"Care of the elderly": by Dr. Howard Tenenbaum, DDS, PhD, Ali Shultz, JD, and Carol Crevier, RN MPH
by Paul Alexander
Some colleagues of mines whom I greatly respect, asked me to share this as they wrote specific to caring for our older parents and family etc. I found the content superb and informative.
The paths of the co-authors here have crossed in significant ways as they engaged with the events of the last three years. They share a common ethos to preserve and enhance human health and freedom.
Authorship: Carol Crevier, RN MPH, Ali Shultz, JD, Dr. Howard Tenenbaum, DDS, PhD
Dr. Tenenbaum:
Carol Crevier:
Ali Shultz, JD has a unique background in both healthcare and the law, which allowed her to run point on litigation against the CDC and Fauci, and develop resources for the public to use against mandates. After becoming intimately acquainted with the hospital protocol for the care of COVID patients that is standard nationwide, Ali established Hands for Health and Freedom (https://handsforhealthandfreedom.org) to assist other patients and families.
Carol Crevier, RN MPH received her baccalaureate degree magna cum laude from Rush University and her masters in public health from the University of Illinois at Chicago. Her nursing experience spans three decades in the fields of medical nursing, public health and primary care administration. The last three years she has been involved with patient advocacy and education regarding COVID-19 public health policies.
‘Part 1
Care of our Elderly loved ones
Many of us have elderly parents and loved ones for whom the change of seasons brings us concern for their wellbeing. Here, we outline strategies for seniors and their caregivers’ to: a) optimize well-being to prevent illness and b) strategies to manage illnesses at home, when possible, and finally, c) we discuss ways in which families can assist their loved ones to structure the care within a hospital stay to be consistent with their values and optimal outcomes.
Live a Semi—Structured and Purpose-Filled Life
Healthy seniors are often those who have a flexible but structured schedule- Waking, eating, exercising and sleeping in a regular pattern, and maintaining scheduled commitments to contribute their talents within their communities.[1] Many seniors continue to work within their profession or trade well past 80 years of age. Others volunteer in local schools, their church or other religious communities or civic organizations, contributing their talents for the betterment of all. Meaningful work plays an important role in supporting our mental health and family members should encourage these activities. It has now become abundantly clear, and was quite frankly predictable, that locking down our elderly and breaking their social ties as part of our COVID pandemic response did not strengthen them and in fact had precisely the opposite and rather horrific effect.[2] Many withered away from lack of purpose and loneliness and this is borne out by published research![3],[4] When an elderly person’s capacity for work has passed, we ought to look for creative ways to envelop them into the rhythm of the work of our homelife,[5] but this was prevented by enforcement of lockdowns and similar isolation measures for people who were otherwise well.
In relation to the foregoing, we now present strategies that should be followed for the betterment of the elderly and their families. Strategies for which it should be self-evident, that we shall never again implement the disastrous lockdown, isolation and even masking policies that we saw over the past several years.
Optimize Hydration
As persons age, the sensation of thirst diminishes which then often necessitates external reminders to drink sufficient amounts of fluid, particularly water.[6] Shockingly, only 2-3% of fluid loss can alter a person’s clarity of thinking negatively![7],[8] By ensuring proper hydration several problems can be avoided in the elderly, including but not limited to urinary tract infections, respiratory infections, lethargy, constipation, headaches and dizziness. Even with vigilance, it is difficult to ensure adequate hydration with the multitude of disruptions the elderly experience such as: exertional stress, extremely warm temperatures, swallowing difficulties, cognitive decline, reduced mobility, depression, diarrhea and vomiting.[9] Acute confusion can be the first symptom of dehydration (among other things including undeclared infections). If an elderly person suddenly becomes confused, it is necessary to obtain medical attention and assessment of this problem promptly, as it might be related to dehydration or could be a symptom of a stroke or other serious problem.
But how do we monitor and manage hydration? This can be done for the homebound elderly through the use of designated water containers marked with targets for drinking a certain amount of liquid throughout the day. It can be a chore for a senior to drink sufficient amounts, so the creativity of their caregivers should be employed. Afternoon routines like ‘afternoon tea’ (noncaffeinated of course) can work wonders. Even simple actions such as switching beverage containers or flavoring the water can stimulate an interest or act as a reminder to hydrate.[10] Simply put, (gentle) persistence is needed in order to assist the frail elderly person to consume adequate fluids and must be made a part of daily routines.
Precise guidance for the ideal amounts of fluid intake needed in the context of multiple chronic illnesses and aging is lacking within the clinical and scientific research literature.[11] Caregivers of seniors need to be aware that certain conditions such as congestive heart failure and kidney failure require medically prescribed fluid restriction in the face of the still ever-present need for hydration.
Care-Filled Observation
Caregivers of the elderly need to use their best powers of observation and be on the alert for dehydration in their charges, as it is among the top ten reasons that elderly persons are hospitalized. Seniors without co-morbidities can adhere to the general guidance to drink about (8) eight-ounce glasses of fluid per day. Measuring intake and output should be done when a frail elder becomes ill (urine ‘hats’ for collection purposes are inexpensively obtained at medical supply stores, these plastic containers sit inside the toilet and allow measurement of output). A person should have at least 1000 cc of urine output per day.
