Monthly Archives: September 2018

How Long $1 Million in Retirement Will Last in Every State

September 12, 2018

Anywhere between 12 and 26 years, depending on the state.

By Joel Anderson
ELA News
August 6, 2018

About 10,000 people turn 65 in the U.S. every single day. The average American retirement age is 63, and the life expectancy for retirees is about 79. That means Americans should plan to spend 16 years in retirement. However, many Americans lack the savings needed to survive retirement.

Conventional wisdom suggests a retirement income nest egg of at least $1 million, but the buying power of $1 million varies wildly depending on where you live. So if you’re asking “how long will my money last in retirement,” the answer is “it depends on your state.”

In order to determine how long $1 million will last the average retiree in every state, GOBankingRates found the average total expenditures for people 65 and older, which includes groceries, housing, utilities, transportation and healthcare, then factored in the cost of living index in each state to find the average budget for a retiree.

Dividing a theoretical $1 million by the costs per state reveals the number of years $1 million will last retirees in every state. Click through to learn just how long that is, and see if $1 million is enough for retirement in your state.

Read full article: How Long $1 Million in Retirement Will Last in Every State.

Medigap Enrollment and Consumer Protections Vary Across States

September 12, 2018

By Pam Belluck
ELA News
July 25, 2018

One in four people in traditional Medicare (25 percent) had private, supplemental health insurance in 2015—also known as Medigap—to help cover their Medicare deductibles and cost-sharing requirements, as well as protect themselves against catastrophic expenses for Medicare-covered services. This issue brief provides an overview of Medigap enrollment and analyzes consumer protections under federal law and state regulations that can affect beneficiaries’ access to Medigap. In particular, this brief examines implications for older adults with pre-existing medical conditions who may be unable to purchase a Medigap policy or change their supplemental coverage after their initial open enrollment period.

Key Findings

  • The share of beneficiaries with Medigap varies widely by state—from 3 percent in Hawaii to 51 percent in Kansas.
  • Federal law provides limited consumer protections for adults ages 65 and older who want to purchase a supplemental Medigap policy—including, a one-time, 6-month open enrollment period that begins when they first enroll in Medicare Part B.
  • States have the flexibility to institute consumer protections for Medigap that go beyond the minimum federal standards. For example, 28 states require Medigap insurers to issue policies to eligible Medicare beneficiaries whose employer has changed their retiree health coverage benefits.
  • Only four states (CT, MA, ME, NY) require either continuous or annual guaranteed issue protections for Medigap for all beneficiaries in traditional Medicare ages 65 and older, regardless of medical history (Figure 1). Guaranteed issue protections prohibit insurers from denying a Medigap policy to eligible applicants, including people with pre-existing conditions, such as diabetes and heart disease.
  • In all other states and D.C., people who switch from a Medicare Advantage plan to traditional Medicare may be denied a Medigap policy due to a pre-existing condition, with few exceptions, such as if they move to a new area or are in a Medicare Advantage trial period.

To read the entire article, see Medigap Enrollment and Consumer Protections Vary Across States at kff.org.

Exploding hospice industry vulnerable to fraud, OIG says

September 10, 2018

The hospice care industry has ballooned in interest over recent years. But at the same time, nursing home residents and others receiving such care are often subject to improper care and fraudulent billing, according to a new government report released Tuesday.

In 2016 alone, Medicare paid some $16.7 billion for services to about 1.4 million patients. That’s more than 81% more than the $9.2 billion spent a decade prior to 1 million beneficiaries, the Health and Human Services Office of the Inspector General noted in its new report. About one-quarter of beneficiaries received hospice care in a nursing home or skilled-nursing facility in 2016.

Given those vulnerabilities — along with recent government actions against hospice providers, such as this one — the OIG took a closer look at hospice use dating back to 2005. Its investigator found vulnerabilities in the program, including that patients sometimes receive poor and/or unnecessary acre, and providers often don’t share crucial information to help nursing home residents and others make informed decisions. Hospices provided fewer services than outlined in care plans for 31% of claims for beneficiaries residing in nursing facilities, for instance.

