Lesson 2 from 2011

Just because an elderly person is known for outrageous accusations and for crying “wolf” doesn’t mean they aren’t going to be accurate some of the time. One of our caregivers spent 10 hours Monday through Friday with a particular client. They each felt they had gotten to know the other’s habits and tendencies to the point that it was almost comical to listen to them each, separately describe an interaction. There was a lot of genuine affection that kept them happy enough to continue working together. But, over a two-week period the client mentioned a concern for the caregiver, wondering about her wanting to leave, suggesting she was having personal problems, and otherwise psychoanalyzing her behavior. Since the client’s natural tendency was to psychoanalyze and she also had a history of (verified) false reports of theft and transgressions at her assisted living facility, the “warnings” about the caregiver were dismissed and the caregiver convincingly insisted she was fine. As it turned out, she was not and suffered burnout and we had to make a change in caregivers. While there was affection there was also condescension and that took its toll. Were the signs there? In hindsight, yes. Was there something we could have done to prevent it? In hindsight, yes. Was the client accurate in her observations about the caregiver? Yes, but they were hidden among so many incorrect observations; the client had cried “wolf” too many times for it to sink in. The lesson: it is important to look into every accusation, complaint, or concern raised by a client. Work with the families to share information so that you can compare reports and learn both sides of a story without directly confronting the elderly client or the employee. Sometimes it means addressing concerns superficially, other times it means changing caregivers for no reason except perception that there is a need for a change. We also learned that things that are going along smoothly one week may not the next, so you have to remain alert for signs of a concern whoever raises the concern.

Planning Ahead Leads to Happier Family Events

December is a time to look back on what we learned during the year and what events stood out. My 2011 included several lessons, many from unlikely sources.  One lesson from 2011 is that if you have a big family event planned and want to include an elder, especially one with health or cognitive issues, planning ahead is better than hoping everything will work out.  Here is a real life example from my own special event in 2011.

My son got married this summer and his grandmother-in-law, with some age-related health issues, was to be included in the wedding here in Boston. She would be traveling 2,000 miles and would need some support to be able to be both involved in the wedding and to enjoy the many events on the schedule.  The solution was to have a younger friend escort her to Boston and serve as her “plus one” for the wedding. “Grandma” had someone who could help her travel, watch for any fatigue or confusion that might lead to a problem or become embarrassing, and otherwise serve as her chaperone.

Her escort was prepared to leave an event (rehearsal, rehearsal dinner, final gown fitting, etc.) when and if the need arose. This allowed the happy couple, and her daughter (the mother of the bride), to relax and enjoy the weekend! Such foresight and planning led to everyone having a great weekend, including grandma! She never became overtired, she was able to be involved and engaged in all the festivities, and she always looked fabulous!

The winners were: 1) the happy couple who were able to share their wedding with grandma; 2) the mother of the bride who, while she loves her mother ,had a right to enjoy the weekend without worrying; 3) grandma’s escort, who clearly was enjoying the weekend; 4) the wedding planner, who didn’t have to tell grandma more than once where she was supposed to be standing for the ceremony; and of course 5) Grandma, who had a great time and felt special because she got lots of attention, got to be a part of her only granddaughter’s wedding and never had anything happen that even bordered on embarrassing.

The lesson: When making a decision about whether or not to include an elderly loved one in a family event take steps to ensure that the experience is a positive one for everyone involved. The steps that should be taken vary by situation and with the people involved. Yes, there is an added cost and it takes some time to plan, but avoiding tension and frustration for you and embarrassment for the elder is going to be worth it.

More lessons to follow! Have a great holiday!

Downsizing In Place

Downsizing usually means moving to a smaller, more efficient space that costs less to maintain and provides a safer environment. It also often means moving to where you can receive services such as meals, maintenance, and housekeeping.

For older residents, downsizing has negative connotations. It is something someone else suggests. It is typically associated with older people in transition, people who have reached a turning point later in their lives. Often, it is considered practical after the loss of a spouse, at the sign of deteriorating health, or at some other point where continuing to live independently is brought into question.

But there are positives. It can coincide with a point in your life when less effort and money are needed to sustain the same quality of life. Or, you are at a point where demands on your life (kids, college tuition, maintaining a large home, a dependent spouse) have ended and you can start thinking of your own needs and wants. Downsizing often equates to transitioning to a new way of living. While those recommending it might emphasize that it doesn’t mean giving up independence they probably don’t also point out that it doesn’t have to mean moving, either!

