Key Tasks to Implement a Long Term Wellness Plan

Clinic ImageImplement a fundamentally holistic plan for longevity that will maximize long-term wellness and lifespan. Dan Carlin, M.D., founder of World Clinic, a concierge medical services noted in FamilyOfficeReview.com (2011) for this type of a plan to be successful there are several key tasks to fulfill:

  • Retrieve and summarize medical records. Gather all existing medical records, then identify and summarize the core data; past medical history and physical exam findings to date, active medical conditions, allergies, medications, family/genetic risk and lifestyle variables.
  • Match the findings of the records review against a best practices checklist. This an essential step to identify what is missing in the baseline information set. Specifically this identifies problems that have gone unaddressed or are currently undermanaged.
  • Execute a comprehensive baseline health evaluation unique to the patient.
  • Based on the cross match of their records against the best practices checklist, create a detailed list of the necessary exams and labs to fill in any obvious gaps and address specific personal risk (such as early heart disease or breast cancer)
  • Schedule an executive physical exam that includes all the necessary exams and labs.
  • Develop a long-term calendared plan to track the specific findings associated with the patient’s unique risk. Calendar the specific events required to capture those metrics. This could include weekly blood pressure readings for clients with hypertension, semiannual blood draws for those clients with elevated cholesterol or annual mammograms for clients at high risk for breast cancer.
  • Keep score. Now that you have identified the key metrics associated with the client’s long-term health, track them. Ensure compliance with the plan by making it easy for the client; utilize their personal support staff as much as possible. Additionally coordinate exams such as blood draws to occur at the client’s residence at their convenience.

Once this is done Dr. Carlin then establishes a customized scoring system to track the individuals health needs. Compliance with this system is tracked by a clinical support team to ensure that goals are met.

Dr. Carlin also believes that the single biggest unmanaged risk for the high net worth family is a medical emergency. As he noted in Private Wealth Magazine (July/August 2011), the risk of the high net worth family is compounded by three variables which the average person does not bring to the table: they often reside and travel to areas with limited care resources, like ranches and tropical islands, they are often too busy to manage all the records and details of personal health and the need for total privacy is non negotiable.  For these reasons he underscores the importance of the high net worth family to be aware of the advances in telemedicine and the growth of concierge medicine. When used together with traditional medicine they provide two key resources for the high net worth family- immediate diagnosis and treatment (no matter where in the world the family member is) and longevity planning (a formal customized strategy designed and monitored to achieve maximum health).

AREA OF COMPETENCE: Divorce- Cherny Case  Jane Rood Case

ALL OF THIS UNDERSCORES the Importance of Long Term Care Insurance no matter what the level of wealth is Long term care insurance allows you to:

  • own the responsibility to protect yourself
  • maintain independence
  • preserve dignity
  • the system of care attached to the policy may lead to getting you faster care
  • protects health of caregiver
  • there may be no family members living near by who can help you
  • protects the inheritance of the children
  • in second marriages protects the income and assets of the health spouse
  • expands care options

 

Patricia Annino is a sought after speaker and nationally recognized authority on women and estate planning. She educates and empowers women to value themselves and their contributions in order to ACCOMPLISH GREAT THINGS in the world – and in so doing PROTECT THEMSELVES, those they love, and the organizations they care about. Annino recently released her new book, “It’s More Than Money, Protect Your Legacy” available at Amazon.com. To download Annino’s FREE eBook, Estate Planning 101 visit, http://www.patriciaannino.com.

The Pros and Cons of Guardianships for Parents of Impaired Adults

guardianship of elderly parentGuardianship offers additional options, but is hard to obtain, for a very good reason.

When we think of legal guardianship or conservatorship, several types of situations typically come to mind. We imagine instances involving a minor child whose parents may have died young, an elderly parent with dementia, or an adult who has been severely injured and can no longer take care of himself.

But a new category is evolving: an adult child whose decisions are impaired. This category has made headlines in recent years thanks to celebrities such as Britney Spears, whose father has been her court-appointed conservator since 2008. Spears records albums, performs worldwide, and is one of the most recognizable celebrities in America. Yet while she is under conservatorship, she does not have the right to make financial or legal decisions.

When a person is put under guardianship or conservatorship (the specific term used varies by state), that court-appointed fiduciary has the legal right to overrule the decisions the ward makes. The court-appointed fiduciary must report to the court and in certain circumstances, such as ordering antipsychotic medication, must prove to the court that the decisions are necessary.

It’s tricky to determine when it makes sense to appoint a guardian for a young adult whose decision-making is impaired. Many young adults make bad, and sometimes unsafe, decisions. These often involve alcohol or drug addictions. Even so, the key question is whether that is enough to justify taking away their personal liberties and overruling their rights.

Proceedings can divide families

An adversarial protective proceeding is fraught with emotional and legal peril, and the decision to seek a guardianship often divides families. Some family members may think a guardianship is the only alternative, while others might believe it is a mistake. The uncertain outcome of a proceeding complicates the situation. If the adult child “wins” and retains competence, then family relations can break down and any trust or confidence between the parent and adult child can evaporate.

It is noteworthy that in many states the protective proceedings of guardianship or conservatorship can be voluntary—the person involved can agree to have a legal guardian or conservator appointed. A distinct advantage to this type of protective proceeding is that it does not have to be adversarial. Twice in my practice, I have seen a person enter into a voluntary protective proceeding and then have that protection end in a few years, after which the person again took charge of his own legal and financial decisions. But voluntary guardianship isn’t always an option.

It is (and should be) difficult to put adults under guardianship or conservatorship against their will. Courts must tread slowly and carefully on this slippery slope. To complicate matters, many states define competence for legal purposes differently from competence for medical purposes. In all states, however, those seeking to place someone under involuntary guardianship or conservatorship must first produce ample medical evidence to support this course of action.

The person being put under guardianship or conservatorship receives advance notice of the court proceeding and has the right to object to it. Court proceedings, which are public, can take time and can be costly due to legal fees and related bills. If the proceedings involve finances, the court-appointed fiduciary must also file annual accountings.

Other Options

A less severe option, and an important first step for many, is putting in place the basic estate planning documents—durable power of attorney (for financial purposes) and health care proxy (for medical purposes). These documents are important because they start the process of providing another person with the legal authority to act. One advantage of these documents is that they exist outside the court system. Therefore, any financial actions taken by the attorney-in-fact under the durable power of attorney or health care actions taken by the health care proxy are private.

These documents are also important for parents who wish to view the medical or financial records of their adult children. Once young adults reach the age of majority (age 18 or 21 depending on which state they live in), no one has the right to access their records without a Health Insurance Portability and Accountability Act (HIPAA) release. But a durable power of attorney and health care proxy can be used to waive HIPAA privacy rights. In most states, adults have the right in a durable power of attorney to designate whom they would name as their guardian/conservator if protective proceedings commence. The person nominated as a fiduciary has the right to be present in a protective court proceeding, if such a proceeding commences.

