care circle.

So it makes sense for all older adults to plan ahead, to minimize their financial vulnerability as they age and also to enable a family member or other trusted person to spot financial problems and intervene if necessary at some point.

5. Alzheimer’s and related dementias. Experts estimate that about 30% of people aged 85 or older have dementia, with the risk of dementia increasing rapidly as people reach age 90 or older. Although encouraging recent research suggests that the risk of dementia at a given older age is going down, this is still going to be a common problem for the foreseeable future.

The possibility of developing dementia is perhaps the most important challenge that older adults should plan for, because it has profound repercussions for financial safety, impact on family caregivers, safety at home, and of course, the ability for the affected person to make decisions.

Although people with mild (early) dementia generally can make decisions about their life and health, I’ve found that most of them are prone to becoming very anxious and/or defensive about their abilities. In fact, some become quite paranoid about others trying to control them. This is a problem because not only does the older person become distressed when a family tries to talk about the future, but in dementia, thinking also usually gets worse when a person is anxious or stressed.  So once mild dementia has developed, conversations about their future and delegating authority to others become much more difficult than they would have been before. (And these conversations are not easy even with older adults who have good cognition.)

Planning ahead can enable an older adult’s family or other trusted individual to assist with medical, financial, and legal matters, should an older adult lose mental capacities.

In the absence of durable power of attorney documents,  if an older adult develops Alzheimer’s and loses the thinking abilities needed to soundly make decisions related to health, safety, and management of one’s affairs, families and others often must resort to seeking guardianship in court. This is an expensive and difficult process. It’s much better to avoid it by having planned ahead and completed the necessary legal paperwork ahead of time. You don’t have try to map out an entire dementia journey ahead of time, but it’s important to consider what family should do if it does seem that cognition is slipping. A durable power of attorney for healthcare and for general affairs (covering finances) will make a big difference, should dementia ever become an issue.

Study Reveals How Older Adults Feel About Planning

Before moving on to some practical tips on planning, I want to acknowledge something important, which you surely already know:

This type of planning is very hard for most older adults to address.

We intuitively know why: it’s hard and unpleasant to think about future aging problems (especially when it comes to loss of independence or abilities), one’s family often doesn’t seem amenable to the discussion, difficult and uncomfortable conversations are required, plus people often aren’t sure how to proceed with paperwork and actual actions.

A research study confirmed all of this. The researchers conducted focus groups with older adults and asked them to address perceptions of future health events, needs, and planning. Most older adults were able to identify the following problems as challenges that disrupt aging-in-place: hospitalizations, falls, dementia, the loss of a spouse, and home upkeep issues.  However, the researchers found that:

While recognizing that advanced life events (ALEs) frequently occur, many subjects reported a lack of planning for ALEs and perceived that these ALEs would not happen to them.

Themes for the rationale behind the lack of planning emerged as: uncertainty in future, being too healthy/too sick, offspring influences, denial/procrastination, pride, feeling overwhelmed, and financial concerns.

Subjects expressed reliance on offspring for navigating future ALEs, although many had not communicated their needs with their offspring.

Overcoming the reasons for not planning for ALEs is crucial, as being prepared for future home needs provides seniors a voice in their care while engaging key supporters (e.g., offspring).”

I thought it was especially interesting that older adults often voiced an expectation that their adult children would help them out, but had not had discussed this in depth with their kids.

And many had not completed the advance planning documents that would be needed, for their children to step in and assist.

What should these documents entail? In the next section, I will list what I consider as the minimum steps to take for advance planning.

The Most Important Things to Do for Advance Planning

For the purpose of this post, I will divide advance planning into healthcare and legal/financial, since  most states specify that the durable power of attorney for healthcare is distinct from a general durable power of attorney (which often covers finances).

I especially focus on planning that enables others to step in and assist if/when it becomes necessary. More comprehensive financial planning for long-term care and estate planning is beyond these suggestions, but is covered in the books I suggest at the end of this post.

Advance Planning for Healthcare:

The minimum key steps to take are:

1.Reflect on current health status, values, and preferences.

Why: Experts agree that advance planning works best when people go through a process of reflection and conversation with others before completing any documents.