One can also use urine color as a rough indicator of hydration status. In this regard, dark orange coloured urine is a warning sign that a person might be dehydrated. Skin turgor is another indicator of hydration, assessed by pinching the skin between the thumb and forefinger. If an individual is underhydrated, it will take a protracted amount of time for their skin to return to its normal shape after the pinching pressure has been released.[12] If dehydration is becoming a concern, caregivers can provide oral rehydration drinks. The product: ‘Drip Drop’ is available in a powder solution to be added to water, the cost is about $1.00 per serving, to be mixed with water. Sports drinks often have too little sodium and too high a sugar content to serve as rehydration fluid (7) (Schleh & Dumke, 2018). It is also possible to make a rehydration solution at home (see recipe below). Individuals who are experiencing significant diarrhea may need up to 750 cc per hour to be rehydrated, over 3-4 hours.[13] Providing small sips of fluids or assisting with a large syringe can assist a weakened person in drinking.
Oral Rehydration Recipe
3/8 tsp salt (sodium chloride)
¼ tsp Morton Salt Substitute® (potassium chloride)
½ tsp baking soda (sodium bicarbonate)
2 tbsp + 2 tsp sugar
Add water to make 1 liter
Communication and vital signs
Communication with a person’s physician should occur when these symptoms of dehydration: poor skin turgor, darkening urine, dry mucous membranes or a low blood pressure are observed. Automatic cuffs for at-home measurement of blood pressure (BP) are used widely by patients and their families. An investment in a ‘pulse oximeter’; will allow for an automatic reading of a heart rate. If you are concerned about dehydration, taking vital signs is helpful. Caregivers can measure BP and heart rate while a person is lying and then sitting or sitting to standing. A decrease in the BP of 10 points or a rise in heart rate of 10 points upon changing positions indicates a person may be suffering from dehydration. It bears repeating that when these problems are noticed, prompt communication with a person’s physician is necessary.
Resources related to hydration:
Personalized voice reminders can be used to remind homebound seniors living alone to drink their water/other fluids using programmable electronic devices.
Visiting physicians and nurse practitioner practices are available in some communities for home visits. Mobile IV clinics which provide intravenous hydration in the home are an option in an increasing number of communities. ‘Mobile IV Medics’ and ‘Drip Hydration’ are just two companies with a national footprint. Homebound Medicare recipients may qualify for professional nursing supervision when experiencing exacerbations of chronic illnesses.
Optimize Nutrition
In many faith-traditions, sharing great food at a banqueting table is one of life’s most treasured experiences. Food is good for our soul as well as our bodies. The age of ‘fast foods’ not only lured us into eating processed foods but it lured us away from the fellowship found around a table with family and friends. We exchanged a part of life which can be sacred for cheap convenience. Restoration of life shared across a thoughtfully arranged table, is one of the gifts we can give to our elderly loved ones. They will eat better when they do not eat alone.
The adage: ‘You are what you eat’ is really true, and this holds at the cellular level as well! Your body’s ability to function is directly impacted by what you put in your mouth. Gary Hallgren has done a fantastic job of illustrating the body’s cellular realities in the book You: Staying Young: The Owner’s Manual for Extending Your Warranty.[14]
Unfortunately, the Big Food giants have been altering food chemically for so long, that many retirees have eaten fast foods for their entire lives. The claim that “Processed foods kill us (eventually)” is no exaggeration.[15] Ultra-processed food, high in refined sugars, have captured our appetites, such that fifty percent of those over 65 years of age have diabetes or ‘pre-diabetes’.[16] Interestingly, sugars, which cause inflammation and promote the development of diabetes are found in high levels within processed foods.[17] Sadly, addiction to sugars has been demonstrated experimentally to be even more addictive than addiction to cocaine and so it’s relatively easy to understand why eating processed foods is problematic to say the least![18] The consumption of highly processed food is leading to severe deficiencies in vitamins and minerals which contribute to many chronic inflammatory illnesses.[19],[20] If we are to live resilient lives into our 80s and 90s, we must return to eating foods that are whole or minimally processed —real foods--recognizable in the form God created them. Seniors on a fixed income may benefit from assistance to afford their food and can inquire about eligibility here: https://benefitscheckup.org/pages/supplemental-nutrition-assistance-program
Part 2
What if I’m already diabetic and overweight?
Perhaps there are some reading this who are overweight, diabetic and hypertensive thinking- ‘well, it’s too late for me’.
It is not too late for you to build resilience for longevity. The tools are at everyone’s disposal, no matter how old.