For many of our clients, dealing with an adult child who has a significant mental health or addiction issue can be a considerable challenge. In addition to the traditional paths of medical and psychiatric care, the appropriate legal options also should be explored. At a minimum, for any child at the age of majority, a health care proxy and a durable power of attorney should be executed. For more extreme situations, the legal protective proceedings of guardianship or conservatorship may be an answer. To fully explore the available courses of action, clients should consult an estate-planning or disability-planning attorney, a physician, and a psychiatrist.

 

Patricia Annino is a sought after speaker and nationally recognized authority on women and estate planning. She educates and empowers women to value themselves and their contributions in order to ACCOMPLISH GREAT THINGS in the world – and in so doing PROTECT THEMSELVES, those they love, and the organizations they care about. Annino recently released her new book, “It’s More Than Money, Protect Your Legacy” available at Amazon.com. To download Annino’s FREE eBook, Estate Planning 101 visit, http://www.patriciaannino.com.

Putting a Price on a Human Egg

Lawsuit claims price guidelines used by fertility clinics artificially suppress the amount women can get for their eggs. Current demand means egg donors can typically make between $5,000-$10,000 for their efforts. What process do they go through to donate?

By Ashby Jones

human egg image, healthcare and legal issues for parentsHow much is a human egg worth? The question is at the heart of a federal lawsuit brought by two women who provided eggs to couples struggling with infertility.

The women claim the price guidelines adopted by fertility clinics nationwide have artificially suppressed the amount they can get for their eggs, in violation of federal antitrust laws.

The industry groups behind the price guidance—which discourages payments above $10,000 per egg-donation cycle—say caps are needed to prevent coercion and exploitation in the egg-donation process.

But the plaintiffs say the guidelines amount to an illegal conspiracy to set prices in violation of antitrust laws. The conspiracy, they argue in court papers, has deprived women nationwide a free market in which to sell their eggs, and enabled fertility clinics to “reap anticompetitive profits for themselves.”

“It’s naked, illegal price-fixing,” said Michael McLellan, a lawyer for the women.

The lawsuit, filed in the Northern District of California, could go to trial next year. In February, Chief Magistrate Judge Joseph Spero allowed the suit, first filed in 2011, to move forward on behalf of women who have donated eggs in recent years. Later this summer, Judge Spero will consider whether to broaden the case to include women who plan to donate eggs in the future and want to eliminate the caps entirely. If successful, it could upend the industry of egg donation, which has increasingly become an important option for women who have trouble conceiving because of advanced age or other problems.

The technology behind donated human eggs dates to the late 1980s. The fee hovered around $2,000 until the late 1990s, when demand went up and clinics began paying more, said Rene Almeling, a sociology professor at Yale University and author of a 2011 book on the business of egg and sperm donation.

The market for sperm donation, which has also ballooned in popularity in recent years, works differently than that for egg donation. Sperm donors generally contract with a sperm bank to give weekly samples for a year, for which they are paid about $100 each. There are no price caps on sperm donations, which are sold for between $400 and $700 per vial.

Sperm banks generally don’t charge a premium for sperm from men with particularly desirable characteristics of looks or intelligence. Such screening is often done by sperm banks, said Ms. Almeling, by requiring donors to either be enrolled in a four-year college or have a college degree, and to be taller than around 5 feet 8 inches. “Short doesn’t sell,” she said.

Rising prices for donated eggs prompted concern within the American Society for Reproductive Medicine, a nonprofit medical-specialty group focused on reproductive medicine and a defendant in the lawsuit. In 2000, the organization, made up largely of doctors who pay to join, suggested that payments should not go above $5,000 without justification, and said that payments greater than $10,000 went “beyond what is appropriate.”

The price guidelines aren’t mandates. But more than 90% of the nation’s clinics belong to the society, which has adopted the guidelines.

Fertility clinics generally charge patients $12,000 to $20,000 for each donor-egg cycle, a weekslong process, which, with the help of hormones, can yield more eggs than the one or two normally released by a woman each month. About half of each payment goes to the donor. Whether a donor makes $5,000 or $10,000 or something in between depends on, for example, whether the woman has donated successfully before, and whether a clinic thinks her profile will suit the needs of an infertile couple.

Location also matters. Payments in urban areas with high demand tend to fall between $8,000 and $10,000.

More than 9,500 babies were born from embryos created with donor eggs in 2013, the latest annual figure, according to the Society for Assisted Reproductive Technology—a nonprofit organization of doctors and others who practice in assisted reproductive technologies and the other defendant in the suit.

A spokesman for both defendant organizations declined to comment, as did representatives from several fertility clinics. But many fertility clinics clearly state in promotional material that they adhere to the guidelines.

The organizations have claimed in court papers that the purpose of the pricing guidelines isn’t to enrich fertility clinics or doctors. Rather, they say, the aim is to lessen the chance that outsize payments will entice women to donate and either hide health risks that might disqualify them or ignore the possible side effects of donating.

The problem is finding a payment amount that fairly compensates women for their time and effort, but isn’t seen as too hard to pass up by college students or low-income women. The $5,000 price recommendation “might be enough to coerce some women into donating, while for others it wouldn’t be nearly enough,” said Ms. Almeling.

Leah Campbell, a 32-year-old writer in Anchorage, Alaska, suffered complications following two donor-egg cycles while in her 20s and said she became infertile as a result. Ms. Campbell, who saw fliers around her college campus promising thousands of dollars to egg donors, said she worries about the effects of unlimited compensation. “The money entices women to take on risks that they probably wouldn’t otherwise,” she said.

Ms. Campbell said she preferred the policy in other countries, including the U.K. and Australia, which don’t allow payments for eggs. “If you want to donate for altruistic reasons, go for it,” she said. “Otherwise, let’s leave the money alone.” The price caps strike others as unnecessary, even sexist. “It’s overriding a woman’s ability to choose what she wants to do, even if it’s risky,” said Julie Shapiro, a law professor at Seattle University and author of a blog on law and reproductive technologies. “We don’t ban people from cleaning nuclear waste sites because it carries some risk, we allow them to charge more to make up for it.”

Other egg donors say a robust market depends on compensation. “I helped couples achieve their dreams, and in return they helped me go to law school, buy an apartment, pursue my dreams when I was in my 20s,” said Gina-Marie Madow, a four-time egg donor now working as a lawyer at Circle Egg Donation, a Boston-based egg-donation agency. Ms. Madow said $10,000 “feels like the right amount for women to get” for a cycle but didn’t understand the reason behind the price cap. “I just don’t think the [organizations have] done a good job explaining why it exists,” she said.

The price caps might also guard against worries that women might pay more for eggs from mothers of certain ethnic or racial backgrounds, or with such traits as physical beauty or high intelligence. Such a market exists, largely through a small number of agencies that cater to couples willing to pay a premium.

“It’s a concern about eugenics, that women will pay more for eggs from an Ivy League grad,” said John Robertson, a professor of law and bioethics at the University of Texas.

Kimberly Krawiec, a law professor at Duke University who has studied the egg-donor industry, played down such concerns, adding that mothers-to-be generally aren’t looking to build a genetically superior child. Ms. Krawiec said she had little issue with couples paying more for eggs from women with, say, high SAT scores. “Fertile people have been screening for beauty and intelligence for years and years,” she said. “It’s called dating.”

