Title and Date

ALZwell Tonight with Susan Grossman
"Difficult Questions and Decisions"
26 July 2000 9PM-10PM

[louise62] I'm a 1st timer, deal with end of life issues as a Geriatric Care Manager

[SusanALZwell] I'm an ex-caregiver who still runs a caregiving/AD website (http://www.alzwell.com). I get all kinds of questions that people are afraid to discuss with their doctors/workers

RichOBoyle> how did you hear about us, Louise?

[louise62] GCM list serve

RichOBoyle> I don’t recall posting the chat announcement there...But I am glad you came along

RichOBoyle> do you have any clients right now who are dealing with these issues?

[louise62] Rich you have a wonderful website, great for research. I don't buy drug books anymore.

[louise62] Yes, need a EMT DNR for a AD pt. at home. MD wants her to sign VA form, but she is not capable of understanding it.

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[SusanALZwell] What issues in particular are you interested in?

RichOBoyle> Hi Vicki and welcome to ALZwell Tonight

[Vicki1] Hi all!

[Vicki1] I'm interested in discussing difficult decisions about advance directives

RichOBoyle> Susan is our host tonight..

RichOBoyle> Susan: Would you like to wait 3-5 minutes for newcomers?

[louise62] Hard Choices for Loving People by Hank Dunn has excellent explanations for families.

RichOBoyle> thanks for the suggestion Louise. I will check it out...we are building a list of recommended readings for CGs

[Vicki1] Thank you, Louise.

[SusanALZwell] Sure I'll wait - some of the questions that most people ask me about concern advanced directives, calling 911, durable powers of attorney for Health, feeding tubes, hospice and others. I will cover any of these things when we start that y'all want

[Vicki1] Susan, I'm very interested in hearing what you think about hospice as an alternative to NH.

[louise62] To order book call Hospice of Northern VA 703-534-7070

RichOBoyle> late arrivals will have to read the transcript :)

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RichOBoyle> Hi SSB and welcome to ALZwell Tonight ... you got here just as we were staring

[ssb1226] Hi

[SusanALZwell] Let's start with Advance Directives since they are a big issue with any patient with visible dementia.

[SusanALZwell] The first issue is getting one done. Not just expressing the wishes that will go over next, but the issue of the capability of the patient to sign and their willingness.

[SusanALZwell] Has anyone here yet experienced the difficulty of signature and want me to cover the issues and some solutions?

[ssb1226] please

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[SusanALZwell] If the patient is able to sign, not visibly demented and not diagnosed with an illness that presents it self as dementia (AD for example) they need to have one down immediately. The easiest way to accomplish this is actually if they have to go to the hospital for anything at all including outpatient.

RichOBoyle> Hello Barb and welcome to ALZWell Tonight...we just got started

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[Bubblehead] Hello

[Vicki1] Susan, I'm confused -- are you saying that the advanced directive should be on file at the hospital?

[SusanALZwell] For an advanced directive - It is now standard procedure in most hospitals to ask if the patient has an advanced directive and offer one if they don't If you say know they’ll just do a quick one right there and have it in the signing stack of other hospital papers.

[barb1248] hi, please be patient with me, as I have only done chat rooms a couple of times last year

RichOBoyle> Hi BH and welcome to ALZWell Tonight...we just got started

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RichOBoyle> have any of you seen resistance in your LO to creating one? A fear in facing the issues?

[SusanALZwell] yes - the hospital will keep an advanced directive on file and the doctors and nurses will refer to it and follow it!

RichOBoyle> Hi Diana and welcome to ALZwell Tonight

[Bubblehead] It is good to see everyone here

[DianaM] Are we chatting?

RichOBoyle> we sure are :) we just got started

RichOBoyle> Susan is our Group Leader tonight...I am here to help the host

[SusanALZwell] We've just started delving into Advanced directives. Anyone hear have for themselves or their loved ones?

[louise62] definitely, and it's very specific

[barb1248] no have not done one yet

RichOBoyle> I must say that neither have I...

[Vicki1] Unfortunately, my father's is a very generic living will and health care power of attorney. The group home where he lives wants me to sign advanced directive re "calling a code." I'm not ready to sign a DNR, and that seems to be what they want.

[SusanALZwell] So is mine - For an AD patient, the are especially on items such as a feeding tubes, CPR, heroic measures, etc.

