Just wanted to follow up from last week. Troy’s about to send out a link to a podcast. I don’t know if any of you all have heard about the Jerry Powell podcast. It’s some geriatricians in palliative care positions that have like a weekly podcast where they talk about different topics and dementia and palliative care. Just by luck, they had one that talks about the D.I.C.E. model, which I talked about last week, or a month ago, excuse me in our ECHO sessions. So if you want to learn more about it, find another good resource for learning, I highly recommend them. They’re pretty good, very enjoyable. Acoustic singing too, if you’re into that. So, again, any cases other than that, I will hand off to Kelley. Alright thank you very much. So I work at the Sanford Center for Aging, where we do comprehensive assessments of older adults. And it’s frequently that questions come up about dementia, cognitive impairment, and how that impacts individual’s ability to make decisions for themselves. We have the benefit of working as a team, but I also engage family members, which I think are also core players on the team. Ultimately our goal at Sanford Center is to respect people’s autonomy and self-determination as much as possible. So this conversation about capacity, I think, really fits well. So it’s important in many ways because I believe ultimately, it supports individuals’ human rights. We don’t think of that term in this country very often, but basically we have human rights that just come naturally with us, and when there’s a question about capacity, we begin to think about taking away some of those basic human rights around decisions about medical care, even such things as where they live, and medications, who administers them, how they handle their finances. So those are basic human rights that were dealing with. In addition, I think, looking at this, clinicians are also balancing this thing around beneficence or protection, and autonomy. So we consider that also a human right. It’s the ability to exercise their free will. As I said, the clinician frequently is balancing the protection versus autonomy. We also want to take a look at the idea of what’s the right treatment at the right time? Frequently, when people talk about capacity it seems to be an all-or-none thing, in other words, we’re going to remove people’s ability to make self determined decisions or not. And, I think as we talk, as you all talked about dementia and delirium recognize that those kind of conditions can change over time through the illness, disease, use of medication, etc. So it becomes really important to determine what’s the right treatment and right decisions at the right time. Also, I believe it’s important to include shared decision-making. In the clinic where I work, that frequently is the case. The team is asking the individual, the client we’re seeing, as well as family members, whether they believe it’s important in terms of decisions to be made about where people live. When it comes to individuals decisions about their POLST or advanced directive, we certainly want to understand what the individuals values are in terms of life-sustaining treatment, removal of treatment, or not even starting treatment. In all those situations, they’re very very complex medical decisions, frequently they’re being made and it becomes important to have a lot of conversation, be sure people are all on the same page as decisions are being made. And, our approach at the Sanford Center, also is a person-centered approach. Again, regardless of folks’ cognitive impairment, or status, we want to include them in conversations along the way. As I mentioned earlier, this issue around capacity really comes about when there’s decisions to be made about treatment, procedures, or complex medical interventions, and yet there are also decisions about capacity when we’re talking about where people live, are they safe from falls, can they manage their finances, etc. I think with a thorough conversation, good decisions can be made people’s wishes can be honored and again, like I said I think it behooves us to talk about this whole notion of capacity versus competence. In reading the literature essentially assessment of decision-making capacity is the domain of the health care professional that has historically been the case and there’s no change there. What I experience frequently in practices people talk about this notion of competence and that’s really a legal term and that the termination of competencies really something that’s taken place in a court of law. Physicians, Psychologists, Clinicians may provide evidence to a judge. A person’s lack capacity, ultimately, it’s the judge who determines whether or not they’re competent. And, I just want to emphasize when it gets to this place I think it’s a very serious consideration when this question of competence is determined, if people lose their right to make their own decisions that may be a permanent thing and even though people may improve, there’s no automatic reversal of that decision individuals usually have to go back to court and appeal that decision and that can be really costly and time-consuming, so I just really recommend some sound judgment before going to the court system and I do believe there are options in between. So, capacity is defined by the uniform Health Care Decisions Act as the ability to understand significant benefits, risks and alternatives to proposed healthcare and to make and communicate a healthcare decision. So, this is pretty standard, it’s I think it’s been helpful in terms of defining state statutes around capacity and this definition was determined by experts psychologists, psychiatry, attorneys, and clinicians as well. One of things I want to point out is that some researchers have studied people’s consent comprehension and they found that healthy unimpaired adults comprehend and remember less information than what we assumed, so in reading this definition there’s a lot that I think that’s implied in terms of people’s ability to understand things and the best way from my perspective in terms of