Source: www.WSJ.com Ashby Jones at ashby.jones@wsj.com
http://www.wsj.com/articles/putting-a-price-on-a-human-egg-1437952456

 

Patricia Annino is a sought after speaker and nationally recognized authority on women and estate planning. She educates and empowers women to value themselves and their contributions in order to ACCOMPLISH GREAT THINGS in the world – and in so doing PROTECT THEMSELVES, those they love, and the organizations they care about. Annino recently released her new book, “It’s More Than Money, Protect Your Legacy” available at Amazon.com. To download Annino’s FREE eBook, Estate Planning 101 visit, http://www.patriciaannino.com.

New guidelines may encourage more talks about end-of-life care

Discussing end-of-life wishes a strain for doctors, patients

 
healthcare for legal issues with parentsBy Felice J. Freyer Globe Staff

Susan Johnson was never afraid to talk about death. But whenever she tried to discuss her end-of-life wishes with her children, both in their 40s, they deflected the topic with jokes. And her primary care doctor never raised the issue.

Then, a few years ago, a surgical complication left Johnson hospitalized for months. She felt death close by, and it scared her. When she recovered and returned home to Salem, N.H., she invited her son and daughter for an Italian dinner, followed by a mandatory conversation — one with no jokes allowed.

These are some of the toughest conversations a person can have, and many never get there. For Johnson, a serious illness emboldened her to break through the barriers. She told her family that if she were incapacitated, she did not want to be resuscitated.

Advocates for better end-of-life care are hopeful that such conversations will happen sooner, and more frequently, when a new Medicare rule takes effect.

Earlier this month, the federal health program for the elderly proposed to start paying physicians, nurse practitioners, and physician assistants to talk with patients about their end-of-life wishes. Details of the plan are expected later this year, with possible adoption next year.

“It’s really an important first step. It shows we value these conversations,” said Dr. Jennifer S. Temel, a Massachusetts General Hospital oncologist, who often treats terminally ill patients.

But advocates agree it will take much more than Medicare reimbursements to overcome the obstacles to end-of-life conversations. Both patients and doctors are reluctant to talk about death, and even the willing are unsure when to start. And medical professionals get little training on how to conduct such conversations.

But as Johnson learned, talking to a doctor can make all the difference. The 67-year-old former lab technician thought she was all set after she talked with her children and filled out a form that said “do not resuscitate.” But then she had an allergic reaction to medication and doctors needed to temporarily place a breathing tube. That would have violated her directive. Her husband, Jerry, had to sign forms to authorize putting her on a ventilator.

Johnson needed only two days on the ventilator. Afterward, back home and in good health, she realized she needed to be more specific. She went to her primary care doctor, who helped her refine her instructions: no more than 10 days on a ventilator and then “remove all the machines and let me die in peace.”

Dr. Lachlan Forrow, director of ethics and palliative care at Beth Israel Deaconess Medical Center , said some patients have the opposite experience as Johnson. They say they want life-sustaining treatment without understanding what that might entail: breathing machines, feeding tubes, an array of painful and invasive treatments.

Such predicaments, he said, point to the hazards of black-and-white directives. “The conversations aren’t about feeding tubes and DNRs [do-not-resuscitate orders],” he said. “They’re about what matters to me in life. . . . Every medical thing, they’re just tools. Any advance directive that’s about the tools but not about the person is dangerous.”

But doctors find these conversations painful and feel ill-prepared to have them, said Dr. Susan D. Block, codirector of the Harvard Medical School Center for Palliative Care. “They don’t want to make their patients upset by talking honestly. They worry that these conversations take away hope,” she said. “They wait for patients to initiate [the talk]. Patients say they want their doctors to initiate.”

Patients struggle, too. A survey in 2013 found that 9 in 10 Americans think it’s important to discuss their end-of-life wishes but just over a quarter had done so.

Ellen Goodman, a former Globe columnist who founded the Conversation Project to promote end-of-life planning, sees change afoot. The project’s Conversation Starter Kit, which gives tips to patients on talking to loved ones and medical professionals about their wishes, has been downloaded 200,000 times.

The proposed Medicare payment is further indication of cultural change, Goodman said. “Let’s be sure,” she cautioned, “that it doesn’t become a quick and dirty checklist, that it becomes a thoughtful conversation.” She predicted that the Medicare rule would lead to new efforts at training.

Some of these efforts are already underway.

At least 136 medical schools include end-of-life care in a required course and 94 in elective courses, according to the Association of American Medical Colleges.

Since 2012, all physicians in Massachusetts, regardless of specialty, are required to take two hours of instruction on end-of-life issues, when obtaining a license and before license renewal every two years.

A collaborative of medical professionals called Ariadne Labs has developed a program to guide doctors in communicating with seriously ill patients. Ariadne is led by surgeon-writer Atul Gawande, author of the best-selling book, “Being Mortal: Medicine and What Matters in the End.” Ariadne’s Serious Illness Care Program helps doctors identify patients who are likely to die within a year and provides guidance on how and when to discuss end-of-life preferences. The group plans to test the program in 20 health care systems across the country, starting in September.

Harvard Vanguard Medical Associates, a large group practice, also has recently been offering training. Doctors are advised to ask themselves this question about each patient: Would you be surprised if this person died within the next year?

“If the answer is no, then you really need to start asking about end of life,” said Dr. Holly Thomas, a primary care doctor and regional medical director for the group’s parent, Atrius Health. The goal, Thomas said, is to avoid facing such tricky decisions amid a crisis.

But there is disagreement about the right time to start the talk. The Conversation Project urges an early start, when a patient is healthy, to establish values and lay the groundwork for the more detailed conversations that occur with serious illness.

Others say there’s little value in such talks before a person is ill and can envision what lies ahead.

Dr. Angelo E. Volandes, cofounder of ACP Decisions, a nonprofit that helps patients plan their care, recommends having the discussion when the patient has “just run the Boston Marathon and they’re feeling wonderful.”

He has created a series of videos that make the options less abstract. They depict a patient on a ventilator, immobilized and invaded with tubes and wires, and show the pummeling involved in cardiopulmonary resuscitation performed on a dummy. About 200 health care organizations, such as hospitals and hospices, have licensed the videos, intended to be shown as part of patients’ conversations with doctors, he said.

Medicare reimbursement for end-of-life talks will probably bolster two recent changes in Massachusetts law.

Doctors can now consult with patients to fill out a MOLST — Medical Orders for Life-Sustaining Treatment — form, which details the level of medical interventions wanted by seriously ill patients. The form becomes part of the patient’s medical record.

Additional new rules require hospitals, clinics, and nursing homes to distribute brochures about end-of-life options and instruct nurse practitioners and physicians to counsel those nearing death.

But talks and forms are often insufficient to stop the gears of a system built to repair and cure. A study last year found that the number of people with advance directives increased from 47 percent in 2000 to 72 percent 2010, but that had little effect on how many ended up in the hospital, and how many died there — an end few would choose.

 

David L Ryan/Globe Staff

Maureen Bisognano keeps this photograph of her brother Johnny, who had Hodgkin’s disease and at 17 chose to spend his last days at home with his family.