[Bubblehead] Rich you know the main ones I have always found the most resistant to discussing advance directives have been those around the LO more than the LO themselves

[louise62] Vicki what would your father want? Is he a poor candidate for good outcome of CPR?

[Vicki1] My dad is in very good health for someone in late middle stage of Alz. His heart condition is excellent, as is his blood pressure.

[Vicki1] He is at slightly greater risk for stroke.

RichOBoyle> Have the two of you talked about his wishes before his condition worsened?

[SusanALZwell] Just to back up one moment - Does everyone here understand that an Advanced Directive is a very important part of a Durable Power of Attorney? And that in some states they need to be part of such?

[Vicki1] I have discussed the issue with my brother (my only sibling) and we have agreed that Dad's quality of life is still at the stage where a DNR is not appropriate. I will consider signing a DNR at the point where I have to move him to a NH or hospice when he is end-stage.

[Bubblehead] .

[louise62] people with cognitive impairment and dependence for some ADLs usually do not have good outcomes. Once CPR is started things go forward quickly including ICUs and respirators.

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[SusanALZwell] Since it's part of a POA - it can be updated as the disease progresses if you have signing privileges.

RichOBoyle> Hi Patty and welcome to ALZwell Tonight...we are discussing advance directives

[Patty] How does advance directive differ from POA?

[SusanALZwell] No one should commit to non-extreme measures if they don't feel the patient is ready for it.

[Vicki1] Susan, when you talk about advanced directive as part of durable POA, do mean a living will, a DNR, or some other instrument?

[SusanALZwell] I meant no extreme measures - not non.

[Patty] who defines "extreme measures?"

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[louise62] good?

[Patty] How can I enlarge the font on screen?

[SusanALZwell] An advanced directive is just the piece that states what measures you want taken in emergencies, near death, dying, at death. POA includes items of caring also.

[Bubblehead] click on float

[Vicki1] My father's living will specifies no extreme measures. My mother had the same living will, but I had to write specific directives for the NH when she had pneumonia and they wanted to know exactly what they could do and not do.

[Bubblehead] and then click on the middle box on the right hand corner of the new window that appears

[SusanALZwell] Extreme measures is defined by each state. The forms you fill out actually list them for you to check off including feeding tubes, resuscitation, etc.

[SusanALZwell] Directives have been more clearly defined in recent years in many states.

RichOBoyle> so the key areas are DNR, feeding tube, hydration and ventilation?

[SusanALZwell] A Durable Power of Attorney for Health allows someone else to (names the person) to make health decisions for the patient - it also specifies specific wishes of the patient that the named person must follow.

[SusanALZwell] Basically those are the key areas - in effect, you can choose to say no to everything except an I.V. because that would be starving/hydrating them to death and therefore willful and a moral/legal issue.

RichOBoyle> I guess it gets even more complicated when the person is in the latest stages and develops an infection or pneumonia...which can be treated with antibiotics

[Patty] where does one get a copy of a health care directive - are they in nursing homes, rehab centers?

RichOBoyle> but only prolongs life...without really promising any improvement in the overall condition

[louise62] Susan I beg to differ. You can request no IVs in your living will. Dehydration is part of the natural dying process, and not a painful experience.

[Vicki1] Interesting point, Susan. The home where my mom was said they could not administer an IV without sending her to the hospital. We did not want her moved to a hospital (she was very late stage).

[SusanALZwell] Yes - but many homes/doctors will take the instructions very seriously - and whether the named person agrees with the choices, if the patient did one while able to make choices, they must be followed.

[Vicki1] I agree with Louise. The NH in FL did not have a problem with no IV as part of the dying process. The kept my mother hydrated by mouth as much as possible, but did not insist on an IV.

[SusanALZwell] In California they tell you no - it's not a choice and having it may cause legal and nullification issues. You need to check and see what your state allows. Yes - some do.

[Bubblehead] I find that the laws in Ca. can be very different then other states

[Bubblehead] I know here in Ohio you do not have to have an IV during the stage of death were the LO can not longer swallow

[Vicki1] Thanks for the heads-up. I will check with our elder care lawyer in MD and the NH where I plan to place my dad when the time comes.

[SusanALZwell] Another thing - with a DNR in place, in most states – homes are not required to call 911 and so they can be honored. In many states - if 911 is called you are saying you want extreme measures - they have no choice at all.