Lay persons rediscovered the power of low carbohydrate or ketogenic nutrition in the last decade. Many elderly patients are able to reach their desired body weight, normalize their blood sugar, improve lipids and blood pressure by consuming real food. Reduction of carbohydrates to less than 50 gm/day, shifts calories to protein and high-quality fats—which produces a sense of feeling full. Reducing carbohydrates also reduces the amount of insulin one’s body produces which is a driver of excess weight. This becomes a sustainable way of eating because it does not require special foods, pills, or constant counting of calories. With a modest 5-7% weight loss, metabolic disease (the triad of diabetes, atherosclerosis and hypertension) is reversed in nearly all patients. Intermittent fasting is also employed with success to achieve the same ends. Patients find the CarbManager app helpful to begin to understand the macro-nutrient content of their foods (carbohydrate/protein/fats). The folks at dietdoctor.com have a map for patients to search for a low carb physician near them: https://www.dietdoctor.com/low-carb/doctors/all, as well as many other resources. Seniors with pre-diabetes are eligible for participation in the Medicare Diabetes Prevention Program and can locate a local program here: https://innovation.cms.gov/innovation-models/medicare-diabetes-prevention-program/mdpp-map
While 35% of the senior population struggles with obesity; the loss of lean muscle mass (sarcopenia) is also a concern across the elderly population. The insidious loss of muscle mass and function occurs as human beings age and this becomes even more problematic, severe and prevalent in the face of poor nutrition as well as reduced physical activity. Without intervention, lean muscle mass loss occurs at a rate of up to nearly 1.0 kg per year in the elderly.[21] This is the old ‘use it or lose it’ adage: preservation of muscle mass is critical to maintenance of balance, strength and prevention of disability which supports independence.[22]
Current nutritional research indicates that the elderly require significantly higher intake of protein than younger individuals, because as we age, we are not able to build and repair tissues as efficiently. Protein intake of 1.2 gm/kg/day or higher in the elderly overcomes ‘anabolic resistance’ that is now well documented.[23] This recommendation for protein intake is 30% percent higher than the Food and Nutrition Board’s existing guidance published in 2006, which recommends only 0.8 gm/kg/day protein intake for all women over 31 years of age. These outdated guidelines rely upon nitrogen balance studies conducted primarily on persons younger than 55, dating from 1951-1995.[24] For a 150-pound person, protein intake of 1.2 gm/kg/day translates to 84 gm of protein per day.
Proteins containing all the essential amino acids are acquired most easily from animal sources. Plant sources of protein might not contain all the essential amino acids. Unless amino acids are present in the right balance, protein will not be utilized properly by the body. Although one might be tempted to provide so-called protein shakes to provide adequate intake of protein it should be understood that these shakes often contain excessive sugar content, and may be less than optimal for those with hyperglycemia (high blood sugar) to say the least, notwithstanding the fact that sugar overload itself can lead to diabetes and increased levels of generalized inflammation as alluded to above.
Recipes containing protein amounts that would provide higher and more appropriate levels of protein can be found at dietdoctor.com. Amino acid supplements (8-12 gm/day) have been shown to improve endurance in walking and may be helpful for those with congestive heart failure to increase exercise capacity by improving circulatory function, muscle oxygen consumption, and energy.[25],[26]
As mentioned above, physical activity, in addition to the intake of adequate amounts of protein plays an important role in the prevention of sarcopenia. It is absolutely essential to exercise muscles with pushing and pulling type activities to retain muscle mass. This is termed: ‘Resistance exercise’ and mitigates against the loss of skeletal muscle mass in the elderly, including the frail elderly. Because muscle mass serves as a reservoir for storage of fluid, it is critical for even wheelchair-bound and bedbound elderly patients to do these types of exercises using broad elastic bands referred to as ‘therabands’. The health authorities in Alberta provide a good explanation of these exercises here: https://findingbalancealberta.ca/wp-content/uploads/Resistance-Band-Exercises-DIGITAL2.pdf
Tieland and colleagues tested the use of resistance exercise and protein supplementation among the frail elderly in a randomized controlled trial.[27] The pairing of these two interventions resulted in a net gain of 1.3 kg of lean muscle mass, as well as an increase in function, particularly the ability to get up out of a chair independently. This can encourage caregivers of the frail elderly to take seriously each action they take which structures simple exercises and encourages protein consumption--because it makes a critical difference.
If you have concerns about sarcopenia for yourself or your loved one, this is a simple assessment tool: https://www.cgakit.com/sarc-f-questionnaire. Homebound Medicare recipients may request an order for a physical therapist to come to their home to set up an exercise program. Eating adequate amounts of protein--(about 30 gm per meal-- and incorporating resistance exercises into the routine of life will strengthen the quality of life as we age.
Part 3
Optimize Nutrition at the micro-nutrient level
As discussed above, highly processed foods contribute to deficiencies in the levels of micro-nutrients. Three common micro- nutrient deficiencies which impact immune health negatively are outlined below. Many patients ask, ‘But what about my multi-vitamin, isn’t that good enough?’. Unfortunately, while multi-vitamins are excellent foundationally for micro-nutrient health, they do not contain the levels of vitamin D, magnesium and zinc required for immune health.