“Most of the things that the health care system does is driven by forces other than what patients themselves want,” said Forrow, of Beth Israel Deaconess.

Maureen Bisognano, a nurse who is president of the Institute for Healthcare Improvement, learned early in her career the importance of knowing what patients want.

Bisognano’s brother developed Hodgkin’s disease, a form of lymphoma, when he was 17. She recalls a gaggle of doctors discussing his prognosis after a grueling round of chemotherapy. When all the other doctors left, one went back into the room and asked Johnny, “What do you want?” He replied, “I want to go home.”

Immediately, the doctor lifted the sick boy from his bed and carried him to his sister’s car.

Johnny went home, and died there a few weeks later, surrounded by his parents and eight siblings. That was 1976.

Just over three decades later, Bisognano’s mother suffered a massive stroke at age 78. Patricia Marie McEachern had already discussed and written down her preferences at the end of life. Though she never regained consciousness, her family knew what she wanted.

They had the tubes and lines detached, and brought McEachern home to Milton. Her children and grandchildren took turns taking care of her throughout her last days. “We were all giving back to her,” Bisognano said.

Source: The Boston Globe – Felice J. Freyer can be reached at felice.freyer@globe.com. Follow her on Twitter @felicejfreyer

 

Patricia Annino is a sought after speaker and nationally recognized authority on women and estate planning. She educates and empowers women to value themselves and their contributions in order to ACCOMPLISH GREAT THINGS in the world – and in so doing PROTECT THEMSELVES, those they love, and the organizations they care about. Annino recently released her new book, “It’s More Than Money, Protect Your Legacy” available at Amazon.com. To download Annino’s FREE eBook, Estate Planning 101 visit, http://www.patriciaannino.com.

Harper Lee’s Condition Debated by Friends, Fans and Now State of Alabama

By SERGE F. KOVALESKI, ALEXANDRA ALTER and JENNIFER CROSSLEY HOWARD

MONROEVILLE, Ala. — The doubts arose almost immediately when HarperCollins announced last month that it caregiver for elderlywould release a rediscovered book by Harper Lee: Did Ms. Lee — 88, publicity-shy and famously resistant to producing a follow-up to her masterpiece, “To Kill a Mockingbird” — really want to publish a second novel that she wrote and set aside more than a half-century ago?

Weeks later, that question remains a matter of passionate debate. Despite reassurances from her publisher, lawyer and literary agent that Ms. Lee has enthusiastically endorsed the publication, the controversy over the new book, “Go Set a Watchman,” has divided some residents of her hometown here, as well as longtime friends who live elsewhere. One faction argues that Ms. Lee’s mental health is too shaky for her to have knowingly authorized the new book, while the other just as vigorously affirms her competence.

Now the State of Alabama has been drawn into the debate. Responding to at least one complaint of potential elder abuse related to the publication of “Watchman,” investigators interviewed Ms. Lee last month at the assisted living facility where she resides. They have also interviewed employees at the facility, called the Meadows, as well as several friends and acquaintances.

It remains unclear what, if anything, will come out of the investigation, now more than a month old. One person informed of the substance of the interviews, who did not want to speak for attribution because the inquiry was ongoing, said Ms. Lee appeared capable of understanding questions and provided cogent answers to investigators.

The fact that the state has undertaken an inquiry highlights the scrutiny that Ms. Lee’s publisher and lawyer are facing as they prepare to release one of the most hotly anticipated titles in decades. And the spectacle of a very public debate about Ms. Lee’s mental condition and true intentions has added an operatic blemish to what should have been a triumphant moment for HarperCollins and the millions of fans who have clamored for decades for Ms. Lee to produce another book.

A lot is at stake, including the legacy of one of the country’s most beloved authors. Many wonder whether “Watchman,” which was rejected by a publisher in the mid-1950s and then rewritten as “Mockingbird,” will turn out to be a flawed, amateur work when it is released in July, and a disappointing coda to a career that has been defined by one outsize hit.

With an investigation involving Monroeville’s most famous resident underway, friends and acquaintances who have come forward in recent weeks have offered conflicting accounts of Ms. Lee’s mental state, with some describing her as engaging, lively and sharp, and others painting her as childlike, ornery, depressed and often confused. Several people said that her condition varied depending on the day.

Ms. Lee — known to many as Nelle, her legal first name — had a stroke in 2007 and has severe hearing and vision problems. But friends who visit her regularly say she can communicate well and hold lengthy conversations if visitors yell in her ear or write questions down for her to read under a special machine. (A black marker is kept in her room for this purpose.)

Philip Sanchez, a lawyer who was a pallbearer at the funeral for Ms. Lee’s older sister, Alice, last year, and visits Ms. Lee regularly, said he is not prepared to judge whether Ms. Lee is capable of consenting to publish the book. “It’s a call only God or a doctor can make,” he said. “I am more concerned that Nelle is content than the discussion of her cognizance.”

Wayne Flynt, the Alabama historian and a friend of Ms. Lee, said the author is mentally fit, engaged and can recite long passages of literature. When he visited her a few weeks ago after hearing reports that she was depressed, they spoke about his grandson and she laughed at the stories he told. He said he believed Ms. Lee was capable of assenting to the publication of “Watchman.”

But he also said she occasionally has problems with her short-term memory. When he asked her about her new novel, he said she seemed to be “in her own world” at first, and asked, “What novel?” Reminding her of “Watchman,” he told her “You must be so proud,” and she responded with “I’m not so sure anymore,” Mr. Flynt recalled.

The only statements from Ms. Lee about the new publication — affirming her enthusiasm — have come through her lawyer, Tonja B. Carter, who handles her day-to-day affairs. Ms. Carter came across the manuscript in August and negotiated the book deal with HarperCollins. Over the course of a week, Ms. Carter did not return a phone call and text messages seeking comment. A lawyer for Ms. Carter, Bobby Segall, declined to comment. In a previous interview with The New York Times, she described Ms. Lee’s excitement that “Go Set a Watchman” would be published, and stressed she would never go against the author’s wishes.

One person who said that he had filed an anonymous complaint with the state is a doctor who has known Ms. Lee for years. The doctor said in an interview that he had called Alabama’s adult protective services hotline and asked the state to investigate whether Ms. Lee was too infirm to have fully consented to the publication of “Watchman.”

The doctor, who has not treated Ms. Lee and asked to remain anonymous because of the divisive nature of the issue, said he had been alarmed by reports of her frailty and by an account from someone he trusted who visited Ms. Lee last fall after the death of her sister, and said she was largely uncommunicative, lying in a fetal position in bed in the middle of the afternoon.

The investigation is being led by the state’s Human Resources Department with the help of the Alabama Securities Commission, which among other things, works to prevent financial fraud against the elderly. Barry Spear, a spokesman for the Human Resources Department, said he could not comment on any investigation, noting that such inquiries are confidential. But he said investigations into elder abuse are done at the discretion of the department, based on an initial assessment of a complaint, and they can involve law enforcement if there is evidence of financial exploitation.

Caseworkers generally talk to people who may be victims to evaluate their physical, mental and emotional state, and they interview doctors, family members, caretakers and friends, Mr. Spear said.