If you could reap the benefits of downsizing without having to move, wouldn’t that be a good thing? Well you can. This column is the first of two that will highlight some ideas on how to downsize in place. The steps are to assess your situation and your home, develop a plan, and then implement that plan. The key benefits of downsizing are: 1) reduced expenses; 2) improved convenience and comfort that fits your current lifestyle and physical condition; and 3) safer living space that can more easily be adapted to your needs if they change down the road.

Can you downsize? To decide, start by taking stock of your home AND your life. Start with some key DON’Ts: don’t get stuck on maintaining long-standing routines just because they’re your routines; don’t magnify the difficulty of change or exaggerate the convenience/comfort of the status quo; and don’t assume changes can’t be made.

Now for some key DOs: do think about what you would do if you were starting over; do focus on the space you need to live in day-to-day or week to week; do think of what you enjoy about your home now; do look for opportunities to make your space work better; and do be open-minded about change.

What rooms would you need if you were starting over? Kitchen. Bedroom. Bathroom. Laundry. Storage. Office/Desk. Then make a list of your routines through a normal week. If it seems difficult, carry a notepad for a week and take notes or pay attention to what you do for a week or so and then make the list. Remember this is about what you do, not where you do it. If you rely on your dining room table as your desk then list it as an office. If you use the basement for laundry and little else, then you need a laundry space not a basement. If you use the basement for storage, then list the need as storage. And so on. Remember, if you use the dining room as a dining room only a handful of times per year, then it isn’t part of your normal routine. Leave it off. The same with an extra bedroom the grandchildren sleep in just three times a year. These are not activities or uses you need to make sure are incorporated in your downsized home. The goal here is to address routine activities, not sporadic ones. These other needs can be addressed on an as needed basis afterwards.

Then, think of the aspects of your home that you enjoy most? The views out the back windows from a favorite chair? The coziness of the living room or den? The convenient layout of the rooms? There may be ways to enjoy these features even more once you downsize to make these favorite features even better.

Next, consider how spaces can be adjusted or revamped to enhance your routines and enjoyment of those special features of your home. Keep an open mind about consolidating uses into a single room or relocating other purposes completely. Is there a way to put a desk in the room with the nice view of the yard? Can the coziness of the living room be duplicated in another room with a bit more space?

Finally, embrace the change. Downsizing in place is an investment in your future. The changes you will make will allow you a better chance of remaining in your home for the long-term. Seek to reduce your footprint by bringing together multiple uses into a single room or space. Be bold and think outside the box: Can a wall be removed to combine the kitchen and dining room into a family-room-style space with a single table instead of having kitchen and dining room tables? It may seem too expensive or too complicated but construction, wiring, and plumbing methods have changed over the last few decades and something impossible years ago might be simple now. At least look into it.

And through it all, you need to be honest with yourself. Whether you are able-bodied or not, it is safer to have a washer/dryer on the main floor than to have to navigate the steep, narrow, dark basement stairs relying on a shaky banister while carrying a laundry basket. A primary reason for downsizing is safety. Downsizing in place includes adding or allowing for safety features to be to proactively make your home safer to live in.

Next week we will consider some examples of specific changes that can be made to downsize in place. Again, the goal is to redesign your current home and lifestyle to reap the benefits of downsizing while at the same time staying put.

Here are some examples of steps that can be part of downsizing in place:

Laundry: Install a new, compact or stacked washer-dryer on the main floor so you can avoid the steep, narrow, dark stairs to the basement that are an accident waiting to happen. You can save on water and hot water costs as well as improve safety.

Kitchen: You probably have rarely used pots, pans, or utensils in easy to reach cabinets with other items are in less convenient places. So rearrange. Remove some of your dishes and glasses from the most convenient cabinet and some of your flatware from the most convenient drawer so more commonly used items can be stored there.  Move the extra or less used items to less convenient places.   And do you even need to keep the popcorn popper or juicer? Consider removing them to storage or giving them away.

Consider clearing out the pantry by moving the food stuffs into the freshly emptied cabinets.  The pantry can then be redesigned to place a desk and computer station where you can pay your bills or open mail.  Or maybe this is where the washer/dryer can go!  If excess cabinet and counter space can be removed completely it might make it easier to move through the kitchen with a walker in the future.

Yard/Driveway/Garage: With a bit of advice from a landscape designer your lawn and driveway can be redesigned in subtle ways to make mowing and plowing more efficient and therefore cheaper to maintain. Although only incremental, saving $15 per week on the lawn or $30 per storm on plowing adds up. And if you do your own shoveling of the walk maybe that can be redesigned to be easier.  Also, if you no longer have two cars, consider organizing the second bay of the garage into a storage space by adding second-hand shelves, cabinets and even a few simple partitions.

