Square One Podcast
Square One Podcast: Cornerstone Legal PLLC Ft: Visiting Angels Spokane
The following is the transcript from the first episode of Cornerstone Legal's new podcast series, Square One, where estate planning attorney and managing partner Gregory Hill interviews local community partners, clients, and business as he seeks to provide estate planning solutions from square one to squared away. If you have a business or perspective you think would be a valuable addition to the community, reach out to info@cornerstonelegalpnw.com to see about being a guest on the podcast.
INTRO
Gregory Hill [Cornerstone Legal] (00:00)
Well, good morning. I'm Greg Hill. I am the attorney here at Cornerstone Legal. We're here with Jessie Coberley from Visiting Angels [Spokane] to discuss legal issues that may or may not arise when it comes to in-home caregiving.
Why don't we start off by talking about what Visiting Angels [Spokane] does and what their role is in the community? I think that's a good place to start.
Jessie Coberley [Visiting Angels] (00:27)
So, Visiting Angels [Spokane] is essentially an in-home caregiving agency. If you're over the age of 18, you can qualify for in-home care. This is non medical help in your home. So we send a caregiver out to you and we can help out with daily tasks such as showering, personal care, we can do light housekeeping, we can do meal prep, we can vacuum, we can change that stupid fitted sheet that no one can do anymore because all the mattresses weigh 500 pounds...
Essentially, whatever we can do to make you stay independent in your own house in a healthy manner, we can generally do it.
So that's what we do. And our job when we come in is… a lot of the time the biggest question we get is, “Is my mom declining? Is my dad declining? How do I tell?”
People are coming to us because they need help. They just don't know [how much]. And so what we do is our case manager is gonna come in for a free assessment and they'll look around and generally the biggest way you can tell decline is patterns.
So everyone forgets their keys. I mean, when I was pregnant I called my husband crying because I forgot where my phone was.
I was on my phone.
So things happen. But what we're looking for is a pattern.
Pattern Recognition for Concerns of Declining Health
Jessie Coberley [Visiting Angels] (01:42)
Are we consistently forgetting personal care? Has your dad not showered in three weeks? Has your mom been forgetting to eat, you know, every Wednesday night? Or are there posted notes all over the house because they're continuously forgetting stuff and they need that constant reminder?
So what we're looking for is a pattern and that's generally indicating decline where it may be time to seek outside help, such as in-home care, to help out with these personal care needs.
Jessie Coberley [Visiting Angels] (O1:14)
So this is obviously from a non-medical standpoint. So the question is why we're here with Greg, at one point at what point does this need to reach an attorney?
And hopefully, honestly, at this point, the family has already spoken to an estate attorney. The family already has stuff in place because there is stuff that makes it a lot easier for us. And then there's stuff [where] honestly it's gonna get to a point where it's no longer valid to speak to an attorney and we're in a difficult place.
Gregory Hill [Cornerstone Legal] (01:48)
Yeah, and what things make your job easier?
Jessie Coberley [Visiting Angels] (01:52)
So the biggest things that make our job easier is when we have defined roles such as power of attorney - and that's for financial and medical because who we're dealing with essentially is the power of finance. That's how we get paid.
Unfortunately this is not a free service. It would be lovely if it was, but my caregivers still need to get paid. So who we're dealing with is [typically] the power of finance [agent]. And we also need the power of medical because they're the ones who are making the decisions for someone.
Jessie Coberley [Visiting Angels] (03:25)
Now, this is helpful to know because oftentimes our clients are very independent, but we're there at the start of a decline. So the question is how far is it gonna go?
Gregory Hill [Cornerstone Legal] (03:30)
Right. Now at the point that you guys are called, I mean, you know, grandma and grandpa, mom and dad, whoever needs help, I mean they're generally able to take care of themselves, correct?
Jessie Coberley [Visiting Angels] (03:43)
Correct.
Gregory Hill [Cornerstone Legal] (03:45)
So they're still able to shower, but may need some help getting to doctor's appointments. Or reminders to take their pills?
Jessie Coberley [Visiting Angels] (03:51)
Exactly. I mean we're there because usually there's some independence. There's also a desire to stay in their house. There's a desire to stay independent. And so just like when you're talking to a new mom. Sometimes things pile up and it just gets exhausting. That can happen when you get older too. And so if we can take one or two things off their plate, then we can do that.
They find driving in traffic exhausting and it wears them out for the rest of the day.