consent is really looking at conversation. The Nevada Revised statute also has a definition which is very similar: An incapacitated person is unable to receive and evaluate information how may or communicate decisions to such an extent that the person lacks is going to meet the central requirements for physical health safety or self-care without appropriate assistance. This material piece of legislation really is the basis upon which a judge may determine somebody needs a guardian or they need to be a protected person. So this is the statute as of 2017 and the thing I really want to point out is that the earlier definition use the frame of incompetence and so again there’s language shifts that were because he legislatively as well as clinically. The former definition was incompetent means an adult person who, by reason, of mental illness, mental deficiency, disease, weakness of mind, or any other cause is unable without assistance properly to manage to take care of himself herself or his property or both and it includes people who are determined to be mentally incapacitated. Again, some of that language, I think, is a little bit archaic and we’re just beginning to shift and recognize that there are better ways to describe folks who lack capacity to make decisions. The clinical definition of capacity is very similar refers in the clinicians’ opinion a person’s ability to make decisions or perform certain functions and again, recognize that the decisions may be about consent for treatment on based on understanding or performing certain functions and so physicians, psychiatrists, psychologists presumably asked can this person manage their medication? can this person manages their finances? etc. Again, the term capacity is different than this broad removal of human rights that we associate with competency or guardianship and again, recognize a capacity to a specific task can fluctuate over time and it’s not necessarily of global all or none. In other words, in a given hour, a person’s capacity may change and human behavior capacity may change, it all depends on what’s going on for them physically, what sort of disease processes we’re on that patients are on board and even some folks who have some cognitive impairment their capacity may vary throughout the day and throughout the weeks. Could you give us an example of a patient where they might have capacity for one decision but not have a capacity for another decision? From my perspective, if I do believe people have really good understanding of what becomes important for them in terms of end-of-life care you may have a value set that doesn’t change over time and if we have a conversation about what’s important to you in terms of CPR and again, we have to break the language down so I think in those situations people might have the capacity to tell us what their wishes were. Yet, when it comes to balancing the checkbook or paying the bills they forget they can’t do the numbers anymore and so, those are some variations over time I think depending if the person has the urinary tract infection you know at the onset they lack capacity to make decisions for themselves and with treatment that may need to change. Those are couple examples. I don’t know if you have some others. Thank you. Sure. Also, keep in mind that this notion of capacity really relates to their risks of the decision of the social environment and resources that support of an individual’s functioning so from my perspective, I think again I want to separate there might be medical decisions people will make around treatment should I have this procedure, should I have this surgery, etc. that’s what I host, but frequently with older adults I think the question on capacity comes up frequently around can they live alone? How much support do they need? How are they functioning at home? And, in that regard then the social environment makes it a difference somebody living in their own home a function poorly in anybody’s judgment but in an assisted living facility they might function much better because they have routine yields they have supervised care in a way. And, also depends on what kind of social support folks have there are some older adults who, for the home, they have frequent family contact maybe a spouse, an adult child who comes by, or a neighbor who checks-in on them to make sure they’re doing quite well, so. There are those individuals though that don’t have that social support and their self-care may continue to be neglected, they may not be taking their medications on a routine basis and their condition deteriorates that the Elder Protective Service Team gets called in. So, in thinking about the the individuals’ ability to consent, one of the first pieces is do they have an ability to express a choice? and, I think from a consent perspective it’s is conversational how do we talk to them about what their choices are? Do we use language that’s clear and understandable for them? or is it a technical language I also believe in consent processes it’s really about providing information, answering questions, and then giving people some time to maybe think about well what are my choices here, it may vary again depending on how quickly a consent may need to be made but if there’s no hurry by giving people time to think about some stuff that would be important. So, again, understanding information relevant to the treatment decision that’s important how might we involve other people in that frequently I think it’s helpful if there’s a question about somebody’s decisional capacity to include the family member because they also can be supportive, they may have the information sufficient enough to reinforce that with the older adults. People need to have the ability to appreciate the significance of the information in their own situation and I think that becomes a little bit more complex as you describe their medical condition, what are the risks, what are the benefits and again, keep in mind that for folks without decisional capacity problems understanding all the nuance of risk benefit the procedures can be very complex. And