Extra Bedrooms: if you maintain a bedroom year round so it can house guests a few times a year consider closing it down. Shut the blinds, turn off the heat, unplug clocks and other electronics.  You can always open it up when someone comes for a visit but in the meantime you are saving energy and electricity.  Likewise, consider rearranging some furniture or adding a set of shelves or a small chest of drawers so the space can double as storage space. Even if the room isn’t laid out as it was while the kids were growing up it can still be used as a bedroom for a few days in this condition.

Electrical System: Add three-pronged outlets and upgrade existing ones.  Install overhead lights and more light switches.  Your house wasn’t designed to current building standards or for the electronics age.  It also wasn’t designed to accommodate someone your age nearly as well as it could have been.  Back when your kids were young the TV only needed one two-pronged outlet!  Now you have a converter box, a VCR or DVD player, and a cable outlet. Now you also need another half-dozen grounded outlets for the computer, monitor, keyboard, printer, modem, router, etc. If you are like many in an older home, these electronics are currently squeezed into the only corner of the house where there was a grounded outlet and where the cable guy provided an internet connection!   Have you considered where you would place these electronics if electric service wasn’t constrained?

Heating and Cooling: Are multiple zones possible? Depending on the type of system it might be easy or it might be impossible, so call a couple of professionals for estimates and ideas on how you can reduce heating and cooling costs. Get them to give some ideas on how to redesign the system so you heat only the part of the house you are using. Although many homes don’t have central A/C you should also consider how to efficiently cool with window units. Finally, consider whether installing doors to compartmentalize the house might improve and reduce the cost of heating and cooling.

Finally, since falls are the biggest obstacle to remaining in your own home, consider ways to make your house safer.  Install brighter and more accessible lighting, create wider spaces between furniture and fixtures, add hand rails and banisters, and consider more practical furniture and rug layouts.  Just because you haven’t fallen before doesn’t mean you never will. It is better to take steps so you never fall than to boast how long you went before your first fall. And if you are human you will have a first fall at some point and the odds are it will be in your own home!

Avoiding falls isn’t simple about avoiding bumps and bruises or some aches and pains.  Broken bones, concussions, lacerations, internal bleeding can all result from a fall.  This is what your family is worried about and why they encourage you to move to a safer home.  By taking steps to downsize in place your family will see that you are taking their concerns to heart; perhaps they will help in the effort rather than continue to encourage you to move!

So, let’s recap.  The benefits to downsizing in place are that you get to stay in your own home AND benefit from the positives of downsizing.  You maintain far more of your preferred routines and habits than if you move.  At the same time you benefit from a safer, more efficient, and more comfortable place to live.  The best of both worlds!

Why does care cost so much?

My last blog post generated a number of comments, mostly on the websites where I posted links, such as LinkedIn.com. Unfortunately, most commenters – all, in fact – did not also post to this blog website. Whenever possible, please comment here so that other readers can see what you think. That blog discussed the frustration of being the first person someone talks to about care for seniors since it is almost always a lot more expensive than people expect. Those prior comments fell into two categories. One group had been in my position before and understood my perspective . The other group felt I was thumbing my nose at people who could not afford home care and worse, that I had no patience for them. I apologize to the latter group. What I was trying to say, apparently not so well, was that care is not cheap but people usually expect it to be far cheaper than it is. Why? My theory is that people do not have prior knowledge of what it should cost. When we stop for a cup of coffee at Dunkin’ Donuts and the cashier asks for a $1.50 we don’t bat an eye; if he asks for $4.00 we stop in our tracks. Why? Because we have a general sense of what a cup of coffee should cost. The same goes for many other things we purchase on a daily, weekly, or monthly basis including our cell phone bill, a sandwich at the deli, or even a gallon of gasoline. But when it comes to home care, most people have no experience with it and therefore no frame of reference. As with any business, a consumer sees only the tip of the iceberg of what goes into the service. In the case of that deli sandwich, we can add up the costs involved: Bread, deli meats, condiments, the ovens or other equipment used, wages for the counter staff, rent, cleaning the store, etc. So we can accept that buying a sandwich at a deli costs more than if we were to make it for ourselves at home. And most people understand why good sandwiches cost more than lousy ones. This is not the case for home care or other support for elders. Many adult children who have taken dad to the doctor or the grocery store or spend a Saturday putting away porch furniture and otherwise maintaining their parent’s home do not see the costs as concretely because time and patience is the most valuable raw material and there is no clear value for these. They also often do not realize how long each task actually takes. These tasks don’t cost these adult children anything out-of-pocket so they have no frame of reference for how much is reasonable to pay someone else to do it. If they sat down and figured out what they give up in income by taking half a day off and then factor in the emotional stress from the activity they can start to see why paying someone else is a good value! But when they make that first call for support they haven’t done this math yet. There is more to providing care than paying the caregiver/employee a decent wage. Having someone step in quickly if a regular caregiver calls in sick leads to bonuses paid for last-minute fill-ins and there is often overtime that isn’t passed along to the client. And aside from the overhead associated with running any business, senior support is very labor intensive and requires several different and significant insurance coverages. Workers compensation, unemployment, liability and commercial policies are all required. I could go on but that would not only be uninteresting but also sound like I am whining, which I am not. I am simply pointing out that when people first look for care for a senior it is often their first experience with the industry and the lack of realistic cost expectations leads to sticker shock. There is significant value added by having someone besides a close relative providing care. Those are worth talking about in a different entry. Please add comments on the blog website so anyone else reading it will see them. And thanks for reading!