[Bubblehead] In some states however unless you have Hospice involved they are required to dial 911

[louise62] In VA you can have a DNR for emergency personnel. You can call 911 and they can assist but will not resuscitate.

RichOBoyle> It is probably a very good idea to talk with the NH administration and the director of nursing NOW...and then craft the DNR...rather than wait until an emergency to determine what there policy is

[SusanALZwell] In some states - if not on hospice, they must call 911 regardless. At home - you can make sure they’re carried out by being on hospice and calling them - not 911.

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[Mare] Hi all

RichOBoyle> Hello Mare...good to see you

[Vicki1] Susan, when you're ready, can we segue into a discussion of hospice and how it can help alz. families?

[Mare] Thanks

[SusanALZwell] In some states though - If someone else calls 911 and you have a DNR you can show it to them and they'll leave - but no half measures - they won't just help a little...

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[Bubblehead] .

[SusanALZwell] OK - how about some last quick questions on things I haven't answered yet and we'll move on to hospice for a moment. We can also move to feeding tubes or other issues after hospice.

RichOBoyle> Hi Telly...welcome to ALZwell Tonight...we are discussing advance directives and DNR orders

[telly] OK, have that for my dad. HI all!

[SusanALZwell] Basically the hospice concept is to helping the family ease the loved one through the dying process and support the family. not about saving or lengthening lives, but about providing comfort measures, pain relief, and maintaining dignity of the patient once evident that they have 6 months more or less to live.

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[Vicki1] Can hospice offer anything to a LO in a NH?

[louise62] yes, support

RichOBoyle> Hi Thumpy and welcome!

[Thumpy1] hello Rich

[SusanALZwell] Some homes will deal with hospice, others move their extreme patients to hospice facilities.

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[Mare] Is hospice at home possible?

[Bubblehead] Some of the hospice facilities are extremely good

[Thumpy1] Vicki...my Mom was in hospice while in the NH

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[Thumpy1] they covered her pain management, had aides feed and bathe her

[Vicki1] I didn't realize you could do both simultaneously. Will hospice people come to the NH?

[Thumpy1] yes they did

[Vicki1] Oops. Thanks!

[SusanALZwell] For hospice in home - when the patient dies and you call them instead of 911 - you miss that awful hooplah of ambulances, police, workers, etc. Hospice even takes care of the pick up of the body because they pre-arrange all the necessary things in advance - ask all the questions - help you even with the obit on top of the end of life support.

[Thumpy1] I was unaware of it too. until it happened to Mom

RichOBoyle> Bubblehead and I were discussing hospice this afternoon....it is getting harder to have hospice cover Alz end-stage

[Bubblehead] Hospice when caring for a LO to the last days is the most valuable use of Hospice. They offer a lot of support, training, assistance, equipment and protection in the home

[Mare] Rich why?

[Thumpy1] I thought that hospice was only for homecare...I was surprised to find out different

[telly] You have to know like in advance you need them right like a month or so right?

[SusanALZwell] Hospice will also make sure the advanced directives are in order and followed and let you know if something is amiss.

Bubblehead] Yes they have changed the guidelines and most no longer go by the 6 month rule for Alz. and related diseases

[SusanALZwell] Hospice care is within a period believed by the doctor to be within 6 months.

[Patty] who calls in for Hospice care?

[Thumpy1] it seems that the guidelines are getting much worse, instead of better

[SusanALZwell] I hadn't heard of this not 6 month change - at least not out here. Could you tell us what this means to those who are in need of hospice?

RichOBoyle> and it is hard to tell how long an ADLO will live as time goes on...especially without other chronic or acute medical complications

[Thumpy1] usually the physician makes the recommendation

[Bubblehead] Now the LO basically needs to be fully stage 7 and have some form of complication

SusanALZwell] It's often the complications that often kill an AD patient - not the AD that "qualifies" the patient for hospice.

[Bubblehead] then they are re-evaluated every 3 months now for continuing decline

[Thumpy1] bedsores, eating difficulties, etc are examples of complications

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[SusanALZwell] The home caregiver is usually the one to call hospice - the doctor will suggest it also when he feels it's appropriate.

[Bubblehead] If you can not show that the LO has continued in the decline they will be discharged from Hospice till they can requalify

RichOBoyle> doesn't the doctor "prescribe" it, in a sense?

[Thumpy1] yes rich

[Mare] What criteria do they use for decline

[Bubblehead] The new ruling is suppose to be more fair to those with Alz. and related diseases.