so, ultimately then people have to have the ability to reason with this information and engage in a logical process to aid their treatment outcomes. I think it’s appropriate for clinicians many times to not so much for statistics, but talk about you know those treatment options, what are the benefits and being sure people understand that and it may be important also to put in some sort of basic language how is this treatment going to affect your day to day living, what’s the negative impact if you don’t have the treatment of terms of your choices today but also in the future. Any questions so far? The one thing I would want to add, is that sometimes as providers that, you know, we’re giving patients numbers these options making sure that you’re actually knowing what benefit you’re doing the benefit you’re providing by providing that treatment option is really important too because sometimes, I feel like we offer things that don’t necessarily have a great rhyme or reason for lack of a better way to put it and so making sure that we make every you know rather than making other people make these decisions making sure that we’re making the best decision for the patient to be good one. Yes, good point, thank you. I’m going to go ahead and spend some time on a case and my hope is that you all engage us in some conversation, so this is a patient who’s 82 year old female so imagine you’re a psychiatrist, psychologist, practitioner and this case is presented to you the individual is wheelchair-bound, oxygen-dependent. Individual is diabetic, wears glasses, and has a hearing aid. Four months earlier, when they were hospitalized there was a neuropsych evaluation then they were determined to lack capacity The family is now at a point where they believe that the older adults does have some capacity. So, the referring physician in this situation has referred to you did administer the MMSE they scored a 23 out of 30 points. It’s not really clear what their instrumental activities of daily living capacity is and the physician referring to you wants to know: Does this person have dementia? The family’s question is: Does she have mental capacity? So, my question to you is how would you proceed? What are the important factors or things to consider before moving in this case. So, I’m opening up to the floor here. Yeah, please feel free to take yourself off mute or write in on that chat function. We’d love to hear from you, please. In the meantime why don’t we start conversation here, I think reviewing the medical records from the previous admission where they were declared to lack capacity might be a first step and going back to your lecture maybe making sure they had the hearing aid on — it’s very important. For me, maybe I would assist the patient how much he understands about this condition and what the consequences of taking this pathway or that pathway. Mhm. Yes. Yes? I want to know why the family believes the patient has capacity, because they are probably the best indicator of why you know like why tell me why how independent is this patient. I mean you’re only seeing the patient for 20 minutes 30 minutes, so that would be nice to know what they are like outside. Absolutely, yes. comment here that kind of as well just have a conversation with the patient Correct. Does the family have a specific reason to change a will to choose code status? Yes. or what’s the intent? One thing I want to point out is if the physician wants to know if the person has dementia and my question is what difference does that
make? Dementia is a broad spectrum diagnosis and so the families question about does she have the capacity? Gets closer to the mark about you know what is her capacity and as the audience points out, for what purpose? I think that becomes really critically important what why do we want to know about this individuals capacity. Other feedbacks? Questions? And, since the patient was in the hospital when the first test was done probably he was suffering from delirium and that could have, I mean, diagnosis that was mislead that he does not have give us that statement. I always like to see patients in different environments maybe alone and then with family because sometimes they’re guided in their answers or they provide different answers when there are other people around them. Good points So, I think these things take some time So it’s important to really give the individual time because depending on sort of outcome up your determination may have some impact in terms of their autonomy and self-determination you’d want to know also what medications are they currently taking and as far as like what’s the difference today between what’s going on the hospitalization? It seems likely that capacity may have change and certainly valid to talk about. Other questions or comments? I think you’ve gone on the next slides and you’ve hid some key points and I would point out I think for those of you who are clinicians, sometimes you get a referral and becomes really important sort of clarify it though how come you want to know what is it that you really need to know, like I said, in this case does the person have dementia? and what’s the relevance in terms of her living, medical decisions, etc.? and sometimes, our conversation directly with the referring physician could be really helpful. As you pointed out, really, the family may be key in terms of deterring was different and how come they want to bring about some real evaluation of the individual. And as point out, you know, looking at previous reports determining what’s different, what might have been contributing factors then and as I said also take a look at what medications might be impacted the individual. Other questions or comments? I want to go on to another piece, and it has to do with a certain decision making. I think the natural default is to refer to the patient ask them what they want, but there are times especially if we want to involve the family in some sort of decision making this is understandable what is the state statute about that. In best practice, people have an advanced