Don’t shoot me, I’m only the messenger!

“Don’t shoot me, I’m only the messenger.”  We are all familiar with the saying:  Just because I am the one delivering bad news doesn’t mean I created it.  Anyone who has ever explained that senior care of any type is not cheap can relate.  And when it comes to being the one to share the news that ongoing care (assisted living or home care) is almost never covered by health insurance or Medicare, well, you better duck! 

First, a large percentage of those suddenly thrust into the realm of finding care are not at all aware of the limits of Medicare and often do not realize Medicaid is only for the financially disadvantaged, so that’s the first shock.  Then they start to consider options to keep costs low.  Maybe start with a caregiver a couple of hours a day, sounds good, but then they explain what two hours they want:  An hour in the morning (get mom up, fed, and dressed), a half hour check in visit midday, and then a half hour in the evening to say hi and drop off some dinner.  Do you think you could set that up?  And how much will it cost, maybe $40/day at $20/hour?  If you are in the business you are probably laughing right now; if you are not you are probably thinking that sounds reasonable and wondering what’s so funny.

Put yourself in the shoes of the agency, explaining how $40 a day will get perhaps one of those visits assuming an agency will offer their services in 30 and 60-minute increments.  Now explain that the caregiver is not a registered nurse but a non-technically trained companion or a home health aide.  As I said above, you better duck! 

Yes, senior service providers are familiar with “sticker shock.”  Many people are unaware of the limitations of insurance.  The first shock is the realization that it will have to come out of their own pocket.  The second shock is the realization that you cannot buy an hour here and a half hour there nor is there a surplus of caregivers willing to work odd hours at low pay.  Finally, they are surprised to realize that most agencies do not have a full-time staff ready and waiting to visit a client on a moment’s notice.  Others think providers are like a taxi service, able to pick you up and drop you off then return later to bring you home and allow you to pay only for the travel time each way.

Most people can understand the rationale for why services can’t be so customized or micro-managed at a low-cost but they usually only reach that point after the shock has worn off.  Most go through a predictable progression dismissing the first agency they speak with as greedy and uncooperative.  Agency number two has a better chance of getting past the shock and the caller might be more or less polite in their rejection, but chances are they will also be rejected.   At this point the person seeking care will either call agency number three with an open mind or start a new search with different parameters based on the lessons learned.  They read between the lines looking for an edge to make it work better for them.  It is about this time that they become distrustful and wary of agencies, casting them as carpetbaggers out to take advantage of those in need.

The next step for some of the more skeptical is to stop searching and figure out how to provide the support as a family or they give up and decide maybe moving mom to a “home” is the best choice after all because then they don’t have to deal with all those gouging home care agencies.  Of course then they will experience déjà vu as they go through the same process with assisted living residences and their costs.  Okay, I may have exaggerated things but the description is not so far off the mark. 

There are two issues that emerge from this initial effort by families.  The first is that they are angry and distrustful of the agency they finally do hire, often out of necessity – if you are trying to get more than you pay for it can easily become an adversarial relationship.  Second, they make a bad decision to eschew help altogether and take on the very real risk that the eventual costs of not getting help (both financially and emotionally) is often far higher.  There is a significant need to trust an agency in order to get the best results for a loved one. 