Vitamin D
Insofar as regulation and the health of our immune system is concerned, we might say that Vitamin D is ‘king’! Supplementation with Vitamin D is the first priority in establishing immune protection. Hypothetically, we suggest that in households where all members supplement with Vitamin D, the collective risk of contracting respiratory illnesses may be significantly, as this has been demonstrated to be the case in highly exposed healthcare workers[28]
Guidance for vitamin D3 supplementation developed by Sunil Wimilawansa MD (endocrinologist) can be found here: https://covid19criticalcare.com/treatment-protocols/i-prevent-protect/#table-two
If you are unable to get your vitamin D3 level tested at your physician’s office, grassrootshealth.net has home kits that can be ordered.
Vitamin D is also a pleotropic substance for human beings. This means it is multifunctional and actually ‘does a world of good’ for prevention of many things including: cancer, depression, hypertension, autoimmune and inflammatory and respiratory conditions, as Sunil Wimalawansa, MD shows us here:
(Wimalawansa, 2019)
We have ignored the public health crisis of vitamin D3 deficiency for decades and in fact it is virtually impossible to obtain sufficient amounts of vitamin D3 through a North American diet, particularly in people living in the higher latitudes where exposure to good levels of sunlight are restricted.[29]
Our public health officials have failed abjectly when it comes to understanding the importance and benefits of the provision of biologically required levels of vitamin D3. This is particularly inexcusable, as the evidence for benefit was so strong as shown from correlational data which led Richard H. Carmona, MD, MPH, the 17th Surgeon General of the United States, to pen this warning to physicians in January, 2021:
…”we need to act now. Identifying and eradicating vitamin D deficiency with early and aggressive supplementation in COVID-19 has the potential to save thousands of lives and should be one of our highest public health priorities.” [30]
When individuals deify themselves in the likeness of the modern god of SCIENCE, the traditions of Nebuchadnezzar, Herod and Diocletian are recalled—a deadly mixture of self-aggrandizement accompanied by cruelty. Sharing this singular intervention would have spared the lives of countless individuals in the last two years when COVID-19 was rampant.[31], [32] It is up to lay people to share this knowledge with one another.
The production of Vitamin D from sunlight requires the transformation of a cholesterol like substance within human skin. Multiple metabolic changes must occur before Vitamin D3 circulates within the blood in its useful form. Unfortunately, aging decreases one’s ability to synthesize vitamin D3 from sunlight and this is one of the reasons why supplementation is necessary for nearly everyone, particularly the elderly, to obtain serum vitamin D3 levels of 50 ng/ml or greater. (21) (Wimalawansa, 2022)
Why is a blood level of Vitamin D3 of 50 ng/ml the target?
Currently, medical testing laboratories index Vitamin D levels in relation to the reference range required for bone health. But as noted above, Vitamin D is important for many metabolic needs and not only for bone health--as was taught previously. During the last two years, we have been gifted with well-designed clinical studies which confirm three decades of bench science. Evidence has emerged in clinical trials demonstrating that patients with vitamin D3 levels of 50 ng/ml or greater do not develop respiratory illness, in this case; COVID19, requiring ICU admission nor suffer death from this disease either.[33]
Even though the data are now emerging, which demonstrate the need for a minimum level of 50 ng/ml. Unfortunately, it will take some time before professional medical societies sift through the data and start to change their now out-of-date recommendations relating to target blood levels of Vitamin D.[34]
Unfortunately, but not unexpectedly, various ‘hit’ pieces’ have been published within (now known to be corrupt) medical or popular journals disparaging the need for higher levels of Vitamin D3.[35] Sadly, some studies appear to have been constructed to fail with regard to asking the question of whether or not Vitamin D supplementation (to obtain a level of 50 ng/ml) is useful from a preventive and therapeutic standpoint when considering prevention or management of infectious, and predominantly respiratory diseases.. In this regard, Vitamin D supplementation in these studies was wholly inadequate and could not possibly have led to the establishment of meaningful levels of Vitamin D in the blood (i.e., minimum 50 ng/ml).[36] Unsurprisingly then, no impact of Vitamin D supplementation was detected. Woefully, a vitamin D-deficient population will continue to suffer from preventable chronic illnesses, creating markets for pharmaceutical products, unless ordinary people push public health officials to change, like the indomitable Robin Whittle has done in his appeal to the British government.[37]
In addition to Vitamin D supplementation, magnesium is another important micronutrient on its own (see below) but it also aids in metabolism of Vitamin D. Fortunately, recipients of Medicare may have benefits to purchase these items, avoiding an out-of-pocket expense. Your pharmacist should be able to assist you. Otherwise, vitamin D is inexpensively and readily available in 5,000 IU and 10,000 IU capsules in many retail stores, as well as drops and nasal sprays.
What if your loved one refuses to take vitamin D and then becomes ill? Sunil Wimilawansa, MD, endocrinologist addresses this eventuality in his recent paper entitled--Rapidly Increasing Serum 25(OH)D Boosts the Immune System, against Infections—Sepsis and COVID-19 (2022)(31) He describes the safe use of calcifediol, available online as an over-the-counter supplement.