In some cases, an investigation may involve subpoenaing financial and other records. Among the records that may be available are cognitive assessments of Ms. Lee by the staff of the Meadows. The facility agreed to make such monthly assessments on each resident as part of a settlement of a 2014 review by inspectors of the Alabama Department of Public Health.

Several of Ms. Lee’s friends and two of her caretakers said that they had been interviewed by investigators. Marcella Harrington, an aide paid by Ms. Lee’s lawyer to sit with her regularly, said in an interview that investigators had asked her if Ms. Lee could recognize friends and if she was receiving proper care. Ms. Harrington said she told them that Ms. Lee is lucid and aware of the book. Asked by a reporter whether Ms. Lee was mentally alert, Ms. Harrington said, “As far as I know, she is.”

Others who met with investigators painted a different picture of Ms. Lee’s condition. The writer Marja Mills, who lived next to the Lee sisters in Monroeville for about 18 months beginning in the fall of 2004 and wrote a book about the experience, “The Mockingbird Next Door: Life With Harper Lee,” recently met with investigators. She shared excerpts from a transcript of what she said was a recorded conversation she had in 2010 with Alice, who died in November at 103. In the conversation, recorded with Alice’s consent, Alice described her sister as having serious memory lapses during discussions about her personal affairs, Ms. Mills said.

“She doesn’t know from one minute to the other what she’s told anybody,” Alice said of her sister, according to those excerpts. “She’s surprised at anything that she hears because she doesn’t remember anything that’s ever been said about it.”

Ms. Lee’s publisher and literary agent have dismissed suggestions that she is too mentally infirm to consent to publishing “Watchman.”

Michael Morrison, the president and publisher of HarperCollins, said he and Jonathan Burnham, the senior vice president and publisher of Harper, visited Ms. Lee over two days in February, the week after the new book was announced. “She was in great spirits, and we talked about how much we love ‘Go Set a Watchman’ and the details of the publication,” Mr. Morrison said in a statement to The Times. “It was a great meeting, and as expected, she was humorous, intelligent and gracious.”

Through a HarperCollins spokeswoman, Mr. Morrison said the company was aware of the state’s inquiry but had not been contacted by investigators.

Andrew Nurnberg, the agent handling international rights for “Watchman,” has brushed off reports that Ms. Lee is somehow being taken advantage of as “nonsense.”

But skeptics point to a different picture of Ms. Lee that emerged in a 2013 lawsuit she filed against her former literary agent, in which she said he had “engaged in a scheme to dupe” her by hiding royalty payments and appropriating the copyright to “Mockingbird.” In the lawsuit, which was confidentially settled, she was portrayed by one of her lawyers as infirm and vulnerable to those she trusts.

As the debate over Ms. Lee’s condition continues, amplified by the investigation, what was once a source of pride in this small town is now a flash point, with much of the animosity settling on Ms. Carter. Some residents of Monroeville, a town of about 6,300, seem resentful of her, calling her aggressive and needlessly protective of her client in ways that have isolated Ms. Lee from some longtime friends.

Others say Ms. Carter is a dutiful steward of Ms. Lee’s affairs and have noted that Alice Lee had retained Ms. Carter as the lawyer on her will.

“Ms. Carter has been with the Lee sisters for many, many years, and she is a first-rate lawyer,” Greg Norris, a probate judge and president of the Monroe County Commission, said.

Mr. Norris worries that the fractious debate over the new book could erode Monroeville’s literary legacy.

“I just don’t know why people would be so negative,” he said. “We are a poor rural county and this new book puts us on the map again.”

Serge F. Kovaleski reported from Monroeville, Ala., and Jennifer Crossley Howard reported from Decatur, Ala. Susan Beachy, Elisa Cho and Alain Delaqueriere contributed research.

Source: NY Times http://www.nytimes.com/2015/03/12/arts/artsspecial/harper-lees-ability-to-consent-to-new-book-continues-to-be-questioned.html?_r=1#story-continues-1

 

Patricia Annino is a sought after speaker and nationally recognized authority on women and estate planning. She educates and empowers women to value themselves and their contributions in order to ACCOMPLISH GREAT THINGS in the world – and in so doing PROTECT THEMSELVES, those they love, and the organizations they care about. Annino recently released her new book, “It’s More Than Money, Protect Your Legacy” available at Amazon.com. To download Annino’s FREE eBook, Estate Planning 101 visit, http://www.patriciaannino.com.

Surrogate Children Get Legal Recognition in France

Until now, surrogate children were deprived of any legal connection to their parents

(PARIS) — France’s highest court has granted legal recognition to surrogate children, in a major turnaround that willholding baby feet image, surrogate children make their daily lives easier and could lead to greater acceptance of new forms of families.

The Cour de cassation ruled Friday that, while surrogacy will remain banned in France, children born abroad through this practice will now be legally tied to their parents and will be granted birth certificates and immediate means to prove their French citizenship.

Surrogacy can involve a woman carrying an embryo created by in vitro

fertilization using another woman’s egg and her partner’s sperm. In some cases, such as those involving male gay couples, the surrogate mother is also the genetic mother of the child.

Until now, surrogate children were deprived of any legal connection to their parents, or any civil status in France. They were considered as children born from unknown legal parents, since their foreign birth certificates weren’t recognized. One lawyer has described them as “ghosts of the republic.”

Unlike other children born abroad to a French parent, these children couldn’t get automatic ID cards or passports, or register for state health care or other services.

This exposed them to frequent problems, because many basic tasks are impossible in France without an ID or authorization from a legal parent.

In addition to potential psychological troubles due to their incomplete identities, the children were also deprived of eventual inheritance, and faced major imbroglios in case of a divorce or the death of one parent.

Many hope that Friday’s ruling will increase the options for infertile and same-sex couples in France. For-profit sperm banks are forbidden, as is surrogate parenthood, seen by many as turning the womb into a commodity.

Europe’s top human rights court last year ordered the country to change the law on surrogate children, saying France’s refusal to recognize them was “an attack on the child’s identity, for which descent is an essential component.”

Until recently, the Cour de cassation had repeatedly refused to give surrogate children any legal recognition, saying they were born abroad from a “fraudulent process.”

In Friday’s ruling, the top judges had to take into account the European decision. They found that their previous case law was contrary to the European Convention on Human Rights, and so decided to allow the transcription of the foreign birth certificates into the French civil status.

Two separate cases leading to the new ruling involved a gay couple and a single man who had gone to Russia to have babies through surrogate mothers.

The Cour de cassation said that the French birth certificates will have to mention as the fathers the men who recognized the children abroad. The mothers listed on the birth certificate will be the surrogate women who gave birth to the children. (Is this for these two cases specifically, or in general? Would it be the same if a French woman’s egg was used for IVF into a foreign surrogate?)

The overwhelming majority of the French parents using surrogacy abroad are heterosexual couples. But the judges left open the possibility of changes for heterosexual parents as well.