Note: Most people find it helpful to use one of several existing reflection tools (see below), which are designed to help people think through important issues so that they later feel better prepared to complete their healthcare advance planning.

Resources:

• PREPARE. This is an easy web-based tool that uses questions and videos to guide older adults through preparing to complete an advance directive. PREPARE has been clinically studied and was developed by a group of experts in advance care planning.
• Consumer Toolkit for Health Care Advance Planning. This downloadable PDF from the American Bar Association’s Commission on Law and Aging contains a series of worksheets designed to help an older person think through several aspects of advance care planning. I especially like that it includes practical examples to consider, and also includes examples of statements one can use when talking to family or others.
• The Conversation Starter Kit. You can find many practical PDF guides from the Conversation Project, an organization dedicated to helping people talk about their wishes for end-of-life care. They also offer a guide for caregivers of people with Alzheimer’s or other forms of dementia.

2. Obtain information on what future health declines or crises to expect.

Why: Research has shown that people sometimes change their stated wishes once they better understand what types of health declines to anticipate. Doctors can often advise older adults on what crises or declines to expect, based on a person’s current health state and chronic conditions.

Note: Physician Angelo Volandes has published several clinical studies demonstrating that people made different advance care planning choices once they had seen videos clarifying what to expect in the future. His videos are now available through a number of large healthcare organizations. If videos are not available to you, find other ways to learn more about what to expect in the advanced stages of a disease you’ve been diagnosed with, or in the last stage of life.

Resources:

• Videos aim to inform patients about their medical options at the end of life
• 5 Ways to Improve End-of-Life Planning

3. Complete a durable power of attorney for healthcare (DPOAH) and document care preferences in an advance directive.

Why: The DPOAH specifies the surrogate decision-maker for healthcare, and often designates a back-up surrogate as well. This surrogate decision maker is usually a family member, a close friend, or sometimes a professional fiduciary. The DPOAH form is often included as part of an advance directive document (sometimes called a living will) that may include additional information regarding preferences for care at the end-of-life.

Note: These documents are governed by state law, so you should get one specific for your state. Generally it’s possible to find several different versions available online for a given state. Many are in “legalese,” but there are simpler (and more informative) forms available that are just as legally valid. I highly recommend the power of attorney advance directives available at PrepareForYourCare.org; they are freely available for all 50 states here. 

It’s always best to get input from a professional before having a form signed and witnessed, and/or notarized (required in a handful of states). That’s because a healthcare professional or other professional can help ensure that an older adult understands the nature of what is being signed.

Resources:

• PREPARE Advance Directives (Healthcare Durable Power of Attorney). These are available for all 50 states.
• Advance Care Planning Resources.  This extensive resource list is maintained by the National Healthcare Decisions Day Initiative.
• What is a professional fiduciary? This page explains professional fiduciaries, who can serve as durable power of attorney for healthcare for people who have no family or prefer to not involve family or friends in this role.

4. Consider a POLST/MOLST (Physician/Medical Orders for Life-Sustaining Treatment) form.

Why:  These are special forms designed to make it easier for a person to get their preferred care, in the event of a medical emergency. These may be suitable for older adults who have limited life expectancy or prefer to be “DNR.”

Note: POLST/MOLST forms require state-level legislation to implement. Find out if your state offers this type of document here.

Resources:

• POLST: For Patients & Families
• POLST Resources & Tips on Avoiding Pitfalls

5. Re-assess documents and preferences periodically.

Why: A person’s preferences regarding medical care and end-of-life wishes often change over time, especially if a person has declined substantially, or had difficult experiences as a patient. Sometimes a person also decides they want to designate a different person as their durable power of attorney for healthcare. For these reasons, it’s important to plan on reviewing and revising advance care planning for healthcare regularly.

Experts generally recommend that advance care planning documents be reviewed and revised in accordance to 5 Ds:

• Every Decade
• When a loved one Dies
• When there is a Divorce or other major family change
• When you are Diagnosed with a serious medical condition
• When there is a significant Decline in health or independence

Resources:

• American Bar Association: When should you review your advance directive?
• Helpguide.org: When to reassess your advance healthcare directive

Advance Planning for Legal and Financial Matters

The key steps an older person should take are:

1.Reflect on current and future care needs, existing documents and plans, financial assets, and the family members and friends within one’s trusted care circle.