Let's take that off their plate.
You know, they find meal prepping exhausting. And because of that, they don't eat a good healthy meal.
Well, let's take that off their plate too.
Gregory Hill [Cornerstone Legal] (04:30)
So you guys chauffeur and do personal chef services too?
Jessie Coberley [Visiting Angels] (03:45)
Yes, essentially. If you want cooking, we're gonna find a caregiver who can cook though, because let's be honest, not everyone has that skill.
But we do provide transportation and that's not just to and from hospitals, that's also to your favorite bingo game, that's to Taco Tuesdays with your buddies, essentially whatever it is that's gonna add that quality of life.
The Documents that Direct Your Care
Gregory HIll [Cornerstone Legal] (05:02)
I love it.
Excellent. And so, I mean, when you start talking with the family, I mean, do [you] find that most people already have these documents in place, these powers of attorney, or is it kind of a toss-up?
Jessie Coberley [Visiting Angels] (05:15)
It is a little bit of a toss up and when we go in for an assessment, we do try and direct them towards some more helpful resources if we find they're missing these medical documents.
The biggest thing we look for is a PULST form. And for those of you who don't know, a PULST form essentially is outlining a DNR. And for us it's a big deal because these things are in their house and you know, things might happen when we're there.
Jessie Coberley [Visiting Angels](05:47)
Generally they're pretty healthy, so if something happens, we want to be able to fulfill their full wishes. And honestly, if we have to call the first responders and they come in, if they can't find a PULST form with the DNR, they're…essentially their training says just keep going until somebody shoves something in their face. And so if this is against our clients' wishes, we would really like to redirect that.
We also want to know what medications there are just in case something happens. We want to be able to just, you know, we want to be the caregivers. We want to be able to hand this all over to first responders and get them the best care that they can get.
Gregory HIll [Cornerstone Legal] (06:25)
Is there, when you're looking for a PULST form in somebody's home, I don't know if that's something you do. Is there a place you know like the first location that you look for one?
Jessie Coberley [Visiting Angels] (06:37)
So what we would like and actually when we go into independent living communities and assisted living communities it's required to be on the back of the door. And that is one of the most helpful places to be, is on the back of the door or front and center on the refrigerator for two reasons. It's also the most visible and it's the first place those first responders are going to look as well.
Gregory Hill [Cornerstone Legal] (07:03)
Okay.
Are there any other documents the first responders would want to see besides the PULST?
Jessie Coberley [Visiting Angels] (07:07)
Umm, if that PULST is filled out correctly, then no, because PULSTis gonna have doctor information, your DNR, it's gonna have contact information, it's gonna have medications, it's gonna have all the pertinent information.
So, when they're coming in an emergency, that should have everything on it. And that's why we want it filled out so we don't have to run around and hope that we’re acting in their best interests.
What is Capacity?
Gregory Hill [Cornerstone Legal] (07:27)
No, that makes total sense. I think if you don't mind, I think now is a good time to talk about the difference between what we consider to be capacity and legal capacity. Because that's a question that I get all the time, right? I mean, obviously in doing what I do, I have a lot of seniors come to my office and talk about it, you know, or concerned family members.
And they say exactly what you described. Mom and dad are declining, they're having issues with things. And capacity is crucial on my end of things when it comes to deciding what we can and can't do for mom and dad.
So I think most of us, just in our day-to-day, consider capacity to be our ability to take care of ourselves, right?
To be able to do exactly what you guys are describing, right? Get in the car and drive yourself to the doctor, pick up your medications, make meals for yourself.
But it's really important to know that legal capacity is actually a much lower standard than that. As far as the law is concerned, you generally just only have to know what it is that you're doing, right? Basically who you are and the ramifications of that document.
So with Wills, for example, this is again one that I see all the time. In order to have the legal capacity to make a will, you have to know what it is that you have, right?
So if grandma can come into my office and say, “Well, I own a home,” that's generally enough.
It's kind of split as to whether that means she has to know where that home is located, right? If she can't say her street address or not, and then who she could give that to.
So if she comes into my office, if I have somebody come in and say, “hey, I own a home that I would like to, you know go to my grandson”, generally speaking, that's legally sufficient for capacity.
And so where it gets kind of interesting in dealing with estate planning is oftentimes I'll have people come in my office who are in the later stages of degenerative diseases, such as Parkinson's or Alzheimer's, who may not have great short-term memory recall.