“No one wants their loved ones to suffer needlessly in their final days. We need to improve hospice care for our mothers, our fathers, our friends, ourselves,” Nancy Harrison, deputy regional inspector for HHS and lead author of the report, said in a news release. “It is so important to have reliable information and good resources when you’re facing a terminal illness and considering hospice care. As it stands now, you have the least information when you are thinking about end-of-life care.”

In its 45-page report, the OIG also recommended several steps to fortify the hospice program. Those include strengthening the survey process to better ensure that hospices provide beneficiaries with quality care and necessary services; giving the federal government more authority to address poor-performing hospice providers; educating nursing home residents and their families about the hospice benefit; and strengthening oversight of hospice providers to reduce inappropriate billing.

The inspector general also suggested decreasing payment for hospice care delivered at nursing homes, which already provide some similar services.

1,400 Nursing Homes Get Lower Medicare Ratings Because Of Staffing Concerns

September 10, 2018

Blend Images/Getty Images

Medicare has lowered its star ratings for staffing levels in 1 in 11 of the nation’s nursing homes — almost 1,400 of them — because they either had inadequate numbers of registered nurses or failed to provide payroll data that proved they had the required nursing coverage, federal records released last week show.

Medicare only recently began collecting and publishing payroll data on the staffing of nursing homes as required by the Affordable Care Act of 2010, rather than relying as it had before on the nursing homes’ own unverified reports.

The payroll records revealed lower overall staffing levels than homes had disclosed, particularly among registered nurses. Those are the highest-trained caregivers required to be in a nursing home, and they supervise other nurses and aides. Medicare mandates that every facility have a registered nurse working at least eight hours every day.

“It’s a real positive that they actually are taking the payroll-based system seriously, that they’re using it to punish those nursing homes that either aren’t reporting staffing or those that are below the federal limit,” said David Grabowski, a professor of health care policy at Harvard Medical School. “Could they do more? Sure, but I think it’s a really good start.”

Nursing home industry officials have acknowledged that some facilities are struggling to meet the new payroll reporting requirements. Katie Smith Sloan, president of LeadingAge, an association of nonprofit providers of aging services including nearly 2,000 nursing homes, said the lowered star ratings were disappointing and attributed them largely to a workforce shortage.

“Our members are battling on multiple fronts to recruit and retain all types of qualified staff, and nurses in particular,” she said in a statement.

Medicare rates nursing homes on a five-star system, and the homes’ failures to either keep the facilities consistently staffed with registered nurses or to provide the data to prove they were doing so led the government to give its lowest rating for staffing to 1,387 of the nation’s 15,616 skilled nursing facilities, according to a Kaiser Health News analysis of the latest data released by Medicare. They all received one star out of a possible five on July 25, when Medicare updated its Nursing Home Compare website, replacing the first ratings based on payroll data issued in April.

In footnotes on the site, Medicare said those homes either lacked a registered nurse for “a high number of days” over three months, provided data the government couldn’t verify or didn’t supply their payroll data at all. The downgraded homes reported seven or more days without any registered nurses, the analysis found.

For roughly half of the homes, the downgrades lowered their overall star ratings, which are the measures displayed most prominently on the site. But some of the homes saw their overall ratings stay the same or even rise, buoyed by their scores on other quality measures. Seventy-nine are still rated with a coveted five stars.

While the Kaiser Health News analysis found substantially lower average staffing of nurses and aides at for-profit facilities than at nonprofits and government-owned homes, the number of downgraded nursing homes was roughly proportionally divided among the three categories, indicating an industry-wide issue with staffing by registered nurses in particular.

Medicare concedes that because the payroll system is geared toward reporting hourly work, salaried staff may not always be reflected correctly, especially if they were working overtime. But Medicare had warned the nursing homes in April that the downgrades would be coming if facilities continued to show no registered nurses on duty. The agency noted it has been preparing nursing homes since 2015 for the new payroll system.

“We’ve just begun to leverage this new information to strengthen transparency and enforcement with the goals of improved patient safety and health outcomes,” the Centers for Medicare & Medicaid Services said in a statement.