Why: Planning should always start with a period of review and conversation. This should include reviewing any existing power of attorney documents, estate planning, financial planning, or trust documentation.

Note: Be sure to discuss reflections and available information with your family and anyone else who qualifies as part of your “inner circle.” Also, consider working with a professional (e.g. geriatric care manager or other expert in aging and family dynamics) to mediate any challenging conversations or family conflicts that may arise during this time.

If possible, obtain information on long-term care options that might be a fit for future care needs and your family’s financial resources. But don’t let yourself get too bogged down by this part. Many families get stuck in the review phase and never move on to completing documents.

Resources:

• AARP “Prepare to Care” Planning Guide for Families
• Alzheimer’s Association Legal Planning and Financial Planning (these tools are intended for people diagnosed with dementia but provide a useful framework for all older adults, and include helpful worksheets)

2. Complete a durable general power of attorney (POA) document and/or a financial power of attorney document.

Why: A legally valid durable power of attorney document is necessary, to enable another person (the “agent”) to manage affairs if the older person ever becomes incapacitated. The document usually specifies whether the agent’s authority is effective immediately or only once the older person has become incapacitated. The POA must be “durable” to remain valid once a person is incapacitated.

In many cases, the authority to manage financial affairs is included in the durable general power of attorney. But in some cases, people elect to complete “special” powers of attorney which cover only specific powers, such as those related to finances. Check with your state laws and an attorney to find out what is required in your state.

It is also possible to designate someone else to help you with your affairs through the creation of a trust, such as a revocable, or living, trust. (Trusts also offer other potential estate planning benefits, such as avoiding probate.) Trusts can designate additional trustees or successor trustees, which creates a legal mechanism for someone else assisting with finances. You can get a good overview of this type of trust here.

Note: For all legal paperwork, especially durable powers of attorneys, I highly recommend you work with an attorney if at all possible, preferably one experienced in elder law. This helps protect older adults from undue influence and ensures that documents are completed correctly. Free or low-cost legal assistance is often available; learn more from the Administration on Aging here, and contact your local Area Agency on Aging to find help near you.

Resources:

• Nolo: Durable Financial Power of Attorney: How It Works
• Legal Assistance for Older Adults
• How to Avoid Problems Due to Senior Incapacity: The (Better) Durable General Power of Attorney
• What is a Revocable Trust and Do I Need One?

3. Simplify finances.

Why: This will make it easier for older adults to safely manage money and avoid being exploited financially. It will also make it easier for one’s agent (the person authorized to manage finances or other non-health affairs on behalf of an older person) to assist if it ever becomes necessary.

Note: Recent research on cognitive aging suggests that the ability to manage finances peaks in one’s mid-50s, and then slowly declines due to normal decreases in cognitive function. Between this phenomenon, the general risk of eventually developing Alzheimer’s, and the possibility of financial abuse committed by scammers or even family members, simplifying finances makes good sense.

Resources:

• ConsumerFinance.gov: Financial Protection for Older Americans
• 5 Things to Know About Aging & Financial Decline
• Money Smart for Older Adults

4. Complete POA forms for the banks and other financial institutions involved in your assets and affairs.

Why: Banks and other financial institutions often will often insist on the use of their own internal POA forms before allowing agents to access information or conduct transactions. They may also resist a POA form that is “too old.”

For Social Security benefits, which cannot be managed with a power of attorney, you can instead complete an “advance designation of representative payee.” This basically means telling the Social Security Administration ahead of time who you think would be a good candidate to manage your Social Security benefits on your behalf, should it ever become necessary.

Note: It may not be entirely legal for them to do so, but in many states, it remains common for banks to resist legally drafted power of attorney documents. Families can save themselves time and hassle by obtaining institution-specific power of attorney forms while an older adult still has the capacity to complete them. Simplifying finances and accounts beforehand will make this process easier. You can also check to see if your state has implemented any laws related to banks accepting power of attorney; here is a post describing such laws in Connecticut.

Resources:

• Can banks legally refuse to accept a durable power of attorney?
• Social Security: Advance Designation of Representative Payee

Tips for Family Caregivers & Adult Children

If you’re a family caregiver, you will often play an important role in advance planning. Because family caregivers often become involved when there are concerns about an older person’s mental abilities, I address this below.

