Law
Kate Mewhinney, managing attorney of Wake Forest's new Legal Clinic for the Elderly, makes a convincing case for the pressing need to train lawyers for a country that's getting older and living longer." She asks, "what law firm would not want a lawyer who could save their clients $20,000 to $30,000 a year?" Her answer is that a lawyer who has the ability to advise clients how to plan wisely for the future can save their clients a lot. The cost of living in a nursing home, 20,000 to $30,000 annually, or paying for live-in-care or medical treatment can be greatly reduced by planning ahead with legal counsel. The advice given by a lawyer who is well versed in all aspects of elder law-benefits, wills and estates, and long-term care insurance-can save a client money and, more importantly, peace of mind.
This past May, Dean Walsh and Associate Dean Taylor of the law school and Dean Janeway of the medical school, followed through on their idea to form a legal clinic for the elderly. The law school applied for a grant from the United States Department of Education. The government awarded Wake Forest a $279,000 grant, allowing law students and faculty members at the J. Paul Sticht Center on aging to serve the indigent.
About halfway through the semester, Professor Mewhinney enthusiastically reported that the elderly clinic was "going well." As a new program, Mewhinney had the task of laying groundwork for the clinic. She was and is occupied by finding new sources of clients; learning about community resource that benefit the elderly; educating Wake Forest administrators, alumni, and friends about the program; and overseeing law students' work.
Although it took about six weeks to really get the clinic program rolling, Professor Mewhinney was not deterred from her objective. She states that she "has the best legal job of anyone in the state!" Much of her legal background has oriented her to this field of work. From 1978 to 1989, she served as an attorney for the Legal Aid Society of Northwest North Carolina. During seven years of her time there, she participated in advising law students involved in the basic clinic program. In 1989, Mewhinney went into private practice. She continued her association with Wake Forest by teaching Trial Practice. In search of a more narrowly focused job that would enable her to continue to "help people and teach students." She was a natural for the position of managing attorney at the clinic for the elderly.
The law students involved in the clinic have two or three cases at any one time. The students have extensive responsibility in handling their client's cases, although, all of their final work is reviewed by Mewhinney. Students practice their skills in research, client interviewing, letter drafting, and document drafting. Some cases also require oral advocacy before judges, clerks of court, or administrative law judges.
Students are also immersed in lectures and discussions concerning elderly law. For example, each student participates in making rounds at Bowman Gray School of Medicine with a geriatric assessment team. During rounds, the students provide elders and their families with information about advance directives, such as living wills and health care powers of attorney. Guest speakers, including local attorneys and geriatric physicians, also give weekly lectures to the clinics participants.
The substantive education offered by the clinic program is just as valuable as the practical experience awarded. Some of the everyday issues that clients bring to law students involve: consumer rights, nursing home patients' rights, Medicaid appeals, Medicaid hearings, guardianship questions, powers of attorney, and will and estate planning questions.
The interesting aspect of all these legal issues is that they are not merely doctrinal questions. Each substantive area can be highly affected by the health of the elderly person. For example, a client might come to a student to find out how to execute a living will. Although some elderly clients are well read in current issues that effect them, the student must be aware of a number of factors. The student needs to know what medical condition may cause the living will to go into effect and what resources exist to evaluate a client with questionable competence-competence being the threshold requirement for executing documents, such as wills. The student should be in contact with the client's doctor, making it easier for the doctor to implement the client's desires.
The opportunity provided by the clinic for the elderly to become familiar with this information from receptive, encouraging medical professionals is unique and practical. The medical aspects add another dimension to the surface legal controversy faced by the elders.
Also adding another element to legal issues is the fact that the elderly are often discriminated against. Many direct and indirect government benefit programs are fraught with abuse. The elder may face physical and financial abuse in nursing homes or even by family members. Becoming aware of the realties an elder faces when trying to receive deserved benefits or exercise right is another service the clinic provides for it's participants.
A third dimension that law students confront in elder law issues is the ethical dilemmas of medical decisions. Dr. Richard Vance, the chairman of the ethics committee at the medical center addressed the ethical concerns of serving the elderly at one of the clinic's weekly sessions. Perhaps the most controversial topic in medical ethics in the termination of life sustaining treatment, including tube feeding, for patients in persistent vegetative states. By their involvement in the legal clinic for the elderly, students can develop their own philosophies toward euthanasia in a more educated and progressive matter. Whether the retract or expand their notion of when termination of life-sustaining treatment is permissible, they will have had a real life look at how the issue affects patient's decision-making.
Issues of legal ethics and the Code of professional Responsibility were also addressed in a lecture to the students by Professor Joel Newman of the law school. Elder law is fraught with ethical concerns for the attorney. A common issue involves simply determining who the client is. Another frequent ethical dilemma arises when the attorney is unsure of her client's mental competency to execute documents. Can she consult with a medical professional for input without violating the attorney-client privilege? Is that client's signature on Consent to Release Confidential Information authorizing contact with a physician? And what role should the attorney play when the client is determined to be incompetent? Not all these questions have easy answers in the ethical guidelines for attorneys, but the clinic students learn to spot the issues and gain an understanding of the ethical precepts that should guide them
Although the article only briefly outlines the Clinic for the Elderly, it is apparent that the clinic brings a great opportunity for learning to its participants, and allows its participants to use the knowledge for the benefit of the elderly community. When Mewhinney states that there is "a lot happening" in North Carolina that is exciting in terms of elder law, she is not underestimating the type of work in which clinic students participate.
Medicine
The Geriatric Assessment Clinic constitutes a part of the Section on Internal Medicine and Gerontology at the Bowman Gray school of Medicine. The Assessment Clinic was established in 1987 to serve the frail elderly. This fall, for the first time, law students began interacting with the medical team to assess and to provide legal counseling for these elderly patients.