The new payroll data, analyzed by Kaiser Health News, showed that for-profit nursing homes averaged 16 percent fewer staff than did nonprofits, even after accounting for differences in the needs of residents. The biggest difference was in the number of registered nurses: At the average nonprofit, there was one RN for every 28 residents, but at the average for-profit, there was only one RN for every 43 residents. Researchers have repeatedly found lower staffing in for-profit facilities, which make up 70 percent of the industry.

The data also revealed that nursing homes have large fluctuations in staffing. The average nursing home had one licensed nurse caring for as few as 17 residents or as many as 33, depending on the day. On the best-staffed days, each certified nursing assistant or other aide cared for nine residents, but on the worst-staffed days, each aide was responsible for 16 residents.

Weekend staffing was particularly sparse. On weekends on average, there were 11 percent fewer nurses providing direct care and 8 percent fewer aides.

Denial Of Medicaid Based On Applicant’s Failure to Timely Provide Irrelevant Information Was “Arbitrary And Capricious”

September 10, 2018

A.F. is a quadriplegic as a result of an accident that occurred 20 years ago. She is totally disabled and needs personal assistance to perform all activities of daily living. For many years, A.F. has relied upon Medicaid benefits to provide her with the assistance she desperately needs.

Under regulations, the Medicaid agency must re-determine a recipient’s eligibility to receive Medicaid benefits at least once every 12 months. Accordingly, the agency sent a letter requiring A.F. to provide information as well as a utility bill and copies of bank statements. A.F. responded and provided the information and documents requested.

In a second letter, the agency sought additional information and copies of life insurance policies allegedly owned by A.F.

A.F. did not respond to the agency’s second request on a timely basis. As a result, the agency terminated A.F.’s Medicaid benefits. The termination letter stated: “This action was taken for the following reason: CLIENT DID NOT SUPPLY LIFE INSURANCE INFORMATION.”

Upon receipt of the termination notice, A.F.’s attorney asserted that A.F. did not have insurance policies on her life. Rather, counsel disclosed that he had obtained two life insurance policies on his life in which he named A.F. as beneficiary on both policies. The Board did not respond to A.F.’s counsel.

Unable to reach a suitable resolution with the Medicaid agency, A.F. requested a fair hearing. After conducting two hearings, the administrative law judge (ALJ) issued an Initial Decision, finding that one insurance policy had lapsed and the other was a term policy with no surrender value. Neither policy had any affect on A.F.’s Medicaid eligibility. As a result, the ALJ recommended that the Medicaid Director uphold A.F.’s appeal and reverse the agency’s denial of redetermination.

However, the Medicaid Director rejected the ALJ’s Initial Decision. Although the Director admitted that information sought would not have affected A.F.’s eligibility to receive Medicaid benefits, the Director held that A.F.’s failure to provide the information and documents sought by the agency on a timely basis was sufficient grounds to deny the redetermination. The Director held as follows: “The credible evidence in the record demonstrates that Petitioner failed to provide the needed information prior to the . . . denial of benefits.”

A.F. appealed to the Superior Court of New Jersey, Appellate Division. The Court found that the agency’s decision in denying redetermination based on A.F.’s failure to provide information which the agency conceded would not have affected her eligibility to receive benefits was arbitrary and capricious. The Court ruled as follows:

The record shows A.F. was eligible to continue to receive Medicaid benefits . . . . The Board conceded before the ALJ that the information it requested, even if timely received, would not have provided a valid basis to deny A.F. Medicaid benefits. Distilled to its essence, the Director’s decision to deny Medicaid benefits to a severely disabled person based only on her failure to timely provide irrelevant information does not promote the Medicaid program salutary policy. Under these circumstances, the Director’s decision was arbitrary and capricious.

The Court reversed and remanded the Medicaid Director’s decision, ordering the agency to reinstate A.F.’s Medicaid benefits.

New Alzheimer’s Drug Slows Memory Loss in Early Trial Results

September 10, 2018

The new drug slowed cognitive decline and reduced amyloid plaques, shown lower right in a colored light micrograph of an Alzheimer’s patient.CreditCreditSimon Fraser/Science Source

By Pam Belluck

ELA News

July 25, 2018

The long, discouraging quest for a medication that works to treat Alzheimer’s reached a potentially promising milestone on Wednesday. For the first time in a large clinical trial, a drug was able to both reduce the plaques in the brains of patients and slow the progression of dementia.

