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nymima,

I still don’t understand the difference between palliative care and hospice. Is palliative the same across the board everywhere? I know there are different hospice companies and it is a ‘business’. Is palliative care similar? All of us as caregivers need to know these things. Could you explain in detail what you know about it? I’m in Louisiana. Is it different in different states? Forgive my ignorance on the topic. I’d like to be better informed about it in case I need this service for my mom.

We had hospice for my brother but I have no experience with palliative care. Is it less restrictive than hospice?
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Tothill Aug 2019
The difference between Palliative Care and Hospice will vary by jurisdiction.

Here Hospice provides support to the dying and their families. There has been an ongoing fundwaising campaign to raise money to build a Hospice House, which will have rooms in which residents can receive Palliative Care. Locally we used to have Hospice volunteers who would sit with the dying so their family could get a break. They did not provide any medical or care giving, just company, perhaps reading a book, watching a show, playing cards. Currently they had programs for the dying and their families. Mum has been going to a grief support group sponsored by Hospice since David died. It has been a great support to her.

Palliative Care in this part of Canada, refers to keeping a patient comfortable, but not providing any further life supporting treatment. No feeding tubes, no dialysis, or chemo. My step dad received Palliative Care in the hospital as there was no way for Mum to care for him at home.
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When doctor visits become so overwhelming and my mother seemed to need every kind of doctor in the world, then I felt it was time for hospice. One day she was panicking and saying she needs this and she needs that from all her doctors and then even added a few more problems that needed medical attention and more doctors, I called her primary care physician and asked him if he felt she could use hospice. We had been in and out of the ER recently and he took all info into consideration and referred us to hospice. With comfort care from hospice, she is doing better, but is still eligible for their services. I just couldn’t keep up with everything anymore. Hospice keeps her good and so far we haven’t had to go out of her house for any doctors except the audiologist and skin doctor. She is not on hospice for skin cancer. (But she should be). That’s another day. Hospice supplies all medications and all equipment t my mother needs to help her.

Please inquire about hospice or at least palliative care.
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My Moms foot doctor went to her AL. Maybe u can find one who will come to the house.
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My mother can NEVER tell you what's wrong with her, exactly, or where it hurts, or what she wants, or doesn't want, etc. etc. So I let her be. I figure if things are REALLY bad and she's REALLY hurting or in need of medical attention, she will be able to verbalize what's wrong. She has dementia, but she's not that bad.........trust me when I tell you she can verbalize everything ELSE that's on her mind, just not what she's ASKED to verbalize.

Toenail fungus is NOT something I would worry about or schedule a doctor's visit for. Palliative care is called for at this stage of life, in my opinion, and the only time mother needs to see a doctor is if she's very ill, obviously so. She lives in Memory Care and I've hired the in house doctors to care for her. If/when she needs more urgent care, I have an ambulance sent for her to take her to the ER, and an ambulance to take her back to Memory Care. She's wheelchair bound, I should add. When my dad was wheelchair bound & I had to take him to the urologist, they pulled the same nonsense with me about only taking out his staples (from hip surgery) if he was on the table, and gee whiz, we sure CAN'T help you get him ON said table. We don't even have a walker for him to use!! I swear I almost had a heart attack that day from the sheer stress of that doctor's visit. From that point on, there were ONLY in house (in ALF) doctor visits for Dad, and now the same for mom.

When Dad was alive & they both lived in Independent Living, I hired a geriatric doctor that made house calls. It was SO MUCH easier......they'd even order traveling xray companies to come out if needed, and the same with nurses to draw blood. It's just TOO MUCH to try and transport your mother anywhere in the condition she's in. The other thing I've done (recently) is hire a wheelchair van to take my mother from the rehab facility to the Memory Care facility on the day she was moved in. It cost me $100 to have her driven 4.0 miles, but hey, I thought it was worth it b/c it was 100% stress free.

I would choose my battles here........in other words, use your own good judgment to determine when your mother truly needs ER attention and when she just needs plain old attention. Otherwise, YOU are going to have a heart attack yourself!

Best of luck!!
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Redroseman,

My 86 yr old mom also has Alzheimer's, plus one broken right hip, a left partial hip replacement, and severe contracture in both legs, so no walking, but she's wheelchair bound. Her doctor's network had a house calls branch which I got her switched to once she broke her right hip and could no longer walk to get to MD office visits. They helped me get her into the hospice program which she qualified for and we used for a time based on her ailments, but she got better and we were dropped.