[Thumpy1] either the patient's physician, or a doctor that is from Hospice...must be evaluated and meet qualifying criteria

[Patty] Has anyone dealt with definition of FLD stages?

[Bubblehead] In practice however it is much more difficult to qualify and maintain Hospice

RichOBoyle> could you define FLD stages for our transcript readers?

[SusanALZwell] Since for me this is close to when I need to sign off (ya'll can continue) I would like to spend a moment talking about how hard it is to make the end of life decisions.

[Bubblehead] These rules are also design so that Medicare will cover their portion of the care

[Thumpy1] but the new guidelines seem to be backfiring....less are qualifying until it is almost too late to really help

[Bubblehead] In some cases LOs are being discharged from Hospice only to pass a few days later

[Thumpy1] or never qualify, and then die

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[Thumpy1] many docs are afraid to even approach hospice anymore

[Thumpy1] hello msvt

[Patty] why is that?

[msvt] Hi Folks

[Thumpy1] not sure

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RichOBoyle> hi msvt and welcome

RichOBoyle> are there any specific issues we need to discuss...Susan needs to sign off soon

[SusanALZwell] Deciding what is to be in Advanced directive heavily influences the use of hospice also - Deciding not to have a feeding tube - for example - or deciding to have the autopsy to aid research - these things are so hard to commit to paper - that many people wait to long to decide them.

[Thumpy1] hospice usually views feeding tubes as life sustaining and will not qualify you if one is in place

RichOBoyle> Can we discuss feeding tubes...that is a tough decision...

[Thumpy1] sure

[Thumpy1] it is a difficult decision for many

RichOBoyle> i heard a speaker that the Alz Congress in DC...his research suggested that feeding tubes do not prolong life at all

[Thumpy1] I already knew my Mom's wishes, so it was easier for me

[SusanALZwell] Many states consider feeding tubes extreme measures and they are something that can be declined in an Advanced directive.

[Thumpy1] how can that be, Rich?

[Patty] does the wish to have an autopsy get put in advance directive?

[Thumpy1] it is an unnatural form of nutrition

[SusanALZwell] YEs but a feeding tube may be essential for palliative care also or administering meds in an advanced illness that a person may have a chance coming back from - there lies the big decision and the moral issues.

RichOBoyle> ultimately they do not add to overall life expectancy, is what I meant to say.

[SusanALZwell] Yes - an autopsy can be specified in a POA or in a simple advanced directive

[Bubblehead] but current research does show that feeding tubes do increase the level of discomfort nor will they prevent aspiration

[Thumpy1] right...if a gastric tube, they do not prevent aspiration

[SusanALZwell] Power of Attorney - in this case we're referring to a durable power of attorney for health. You can actually purchase the form at an office supply store and have it notarized at Mail Boxes etc., or some such, if you do not wish to go through an attorney. Using the form - you won't accidentally request something your state doesn't allow an nullify it.

[Bubblehead] They still run the same risk of aspiration on their own fluids

[Thumpy1] if patient is not inclined to at least a 30 degree angle, they can still aspirate after a feeding

[SusanALZwell] The other issue on feeding tubes that I hear people who work in facilities question - is should they respect a patient's right to refuse nourishment?

[SusanALZwell] Sorry - but this is it for me now - I need to get my dinner out of the oven.

RichOBoyle> we can continue this conversation for a while

RichOBoyle> thank you Susan...

[Thumpy1] I feel that patients have the right to refuse any treatment, including nourishment...it is up to the POA to follow the wishes of the patient

[Thumpy1] nite susan

RichOBoyle> i guess it is hard if the LO has not been very up front about his/her wishes

[msvt] Thanks for your time susan

[Vicki1] Thank you Susan

[Bubblehead] nite susan

[SusanALZwell] Good night

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[Thumpy1] that would make it more difficult, Rich, but then you must look at quality of life, discomfort, risks, etc

[msvt] .

RichOBoyle> yes...but i would be afraid that an emergency would happen and your LO rushed to the hospital...