We have done cases, instances, where we're working on estate planning for grandma and grandpa and they have moments of lucidity where they can remember who they are.
I'm sure you guys see it. It can be pretty fleeting. We have to time you know our discussions to coincide with that. So I think that's a big misconception that people have when it comes to, I mean, legal estate planning, you know, specifically.
And I think where that dovetails into our discussion is at what point should they be calling [the two of] us.
Right? Because by the time they call you (Visiting Angels: Spokane), they've already picked up on those patterns. They know that mom and dad or grandma and grandpa are having issues taking care of themselves.
I would say as an attorney, that's the perfect time to call.
Right?
There's no, honestly there's no imperfect time so long as, you know, your family members are still able to make, you know, decisions in some way, shape, or form. If we're to the point where they can’t do that anymore, then I mean there’s still things that we can do, but it gets a little more difficult.
Jessie Coberley [Visiting Angels] (10:41)
Yeah, and it certainly is easier if we're coming in and we're coming in because of diminished capacity. Because we're there to take stuff off of mom and dad's plate, it is really handy to have that POA of financial and medical in place because once again, now you're asking mom and dad to think about finances, to look at their accounts, to understand what ACH is, which is pretty new when we're talking about a 90-year-old.
So it's really nice to have that in place so then we can deal with the kids and essentially that's one more thing you're taking off their plate. And that's also something that they don't have to worry about. You don't have to have this discussion at some point because theoretically we are with them and we're watching them possibly decline.
Hopefully they're not, but realistically, they're probably going to decline.
At what point do you want to have that conversation? It's really easy just to have it when they’re in full capacity and that way they don’t have to get upset halfway through in home care when we're like, okay, this is moving forward farther than, unfortunately, we expected.
Do you have this [plan] in place? Do you have this [plan] in place? It's just really nice to have it already in place and then you're taking that off their plate, you're taking that worry, you're taking that conversation.
Differences in Financial and Healthcare Power of Attorney
Gregory Hill [Cornerstone Legal] (12:07)
Absolutely. Now I mean I keep hearing you mention a division between powers of attorney, right? Every time you’ve talked about it, you’ve said Financial and Healthcare.
Now, as an estate planner, I often get to look at what other attorneys do. And some attorneys kind of squish them together. So they just have a general durable power to attorney, which means that these decision-making authorities last past incapacity.
Do you, as a caregiver in the role that you do, I mean, do you have a preference? Do you find one is easier to work with?
Jessie Coberley [Visiting Angels] (12:56)
Honestly, when we're talking about squished together or separated. Honestly, if you combine them, that is probably the easiest thing because for whatever reason, if you've got an extended family where part of them is living on the East Coast and part of them is living on the West Coast…families love to have power of attorney as far away from them as possible and then power of medical on the other side of the state. Which means you're dealing with time differences when we're having these discussions.
We've had assessments where we're sitting there, we're talking about care, and our client is completely on board. You know, her daughter's there and her daughter's power of medical, and is like, yes, this sounds like a great idea for mom. And we say, okay, let's set this up.
We do have to sign some contracts and they go, “hang on, my brother's actually power of finance and he's actually on the East Coast right now,” and so we have to fax back and forth and we have to think about time differences and we basically have to repeat this entire conversation.
And we can do that easily, but that's a delay in starting on care. And honestly, if we have to make any decisions, it's just one more step that we have to take. And we're willing to do it, but it's not always the most efficient.
Gregory Hill [Cornerstone Legal] (14:01)
No, absolutely. So it's far more efficient to have one power of attorney that's set up that covers both medical and financial decisions, correct?
Jessie Coberley [Visiting Angels] (14:07)
It is definitely more…it is definitely a lot easier. Or if for some reason you really do want to separate them out.
It makes it easy if they're geographically in a similar location. Because I mean we want to listen to the power of medical, we want to listen to our clients, but at the end of the day we are, I mean we are bound by financial obligations and so there's only so much we can do without that power of finance there as well.
Gregory Hill [Cornerstone Legal] (14:34)
Right. That makes total sense.
In working with the attorneys that are nominated by powers of attorney what are some common issues that you run into?
Jessie Coberley [Visiting Angels] (14:48)
Like getting things done or getting the wishes?
Gregory HIll [Cornerstone Legal] (14:53)
I mean, yeah, just just essentially in general, right? What I'm looking for is just how to simplify things on my end. One thing that I try to do because a lot of attorneys are very traditional, right?