Depending on the older person’s situation, as a family caregiver you may be involved in advanced planning in one or more of the following ways:

• If your parent is of sound mind and is making his/her own decisions, you will often be in an advisory role. You may be providing encouragement, or facilitating your parent addressing the advance care planning process. It’s important for you to support your parent in doing this, as older adults may feel impeded if their children or younger relatives are uncomfortable with planning. Sibling and parent-child dynamics and disagreements sometimes flare up here; this is a good time to invest in learning to more constructively communicate. (Remember, it’s always harder to manage conflicts after a crisis hits.) Older adults commonly chose an adult child to serve as future power of attorney for health or finances, but even if your relative doesn’t choose you, it’s good for you to know what your parent has in mind, and what his or her wishes currently are for the future.
• If you have taken over making decisions for your parent, due to permanent mental incapacity, you will still need to address some forms of advance planning, such as goals of medical care and advance directives on your parent’s behalf. You may also need to review the financial plan for addressing your parent’s needs.
• If you aren’t sure if your parent is of sound mind, then you will need to proceed with caution and you will need professional assistance from clinicians and perhaps also legal professionals. It is important that an older person has the mental capacity to make whatever decision is in question; if not, the decision will be on questionable ethical and legal ground. Bear in mind that capacity is usually considered to be decision-specific, so people with mild dementia may have the capacity to make some decisions but not others. You should also bear in mind that older adults sometimes experience a temporary decline in mental capacities, such as when they develop delirium during a hospitalization. Decisions and documents signed during this time may also be on shaky ethical and legal ground. For more on decision-making capacity and issues related to “incompetence”, see here. I also have a video about whether an older person can make decisions here.
• If you are concerned about another person inappropriately influencing an older adult, you should also proceed with caution and consider getting professional assistance. Although we must respect the right of older adults to make decisions we disagree with (assuming the older adult has the mental capacity to make the decision in question), it’s true that many older adults are vulnerable to undue influence from others, and may make questionable financial or legal decisions based on this. As a family member, you can play an important role in being alert to this and seeking help if you are concerned about undue influence or even financial exploitation; your local Area Agency on Aging can help direct you. It’s especially important to act if you suspect an older person is being harmed by someone exerting undue influence, or has made legally-binding decisions due to such influence.

A Few Books That Can Help

As I mentioned at the start of this article, advance planning is a very big topic and really requires a book to do it justice. Here are three practical books that I’ve read and can recommend. All were available at my local public library.

AARP’s Planning for Long-Term Care for Dummies, by Carol Levine. This book is written for older adults but can easily be used by family members. It’s quite comprehensive. Along with the legal/document aspects of advance planning, it provides a comprehensive approach to planning for the later stages of life and options for meeting care needs.

The Family Guide to Aging Parents, by Carolyn Rosenblatt. This book is for those with older parents. It may be useful reading for those who want to plan ahead to reduce conflicts and problems for their own adult children. The author is an elder law attorney who specializes in mediating family disputes related to aging parents.

5@55: The 5 Essential Legal Documents You Need by Age 55, by Judith D. Grimaldi and Joanne Seminara. This short book, written by elder law attorneys, is a practical guide covering five key legal documents that all older adults should complete: “Healthcare Advance Directive, Living Will, Power of Attorney, Last Will and Testament, and Authorization to Access Electronic Records and Media Sites.” Each chapter includes several real-world examples illustrating common situations and the role of necessary documents.

Take it one piece at a time; be sure to follow through and finish!

Advance planning is a process that is often emotionally taxing and logistically challenging. Many older adults never start. Others start and never get around to completing the process and signing the necessary documents.

It’s understandable; this is a lot of work. But it’s worth doing, because it’s key to healthy aging.

So make a plan. Do a little piece every week, or at least every month. Get the support of family members and ask them to hold you gently accountable. Talk to doctors about what health declines to anticipate. Get professional help with the legal and financial planning. Consider investing in help mediating family conflicts.

If you keep going, it will eventually be done, and some day you and your family will be very glad you addressed the planning before it was too late.