More extensive trials will be needed to know if the new drug is truly effective, but if the results, presented Wednesday at the Alzheimer’s Association International Conference in Chicago, are borne out, the drug may be the first to successfully attack both the brain changes and the symptoms of Alzheimer’s.

“This trial shows you can both clear plaque and change cognition,” said Dr. Reisa Sperling, director of the Center for Alzheimer Research and Treatment at Brigham and Women’s Hospital in Boston, who was not involved in the study. “I don’t know that we’ve hit a home run yet. It’s important not to over-conclude on the data. But as a proof of concept, I feel like this is very encouraging.”

Aside from a couple of medications that can slow memory decline for a few months, there is no effective treatment for Alzheimer’s, which affects about 44 million people worldwide, including 5.5 million Americans. It is estimated that those numbers will triple by 2050.

The trial involved 856 patients from the United States, Europe and Japan with early symptoms of cognitive decline. They were diagnosed with either mild cognitive impairment or mild Alzheimer’s dementia, and all had significant accumulations of the amyloid protein that clumps into plaques in people with the disease, said Dr. Lynn Kramer, chief medical officer of Eisai, a Japan-based company that developed the drug, known as BAN2401, along with Biogen, based in Cambridge, Mass.

Many other drugs have managed to reduce amyloid levels but they did not ease memory decline or other cognitive difficulties. In the data presented Wednesday, the highest of the five doses of the new drug — an injection every two weeks of 10 milligrams per kilogram of a patient’s weight — both reduced amyloid levels and slowed cognitive decline when compared to patients who received placebo.

Of the 161 patients in the group taking the highest dose, 81 percent showed such significant drops in amyloid levels that they “converted from amyloid positive to amyloid negative,” Dr. Kramer said in an interview, meaning that the patients’ amyloid levels dropped from being considered high enough to correlate to dementia to a level below that dementia threshold.

And on a battery of cognitive and functional tests measuring memory and skills like planning and reasoning, the performance of the high-dose group declined at a rate that was 30 percent slower than the rate of decline in the placebo group.

Dr. Sperling, who briefly advised Eisai last year on a different drug, called the reductions in amyloid “dramatic,” but said the cognitive results were less momentous. Still, she said, “If you could really slow decline by 30 percent for people who are still normal or very mildly impaired, that would be clinically important.”

Dr. Samuel Gandy, associate director of the Mount Sinai Alzheimer’s Disease Research Center, said that for the drug to really be effective, it would have to allow patients to function longer independently without needing caregivers to help them with basic daily activities. That kind of practical application was not reflected in the data presented Wednesday.

“I wouldn’t say this is a quantum leap,” he said. “It is a convincing moving of the needle. But it’s not clear that the needle has moved far enough to make a difference in people’s lives.”

Dr. Kramer said the results were statistically significant 18 months after patients began taking the drug, but improvement began to be noticed after about six months. The 253 patients in the group receiving the second-highest dose also had amyloid and cognitive results that followed a similar trend.

In December 2017, the companies reported that a statistical analysis of the trial at the 12-month mark projected that the drug would not result in a statistically significant slowing of dementia. That meant that the trial did not meet its primary benchmark, which caused some experts and investors to voice skepticism about the drug. The 18-month results allayed some of that skepticism, although the Alzheimer’s Association issued a statement expressing caution and saying the results were “not large enough to definitely demonstrate cognitive efficacy.”

The results came from a Phase 2 trial, which measures both the safety and the efficacy of a drug, but is typically considered an intermediate step to larger and more extensive Phase 3 trials. Other drugs have shown promise in Phase 2, only to disappoint in Phase 3.

In this trial, patients were randomized into six groups, with 247 patients receiving placebo injections while the other five groups received varying doses of the drug.