We like to use a lot of big words. We like to say heretofore and aforementioned and here-to-and all kinds of stuff. And what I found in my practice is that documents are more effective first and foremost if you can understand it.
Right? Because not everybody has a law degree.
So I personally try to draft my documents in a way that, you know, if grandma and grandpa or cousin Susie or whoever picks them up, they can understand what that power of attorney means, right? And what it entails. I'm sure you run into disputes within the family too.
How the Power of the Purse Effects Caregiving
Jessie Coberley [Visiting Angels] (14:49)
We definitely do, especially when, you know, maybe there's a sister who's a power of attorney for finance and then a brother [who is] power of attorney for medical and they're not agreeing on what mom and dad's care should be.
So for one example, we had a client and you know we're gonna call her Samantha, and so Samantha was on hospice, and so Samantha has power of medical, which is her daughter, and power of finance, which is the son.
And so the daughter, Power of Medical, was there, and she was the primary caregiver to Samantha. They were on board with how the care should be. They were living together. I mean it's very copacetic.
Well, the power of finance, the brother, didn't necessarily agree with the level of care that Samantha needed, and unfortunately, it was for kind of a nefarious reason.
He knew that every time he paid us, it came out of his inheritance. And so he was not on board with the care plan. Well, once again, we're bound mostly by the power of finance.
And so when we were trying to up her care level because she definitely needed it and the daughter definitely needed some respite, the power of finance disagreed.
What ultimately ended up happening is we had to turn it over to state authorities because we didn't feel like our client was getting enough care. That's one big thing that when people are understanding the power of finance and power of medical…understand who's really in charge of what.
I feel like clients sometimes give out power of finance to appease their kids, like hey, you're in charge of something. But really, this is a humongous deal.
This is not just what their inheritance is. This is also dictating [your] care if [you] fall under diminished capacity. This is dictating a lot of things. And so I think to be very, very clear about all of the responsibilities and things that could happen with the power of finance and power of medical is very handy.
Don't Fear Adult Protective Services
Gregory HIll [Cornerstone Legal] (17:55)
No, that makes total sense. Now you had just mentioned too that when you see, I don't know, we're gonna say less than wholesome things occurring, you report it to the state authorities.
Is that Adult Protective Services?
Jessie Coberley [Visiting Angels] (18:10)
That is Adult Protective Services (APS). Because we are non-medical, there's a lot of areas where we aren't necessarily bound by a level of care as long as we feel it is sufficient. But when we feel like that care has fallen below a generalized standard, then we can't do much being non-medical but we can report it to APS, Adult Protective Services, and we feel good doing this because this means this is on the state's radar and the state has lots of services and access to services that we don't.
Gregory Hill [Cornerstone Legal] (18:46)
Yes. So when you say “falls below a normal standard of care”, what does that look like?
Is that mom not getting to doctor's appointments or is it more serious than that?
Jessie Coberley [Visiting Angels] (18:57)
It's essentially…It's kind of repetitive.
It's the same reasons why we would come in to help. If our client is missing a doctor's appointment, maybe not taking the prescriptions, maybe we're noticing these prescriptions are getting messed up, maybe we're noticing that the personal care isn't up to what we feel is a good standard.
So if we're showing up in the morning and their briefs are totally sopping wet and it's because yeah, and it's because one of the family members was supposed to take care of them overnight.
That's something that we're gonna keep an eye on. If we're noticing weight loss, you know, just generalize what's going on. They don't seem to be a hundred percent healthy. That's when we step in and we talk to the family and we're like, all right, maybe these are the reasons why we think that maybe your mom or dad needs some more care.
‘Cause oftentimes these conversations aren’t…. the family members aren't trying to be mean. They really aren't noticing their mom and dad declining because they don't want to. And it's just, it's how it is.
You're with someone day in and day out, you want to see them at their best. It's really hard to see them not at their best. And so sometimes they do just need a little, like, “Hey, come on, we might need some help.”
But sometimes, especially if the family members aren't there, that's when we need to say, Okay, we need some help ourselves.
Gregory HIll [Cornerstone Legal] (20:28)
No, that makes sense. Once you call adult protective services, what do they do? What does that look like generally?
Jessie Coberley [Visiting Angels] (20:37)
Well, so adult protective services, especially in Spokane, they're definitely…
They're very active. They've been really trying to keep up with the fact that we do have a very large senior population. So they will come out and they will make a site visit within 24 hours.