directive being designated agent and they have a healthcare directive or a living will, so they specify what they may or may not want. I’m not sure what the current statistics are but several years back you know maybe 20-30 percent of Americans had advance directives and so when there’s a question about capacity it really becomes touchy, it’s like who do we talk to? In the state of Nevada a surrogate sort of schema is that the spouse is the patient is the next person to speak to, if there’s a question about did you have and a person lacks capacity. If a spouse is not available then adult children and again, I’m recognizing that if there’s more than one child you really want to have a consultation to be sure everybody’s on the same page, their questions are answered. Again, this is not in situations where the person is a minor, but if there is no spouse, if there are no adult children, then it’s the parents of the person, if no parents then we go to the adult siblings, then again it’s like how many are there? Whose involved? and what’s their level of involvement? I want to point out that number six really is very specific to the POLST statute, so any adult who has exhibited special care or concern for a patient it’s filling up with the values of the patient but we’re like able to make health care decisions for the patient. Can I actually sign off on a POLST document? I was reviewing the state statute because I was curious about other sort of places in the statute whether they talk about consent and in Nevada this is the only place with the POLST statute but this is a pretty consistent guide throughout the country in terms of spouse, adult children, parents, siblings, nearest adult relative. I think and it comes down to that adult whose not related that’s when I would have refer probably to legal services to get some outside help. I professionally would not be comfortable deferring to friend, neighbor for their involvement in the making the decisions. And they might be helpful in tracking family down, they might be helpful in understanding what the values of an individual are, etc. They might be very informative but, like I said that I’m not comfortable letting them have decisional capacity and again I just want to point out that within the statute I wrap up POLST stuff. I have a question? Sure. So this order’s for Nevada specifically? Yes. And every state has their own specific order? This is pretty consistent across the country again legal advocates practitioners, etc. looked at these things and so there’s some pretty uniformity around this. This has been my experience, my career across several states. And then, kind of a question about the POLST. You know our POLST form that read and think in state look a year or something ago not now much more simpler. Not much more simple, excuse me. What if I guess the question that’s not on there anymore is like dialysis that’s not specifically addressed on a POLST. Is that something that you know if you get down to number six that you should be utilizing that person for? Or is it only those specific things that are on the A, B, or C? That’s a tough question, I know. I didn’t even know number six before. Yeah I think again if it comes to that I think again the practitioner would just needs a document. How come the conversation it wasn’t on there? I would also assume that somebody depends on if they’re already in dialysis, the dialysis unit probably had some conversation about SoLATs. But if it’s a hospitalized patient who requires it I think that could be a bit more difficult. I mean by the time you get number six maybe like if the person really knew the person that person didn’t want to be in dialysis that’s the useful information for doctors who are deciding whether or not to do the dialysis. That can give a little insight on you know how the physicians will proceed at that point. It’s good to get the input but relying solely on that person I mean it’s a little trickier. Yeah and I think in the context of the full treat or mid range you’re touching that might provide some guidance in terms of no let’s try dialysis for a while see about the benefits etc. Good question. Thanks. And also for number two isn’t it the state of Nevada that is actually the oldest adult child who gets the say over the other children? Cause I’ve got lot of while I was doing inpatient palliative at the Renown big problems for that one. We had like, I remember, multiple family conferences where you know there’s a lot of kids and they actually couldn’t agree. I thought that isn’t the oldest child… This is the only place I could find in Nevada statute. Really? (inaudible) According to the Nevada statue, this is the only place where they specify here they see if there’s more than one child majority of children awareness usually available for consultation. Wow that’s like taking a vote. (inaudible) We literally had that problem. And we actually were like… We were actually saying as a group you know in addressing this family Well, technically, the oldest child… (inaudible) So in a hospital setting though you have the advantage of an ethic committee. That’s what it was, it was the ethics committee. I would take it to your ethic committee because again you want outside consultation. I think there’s always value in doing that. Again, speaking to an expert in the field our colleague whatever and getting some consultation to be careful. Having worked in a different institution around removal life support, it had to be a hundred percent and again it was the institution in terms of protecting itself legally which is not inappropriate you just don’t want that’s what conflict is and my experience has been again in those situations family members who remember those days they remember the difficult decision of difficulty and over time, there might be some agreement and that takes a lot of conversation. The ethics committee will be your salvation. Anything else in VA, Dr. McCaleb? Just that I know when we get to number six where we are at an ethics consult by default and so that’s that’s what we would use. Just to give you an