It ought to be in the medicine cabinet of every household and available for use with consultation with a physician for therapeutic purposes at the onset of a viral illness.
Magnesium
Magnesium (Mg+) is a co-factor for hundreds of reactions in our body and as noted above is essential for Vitamin D to be utilized properly.[38] Approximately half of Americans are deficient in magnesium.[39] Serum Mg+ levels only measure one percent of the bodies’ Mg+ content; making it difficult for physicians to easily measure the body’s magnesium and therefore deficiencies are often missed.[40] Magnesium deficiency contributes to many chronic health issues including disturbances in heart rhythm, anxiety, congestive heart failure, muscle pain, weakness and loss of muscle mass.[41],[42]
Prior to the advent of highly processed foods and soil depletion, foods were naturally rich in Mg+.[43] However, Mg+ is depleted by 80-90% in most processed foods.[44] Many commonly used drugs deplete Mg+: (proton pump inhibitors, diuretics such as hydrochlorothiazide).[45] And although this might not seem to be obvious, the poor quality of our soil reduces the content of Mg+, even in whole and organic foods.[46] Soda ingestion also contributes to Mg+ deficiency.[47] The recommended daily values for Mg+ are 420 mg for men over 31 years of age and 320 mg for women over 31 years of age.[48]
Due to these factors, most individuals benefit from Mg+ supplementation.[49] Many oral forms of Mg+ are available over the counter and already mentioned, recipients of. Medicare have benefits which cover the cost of Mg+ so--check with your pharmacist.
In relation to the forms of Mg+ available, you should know that magnesium-citrate is used as a cathartic and should be avoided for daily supplementation. Magnesium-glycinate or gluconate are gentler on the stomach.
Magnesium dosing generally has a wide safety margin. However, because of the possibility of toxicity in sub-sets of patients, it is advisable to coordinate supplementation with Mg+ with your medical provider.
Magnesium is available in capsules, tablets, epsom salts, drops, sprays and creams. Mg+ is absorbed through skin and can be an effective means to bypass the poor absorption common to oral forms.
Zinc
Zinc has an important role in the immune protection of the elderly. As we age, our bodies exhibit low-grade inflammation as a result of dysregulated cytokine (proteins that regulate various bodily functions including inflammation) release. In 2008, Kahmann and colleagues demonstrated that zinc supplementation for mildly zinc- deficient elderly resulted in the reduction of the cytokine IL-6, one of the body’s most potent inflammatory cytokines, by over 96% in cell culture studies.[50] Conversely, the release of IL-10; an anti-inflammatory cytokine is increased by 32%, improving the T-cell immune response.[51] Prasad, et al., (2007) piloted the provision of zinc supplementation in the elderly in a long-term care facility and found that this reduced inflammatory markers in the zinc-supplemented elders, which was also correlated with a 40% reduction in infections experienced across a year of supplementation.[52] A closer look at the Table 3 from Prasad’s team is worthwhile, found here: https://academic.oup.com/ajcn/article/85/3/837/4633003
Unfortunately, though zinc deficiency among the elderly is common and accounts for 16% of all deep respiratory infections globally, it often goes unnoticed. Hence the opportunity to use zinc as a means to prevent respiratory illnesses is overlooked. It has multiple cellular effects! One of the most amazing is its ability to cause the tiny hair-like structures (cilia) in our respiratory tract beat faster and grow longer. This strengthens our ability to move pathogens (germs… bacteria, viruses and even irritating particulates from pollution) up and out from our lower respiratory tract.[53]
The late Dr. Zev Zelenko recognized the ability of zinc to create an inhospitable intracellular environment for viral replication by changing the pH (level of acidity) of the cytoplasm (fluid inside the cell).[54] If a virus cannot replicate within our cells, it cannot overcome our immune defenses. This description does not scratch the surfaces of all the benefits of zinc to our immune defenses, but we can see more of them depicted here:
(Wessels et al., 2020)
The elderly benefit from zinc supplementation from October through April, particularly in the northern hemisphere, since it also functions as an anti-oxidant, an anti-inflammatory and an anti-viral agent. Year-long zinc supplementation should be coordinated with one’s physician.
Zinc gluconate is available in 25 mg and supplies the recommended daily allowance for zinc. Zinc is available as lozenges, drops or capsules. Taking zinc at night may alleviate gastric upset experienced by some.
Protecting your respiratory system
Effective prevention of respiratory illnesses needs to include ‘barrier’ protection. That is--we ought to do everything possible to stop pathogens from invading our respiratory system by enhancing the mucosal barriers that we have in our noses, mouths and throats.