RichOBoyle> and CPR administered and all sorts of life prolonging measures

[Thumpy1] even if your LO has not come right out and said YES or NO....you can take clues from how they made decisions on various things in their life to get a feel for their wishes

[Bubblehead] That does happen at times

RichOBoyle> if your LO is in a nursing home...it helps to have a good relationship with the staff...make sure they know your wishes

RichOBoyle> sometimes they call 911 even after a DNR has been requested

[Bubblehead] when it comes right down to it the CG or the one with a POA has to call the shots not just by what they feel the LO wants but also what they can live with

[Thumpy1] Rich...that is another misconception....even if all the life-sustaining measures are done, the family can still request that their LO be removed from all life support

[Thumpy1] I have had to do that many times

RichOBoyle> I am sure you are right

RichOBoyle> unfortunately ...trauma has been prolonged in the meantime and the family then has to make the decision in real-time

[Mare] does that depend on the state

[Bubblehead] It is something that most families do not know about or are told about

[Thumpy1] they usually have a meeting with pastoral care, social work, the doctor and the family...to make sure of the families' decision

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[Bubblehead] I have seen cases where the family asked about it and the they were answered in such a way it made them feel to guilty to request it done

RichOBoyle> Hi Wendy...welcome to ALZwell Tonight

[msvt] Hi wendy

[Thumpy1] yes, it is better if the DNR is already in place

[Wendy] Hi all, thanks

[Thumpy1] unfortunately, that does not always protect the LO either

[Bubblehead] Yes some states are very sensitive about such issues and it can be very difficult to do

[Mare] How do we insure that our wishes are followed

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[Thumpy1] we recently had a gal that was mentally disabled, arrested in route from her group home to the hospital. caregiver forgot to bring DNR papers with her

[Thumpy1] we legally had to perform CPR

[Bubblehead] Plus what makes the whole DNR issue even more clouded is that what you would not do in one stage you would consider or do in an earlier stage

[Bubblehead] Mare you need to be sure there is a DNR in full view in case 911 is called

[Mare] Is that different than POA directive?

[Thumpy1] heck...our policy in the hospital just got cloudier, for now we have full DNR, Medications only, compressions only, no shocking...not cut and dried either yes or no any longer

[Thumpy1] heck, I want it tattooed on my chest

[Bubblehead] No it isn't Thumpy

[Bubblehead] I will tattoo it on your forehead for you Bunny

[Thumpy1] thanks bub

[Bubblehead] Unfortunately a tattoo would not work

[Mare] backwards for the mirror to see it

[msvt] Thumpy, what you gonna tattoo, do not touch?

[Thumpy1] that sounds good, msvt

[Bubblehead] You know the best time to discuss DNR with anyone is before they become ill or in the early stages of the disease

[Thumpy1] yes, get al their wishes known

[Thumpy1] heck, I even know my Dad's funeral preferences

[Mare] I was lucky to get POA health and financial and will. But the POA health pretty much states Mom's wishes.

[Thumpy1] got everything written down

RichOBoyle> Wendy...what is your care situation?

[Thumpy1] good for you mare

[Bubblehead] I have found that many times the LO is very relieved to discuss End Stage issues

[Thumpy1] well, I am getting off here ...take care everybody

RichOBoyle> goodnight thumpy

[Wendy] I'm the primary caregiver for my 93 yr old Grama. She has congestive heart problems and recently had pneumonia and now lots of complications

[Mare] So will the POA do or do we need a specific DNR?

RichOBoyle> talk to you soon

[Thumpy1] nite

[Bubblehead] They are scared to bring it up with their family because they feel it will upset/scare them

[msvt] Nite Thumpt

[Mare] ByeThumpy

[Bubblehead] Nite Thumpy

RichOBoyle> have you been able to discuss these issues with her?

[Bubblehead] with your POA you can sign the DNR

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[msvt] .

RichOBoyle> Hi Min and welcome

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[msvt] Hi Mina

[Mare] Mom never told us she had AD. All the paperwork was done in case. My Dad told us before he passed

[Mina] hi and thanx for the welcome

[Mare] Hi Mina

[Bubblehead] If they have not already made their wishes known on End life issues than it is up to the one with the POA to interrupt the LOs wishes

[Mare] OK Thanks

[Bubblehead] The one with the POA not only has to make decisions with what they believe the LO wants but because they are the ones making the decision they have to take into account what they can allow to be done/not done with in their own believes

[Bubblehead] My husband had the POA yet when it came to the DNR and most care issues he left that to me to call the shots as he just was not able to do so

[Mina] I'm having a tough time w/ my uncle in NH for 15 years now w/stroke just called in hospice --mom is in later stages of Alz.D but still #1 on calling list - step-dad won't relinquish because he thinks there might be some hidden assets - any suggestions

[Bubblehead] It worked well for us and all involved respected the way we worked it out

[Mare] Thats what I'm afraid of. Brother has POA but won't deal with any info yet

[Mina] when we go (hbby & I) staff is very receptive to any of our requests - yet no one has POA although Mom is on his Banking account

[Bubblehead] Mina that one can be tough but you may try talking to those doing the calling and if you are the one with the POA for your Mom you should be able to be placed in her spot as her representative

[Mare] Mina if your Mom has Alz how can she legally make decision?

