Doctors, lawyers find common ground helping elderly

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By DIANA SMITH, Staff Writer

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Senior citizens who are entering their golden years typically find themselves in unfamiliar territory when it comes to handling their end-of-life affairs.

But their situation can actually get more complicated by doctors and lawyers, who tend to stand miles apart when it comes to discussing problems facing elder patients and clients – even though their medical and legal needs are often intertwined.

Experts say wariness of medical-malpractice claims and a discomfort that arises from occupations with different bodies of training has historically led physicians and attorneys to operate on separate playing fields.

“There’s been a mutual suspicion of the other profession,” said Dr. Stephen Kramer, professor of psychiatry and behavioral medicine at Wake Forest University Baptist Medical Center in Winston-Salem. “They’re both highly traditional and learned professions, and you’d think they’d have a lot in common, but the mindset is very different. Clinical medicine is very different from law.”

According to Kate Mewhinney, managing attorney of the Elder Law Clinic at Wake Forest’s law school, doctors tend to have a “protective or beneficent” approach to elder patients, whom they see on a regular basis for check-ups or tests.

By contrast, lawyers for vulnerable populations don’t have a similar long-term relationship with an elder client.

“If an older person is making a decision that doesn’t seem wise, the physician might be inclined to recommend institutional care to the patient and to the family,” Mewhinney said. “But now and again, you’ll have an older person who is quirky, independent and on a last fling in life who is just not spending the money the way those heirs want them to. Those people deserve a [lawyer] who tells them what their options are.” 

The areas of overlap between elder law and geriatrics occur often. For example, questions about mental capacity and guardianships require a marriage of legal knowledge with medical expertise to determine the best interests of an older adult.

But because “doctors and lawyers have not traditionally been buddy-buddy, our clients lose for that,” Mewhinney said.

That relationship is beginning to change. Hospitals and law-related agencies across the country are adopting a “medical/legal partnership model” that makes attorneys an integral part of a patient’s health-care team.

In August, the Elder Law Clinic and Wake Forest’s Internal Medicine Geriatric Section joined the National Center for Medical-Legal Partnership, a network of 225 hospitals in the country that have developed programs that aim to unite legal assistance with patient care.

The move formalized a longtime collaborative relationship between the two Wake Forest schools, whose medical and legal practitioners have co-taught classes and allowed students to experience “real-life” work with older adults, both as patients and clients.

“We’re looking at an extremely complex system of everything from in-home health-care programs to respite care for folks with dementia, from assisted-living to nursing-home settings, from to hospitals to Hospice, and to dying,” Mewhinney said. “All of those are places where there are laws that affect families, and we need to understand that world.”  

History

The medical/legal partnership model began taking shape in the 1990s in pediatric settings where doctors began to realize they had a limited impact on how to help low-income children suffering from the effects of poor housing or who lacked access to social services, said Ellen Lawton, executive director of the National Center for Medical-Legal Partnership.

However, organizers began to see how cross-disciplinary discussions between the medical and legal worlds could benefit more than just children.

“This is a model that works with all vulnerable populations, whether it’s those with chronic illness or adults with disabilities or the elderly,” Lawton explained.

Programs exist in 38 states. In North Carolina, there is an MLP focusing on children in Durham. Another partnership concentrates its work on health education and legal support in Asheville. 

But Wake Forest’s MLP is unique because it is the first in the nation to start its partnership in elder care.

Other programs nationwide include geriatrics as part of their work, “but most have added geriatrics after starting in other settings like pediatrics,” Lawton said.

A ‘black box’

The goal of Wake Forest’s MLP is to get doctors and lawyers “speaking the same language,” Kramer, the psychiatrist, told Lawyers Weekly.

Dr. Hal Atkinson, a geriatrician at Wake Forest hospital, agreed.

“For the medical student, law is a black box and for the law student, medicine is a black box,” he said.

If all goes well, the medical/legal partnership is intended to help both sides see the light.

For example, medical trainees can benefit by learning when to stress that a patient be seen by a lawyer and understanding the legal ramifications of their evaluations, Atkinson said.  

Similarly, giving law students “a broader understanding of what goes into cognitive functioning, particularly with older people, is very important,” he continued.

“Lawyers could have an older person in a clinic or law office that is well able to cover for their deficits and you don’t realize they don’t have decision-making capacities,” Atkinson explained.

Learning the formal medical process used to evaluate cognitive functioning helps lawyers see “things they really needed to know,” but wouldn’t have gotten without a doctor’s help, he said. 

The teaching doesn’t occur only in the classroom. Law students visit patients at their bedside to observe physicians’ treatment approach and learn medical terminology.

On the flip side, geriatric fellows will attend guardianship hearings to observe how the court process works.

“It’s kind of de-mystifying the court a bit so they’re not so worried about the legal part of it,” Mewhinney said. “We’re helping them get less nervous about law and they’re helping us get less nervous about medical terms and settings.”

Still, these partnerships between doctors and lawyers are only in their infancy, Kramer said. He said it will take a concerted effort among the leaders in both professions to keep the conversations going.

“I think the elder law clinic has been a venue to get these two campuses talking,” he said. “Now when you get them talking to each other, the interactions are very good. Exposure is a great thing, but you need someone to break down the barriers.”