example we’ve had gone down to number six, these are extenuating cases, I don’t want to generalize anything here when I say this, but we’ve we’ve had it go down to number six by an ethics committee and it was the patient’s mechanic. Just because the individual had their car serviced on three times a year and that mechanic and that patient were really close they would send they would talk about cars for hours in touch based socially once or twice a year and that was the only living person who could comment at all and it turned out they had conversations about life and death, oddly enough, based on their shared love of automobiles and so that person was actually able to step in and say no I knew him and this is what he said so just sharing what the extent out is that we would leave I personally experienced through ethics the ethics lens and this sort of surrogate decision. Good example. And again I think, on the one hand, like I said if we don’t want to rule out those non family members but there may be the point of a conversation and their visit cases nationally where that’s actually the case where it’s been a friend a conversation a co-worker that had a sense of what their last wishes were and that’s one particular sets of decision-making capacity the other because more difficult has to do with the older adult who’s living at home who’s not taking medications regularly and it’s not uncommon for the homehealth agency’s, other social service even seems to be dealing with that the threshold to get guardianship in most states all states is really pretty high again because it’s taking away people’s individual autonomy right around decisions etc and where the rub committee level occurs is that there’s a community standard the neighbors, the friends say well the state should come in to do something and then again when we think about sort of the role of the state that is you know whatever agency that is how would you want them to intervene in your life and at what point. Those are very difficult decisions and I think my experience of working with staff members from the Elder Protective Service is that they really are advocating for folks recognizing there there may be certain risks that people are entitled to maintain and their personal life and I think those become really hard I think for family members, neighbors. But even practitioners in the clinic city is the family as a permanent talking about their concerns, etc. So like I said you know guardianship the state’s perspective is the last the last step and there are those folks out there who are the committee’s perspective sort of living on the edge. Usually social service agencies, home health agencies, skin up all that provide some level of service to some degree and in truth meaning the serving in the for the person lacks good judgment about the decisions which I think ties in to capacity very much and but again it becomes really hard that continued to the core level guardianship you have the Public Guardian office in Washoe County and in Elko maybe they’d like to share something. Yeah, Kathy or folks at Washoe County anything you want to chime in there? Hi, everybody this is Sue from the Public Guardians office, we are definitely enjoying your presentation, you’re right, the bar is pretty high for guardianship. When we are presented with especially an end of life decision those are definitely where we are looking for family, committee, shape that may be able to help guide the doctor to choose that kind of a decision because we don’t have we haven’t really gotten accustomed here to the specifics and we’re working on it in the in guardianship court through the Supreme Court but where we’re actually looking at some sort of limitation or I didn’t find what level of capacity this person has — they could make the decisions about A but not about B. We are really trying to push towards that level of so we know what our authority can be as a guardian. A person has testamentary capacity if a person has contractual capacity those kinds of things are a little bit different so unfortunately that takes a great deal of time to kind of unwind and figure out and often times an acute facility is not the best so to do that. So, be sure I understand, Sue what you’re saying is that currently there isn’t a sort of a guardianship that’s provisional for different degrees of decision-making? No, we do have if you have a person who’s able to make that presentation you know you come in with some neuropsychological testing where someone can say “Yes this person can make these decisions”. Sometimes end-of-life decisions we like the individual to be able to participate in, sometimes medical treatment sometimes it’s a place where they can live but that has to be addressed by the court and the court is the one that gets to make that call so the evidence then to the court in order for the court to make that determination you can make distinction between a guardian of the person can make the decisions about their their placement but they can’t they’re not going to give them authority over their finances well that is that makes it nearly impossible for a guardian to make decisions because if you don’t have control over their money you can’t pay for the place where they live. And people, often times, as they get older and progress farther in their dementia can be less cooperative. (laughing) Also a question I would have for you my experience has been that although the guardian may have the decision on capacity responsibility for folks it doesn’t mean that they exclude individuals in conversation or working with them is that correct? Oh absolutely! Our goal is to include the protected person with as many decisions as possible and also if that also includes our members to make sure that families are allowed to you to visit as long as this okay with the as long as it’s okay with the protected person you know usually if a Public Guardian is appointed there’s a reason that family hasn’t stepped in and sometimes those relationships have been strained for many years. And sometimes it’s because a family member who