[Bubblehead] legally she can't

[Mare] Wouldn't it then go to second?

[Bubblehead] You have to be of sound mind to make legal decisions

[Mina] step - dad -- does he get to take over her position by default?

[Mare] There is no second?

[Bubblehead] so legally they can not ask her and the second one will have to be called

[Mina] thanks for that info

[Mare] He can't just assume her POA I believe

[Bubblehead] Is he currently married to your Mom

[Mina] yes..

[Mare] Unless his name is actually on the POA for your uncle

[Bubblehead] Be sure to make it clear to who is doing the calling that your Mom is not of sound mind and if you have paperwork showing her diagnoses that should do it

[Mina] that's just the problem -- no POA that I can find out about -

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[Mare] Does the NH have a copy?

[Bubblehead] They may be willing to call your step dad but i think they will want to call that shot

[Mina] would my diagnosis negate me then?? perhaps I should try and get the next relative in line another niece?

[Bubblehead] Mina not all states and facilities are that insistent on all the legal papers

[Bubblehead] Mina your diagnoses might but you still have many of your cognitive abilities

[Mina] okay - perhaps a sit down with them again (has changed hands 9 times in the 15 years)

[Mare] I would check with a lawyer in your state

[Bubblehead] and legal papers you send would most likely be accepted in any court

[Mina] I appreciate your input

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RichOBoyle> good luck on that Mina

RichOBoyle> Hi Janet and welcome

[Mina] thank you

[janet3663] Hello

[Bubblehead] The diagnosis does not automatically make you incompetent

[Bubblehead] Hi Janet

[Mina] no, "I" don't think so... and I certainly know my uncles wishes

[janet3663] How are you Mina?

[Bubblehead] The stage of the disease and your cognitive abilities is what would do that

[Mina] good ..

[Mare] Yea I was thinking stages and what you are still doing etc. But someone else as next in line would probably be good

[Mina] well you know me -- I'm not going down without a good fight :)

[Bubblehead] Mina I get the feeling his wishes are so ingrained in your mind that they will be there long after many other things are gone

[Mina] oh, it's been very hard... I've been asked on more than one occasion to help him "leave the party"

[janet3663] How are you Mina?

[Bubblehead] The stage of the disease and your cognitive abilities is what would do that

[Mina] good ..

[Mare] Yea I was thinking stages and what you are still doing etc. But someone else as next in line would probably be good

[Mina] well you know me -- I'm not going down without a good fight :)

[Bubblehead] Mina I get the feeling his wishes are so ingrained in your mind that they will be there long after many other things are gone

[Mina] oh, it's been very hard... I've been asked on more than one occasion to help him "leave the party"

[Bubblehead] You may need to call hospice itself

[Bubblehead] Can the NH give you the name of his Hospice nurse?

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[Mina] They said that they didn't have that information ... gave me a # to call-- so that is all I have

[Bubblehead] OK most likely they gave you the Hospice #

[Bubblehead] You will want to call the hospice handling his case and talk to the nurse on his case.

[Bubblehead] You will have to leave a message for her/him

[Mina] yes, but up till now I've only gotten a recording... I guess I need to be more aggressive

[msvt58] Keep getting thrown out, don't think the machinery likes me tonight

[Bubblehead] or if it is long distance call you can find out when they will be in the office so you can call then

[Mina] thank you -- good advice

[Mina] how is your daughter's chat room going EA?

[Bubblehead] It is slow

[Bubblehead] She is learning patience

[Mina] perhaps if the Alz.Assoc. would put it in their news bulletin?

[Mare] Bubblehead can you tell me more about the difficulties getting hospice involved?

[Bubblehead] I am planning to take her down to the Assoc. to talk to them about it

[Mina] I've given it out to three young people now & put it on an AOL board

[Bubblehead] Good I will let her know that

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