In some ways, presenting Extended Family’s model of support makes this process easier on us than if we had a different model.  Our model’s focus is on premium services and becoming more involved and more connected with our clients and their families.  There are plenty of services provided at no added cost to the hourly services.  When someone starts the conversation by asking what our rates are, I have gotten into the habit of suggesting that we end the conversation immediately and wish them luck.  They are quickly confused so I explain that we provide a higher level of commitment and more attention to do this so we charge more than the typical agency.

Frankly, if they are this price sensitive before they even know my name they will not be a good client!  But more importantly it is an indication that they are looking for quantity (lots of hours) over quality (a good fit and a caring support staff).  They want to be able to rest knowing that their $100 provided someone at their mom’s home for five hours making sure she was okay in place of spending $100 to be sure someone engaged and connected with their mom for four hours, including getting her to take a shower and eat a healthy meal.  This is a simplification, but it is to the point – better service and care costs more money.  Period.  If you asked someone whether they would prefer someone actively engaging their mom for four hours over someone sitting across the room texting, internet surfing, or watching TV their answer would be obvious.  But that isn’t what they ask first – at least not often enough.

Basically there is a lot of education involved with those first couple of calls with agencies.  As with anything new there is new terminology, the system of charges is not always clear, the legal and regulatory requirements are unknown, and that doesn’t include the emotional aspects of the situation.  Sometimes the role of educator is an opportunity to show your compassion, sensitivity, and knowledge.  Sometimes no matter how good an opportunity, though, the result is that they walk away frustrated and angry about the costs and problems associated with aging parents and you are the messenger in the crosshairs.

Please share your thoughts by adding a comment and please also share the link to this blog with friends and colleagues.  Thank you!

“I Can’t Afford It” Isn’t Always the Result of a Depression Era Upbringing

Every American above the age of 75 spent all or part of their childhood in the Great Depression. When an elder resists spending money or pinches pennies, someone is ready to note that this is the reason. Sorry, but I do not buy that excuse. These same people have lived another 70 years since that period of American history ended, including the prosperous 1950s. Many of them owned a house and raised a family and are now enjoying grandchildren or even great-grandchildren.

So why do we regularly cite their formative years as the basis for their frugal nature? While it was the period of their lives when they were learning lessons from parents worried about the next meal or a roof over their heads a case could be made for the fact that things just cost more now than years ago because of general inflation and economic growth. Back in the 1970s private college tuition was $4,000/year. Now my youngest child’s tuition bill is $55,000! In my opinion, many seniors who refuse to hire help of any sort are not frugal.

Frugal is when you watch every penny, when you question every charge on an invoice or when you make sure you get two hours of service when you pay someone for two hours of their time. There are many seniors who claim to be frugal but who are simply using that as an excuse to avoid getting support. The same senior that says she cannot afford to hire even a little support is overpaying for many services and products every month. Like the 100-year-old woman who signed up for cable and because she didn’t understand the cable company’s definitions of basic and premium is now paying over $100/month to view a half-dozen channels she likes and dozens she will never watch! Or the 97-year-old man who just renewed his People Magazine subscription (something he doesn’t read anymore anyway) when a solicitor called and offered a great deal on a 5-year subscription.

These charges are obviously the result of unscrupulousness on the part of these companies, but the bottom line is that these costs are added to the monthly base and become part of the senior’s regular fixed monthly costs. They or their families or their accountant or bookkeeper simply pay what they are asked to pay. Later, when the senior is approached by a service provider offering a valuable service the cost is considered “too much” and the expense is rejected even when it might be far more valuable.

Examples of overpayments and unnecessary costs that become embedded in monthly budgets:

• When home maintenance costs are paid in small increments the costs add up quietly, either by small rate increases or product/service downsizing: The snow contractor who no longer shovels your walk but still charges the same fee as before.
• Fees that get added surreptitiously to invoices and statements from service providers with details on how to “opt out” buried in the small print.
• Automobile or homeowner insurance policies that seniors do not review before renewing. Perhaps they now qualify for low mileage discounts or the jewelry riders on the homeowner policy are unnecessary since mom’s jewelry was distributed to her daughters when she passed away a few years ago.

So, where am I going with this? I guess I am expressing some frustration at seniors and their families who reject help from an agency like ours because of the cost. They listen politely but conclude that we are offering something they cannot “afford.” They cite budgets and income constraints and their parents’ frugality left over from their childhood in the 1930s. But many seniors could easily pay for this valuable or, perhaps, necessary support if they simply did an audit of their monthly and yearly “fixed” costs. They should be genuinely frugal and make sure they are getting everything they are paying for!