One unusual aspect of the trial raised questions for some experts. Eisai and Biogen used a cognitive assessment they devised. Called the Alzheimer’s Disease Composite Score (Adcoms), it draws on elements from three other, more established cognitive tests.

Dr. Kramer said Adcoms was developed to compile the measures from those three tests that were sensitive enough to measure change at such an early stage of dementia. The data presented on Wednesday indicated that the patients also showed positive results on two of the three established tests, when those were looked at separately.

Some potential Alzheimer’s treatments have resulted in serious side effects that may cause dangerous swelling or bleeding in the brain. Fewer than 10 percent of the patients taking the new drug experienced such effects, the companies reported, making it relatively safe.

The drug works by attacking the stringy amyloid tendrils that form before they begin sticking together into plaques. The results of the trial add evidence to the idea that treatment for Alzheimer’s is most likely to succeed if it starts early in the disease process, because the brain begins to deteriorate years or even decades before full-blown dementia occurs. Some other drugs have failed because they were tried on patients with more advanced Alzheimer’s; others attacked the amyloid at later points in its progression.

Even if study results continue to be positive, making the drug widely available to patients could take years. Dr. Kramer and Ivan Cheung, the chairman and chief executive of Eisai, said that the companies recently submitted a request to meet with the Food and Drug Administration to learn what steps they need to get the drug approved.

“It’s a bit premature to talk about at this point, but our goal is to bring BAN2401 to patients and families as soon as possible,” Mr. Cheung said.

The F.D.A. typically requires Phase 3 clinical trial data to demonstrate safety and effectiveness. However, the agency does have processes for expediting the review of drugs, said a spokeswoman, who declined to comment on this drug or on conditions that would be taken into consideration for an Alzheimer’s drug.

Eisai is the maker of Aricept, which is one of the few drugs that can help slow early memory decline, but which is effective for only about six to nine months. Biogen is the maker of another Alzheimer’s treatment, aducanumab, that has shown early promise in a small Phase 1 trial in both reducing amyloid and slowing cognitive decline. Many in the Alzheimer’s field are intently anticipating the outcome of two large clinical trials of aducanumab, expected to be able to report results in 2020.

Dr. Gandy said the BAN2401 results were encouraging for the prospects of aducanumab because it suggests that there are at least two compounds that may be able to attack both amyloid buildup and cognitive decline.

In early July, when the companies announced they would soon present positive results from the BAN2401 trial, the stock prices of both companies rose by about 20 percent. They have since stayed roughly at that level.

Ten Signs Your Client Has Dementia

September 10, 2018

Anxiety during middle age may be linked to higher rates of dementia late in life.

Letha Sgritta McDowell | Jul 19, 2018

A recent study has found that anxiety during middle age may be linked to higher rates of dementia late in life. The study followed almost 30,000 participants for more than a decade, and there was a clear link between anxiety mid-life and dementia later in life. The study wasn’t a controlled study with the intent to calculate the magnitude of increased risk. Instead, the study simply indicated an increased risk without eliminating other factors.

When experiencing anxiety or stress, the body produces the hormone cortisol and prolonged heightened cortisol levels have been linked to weight gain, lower immune function, lower bone density, higher rates of mental illness and depression, higher rates of heart disease and more. Dementia may be another possible side effect of prolonged increased cortisol levels. On the other hand, anxiety is often a symptom of dementia, making the corollary between the two difficult to connect.

Therapy exists to assist individuals with the reduction of anxiety and cortisol levels. For individuals who live with high stress and anxiety, pursuing therapy to reduce these levels is critical due to the host of other health problems which may result. The possibility of reducing the chances of developing dementia later in life is simply an added bonus to reducing stress.

While there’s no way of eliminating the chances of developing dementia, there are some things one can do to aid in prevention. Reducing stress is one and maintaining heart health through diet and exercise is another. The Alzheimer’s Association also recommends education and regularly getting the right amount of sleep.

Ten Signs

How do you recognize dementia? The Alzheimer’s Association has provided 10 signs of dementia which, if you notice any one of them in yourself, a loved one or a client, warrants a visit to a physician for further testing. They are:

Memory loss that disrupts daily life. This includes forgetting recently learned information, important dates or events or repeatedly asking for the same information. This doesn’t include occasionally forgetting a name or an appointment, then remembering later.