From there, essentially they're gonna do an investigation. And so this is to look into everything that we were talking about. Like what is this; is it a situation where somebody doesn't have support? Are the family members just not willing to see the reality?
And then from there, they're gonna make a judgment call. On what should happen with this individual. And it could be and then they provide support, whether this be, you know, assisted living services, whether it be Medicaid. you know, they have access to people who can go in, sign these people up.
They can make a, you know, kind of take over power of attorney for them and say, All right, this is what should probably happen.
Gregory Hill [Cornerstone Legal] (21:34)
Okay. And you said they can do that fairly quickly then, is that correct?
Jessie Coberley [Visiting Angels] (21:40)
Yes, they can. Sometimes they're a little bit slower because I mean they are full of people. It happens, but for the most part, especially if you've got an agency calling and saying, “Hey, this is kind of an emergency,” they will act on it quickly because at the end of the day, all of us are in senior care because we like seniors.
We wanna see them…we wanna see people succeed. They're not there to try and push people down. And so if, especially if they're getting multiple calls, they're gonna act extremely quickly because they know that this is something that needs to happen because honestly, these people are vulnerable and they don't always realize the medical situation they're in.
Gregory HIll [Cornerstone Legal] (22:19)
Okay. Now is it a bad thing if somebody calls APS? Is it always negative or is it generally very helpful to the family?
Jessie Coberley [Visiting Angels] (22:22)
I don't think it's a negative thing at all because they will do an investigation and if this is something where the family can easily step in, and it was just like a brief moment where there was chaos happening, someone had a baby. Someone moves away and they need to refocus priorities, then it's gonna get solved. It's not a big deal.
But if this is a situation where somebody actually needs the services It's a great thing 'cause it means our client is gonna get on someone's radar, somebody who has the authority to do stuff, somebody like the state who can actually force action.
Gregory Hill [Cornerstone Legal] (23:05)
I was gonna say I actually had a case here in the last couple weeks where I've been working with a family who thinks that grandpa needs a guardianship, which is, you know, it's a more involved legal process to appoint somebody because a power of attorney doesn't work. And so it's you know the legal way of getting somebody in to make all of the decisions for grandpa. Now it can take a while, especially in Spokane.
We have the Guardianship Monitoring Program and they are very overworked and underappreciated.There's just a couple ladies over there who are doing their very best to keep up, and so it does take us some time.
And that was a question that they had asked me, right? They were worried that grandpa was being isolated by another family member, and that he may not have been being taken care of in the best way.
So it sounds like the best thing to do for families in that situation, if they just want somebody to go and check on grandpa, is to call APS. Is that correct?
Jessie Coberley [Visiting Angels] (24:15)
Possibly - if it's somebody that needs a one time check, that would be actually a welfare check by the police. They are also mandatory reporters. They can do that process as well.
But if it's something where there's no resources, maybe a neighbor that you're noticing and you're like, “All right, this guy has no one, there's no family, I'm not sure what's going on, I'm not involved in this situation and quite frankly I don't wanna be”, which is very understandable, then yes, APS would be the best resource for them if it's an ongoing worry.
Gregory HIll [Cornerstone Legal](24:55)
I'm not involved in the planning aspects of that. So it's good to, you know, kind of get your opinion on it and hear it from somebody that works a little bit closer than I do.
Medicaid in Providing Caregiving Options
Jessie Coberley [Visiting Angels] (25:00)
And the thing is, Medicaid is still becoming very prevalent in Spokane. And it's just a higher cost of living, things happen, the cost of care is going up, whereas some of these folks that retired 30 years ago, obviously their income level is not going up. And so Medicaid is becoming more prevalent.
The nice thing is you see facilities and communities responding to this. And so there is a thing called a spend-down period for getting into some of these facilities. And so a lot of facilities around here will take Medicaid.
These are excellent places. These are, you know, Vineyard Park, these are, you know Pine Ridge Alzheimer's, there's the Spokane rehab. All these places are gonna take Medicaid.
But there are some places like Vineyard Park, they have a spend-down time period, which is usually a couple years.
Well there's some places like Pine Ridge that their spend-down period is getting shorter and shorter and shorter. So now they've got, I believe it's either a two-month or a four-month spend-down, which is insanely doable.
But this also highlights why some planning is needed because these spend down periods, when we're talking about years, you have to privately fund it for a few years.