Our mouths contain a mini-microbiome, just like our guts have a microbiome. Periodontists and dentists have been studying the correlation of the health of the oral microbiome with the levels of systemic chronic inflammation. It is also imperative to understand that dysbiotic alterations in the oral microbiome are also associated with cognitive impairment and dementia, further underscoring the importance of delivering high impact oral healthcare to the elderly population.[55] Good oral hygiene is often difficult for the elderly, as many lack the grip strength and dexterity necessary for brushing and can no longer lean over a sink. Caregivers of frail elderly need to assist their loved ones to brush well. Regular trips to the dentist are difficult but necessary to prevent decay from being a source of a wider infection or even sepsis. There are less invasive, preventive strategies for reducing oral inflammatory load (OIL), something reflective of gum diseases, which can include subantimicrobial dose doxycycline for the frail elderly at risk for periodontal diseases.[56] Geriatric patients with reduced salivary flow can be helped by adhering xylitol tablets (Xylimelt®) to a tooth to stimulate salivation, to keep the oral mucosa moist[57] and to prevent the development of tooth decay. The topical application of high concentration chlorhexidine coatings (e.g., Prevora®) can reduce periodontal disease/OIL dramatically.[58] It is noteworthy that this type of agent does not have to be applied by clinicians with dental credentials or training. This means that nursing staff, assistant nursing staff at elderly care facilities can, after some in-service training, apply these therapeutic agents readily. This intervention is completely non-invasive and painless yet produces dramatic improvements in oral health and reductions in OIL. Moreover, the ambulatory elderly who do not reside in an elderly care facility, have the opportunity to visit clinical centers that focus on interventional preventive care and which provide inexpensive, and as above, painless and non-invasive care when using these topical chlorhexidine coatings along with the other interventions mentioned here.
During the past two years, many in the physician community have learned from colleagues in the ENT (ear, nose and throat) that gargling with various solutions can reduce the oral viral/bacterial load very effectively. Nasal hygiene with hypertonic saline solution or a solution of diluted povidone-iodine is equally effective for this barrier. Dr. Syed is featured on the Healthy Immunity website, explaining these strategies:
https://healthyimmunitynow.org/prevention-%26-treatment-1
The lay people at Healthy Immunity also link several other resources for people who wish to explore early treatment options for COVID19. While the mainstream media has censored and mocked the community of people who have given and received treatment early for COVID19, standard nursing advice has always been that patients concerned about a deadly disease should seek treatment before their symptoms worsen or accelerate. It is easier to care for a person who is not in a fulminate state of a disease. Nurses need to stand with patients in seeking treatment which is supportive of their values and beliefs. In all settings, patients who have different perspectives than their providers regarding treatment modalities--should have the opportunity to request an ethics conference in which these differences can be explored with a neutral third party.
Part 4
If Hospitalization becomes necessary:
None of us want to think about having to go to the hospital, but there are some conditions which necessitate it: fractures, abdominal pain, stroke symptoms, etc. It is best for the frail elderly and their families to consider ahead of time what a hospitalization will mean for them. Ali Shultz, JD; (a co-author here) has a great deal of experience helping families with hospitalized loved ones, through Hands for Health and Freedom.
Her guidance for patient advocacy comprises our best advice for how to ensure that your elderly parent or grandparent receives care in the hospital which is consistent with your family’s values. Pack a ‘to-go’ bag for the hospital and include this advocacy guide, a few pens, and a notebook. Make sure to have copies of the advanced directives and notarized power of attorney for healthcare. Many patients’ have experienced an unnecessary delay in their care because there was no executed power of attorney for healthcare or healthcare proxy documents on hand. A copy of these documents should also be on file with your healthcare proxy and the person holding power of attorney (POA) for healthcare.
Sadly, the last couple years have proved that hospital policy has restricted many doctors’ abilities to provide adequate therapeutics for patients. If you find yourself in a situation where your loved one is hospitalized, here is an advocacy guide using the acronym P A T I E N T.
P is for print. Each person should print out their state’s codified patient rights and responsibilities, as well as the hospital Patient Bill of Rights and Bylaws. The hospital’s patient rights policy will likely be modeled after the state’s policies. Family members can make reasonable requests of the staff for their hospitalized family member, while communicating how these requests fulfill a patient’s rights (ie. the right to pray with another person, or the right to have an auxiliary aide to assist a disabled person, etc.). If you are incorporating these rights into your request, it will make it difficult for providers to argue their way out of their own policies. If you’re already in the hospital, you can ask your nurse for a copy of the patient rights and responsibilities.
Another “P” term is Presence- Patients have better success when their loved ones are present. If the hospital is refusing to allow visitors, and the patient has a disability, make a request for a: reasonable accommodation for a support person.
There are several federal disability civil rights laws that apply to hospitals – Title III of the Americans with Disabilities Act (ADA), Section 504 of the Rehabilitation Act (RA), and Section 1557 of the Patient Protection and Affordable Care Act (ACA).
In short, if a patient with a cognitive or mental health disability needs a supporter or communicator to assist with communication and health care treatment and/or to provide emotional support, the hospital must allow it as a reasonable modification of its visitation policy or as an auxiliary aide or service for effective communication. While it varies with each state and hospital, most should have a disabled support person policy, and the keyword to search for in the hospital policy is “support person.”
Explain that you are requesting a reasonable accommodation and/or an auxiliary aide or service under the ADA, RA, and ACA. Be prepared to explain why the patient needs an auxiliary aide or service (such an interpreter) or a reasonable modification (such as a supporter or personal care assistant). Check out this sample template.