Challenges in planning or problem solving. This includes difficulty with following a familiar recipe or keeping track of bills but wouldn’t encompass the occasional math error or learning a new task.

Difficulty completing familiar tasks at home or work.

Confusion with time or place. While it’s common for many to occasionally forget what day it is but then remember later, it isn’t common to forget and not remember at all.

Trouble understanding visual images or spatial relationships. This includes trouble judging distances or determining color contrasts.

New problems with words in speaking or writing. Examples of this are trouble in following a conversation or having trouble finding the right word for something and calling it by the incorrect name.

Misplacing things. While everyone misplaces their keys on occasion, an individual with dementia may place the keys in an inappropriate location (such as the freezer) then later being unable to find them and not have the ability to retrace their steps.

Decreased or poor judgment. This is difficult to ascertain and is an often-missed early sign. Decreased judgment is often what leads individuals to take action such as gifting sums of money when they otherwise wouldn’t do so.

Withdrawal from social activities. This is often as result of having difficulty in following a certain activity or being able to engage in conversation.

Changes in mood or personality. Different from simply becoming irritable when a routine is changed, an individual with dementia may become easily upset, afraid, depressed or fearful, even when in a familiar setting.

While the strength and nature of the link between anxiety and developing dementia remains unknown, it’s certainly cause for you and your clients to take steps to reduce stress and anxiety now. To the extent any preventative measure can be taken, it’s critical to implement. For those who have prolonged exposure to stress and anxiety, be sure to know the early warning signs of dementia and pursue treatment to improve overall quality of life.

When Are IRA Distributions Not Included in a Spouse’s Gross Income?

September 10, 2018

Private letter ruling deems rollover made by decedent’s wife to be valid.

Susan R. Lipp | Aug 07, 2018

In Private Letter Ruling 201831004 (released Aug. 3, 2018), the Internal Revenue Service ruled that a decedent’s individual retirement account wasn’t an inherited IRA and that his surviving spouse would be treated as the payee of the IRA proceeds because she made a valid rollover of the assets; thus, she didn’t have to include those assets in her gross income.

Survivor’s Trust

A husband and wife established a revocable trust consisting entirely of their community property. When the husband died, the wife became the sole trustee of the trust. Also, the husband had an IRA, which listed the trust as the beneficiary. As per the terms of the trust, all of its assets, including the IRA, were allocated to a subtrust, the Survivor’s Trust. The Survivor’s Trust provided that the wife would receive the right to income for her life and as much principal as was needed for her health, support, maintenance, comfort and happiness. She also had the power to distribute any of the trust’s property, including to herself. Through that power, she distributed and transferred the IRA assets to a non-IRA account of the Survivor’s Trust. Within 60 days, those amounts were distributed from the non-IRA account held by the Survivor’s Trust and paid to a rollover IRA, established in the wife’s name.

Rulings Requested

The wife asked the IRS to rule that:

  • She be treated as the payee or distributee of her husband’s IRA.
  • Her husband’s IRA isn’t an inherited IRA for purposes of Internal Revenue Code Section 408(d)(3)(C ) with respect to her.
  • Her rollover of IRA assets was valid under the same section.
  • She won’t be required to include in her gross income for federal income tax purposes in Year 1 or Year 2 the amount distributed from her husband’s IRA and rolled over.

The IRS granted all of the wife’s requests.

Rationale

Under IRC Section 408(d)(1), an amount distributed from an IRA is included in the payee’s gross income. But, there’s an exception for a rollover contribution that satisfies the following requirements: (1) the entire amount received (including money and any other property) is paid into an IRA for the benefit of the individual for whom the IRA is maintained) not later than the 60th day after the day on which the individual receives the payment or distribution; or (2) the entire amount received (including money and any other property) is paid into an eligible retirement plan for the benefit of the individual no later than the 60th day after the date on which the payment or distribution is received, except that the maximum amount that may be paid into such plan may not exceed the portion of the amount received that’s includible in gross income (without regard to Section 408(d)(3)).