Gregory HIll [Cornerstone Legal] (26:20)
When you're talking about a spend-down period, that just means you know, mom and dad have a retirement account, they have resources that would be available to fund their care, but they would have to go the private pay route before they can qualify for that extra assistance, correct?
Jessie Coberley [Visiting Angels] (26:39)
Exactly. And then when they do – when they do hit that spend-down period and they qualify for that Medicaid assistance, they're not leaving that community. They're staying there under Medicaid. You know they might change rooms possibly, I don't know. That depends on the community's guidelines.
But it does highlight the need for that planning because a lot of people like to spend down into Medicaid and then look for resources. And honestly, I only know one or two places in all of Spokane that take Medicaid through the door. And they’re good places, they try really hard, but like I said they’re not always the first choices for people.
Gregory HIll [Cornerstone Legal] (27:19)
Well, and I'm sure, you know, they get a lot of applications.
Jessie Coberley [Visiting Angels](27:23)
Yes, they get a ton of applications and they…I know some of the people who run these facilities, they feel horrible turning down applications, but they just don't have the room.
Gregory HIll [Cornerstone Legal](27:32)
No, absolutely. I was gonna say, I mean we definitely in Spokane have a growing need for senior care. I'm sure you guys see it all the time, right?
Jessie Coberley [Visiting Angels] (27:40)
Yeah, we're definitely busy.
Gregory HIll [Cornerstone Legal] (27:43)
Good, good that's what we like to hear.
Is there any other, I don't know, things or procedures that families really need to be thinking about when, or as their parents age? Obviously we'd all like them to age in place as much as possible and avoid disrupting everything.
Other than estate planning, is there anything else that, I mean, they could do from your perspective that would help ease that transition?
How to Gracefully Transition Through Age from a Local Caregiver
Jessie Coberley [Visiting Angels] (28:13)
Honestly, one of the biggest things is– I've actually got two – One of the things is just have a good conversation about what these care needs are gonna look like because honestly, I think it's everyone's dream to stay independent until they get to be like 95, 100, and then you die peacefully in your sleep. That's how people want it.
Either that or they assume that something's gonna happen, they'll be in a hospital, and then their needs are gonna be dictated by their medical needs. The doctors are gonna lead them along.
Very few people actually plan on a slow decline. And so, and also nobody wants to talk about it because nobody wants to talk about, okay, so this is what happens if I get dementia, Alzheimer's, this is what happens if I continue to decline, but I'm not sick enough to land in the hospital, or a facility.
So have a frank conversation like what would you like. Do you want to go to an individualized living community? Do you want to be assisted living? Like, do you want to live at home as much as possible? Like what is the level of care that you would want, the level of independence…?
My second thing is a DNR.
It's on the PULST form. I kind of touched on it about how first responders count on it. But a lot of people don't actually understand what the DNR is. They kind of assume it's very black and white, like we're either living or we're not living. Those are your two choices.
When actually a DNR dictates your level of care that you desire, you can have DNRs that include supplemental oxygen, DNRs that include a pacemaker, DNRs that include ventilators, like what level of care would you like? And these are very handy for the kids as well because, well, you can know somebody as much as you want, but you're not in their head.
You don't know their thought process and you don't know how it's changed. And so this is a big thing to give your kids to take it off of their minds. If something does happen, we know the exact level of care that you are willing to go up to.
Gregory HIll [Cornerstone Legal] (30:28)
No, absolutely. Now with a DNR that's short for do not resuscitate, if I'm correct.
Jessie Coberley [Visiting Angels] (30:35)
Correct.
Living Wills and DNRs
Gregory HIll [Cornerstone Legal] (30:36)
Are you familiar with living wills or advanced directives as they're sometimes called?
Jessie Coberley [Visiting Angels] (30:40)
I am a little bit but not as much as you are.
Gregory HIll [Cornerstone Legal] (30:45)
Okay. No, I was just asking because that's another, you know, another question I get asked all the time.
What's the difference between a DNR and an advanced directive?
Conceptually they're pretty close to being the same thing, right? An advanced directive, when I write one, says if I am declared to be in a permanent vegetative state, right, brain dead as we call it, this is what I would like as far as palliative care goes.
So, you know, the person who's setting one up would then say, well, I want to be intubated, I want oxygen or I want feeding tubes or hydration. The idea there is it takes those really difficult decisions off the family. Because at the end of the day, you don't want to be the one that has to decide whether, you know, mom and dad get oxygen or feeding tubes. I mean, especially if you're dealing with rapid declines - which do happen.