Source: New York Times: http://www.nytimes.com/aponline/2015/07/03/world/europe/ap-eu-france-surrogate-children.html?_r=0

 

Patricia Annino is a sought after speaker and nationally recognized authority on women and estate planning. She educates and empowers women to value themselves and their contributions in order to ACCOMPLISH GREAT THINGS in the world – and in so doing PROTECT THEMSELVES, those they love, and the organizations they care about. Annino recently released her new book, “It’s More Than Money, Protect Your Legacy” available at Amazon.com. To download Annino’s FREE eBook, Estate Planning 101 visit, http://www.patriciaannino.com.

Supreme Court rules Canadians have right to doctor-assisted suicide

Sean Fine – Justice Writer

6-16-15_Supreme_Court_Rules_Candians_Have_Right, assisted deathCanadian adults in grievous, unending pain have a right to end their life with a doctor’s help, the Supreme Court ruled on Friday.

The unanimous ruling, by establishing that the “sanctity of life” also includes the “passage into death,” extends constitutional rights into a new realm. The courts have used the 1982 Charter of Rights to establish gay marriage and to strike down a federal abortion law. The new ruling will change the

In a brief, powerful opening paragraph, the court explained why it was creating a new constitutional right to autonomy over one’s death in some circumstances: Those who are severely and irremediably suffering, whether physically or psychologically, “may be condemned to a life of severe and intolerable suffering” by the government’s absolute ban on assisted dying. “A person facing this prospect has two options: she can take her own life prematurely, often by violent or dangerous means, or she can suffer until she dies from natural causes. The choice is cruel.”

The decision was signed by The Court, which happens occasionally when the justices wish to lend their decisions extra weight. The nine judges, who range in age from mid-50s to 74, dismissed the notion that competent adults cannot consent to their death. “We do not agree that the existential formulation of the right to life requires an absolute prohibition on assistance in dying, or that individuals cannot ‘waive’ their right to life. This would create a ‘duty to live,’” the ruling says.

The court decision puts Canada in the company of a small group of countries such as Belgium – and U.S. states Washington and Oregon – that permit doctor-assisted death. And it gives the Conservative government difficult choices as it heads toward an election expected in the fall. The court suspended its ruling for 12 months to allow for new rules and laws to be drafted, but Ottawa could choose to do nothing, and allow provinces and medical regulatory bodies to create the ground rules for assisted death. Or it could do what it did when the Supreme Court struck down prostitution laws 14 months ago: study international models and then create a uniquely Canadian version that may or may not respect the principles established by the court.

Justice Minister Peter MacKay did not directly express concern about the court’s decision, as he did immediately after the prostitution ruling. But he left the government’s options open, and did not promise to respect the court’s ruling. “This is a sensitive issue for many Canadians, with deeply held beliefs on both sides. We will study the decision and ensure all perspectives on this difficult issue are heard,” he said in a prepared statement.

Some advocates of disabled people condemned the ruling. Because it is not restricted to the terminally ill, but to a broader group who have a “grievous and irremediable medical condition,” it means “all persons with a serious disability in Canada can access assisted suicide,” the Council of Canadians with Disabilities and the Canadian Association for Community Living said in a joint statement.

“This degree of permissiveness does not exist anywhere else in the world.”

Gerald Chipeur, an Alberta lawyer who represented the Christian Legal Fellowship in opposing assisted death, said governments should create a system in which patients who fit the court’s criteria and wish to die would apply to a judge for a warrant, that they would then take to a doctor, thus exempting the doctor from criminal responsibility.

Jocelyn Downie, a Dalhousie University professor of law and medicine, said she would like to see an oversight body created – perhaps a Canadian commission on assisted dying – so a new system can earn the public’s trust.

The court overturned its own 5-4 ruling from 22 years ago in which it rejected a right to assisted suicide claimed by Sue Rodriguez, 42, who suffered from amyotrophic lateral sclerosis. In that case, Justice John Sopinka, writing for the majority, said Parliament needed flexibility to protect the vulnerable and respect Canadians’ views on the sanctity of life. Picking up on those arguments, the Canadian government contended in this case that a blanket prohibition on assisted death was necessary because of the difficulty in knowing beforehand who was vulnerable to being mistreated or undervalued by the health system or family members, and thus pushed toward an unwanted death.

But over and over,the court fell back on the factual findings of the trial judge, Justice Lynn Smith of the B.C. Supreme Court, who conducted extensive hearings on legal developments in other jurisdictions since the Rodriguez case. Justice Smith, a former law dean at the University of British Columbia, found that the systems worked to protect vulnerable people from unwanted death.

The court did not strike down the Criminal Code’s prohibitions on assisted suicide, but said they no longer apply “to the extent that they prohibit physician-assisted death for a competent adult person who (1) clearly consents to the termination of life and (2) has a grievous and irremediable medical condition (including an illness, disease or disability) that causes enduring suffering that is intolerable to the individual in the circumstances of his or her condition.”

Madeleine Meilleur, the Attorney-General of Ontario, said she would “love” to see Ottawa take the lead in crafting new legislation governing assisted dying. “I think it would show leadership,” she said. If Ottawa declines to pass a law or set national guidelines for what is essentially a new medical service, the provinces, which oversee health care, could enact their own laws on doctor-assisted dying. Ms. Meilleur said it was “too early” to say what Ontario will do next.

The case involved two women, both now dead. Kathleen Carter, 89, suffered from a degenerative disease, spinal stenosis, that left her lying “flat as an ironing board,” in her own words, and unable even to read a newspaper; her daughter, Lee Carter, took her to Switzerland for an assisted death in 2010. Gloria Taylor, like Ms. Rodriguez in 1993, suffered from amyotrophic lateral sclerosis, and died of an infection in late 2012.

Lee Carter, holding a pink bouquet of daisies in honour of her mother’s favourite colour, said in an interview after the ruling that Canadians now “have a choice to die with dignity in our own country, surrounded by friends and family.”

With a report from Kelly Grant

Source: http://www.theglobeandmail.com/news/national/supreme-court-rules-on-doctor-assisted-suicide/article22828437/ The Globe and Mail

 

Patricia Annino is a sought after speaker and nationally recognized authority on women and estate planning. She educates and empowers women to value themselves and their contributions in order to ACCOMPLISH GREAT THINGS in the world – and in so doing PROTECT THEMSELVES, those they love, and the organizations they care about. Annino recently released her new book, “It’s More Than Money, Protect Your Legacy” available at Amazon.com. To download Annino’s FREE eBook, Estate Planning 101 visit, http://www.patriciaannino.com.

Sofía Vergara’s Ex-Fiancé: Our Frozen Embryos Have a Right to Live

By NICK LOEB

Baby and human cells image, nick loeb and sofia vergaraDELRAY BEACH, Fla. — LAST August, I filed a complaint in Santa Monica, Calif., using pseudonyms, to protect two frozen embryos I created with my former fiancée. I wanted to keep this private, but recently the story broke to the world. It has gotten attention not only because of the people involved — my ex is Sofía Vergara, who stars in the ABC series “Modern Family” — but also because embryonic custody disputes raise important questions about life, religion and parenthood.