might want to do it, doesn’t want to deal with their family members who are opposed or might give them some grief about decisions. Absolutely and guardianship is hard there’s a lot of requirements of the court now and as things kind of blew up down in Las Vegas in 2015 that legislature as well as the Nevada Supreme Court has reacted to that and and in an effort to provide additional oversight and protection to the protected persons the requirements for a guardian have kind of you know shot up to the sky so we got a lot more filings to the court that are required to address the person’s where they are if they want to move someplace if they’re thinking anyway so there’s lots of additional requirements and sometimes it’s a little overwhelming for families who don’t want to do that. And how long does that process typically takes? Just curious. It really depends on where the petition is coming from so oftentimes right now at this moment the public Guardian does not petition for guardianship so we receive other people in the community any other entity and including families can petition the Public Guardian to serve so right now for example, Renown, if a person is at Renown and the physicians at Renown have determined that this individual has lacked capacity. They have tried to engage family either there is no family, family doesn’t want to participate then they have to gather all of the medical evidence that’s required, send that medical evidence to the attorney that creates the petition, sends a copy of the petition to this office, we review it it’s then filed with the court at that point is almost when you start the counting because there’s legal notice requirements for a permanent non emergency guardianship you’re waiting a minimum of 20 days for legal notice to happen to the family members but right now I have seen so we are what at the middle of October? Right now, I’ve seen a couple of hearings that have been set at the end of November for the first part of December. So, that’s a really long time for somebody to stay in the hospital. We are transitioning between two different guardianship court judges so that very well may that tine,… hopefully, that timeline will get shorter but I’m not sure so what I can see after from the point a person is admitted to the hospital to a point when they actually are in court receiving a guardian I’ll bet is anywhere I would say on the quick side four months. Wow! Thank you. We got a comment here from Samantha Eggar She said we find the waiting time to go public or private Guardian close to a year for long-term care residents in skilled nursing facilities in Las Vegas No… that’s unfortunate. Hey Sue, I’m wondering if there’s any provision for the hospitals because if there’s a point at which hospitalization this isn’t the best place to be for a lot of reasons. If the hospital were beginning a petition for guardianship or actually to place somebody at skilled nursing facility how the court and the legal system might look at that with that went to their ethics committee etc. This is the best choice given what the person needs. That gets a little bit complicated for multiple reasons one is that right now there is a provision in the in the statute that prohibits that from happening and I think that is a reaction to the things that happened down in Las Vegas in 2015 where there was some private guardians that were appointed as the private guardian and then removing people and families didn’t have any idea where they were and the private guardian was deliberately making those decisions to keep those protecting people isolated from thier family. Not, not good. But the other piece of the puzzle is that if if you’re basing your decisions if you’re basing it gets complicated because oftentimes, there’s no pay source, you don’t know what the finances are, you don’t know what the individual is willing is going to be able to pay for. So you’re asking the long-term care facility to take a financial risk on a person that they may not reimburse for. The other piece of that puzzle is that then you have an ethics group who are who are taking away the ability the person’s ability to consent to their own placement prior to being adjudicated as incompetent by a judge and that slides into due process rights and that is a significant issue and and in at least in Northern Nevada, we don’t have a lot of options. So for a while, Renown was trying to place people in a group home agreeing to pay for the group home and then the question is if the individual can consent to where they’re going to live you can have it representative payee step in and manage their money why do they need a guardian? Yes, okay. Kind of a circular conversation but you’re right the time frame can be painfully slow. Thank you. Thank you for that information because again I understand that sort of the complexity on people’s human rights by law and protecting them and the difficulty in some situations is pretty complex, thank you. It really isn’t just this last legislative session they’ve approved the the protected persons Bill of Rights. I’m sure you could google one and find it. Which is really specifically outlines all of the rights that the protected person should continue to have and so specifically things that they aren’t doing it right now and it very well may change that way after this next legislative session — I’m not sure, but whether or not in the order granting the authority to the Guardian that each of those items are addressed specifically Does this person have the right to drive? Does this person have the right to enter into a contract of marriage? That is this person are they allowed to vote? Can this person own the gun, keep firearms those kinds of things, so right now there’s the only things that are definitely looked at straight off the bat are voting in firearms so otherwise there aren’t there isn’t a lot of specific guidelines for the Guardians to go by in terms of their authority unless it’s a specific issue that the judge wants addressed. Are most individuals with a guardian now are allowed the right to vote or own the