Once during the semester, each student has the opportunity to make rounds with the geriatric medical team at Baptist Hospital. This team consists of an attending physician specializing in geriatrics, a doctor of pharmacy, a geriatric social worker, and several medical residents. Along with the law students, these people assess the medical, social, and legal aspects of each patient at the hospital to whom they have been referred. As other needs arise, other disciplines such as physical therapist, occupational therapist, or home health nurses, may become involved with the patients.
Usually patients have been referred to the assessment team by concerned family members. Often family members will be grown children who live out of state and are concerned about how well the elderly parent manages in activities of daily living. The spectrum of activities of daily living range from the routine task of caring or one's personal hygiene and taking correct dosage of prescribed medications to more complex task of running errands and managing financial manners. The concerned family member ca notify the geriatric assessment team (via the J. Paul Sticht Center on Aging) during the elderly person's stay that the patient has a questionable deficit in one of his activities of daily living.
Once the family member request the geriatrics assessment team, a variety of professional services are set into motion. Even though elderly patients are usually referred to the Geriatric Assessment Clinic for medical reasons, often more hidden, complex problems arise in the assessment process. One or more of those complex problems can be legal in nature and, in fact, may hinder or assist in finding solutions to the client's other problems. The law student and medical team work together to exchange information and to tailor an optimal outcome for each client.
Each Thursday morning the geriatrics team meets two elderly individuals at Baptist Hospital and spends at least three hours examining, interviewing, assessing, and planning a specialized line of care for each patient.
During the examination phase of the team rounds, each professional separately interviews the elderly client. The geriatrics physicians begin with a routine physical exam, with emphasis on current medical problems (as high blood pressure or diabetes) and on potential medical problems specific to the geriatric patient (as hearing or ambulation problems). A significant teat administered to each client is the Folstein Mini-Metal exam. This team evaluates the client in the following areas: Orientation to self, place, and time: registration/recall: calculation of numbers: language: and the following of commands. Each area is given a numerical value and then each client is assigned a score based on performance.
Another aspect of the medical examination evaluates more of a developmental-type level of cognitive functioning. For example, one test can evaluate if a client operates on a lower, concrete level of reasoning or if a client can function on a higher, problem-solving level of reasoning. The physicians use an interesting technique to evaluate these levels of reasoning. The may ask the client to interpret the meaning of a well-known proverbs, such as, "people who live in glass houses shouldn't throw stones." Based on the client's responses to several proverbs, the physician can determine the client's developmental/cognitive level of functioning.
The doctor of pharmacy interviews the patient to evaluate each person's understanding and adherence to their prescribed medications. It is not uncommon for a patient to take medications at home in a manner inconsistent with the physician's prescribed orders. The doctor of pharmacy also evaluates possible adverse drug interactions among the clients various prescribed medications.
Next, the social worker interviews the elderly client about practical, everyday problems. In this interview the social worker ask the client about his activities of daily living to ascertain areas where the client may have difficulty functioning and, so, may need outside assistance. If a family member or neighbor is not available, the client may be a candidate for outside professional help ranging anywhere from home health care and home health nursing to housekeeping to financial counseling.
Finally, the law student interviews the elderly client and family member to ascertain their legal needs. The law student asks who makes the legal decisions for the client, if the client has a living will, if the client is aware of the financial or health care powers of attorney that can be executed, and other pertinent questions. If the client has a need in one of these areas the student either encourages the client to consult with an attorney or to contact the Legal Ethics for the Elderly.
During the second stage of the team effort, the professionals discuss the specific needs of each patient and evaluate those needs in a brainstorming session. Every professional reveals what they have learned and what conclusion they have drawn about each elderly client. The team looks at the optimal lifestyle the client enjoyed before the onset of illness and the aging process and sets the client's goals based on that background. One very realistic problem for many elderly clients is "loss of expectations." Many times these people are not able to do the things they planned to do during retirement. The team attempts to help the client lower their earlier expectations and to seek newer, more reachable goals.
An important part of the law schools student's education during this phase of the team interaction is to learn how the medical team-especially the physician-evaluates cognitive reasoning. The client's cognitive reasoning forms the foundation of what the physician and, ultimately, the lawyer consider a client's competency. If a client already experiences memory loss or is entering a borderline stage of Alzheimer's Disease, the physicians explain their attempts to draw that fine and wavering line between competency and incompetence to the law student. After interviewing the client and interacting with the physician, the law student begins to appreciate the tightly interwoven fabrics of law and medicine, especially in regard to developing wills, living wills, and the powers of attorney.
In the same regard, the physician and law student can discuss the ramifications of living wills and powers of attorney in the hospital setting. As one physician noted to a law student, physician generally abide by the legal documents which clients present, but documents such as living wills or powers of attorney can help no one if they sitting in a unretrievable location, such as a safe deposit box. So, an attorney can help a client understand the practical implications of what the physician will and will not do one a living will or similar document is drawn up.
From their evaluations, the team establishes a plan of action, including time lines and referrals to other professionals or agencies. They may also suggest the use of the growing services for the elderly people, such as elderly day care and community support groups. But they can also suggest practical everyday solutions, such as encouraging clients to continue a favorite hobby, to continue church or community activities, or to exercise.
In the last stage of holistic client care, the team meets with the client. Not only is the client included in this conference, but the spouse, extended family members, and significant others are encouraged to join. Each disciplinary professional speaks to the patient and his family. As they speak, each professional demonstrates the unique approach and care involved in elderly client education. Each person attempts to sit closely to the client and if necessary, to speak loudly and clearly. Team members note follow-up visits with the clients so that plans are implemented within a short time after the client returns home.