When we create embryos for the purpose of life, should we not define them as life, rather than as property? Does one person’s desire to avoid biological parenthood (free of any legal obligations) outweigh another’s religious beliefs in the sanctity of life and desire to be a parent? A woman is entitled to bring a pregnancy to term even if the man objects. Shouldn’t a man who is willing to take on all parental responsibilities be similarly entitled to bring his embryos to term even if the woman objects? These are issues that, unlike abortion, have nothing to do with the rights over one’s own body, and everything to do with a parent’s right to protect the life of his or her unborn child.

In 2013, Sofía and I agreed to try to use in vitro fertilization and a surrogate to have children. We signed a form stating that any embryos created through the process could be brought to term only with both parties’ consent. The form did not specify — as California law requires — what would happen if we separated. I am asking to have it voided.

My lawyers have identified 10 other cases in the United States in which a parent tried to have a fertilized, frozen embryo taken to term against the wishes of an opposing parent. In eight of those cases, the parent seeking custody lost. In the other two cases, one in Pennsylvania and one in Illinois, a woman was awarded custody of fertilized embryos over the man’s objections. In both cases, the woman had undergone chemotherapy treatment and the embryos were her last chance to have a biological child; judges ruled that the woman’s interest in becoming a parent outweighed the man’s interest in not becoming a parent. In the Illinois case (now on appeal), the judge found that the form the couple signed was not the binding contract, and instead enforced a verbal promise the man made to help the woman have children.

Many have asked me: Why not just move on and have a family of your own? I have every intention of doing so. But that doesn’t mean I should let the two lives I have already created be destroyed or sit in a freezer until the end of time.

For as long as I can remember, I have dreamed of being a parent. I was only a year old when my parents divorced. My father gained custody, and my mother virtually disappeared from my life. I did not see her again until I was 9, and she died when I was 20. This made me yearn for the type of family based on the images one might see in a Norman Rockwell painting.

My father, whom l love, worked as a financier, philanthropist and diplomat. He was not around much, as work and travel left little time for parenting. It fell to my Irish Catholic nanny, Renee, to raise me. Although my father is Jewish and I was baptized Episcopalian, in my mother’s faith, I spent more time going to Catholic Mass with Renee as a child than being influenced by any other religion.

When I was in my 20s, I had a girlfriend who had an abortion, and the decision was entirely out of my hands. Ever since, I have dreamed about a boy at the age he would be now. Later, I was married for four years to a woman with whom I tried to have children, with help from a fertility specialist. The difficulties we had made me feel, more than ever, that the ability to create life was special. When she left me, as I was running for a seat in the Florida State Senate, my dreams of a family were shattered.

Shortly after, in 2010, I met Sofía. Her career was about to take off, and I didn’t want to pressure her, as I wanted her to fulfill her dreams and reap the rewards of her hard work. But about six months into our relationship, I was in a terrible car accident. My pelvis was fractured in five places. For six months, I couldn’t walk on my own. I saw how life could change in the blink of an eye.

When we got engaged, in 2012, I began to push for children. As I said in my complaint, my fiancée insisted that we use a surrogate. With her eggs and my sperm we created two female embryos. I was so excited once the lives were created that I began to suggest names we could call our girls. The first embryo we implanted didn’t take. The second time, the surrogate miscarried, and I felt crushed.

A year later, we tried again, creating two more embryos, both female. But as we began to discuss other potential surrogates, it became clear once more that parenthood was much less urgent for her than it was for me. We had been together for over four years. As I was coming on 40, I gave her an ultimatum. When she refused, we split up.

A few months later, I asked her to let me have the embryos, offering to pay for all expenses to carry our girls to term and raise them. If she did not wish to share custody, I would take on full parenting responsibilities and agree to have her declared an egg donor. She has refused. Her lawyer, Fred Silberberg, has told reporters that she wants to keep the embryos “frozen indefinitely.” In my view, keeping them frozen forever is tantamount to killing them.

This month, Renee, the woman who was essentially my mother, passed away. I had imagined that she would be alive to see my children and play with them. I pray that it won’t be too late for my father, who will be 85 in May, to see his grandchildren.

I take the responsibility and obligation of being a parent very seriously. This is not just about saving lives; it is also about being pro-parent.

Nick Loeb is a businessman.

Source: www.nytimes.com

 

Patricia Annino is a sought after speaker and nationally recognized authority on women and estate planning. She educates and empowers women to value themselves and their contributions in order to ACCOMPLISH GREAT THINGS in the world – and in so doing PROTECT THEMSELVES, those they love, and the organizations they care about. Annino recently released her new book, “It’s More Than Money, Protect Your Legacy” available at Amazon.com. To download Annino’s FREE eBook, Estate Planning 101 visit, http://www.patriciaannino.com.

Creation of a Family Risk Management Policy Statement

risk management policyA solid family risk management policy contains the purpose, principle and procedure for implementation. The purpose of a family risk management policy may be to reduce the risk for family members, both individually and as a whole. Adherence to the policy would go far to protect the family’s human and financial assets and minimize potential liability. The principle of the policy may be to make clear that the responsibility is to identify the areas of high risk and to do whatever possible to mitigate that risk. The procedure of the policy may make it clear that each family member is expected to:
 

  • Achieve financial literacy with regard to his or her own wealth as well as the wealth of the family enterprise.
  • Draft and have both parties sign a pre-nuptial agreement.
  • Contact their insurance providers annually to review their insurance coverage to ensure that they are current and adequate.
  • Have in place basic estate planning documents: will, revocable trust, health care proxy, power of attorney for financial assets.
  • Participate in the development of an investment policy that is aligned with the family’s shared values.
  • Protect the family’s reputation by learning how each individual’s behavior, both positive and negative, can impact the family’s reputation.

 
A family risk management policy statement is dynamic. It should be reviewed and adjusted as the risks that families face evolve and change.

  • Life insurance is a solution and mitigates risk Pay particular attention to gift splitting and use of both exemptions

 
Summary: remember why insurance is an effective solution
 

  • Long term care insurance provides a system of care that accelerates care and makes the conversation easier

 
Long term care insurance preserves dignity, protects inheritances and allows for family harmony by relieving the caregiver spouse and children
 
Long term care insurance protects the income and assets in a second marriage

  • Life insurance can be implemented to utilize the exemption yet take the pressure off current gifting of assets into the hands of the next generation

 
Life insurance and gifting can be effective to utilize otherwise wasted spousal exemptions- look at Non US spouses, same sex marriages, non traditional relationships
 
Life insurance covers the traditional risks of liquidity and equalization.

 
Patricia Annino is a sought after speaker and nationally recognized authority on women and estate planning. She educates and empowers women to value themselves and their contributions in order to ACCOMPLISH GREAT THINGS in the world – and in so doing PROTECT THEMSELVES, those they love, and the organizations they care about. Annino recently released her new book, “It’s More Than Money, Protect Your Legacy” available at Amazon.com. To download Annino’s FREE eBook, Estate Planning 101 visit, http://www.patriciaannino.com.

Honoring a once-scorned voice for medical openness

A look back at some interesting medical history!

 

By Liz Kowalczyk David L. Ryan/Globe staff

ernest amory codmanDr. Ernest Amory Codman told his wife before he died in 1940 not to spend money on a headstone. Dr. Andrew Warshaw spent the last two years raising $20,000 from medical organizations for a granite and bronze memorial that will be dedicated Tuesday.