You know, you're already grieving, you're already in a position of shock where you're just trying to wrap your head around the situation, and now the doctor's saying, Hey, unfortunately, there's nothing we can do. Between the two, it sounds like a DNR covers different kinds of treatments.
Jessie Coberley [Visiting Angels] (32:07)
As far as I know, to my limited ability, all I know is that the PULST form covers the DNR. And I gotta say I don't know if I've ever really understood the differences between DNR and advanced directives. My assumption is a DNR deals with a little bit more one-time immediate care, whereas an advanced directive is a little bit more long term.
So the DNR would say never put me on a ventilator. Like that's it. Never do it. Not even one time. Advanced directive would be a little bit more [detailed], I would like to be removed if I'm on a ventilator for more than one week.
And so that's my understanding is advanced is more for the long term if this is a permanent state of being versus a one-time thing. Because there's some DNRs that if you don't get detailed enough in them, they can be harsh. Like ‘never restart my heart.’
Well, if I don't know you have an allergic reaction…what does that mean? That can be pretty harsh, but [sometimes] unfortunately first responders do have to adhere to DNRs.
Gregory HIll [Cornerstone Legal] (33:16)
Okay. I was gonna say that that is my understanding as well. It is that the DNR covers, you know, when the paramedics show up and the advanced directive covers well this is a permanent condition, so it provides different sets of instructions in different scenarios. but you said the PULST generally has the DNR on there as well.
Jessie Coberley [Visiting Angels] (33:35)
Yeah, the PULST is whatever an EMT is going to see when they show up through the door. I actually used to be an EMT as well.
Gregory HIll [Cornerstone Legal] (33:44)
No kidding?
How Paramedics Use Your Estate Planning Documents
Jessie Coberley [Visiting Angels] (33:45)
Yep. So the way it was trained, the way that was absolutely beaten to me, is if you come in and somebody is non-responsive, you are gonna work on them to the fullest amount of your ability, unless somebody shoves a DNR in your face that is signed and you can verify this. If somebody is just in the background saying, “hey, they have a DNR, DNR,” that means absolutely nothing. I have to have it in my face, I have to see it.
And so to have it in a visual place, to have it signed, that's one of the biggest things we see is we see PULST forms and they're not signed. Okay. Well unfortunately if they're not signed, it means nothing legally.
And so that's probably one of the most helpful things, especially for people who are particular about how their care is going to be dictated. And because like you said, those first responders, they are trained to do their thing.
Gregory HIll [Cornerstone Legal](34:44)
No, absolutely. And I think that's a good point to realize. Understanding that not every EMT is gonna be the same, right? They're human beings. It varies, but I would imagine that there's there's people out there who have different restrictions due to personal beliefs or you know, religious beliefs as well, as far as that kind of treatment.
So if I'm understanding what you're saying correctly, if you fall into that category right, where for example you don't need a you know, for religious reasons you can't get a blood transfusion. You know, you would have to go and tell the paramedics, right? Tell the EMTs, you'd have to give them that form and say, “look, we're not going to do this.”
Jessie Coberley [Visiting Angels] (35:26)
Yes.
Gregory HIll [Cornerstone Legal](35:27)
Is that the best way to do it? Because otherwise you'll you'll be there doing your thing trying to save their lives
Jessie Coberley [Visiting Angels] (35:36)
Exactly. EMTs are bound by law to do their highest level of care that they can perform, which EMTs are basic medical, but we have a lot of paramedics in Spokane and they can do even more. And so same thing, they're bound by law to keep you alive. They will try their hardest, especially if we're talking about rural paramedics, those guys are something else.
But yeah, they need to see the paperwork, they need to see it signed and then they can adhere to it, but until then they've got their marching orders.
Gregory HIll [Cornerstone Legal] (36:06)
Yeah, that is absolutely fantastic. Well Jessie, I really appreciate your time. This has been very, very instructive and been informative for me. So I think it's absolutely fantastic what you guys are doing.
Jessie Coberley [Visiting Angels] (36:18)
Yeah, thanks for having me. It was a great discussion.
Gregory HIll [Cornerstone Legal] (36:20)
Anytime. Thank you so much.
Jessie Coberley [Visiting Angels] (36:22)
Thank you.
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