Note, the above exception doesn’t apply to an inherited IRA where the inheritor wasn’t the surviving spouse of the decedent.

In the present case, the wife, as the sole beneficiary of the Survivor’s Trust, was entitled to receive all of its income and principal to which the IRA was allocated. This is because the wife had the right to, and did, in fact, direct the trustee in writing to pay her any such amounts from the Survivor’s Trust, which included directing the assets from the IRA to first be distributed from the IRA and then, within 60 days, rolled over to the rollover IRA (notwithstanding the fact that the assets were held in a non-IRA account before being paid to the rollover IRA). Accordingly, for purposes of applying Section 408(d)(3)(A) to the IRA, the wife is effectively the individual for whose benefit the IRA is maintained. As such, she was entitled to roll over such amounts.

You may have signed a living will, but scary mistakes can happen at the ER

September 7, 2018

By Judith Graham
ELA News

“Don’t resuscitate this patient; he has a living will,” the nurse told the doctor, Monica Williams-Murphy, handing her a document.

Williams-Murphy looked at the sheet bearing the signature of the unconscious 78-year-old man, who had been rushed from a nursing home to the emergency room. “Do everything possible,” it read, with a check approving cardiopulmonary resuscitation.

The nurse’s mistake was based on a misguided belief that living wills automatically include “do not resuscitate” (DNR) orders. Working quickly, Williams-Murphy revived the patient, who had a urinary tract infection and recovered after a few days in the hospital.

Unfortunately, misunderstandings involving documents meant to guide end-of-life decision-making are “surprisingly common,” said Williams-Murphy, medical director of advance-care planning and end-of-life education for Huntsville Hospital Health System in Alabama.

But health systems and state regulators don’t systematically track mix-ups of this kind, and they receive little attention amid the push to encourage older adults to document their end-of-life preferences, experts acknowledge. As a result, information about the potential for patient harm is scarce.

A new report out of Pennsylvania, which has the nation’s most robust system for monitoring patient-safety events, treats mix-ups involving end-of-life documents as medical errors — a novel approach. It found that in 2016, Pennsylvania health-care facilities reported nearly 100 events relating to patients’ “code status” — their wish to be resuscitated or not, should their hearts stop beating and they stop breathing. In 29 cases, patients were resuscitated against their wishes. In two cases, patients weren’t resuscitated despite making it clear they wanted this to happen.

The rest of the cases were “near misses” — problems caught before they had a chance to cause permanent harm.

Most likely, this is an undercount, said Regina Hoffman, executive director of the Pennsylvania Patient Safety Authority, adding that she was unaware of similar data from any other state.

Asked to describe a near miss, Hoffman, co-author of the report, said: “Perhaps I’m a patient who’s come to the hospital for elective surgery and I have a DNR order in my [medical] chart. After surgery, I develop a serious infection and a resident [physician] finds my DNR order. He assumes this means I’ve declined all kinds of treatment, until a colleague explains that this isn’t the case.”

The problem, Hoffman explained, is that doctors and nurses receive little if any training in understanding and interpreting living wills, DNR orders and Physician Orders for Life-Sustaining Treatment (POLST) forms.

Communication breakdowns and a pressure-cooker environment in emergency departments, where life-or-death decisions often have to be made within minutes, also contribute to misunderstandings, other experts said.

Research by Ferdinando Mirarchi, medical director of the Department of Emergency Medicine at the University of Pittsburgh Medical Center Hamot in Erie, Pa., suggests that the potential for confusion surrounding end-of-life documents is considerable. In various studies, he has asked medical providers how they would respond to hypothetical situations involving patients with critical and terminal illnesses.

In one study, for instance, he described a 46-year-old woman who is brought to the ER with a heart attack and suddenly goes into cardiac arrest. Although she is otherwise healthy, she has a living will refusing all potentially lifesaving medical interventions. What would you do, he asked more than 700 physicians in an Internet survey.

Only 43 percent of those doctors said they would intervene to save her life — a troubling figure, Mirarchi said. Because this patient didn’t have a terminal condition, her living will didn’t apply to the situation at hand and every physician should have been willing to offer aggressive treatment, he explained.