Dr. Ernest Amory Codman was in his mid-40s when his golden career as a sought-after Harvard surgeon began to unravel. He had quit in exasperation from Massachusetts General Hospital, and when he took his dispute with hospital leaders public, colleagues turned against him. Many stopped sending him patients.

Massachusetts General Hospital archives

Dr. Ernest Amory Codman.

It was the early 1900s, and Codman was impatiently pushing hospitals and doctors to adopt a practice many considered heretical at the time: Record the “end results’’ for every patient — including harm caused by physicians’ errors — and make them public.

A century later, many of Codman’s ideas are the bedrock of modern medicine. And a group of doctors, including a former Mass. General surgery chief, plans to make sure he gets the wider appreciation he deserves this week.

Codman’s ashes are buried in his wife’s family plot in Mount Auburn Cemetery in Cambridge, with no personal marker. Dr. Andrew Warshaw, the hospital’s chief of surgery from 1997 to 2011, has spent the last two years raising $20,000 from medical organizations for a granite and bronze memorial that will be dedicated Tuesday.

The headstone is “an overdue homage” to Codman and the ideas he pushed at Mass. General and nationally, Warshaw said. “His senior doctors couldn’t be bothered. They said it wasn’t necessary. Of course, people were threatened.”

Even after Mass. General began tracking some outcomes, making that information public was anathema. “The general executive committee does not consider it advisable,’’ Dr. Joseph Howland, the hospital’s assistant administrator, cryptically wrote Codman in April 1914.

Codman himself lived his beliefs with excruciating honesty.

“I made an error of skill of the most gross character and even failed to recognize that I had made it,’’ he wrote in a published report after a woman died following a gallbladder operation in 1917.

These days, there is little escaping Codman’s notions, as everyone from patient safety groups to President Obama pushes for measurable quality and transparency in medical care.

Codman’s close examination of patient cases led to weekly meetings now held at Mass. General and many other hospitals called “morbidity and mortality’’ conferences, and his insistence on “hospital standards’’ eventually prompted the formation in 1951 of the Joint Commission, a national organization that evaluates hospitals.

“He deserves to be much better recognized,’’ said Dr. William Mallon, a shoulder surgeon who wrote a comprehensive biography of Codman that was published in 1999.

But it was not until another Harvard physician, Dr. Lucian Leape, started publishing studies on the frequency of medical errors in the 1990s that the profession and government began to intently examine the issue.

And it has been only in the past 10 years that regulators, patient safety experts, and some doctors have advocated for making outcomes and errors public, as a way to further encourage improvement. As Mallon pointed out, however, few physicians are as open as Codman about their mistakes, in part because of the threat of lawsuits, and mortality and morbidity conferences remain highly confidential.

Dr. Lamar McGinnis, a cancer surgeon from Georgia who has researched Codman’s career, said it was not only his ideas, but his abrasive personality that hurt him professionally. “He was really stepping on toes,” McGinnis said.

Frustrated with Mass. General’s refusal to fully embrace his ideas, Codman left his full-time job there in 1911 to start his own 12-bed hospital in a Beacon Hill brownstone. He required his doctors to report their results and he tracked his own patients on hundreds of 3 x 5 cards. He advertised the “Medical Ethics of the Codman Hospital’’ — a mission statement of sorts that stated “large fees are only justifiable’’ when a surgeon’s skills have been proven.

Codman continued to pursue changes at Mass. General, and while the hospital began to track patient outcomes, it stopped short of investigating the reasons for poor results, according to letters Codman wrote to hospital administrators. He warned that his ideas were gaining traction in Philadelphia, threatening Mass. General’s position as a national leader.

“It is really easier to overturn a whole city than it is to wake up the trustees of Massachusetts General Hospital,’’ he said in a letter in March 1914, the month he cut ties completely with the hospital to protest the seniority system. Codman urged Mass. General to “do some house-cleaning’’ and stop promoting doctors because of their reputations instead of advancing those with good results.

Codman’s surgical career took a dive in January 1915, when he organized a meeting on hospital standards as chairman of the Suffolk District Surgical Society. Before dozens of colleagues, Codman unveiled a cartoon he had asked a friend to draw.

An ostrich with its head buried in the sand kicked out golden eggs to Back Bay doctors. The heads of Mass. General watched, scratching their heads and asking, “If we let her know the truth about our patients, do you suppose she would still be willing to lay?”

massachusetts general hospital

The audience was aghast, Codman later wrote. He was told to resign as chairman of the group, and as referrals plummeted that year, so did his income — to $5,000 from $8,000 the prior year. He closed his hospital to help treat the injured after two army munitions ships collided and exploded in Halifax, Nova Scotia, in December 1917.

Massachusetts General Hospital archives

Dr. Ernest Amory Codman shocked colleagues with a cartoon critical of Back Bay doctors.

Still, Codman was hard to ignore back in Boston. He became an expert in shoulder surgery and bone sarcoma, and Mass. General reinstated him as a consultant in 1929. By the time he died in 1940 at his home in Ponkapoag, now Canton, the wounds appeared healed.

Two weeks after his death, trustees at Mass. General, which had begun to adopt his ideas, passed a resolution calling him a “champion of truth’’ who was “willing to sacrifice personal place and standing to achieve what he believed to be right.’’

Codman never recovered financially after his surgery practice dwindled, according to his biographer, and he told his wife before he died of melanoma in 1940 not to spend money on a headstone.

The memorial project took far longer than Warshaw expected.

Codman and his wife, Katherine Putnam Bowditch, did not have children, and doctors were unable to find a relative to give permission for the headstone. So Warshaw contacted Mount Auburn, which began researching the expansive cemetery plot, purchased by the prominent Bowditch family in 1845. Nathaniel Bowditch, Katherine’s great-grandfather and a ship’s captain from Salem, was a pioneer of modern maritime navigation.

Mount Auburn determined that it controlled a portion of the plot, and gave Warshaw permission to move forward with a memorial. Warshaw, who will become president of the American College of Surgeons in October, plans to make Codman’s accomplishments the theme of his opening speech in San Francisco.

A small private ceremony will be held at his gravesite on Tuesday. The memorial, which describes Codman as the “father of outcomes assessment and quality measurement in health care,’’ sits under a shady stand of eight Canadian hemlocks, just behind Nathaniel Bowditch’s grave.

Inscribed under Codman’s name and portrait in bronze are these words: “It may take a hundred years for my ideas to be accepted.’’

Source: The Boston Globe -Liz Kowalczyk can be reached at kowalczyk@globe.com.

 

Patricia Annino is a sought after speaker and nationally recognized authority on women and estate planning. She educates and empowers women to value themselves and their contributions in order to ACCOMPLISH GREAT THINGS in the world – and in so doing PROTECT THEMSELVES, those they love, and the organizations they care about. Annino recently released her new book, “It’s More Than Money, Protect Your Legacy” available at Amazon.com. To download Annino’s FREE eBook, Estate Planning 101 visit, http://www.patriciaannino.com.

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