ADA protections don’t necessarily require a previous disability or a doctor’s note- simply that the person is currently disabled per the ADA definition, and requests (in writing!) a reasonable support person. Defined by the ADA, a disability is a physical or mental impairment that substantially limits one or more major life activities, such as caring for oneself, performing manual tasks, walking, seeing, hearing, speaking, breathing, learning, working, etc., … A person who has a history or record of such an impairment, or a person who is perceived by others as having such an impairment.
The ADA, RA, and ACA are not suspended during the COVID-19 pandemic. In fact, the United States Department of Health and Human Services’ Office for Civil Rights, which oversees implementation of those statutes by hospitals, issued a statement specifically reminding hospitals that they must “keep in mind their obligations under laws and regulations that prohibit discrimination on the basis of … disability … in HHS-funded programs” and that the federal disability rights laws “remain in effect” even during the COVID-19 pandemic.
A is for Advanced Directives. It is very important to have your affairs in order before you go to a hospital. There are many types of Advance Directives, but you must establish your Medical Power of Attorney (POA). Choose a person to designate as having the Medical Power of Attorney for you if you are not capable of making decisions for yourself. This can be accomplished on your own by using the forms here. Designating a person as a ‘healthcare proxy’ is another alternative, which gives the proxy the authority to make decisions on your behalf, regardless of a patient’s decision-making capacity. The advantages/disadvantages of Medical Power of Attorney vs. healthcare proxy need to be carefully considered for each individual. Each state has their own laws about witnesses and notaries. There are many online notary services you can use.
A healthcare advance directive is a form that allows you to document your healthcare wishes in advance, for a time you cannot make your own healthcare decisions. If you know there are specific things you would like or would refuse while hospitalized, (e.g. Remdesivir and/or a ventilator, mind-altering medications, etc.), list your wishes in your Healthcare Advance Directive, you can find an example here.
T is for typing up a pre-hospitalization medication list which includes your immune strengthening supplements: vitamin D, zinc, magnesium.
Upon signing your admission forms, your home supplements and interventional preventive care can be added as a condition of your being treated in the hospital, as these are a part of your daily nutrition requirements and routines. Your supplements are a part of the food you eat, and should be spoken of as such while you are in the hospital; one ought not be denied food. Your attending physician should explain changes made to your medication list to you, and you ought to advocate for the continuation of medications from home which do not have interactions with the medications you are given in the hospital.
I is for initiating the chain of command for the purposes of advocacy. Every type of medical center (hospital, long term care unit, nursing home, etc.) must have a ‘physician of record’ assigned to every patient. This person is often referred to as the ‘attending physician’. Other sub-specialists may be consultants, but they are not usually the physician who is coordinating a person’s care. Residents and interns may also be involved in patient care, however the attending physician is ultimately responsible for the care of each person assigned to them. Nurse practitioners and physician assistants also work with them. Most hospitals contract with large groups of ‘hospitalists’ who care for in-patients. Within the ICU setting, the physician in charge of patients may be referred to as an ‘intensivist’. The physician of record has an obligation to see his/her patients every day. You must ask the full name of the admitting physician of record prior to being admitted to a hospital. This information is absolutely vital! The hospital would not admit a patient without a physician of record. Without this information, advocates will be limited on communication ability and if needed, future legal recourse.
The hospital nursing staff usually has its own hierarchy. For example; bedside nurse, charge nurse, nurse unit manager, hospital administration or chief nursing officer. Most hospitals have a designated patient advocate as well.
A lot of advocating has to do with attitude and approach. You want to be assertive but not aggressive, but do not be afraid to be persistent in presenting the needs of your loved one. This is your loved one! And these are services the hospital and patient have contracted for! Empathize with their situation so they’ll empathize with yours. Compassion goes a long way, and your approach makes a huge difference. If time goes on and you’re not being heard, you can escalate through the chain of command. It’s best to do this in writing and to copy everyone involved. If you have the person’s first and last name, as well as any employees’ email address you can put the two together to decipher how to email the care team. The email algorithms are almost always the same for all employees of a particular hospital. For example, FirstName.LastName@BannerHealth.com works with all hospital employees if you have their first and last name.
E is for enroll, and this is a job to do before a loved one is in the hospital. Enrolling in electronic medical records is important beforehand because a patient can authorize healthcare proxy access and viewing permission and still be HIPPA compliant. If this is not feasible, print and sign the record request form listed on the hospital website and grant your healthcare proxy access, and give a copy of this form to your advocate.
It is important to be able to see in almost real time what the patient is being tested for, what medications they’re being given, how much hydration/nutrition they’ve had, etc. It is very important to see the record with your own eyes, this is not the same as simply listening to someone read off medications to you over the phone. With access to this information, you will also be able to send the information to another doctor or get a second opinion easily. Patients have a right to a second opinion!