[Based on my conversations with many seniors, the most fertile place for reducing monthly costs is with snow contractors and cleaning “ladies.” Many have become friends with their housekeeper. In more than one case the senior has two cleaning ladies (that rotate weeks), the second being added because there was “too much” for one person to do when in fact neither did enough to justify their fees. In another case, when challenged about why she still goes up and down the basement stairs to do laundry – against her better judgment and doctor’s orders – a senior explained that her cleaning lady has a bad back and she doesn’t want her to have to go up and down those stairs too much! Then there are the seniors who refuse to get help coming out of rehab but have paid their “poor” cleaning lady for the two months while they weren’t even home!]

You can “take back” the value of these services by being a squeaky wheel or being a bit more vigilant. Remind the lawn service that trimming the flower garden was part of the deal when you hired them or remind the snow removal contractor that he agreed to clear your walk and spread salt at the end of every storm when you agreed to the fee he proposed. You can also compare phone, cable, or bank statements to earlier ones to see if there are any new line items with dollar signs next to them or reduce services without affecting your quality of life.

So let’s circle back to the beginning: When seniors say they cannot afford something like a little help around the house, it isn’t because of their experience during the depression. Back then, they would have expected to get what they paid for while now they might accept poor service because they don’t dare ask for good service. It is a natural human tendency not to rock the boat and risk a confrontation. Alienating a provider is unpleasant and carries the risk of worse service or having to find a replacement.

So, the next time a senior, or an enabling relative, cites cost as a reason for not getting support, ask a few questions. See if they are being as frugal with other monthly expenses. You may not get them to come around right away but at least plant the seed that they might not be getting what they are paying for from other providers. And if you are a senior reading this, make it a point to review all your costs and expenses and reviewing bills from the cable and electric companies. See if you can reduce those fixed monthly costs. You will then have a few dollars more each month to spend on things that could prove to be valuable – or just go out and have some fun with the savings!

Thanks for reading and please leave a comment!

Starting the Difficult Conversation

[This post has been revised since it was initially posted.  I apologize to my in-laws for using our visit and conversations with them as a basis for the points I was making about having difficult conversations with parents.  At the very least I should have run it by them before posting it.  Again, I apologize to them; I meant no offense.]

Having a conversation with elderly parents about growing old safely and happily is no easy task.  The pitfalls are numerous.  It can turn a parent-child relationship on its head.  It can lead to arguments about what is wanted versus what is needed.  It can lead to confusion and hurt feelings.  It can cause rifts and competition between siblings.  In short, a fruitful conversation can be difficult to be a part of and even more difficult to start.

So how do we start one?  With the easier stuff.  After-death issues are simpler than long-term care issues because if they don’t want to participate in the planning they don’t really have to and there will be no second guessing.  So starting there may help.  Some other ideas to consider:

1. Divide and conquer.  “What will you do if dad (mom) dies first?” this question gives you more of a chance to discuss the issue with each of them separately and talking with one at a time makes it a simpler conversation.  Sometimes one parent disapproves of what the other will choose to do which is not necessarily a bad thing since it effectively gets that parent into the conversation.
2. As Victoria once told me about addressing family conflicts, “the conversation is never over.”  The goal is not to reach a complete plan with a single conversation. Aim to develop a framework for discussing it during the next visit or phone call.
3. Avoid a sense of urgency.  Whether there is an actual urgency or not, older adults get anxious and suspicious when pressed to give an answer promptly.
4. Be patient and keep it light.  Humor goes a long way and even if they get away without having made a choice it is likely that you got them thinking about a particular issue.
5. Be persistent and practical.  Some parents, especially those living far away, are unwilling to share the names of their attorney or financial planner or primary care physician because they do not want you checking up on them.  Find reasons why they need to share.  Consider asking them to have these people call you so the dynamic of the request and the conversation is less threatening.
6. Always maintain the appropriate level of parental respect.  This is different for everyone; some parents enjoy the give and take of teasing, others do not.
7. Remind them that the goal of the conversation is to let you be prepared to help them live the rest of their lives the way they want to.  It is about facilitating their ability to have the choices they have always enjoyed.

This is not a complete list but I hope it provides some ideas for you to develop a strategy to start the conversation.  These recommendations are intended to help with parents who are avoiding the conversation out of a sense of denial and not because of dementia or other psychological reasons.  Further, they may not apply directly to families where the relationships between siblings is an issue or where there are serious financial concerns.  In those cases mediators or social workers may be needed to facilitate the conversation.