In another study, Mirarchi described a 70-year-old man with diabetes and cardiac disease who had a POLST form indicating he didn’t want cardiopulmonary resuscitation but agreeing to a limited set of other medical interventions, including defibrillation (shocking his heart with an electrical current). Yet 75 percent of 223 emergency physicians surveyed said they would not have pursued defibrillation if the patient had a cardiac arrest.

One issue here: Physicians assumed that defibrillation is part of cardiopulmonary resuscitation. That’s a mistake: They’re separate interventions. Another issue: Physicians are often unsure what patients really want when one part of a POLST form says “do nothing” (declining CPR) and another part says “do something” (permitting other interventions).

Mirarchi’s work involves hypotheticals, not real-life situations. But it highlights significant practical confusion about end-of-life documents, said Scott Halpern, director of the Palliative and Advanced Illness Research Center at the University of Pennsylvania’s Perelman School of Medicine.

Attention to these problems is important but shouldn’t be overblown, cautioned Arthur Derse, director of the Center for Bioethics and Medical Humanities at the Medical College of Wisconsin. “Are there errors of misunderstanding or miscommunication? Yes. But you’re more likely to have your wishes followed with one of these documents than without one,” he said.

Make sure you have ongoing discussions about your end-of-life preferences with your physician, your surrogate decision-maker, if you have one, and your family, especially when your health status changes, Derse advised. Without these conversations, documents can be difficult to interpret.

Here are some basics about end-of-life documents:

Living wills. A living will expresses your preferences for end-of-life care but is not a binding medical order. Instead, medical staff will interpret it based on the situation at hand, with input from your family and your surrogate decision-maker.  Living wills become activated only when a person is terminally ill and unconscious or in a permanent vegetative state. A terminal illness is one from which a person is not expected to recover, even with treatment — for instance, advanced metastatic cancer.

Bouts of illness that can be treated — such as an exacerbation of heart failure — are “critical,” not “terminal,” illness and should not activate a living will. To be activated, one or two physicians have to certify that your living will should go into effect, depending on the state where you live.

DNRs. Do-not-resuscitate orders are binding medical orders, signed by a physician. A DNR order applies specifically to cardiopulmonary resuscitation (CPR) and directs medical personnel not to administer chest compressions, usually accompanied by mouth-to-mouth resuscitation, if someone stops breathing or their heart stops beating.

The section of a living will specifying that you don’t want CPR is a statement of a preference, not a DNR order.

A DNR order applies only to a person who has gone into cardiac arrest. It does not mean that this person has refused other types of medical assistance, such as mechanical ventilation, defibrillation following CPR, intubation (the insertion of a breathing tube down a patient’s throat), medical tests or intravenous antibiotics, among other measures.

Even so, DNR orders are often wrongly equated with “do not treat” at all, according to a 2011 review in the Journal of General Internal Medicine.

POLST forms. A POLST form is a set of medical orders for a seriously ill or frail patient who may die within a year, signed by a physician, physician assistant or nurse practitioner.

These forms, which vary by state, are meant to be prepared after a detailed conversation about a patient’s prognosis, goals and values, and the potential benefits and harms of various treatment options. Problems have emerged with the increased use of POLSTs. Some nursing homes are asking all patients to sign POLST forms, even those admitted for short-term rehabilitation or whose life expectancy exceeds a year, according to a recent article by Charlie Sabatino, director of the American Bar Association Commission on Law and Aging. Also, medical providers’ conversations with patients can be cursory, not comprehensive, and forms often aren’t updated, as recommended, when a patient’s medical condition changes.

“The POLST form is still relatively new, and there’s education that needs to be done,” said Amy Vandenbroucke, executive director of the National POLST Paradigm, an organization that promotes use of the forms. In a policy statement issued last year and updated in April, it stated that completion of POLST forms should always be voluntary, made with a patient’s or surrogate decision-maker’s knowledge and consent, and offered only to people whose physician would not be surprised if they die within a year.

This column is produced by Kaiser Health News, an editorially independent news service and a program of the Kaiser Family Foundation.