If the patient is not lucid and you don’t have a healthcare power of attorney, the access to records is difficult to obtain/get. Yet records are necessary for second opinions and the ability for future litigation. If you haven’t accomplished this beforehand, you can still request medical records, but this request MUST be in writing according to many state laws.
Alternatively, E is for Ethics Conference. The American Nurses Association’s Code of Ethics obligates every nurse to speak up on behalf of his or her patient, even if the patient has a difference of opinion (than their physicians) regarding their plan of treatment. The ANA has nine provisions and Provisions 2,3,5,6, and 8; all have components which are relevant to this type of situation.[59]
It has been standard of practice for decades, for patients or family members to be able to request an Ethics Conference under these circumstances. Nurses do not have to agree with a patient’s opinion regarding treatment, but they are obligated to make the request on behalf of the patient and work within the institution to arrange an Ethics conference. An Ethics conference is to be moderated by a healthcare professional who is also educated in biomedical ethics. Hospital systems contract with medical ethicists especially for this purpose. Families should expect that such a conference includes all the parties of patient’s/family’s choosing, as well as the health care providers involved with the care of the patient. This is not to be a ‘fly-by’ phone conference; but a sit-down-around-a-conference-table type of meeting. A conference should include a patient, if they are well enough to attend.
N is for notebook. Document everything! The who, what, where, when, and why. Focus should be on who you talked to (last name if they’ll give it, but at least a first name spelled correctly, ask them if you must, and their title and email if possible), when (date and time), and what you talked about. Was it in person or on the phone?
While documenting is important, if you decide to record your conversations, it’s important to know your state’s laws on this. For example, Arizona is a single party consent state, therefore, only one party to a two party conversation needs to consent to record.
T is for transfer. If things aren’t going the way you want, your loved one can be transferred to a different hospital. Another fantastic place to consider transferring is a Long-Term Acute Care Hospital (LTACH). This is different than a Long-Term Acute Care facility (LTAC). Many of these LTACH facilities offer high flow oxygen and employ respiratory therapists that specialize in weaning patients off ventilators. These facilities, covered by insurance for the most part, are motivated by different payment incentives than typical hospitals, and can sometimes be more independent which is refreshing.
If you want the patient home, they can be transferred into hospice care. Coordinate with a hospice agency and they’ll likely facilitate all of the equipment, hospital bed, commode, etc., including oxygen, for delivery to the patient’s home. If the patient chooses to get a second opinion and seek alternative healing treatment while they are at home, they can decide to live and cancel hospice care at any time!
Despite how someone may try to make you feel, no one can ever prevent you from removing your family member out of a hospital. If a doctor will not discharge a patient, the patient can leave “Against Medical Advice” (AMA). If you’re planning to leave AMA, you are not obligated to sign any of the hospital paperwork that will be presented to you. Such paperwork truly only protects the hospital, not the patient. Some have found it easier to sign the form as; “I do not agree to these terms” just to get out of there without another fight. A hospital and a doctor cannot hold you there in a hospital against your will to sign their paperwork, that is false imprisonment and coercion.
Most of the time, there seems to be more success for the patient’s advocate/family to figure out the exit logistics prior to actually notifying the hospital that the patient will be leaving. Sadly, some hospitals have tried to block patient transfers and AMA requests, which is unlawful, but is happening. In those cases, this example of a criminal legal notice may help.
An alternate “T” word is together. Throughout the last few years, many friends and families have experienced conflicting opinions on personal healthcare strategies. It is challenging when families have conflicting opinions on how to handle a hospitalized loved one. Conflicting families seem to thrive when they can agree on two simple facts; (1) support the patient’s advance directive wishes, and (2) agree to never let the patient die alone in a hospital. Families who come together on these two points are able to see their way through many differences.
One last “T” word is to threaten. If it becomes necessary, you can threaten to file complaints against a doctors’ medical license with state boards, specialty boards, and against nurses who fail to advocate for their patients or fulfil their duties required under the state nurse practice act. Medical staff would prefer to avoid complaints as they can be an absolute headache. You can also file a complaint with the state department of health, or the hospital’s accreditation agency (e.g. Joint Commission). Some have found success in looping in state legislators to make calls to the hospital, and publicizing anything the general public would be interested to know about a local hospital’s treatment of patients.
Hospitals love to try to protect their brand, and don’t like negative publicity. If applicable, consider filing a complaint with the compliance officer of the hospital to document the situation at hand. In addition, many hospital administrators and some hospital board members (the ones mandating these protocols!) are bonded, and would hate to have you file a claim against their surety bond. And hospitals most certainly don’t want to deal with civil rights claims of discrimination under ADA, or billing fraud under CMS (e.g. billing ICU rates for longer than medically necessary). So there you have it, just a few procedural options to have up your sleeve in case you ever need a smidge of additional leverage in advocating for your loved one.
Please visit Hands for Health and Freedom and check out the Patient Advocacy Protocol and many additional resources for advocates and patients. HHF is correct to say--that in many ways--our health and our freedom is in our hands. We must ensure, as caregivers, that we always hold out hope to those we are helping. Hope fuels healing in many powerful ways.
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