gun? Usually the rules are yes to voting generally speaking and no to firearms. If you have a guardian, you don’t get to have a gun. (laughing) Makes sense, thank you. There are issues also if you have a family who has…. if they’re a hunting family or there’s firearms in the family and dad is the one who’s living alone in the house, he gets a guardian what do you do with the guns generally speaking they’re they are taken by the Sheriff’s Office but if the if the guardian is appointed and it’s not a family member the issue of personal property comes into play: Who should get the guns? If you give it to the family you have to have court permission in order to do that so it gets, guardianship is really complicated. (inaudible) Yeah. (inaudible) All right, thank you. It’s really helpful to get it from your perspective because again my experience is I think that we need to get those folks in the you know the legal system Elder Protective Service, Public Guardianship, and the clinicians because there are some really difficult questions that come up and typically in my experiences that families are just personable let’s get guardianship it’s like and as you all know here is that’s not an easy process and it may not even be the most appropriate option here. And sometimes, family you know generally speaking when this sort of stuff comes up people are in crisis they aren’t thinking very clearly and the family members are overwhelmed where…. where if they had someone to kind of walk them through all of the steps it it very well might very well might go differently for them. Absolutely. But I agree with you having all of us together to have a conversations with clinicians, Elder Protective, Sanford Center, all of that would be tremendous because I think that we each hold a piece of the puzzle. Correct. And together, we could probably do a better job and making it more run smoothly here. Thank you. I want to go to this references. The things I spoke about today, I would go to Revised Statutes Nevada, by Grass and Appelbaum, Qualls and Smyer were really, really helpful books I encourage you if you have more questions about competency capacity, etc. and take a look at them. Several of these, both of these books have examples of instruments you can use for that I just want to point out that these instruments are not easy sort of two million things they’re very lengthy but but if you think they’re valuable to look at sometimes because they might provide you some guidance for a question that you would or would not ask when you’re talking somebody to try to return you know once the the degree of capacity that they do would you not have so again just referred to both of these these books they are available at the School of Medicine sound of library and other they’re available otherwise they are available and depend on your particular organization might be able to get them lower. I just want to sort of sum up in a just to say that this whole conversation about capacity again is complex depends on the context, what are the decisions that need to be made for an individual, who can be involved around those questions and for the most part some of the questions are not necessary emergency things they take time. As Sue talked about, depending on the circumstances that could take a long time but engaging people with family members those people close to them I think should be really helpful and also rely on your team members to talk things through and there might be social workers or nurse practitioners who can spend additional time with the patient family talking through the various things if you have a conference necessary to talk about a treatment decision provide the information then others can stay by and go into greater detail answer questions help them sort out of trouble but what are their beliefs, their values, what are the other things you may not understand and I think in many ways that we can protect people’s autonomy and you can also protect them from possibly poor decisions.. not always. Anything else before we wrap up? Well thank you that was awesome, I really learn so much, I’ve really appreciated. Thank you to the audience, for everybody for contributing I do have some announcements I want to give the option for any last-minute questions so feel free to chat in I think this finishes up our four-part series on our long-term care a dementia series. I hope you all found it helpful again any feedback we appreciates and through the chat box and did you know how to email we’re happy to hear it. We will be taking a break next month because they’re ones right next to Thanksgiving and we want to just make sure everybody has a good quality of life as well as well as learning so we will be skipping November but we will have another one probably the third Wednesday in December again so we invite you to that. Our topic will likely be false but we still have a couple of things that we’re working through just to make sure that happens exactly that’s most beneficial for you guys. Essentially what we’re looking for and then December will kind of give you the update for the rest for the next six months we’re going to be getting together as a team and talking about some information we’ve gotten from feedback from lots of people around the community to make sure we can come up with a good curriculum and good didactics, good cases which is the most important part to share with you and that you can share with us. Any questions about any of that anything I missed anybody here. I would just encourage everyone to submit suggestions for topics that they’d like to see in the future because we would like to hear that and address what your needs are. Yeah this is Troy I think most of you have my contact information so yeah there are things that you want to see presented in the future, please send those my way and we could put those in. I think we.. I hope you all enjoy, I think we all here enjoy doing this a lot too and we want to continue it and so whatever we can do to keep that going, let us know. We have the time, so thank you. Thank you. Thank you everyone!