So, we went back to the house calls program, which offers MD or NP home visits from anywhere between every 4 weeks to 3 months, depending on the case. I found a good house calls podiatrist from a social worker, and he comes every 8 weeks, which is covered by Medicare. And I've had several home visiting PTs & OTs that have come since '16 when she had the initial hip replacement. (We're in NYC, by the way.)

Definitely check with her current medical professionals and social work folks as well as the local office on the aging, your caregiver support groups, and local Alz. Assocation chapter for referrals to house call docs & home visiting podiatrists, PTs etc, because they are out there. My Alz Assoc. chapter & house call doc. both were also helpful in giving me the names of dentists and hygenists that do home visits too!

Best wishes for you and your mom!!
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First off, toe nail fungus is rarely an issue. Yes the toenails look nasty, but it is not life threatening. So why are you worrying about getting her to the Podiatrist?

Second, the treatment for toenail fungus is oral or topical Rx medicine. The topical does not work well at all, it is more of a placebo. The oral ones is very expensive has to be taken for a long time to be effective and likely would not be appropriate for your mother based on other health concerns.

Yes, I worked for a group of Podiatrists for about 10 years. I am not a medical professional, but you do pick up knowledge from the pros.

Do you have Foot Care Nurses in your community? We are lucky to have them in many Canadian communities and they are far more likely to do house calls. The Podiatrists I knew did some house calls too.

The doctors often worked with patients who could not get out of their wheelchair and although it was not ideal (wheelchairs are not sanitary), they would work on their knees to trim nails etc.

Some swear by Tea Tree oil to help clear up fungal infections, there are other 'home remedies', nut when you have an elder with multiple medical issues, generally it is best to leave it alone. You could cause more issues trying to clear it up, than the fungus ever will.
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Harpcat Aug 2019
I have to agree with this. Toenail fungus is the least of your mom's concerns. It’s not going to kill her but taking her to the podiatrist seems almost to be cruel.
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I'm only asking this out of curiosity - what do the staff at this *fantastically* useless doctors' practice suggest you do? Really, are they just literally standing there like cans of corn saying 'we can't help with that'? Unbelievable. Or at least I wish it was unbelievable.

Find a doctors' service that will make house calls and fire that lot. Meanwhile, take a good picture of your mother's nail on your phone, take it your friendly local pharmacist, and ask.

By the time my mother was literally bedridden only two things would have made me force her out of the house: one was an echocardiogram, which still seemed like a good idea at the time (though looking back I'm not so sure); and the other would have been, but by the grace of God this didn't happen, any injury requiring sutures or reduction. For anything else, I'd have asked them to come to us; and I'm more grateful than I can say for all the dedicated and resourceful people we had to call on.

But! - don't give up :) If you'd like any help with finding resources, try your local Area Agency on Aging or do very specific online searches. Remember, you are *never* the only one who needs the kind of help or service you're looking for, and the odds are good that some practitioner will have spotted the demand.
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Tothill Aug 2019
Country Mouse, I worked for podiatrists for 10+ years and for Physios for 15 years.

Some of the things I was asked to do:

Help tie the shoes of a women whose shoes were covered in horse manure.

Help a patient with Hep C and personal hygiene issues dress, when I was obviously pregnant. I refused this one. Nope, nadda, I am not touching you if you have a communicable disease and I do not know when you last washed your hands.

Help morbidly obese patients up and down from exam tables and treatment beds. How is one person supposed to help someone who cannot lift their own leg 4 inches off the ground?

I did help a when I could without risk to my well being. But I put my foot down at other times.

My job was to book appointments, take patients to treatment rooms, clean the rooms between patients and do the billing. I was not hired to touch patients, put my health and my unborn child's at risk, nor risk personal injury.

We had and still have in our community PT's and Foot Care Nurses that do home visits.
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Medicare covers a visiting nurse if she is homebound. . But the podiatrist needs to agree to the home visit. Not easy.
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Shane1124 Aug 2019
No physician or podiatrist will write orders for homecare skilled nursing visits due to a toenail fungus. Medicare would definitely scoff at paying for this. Toenail/feet fungus can be treated at home. It’s definitely an issue as far as transporting you mother. Respectfully, I ask that you consider palliative care for your mother - that’s probably the easiest way for her to be followed by providers. Conditions such as toenail fungus are NOT a medical emergency, and Palliative Care programs will NOT provide 24/7 care for your mother. But they would visit (even if it’s a NP) & prescribe a med if appropriate. And prevent your poor contracted mother a lot of discomfort.

At 93, God Bless her. Doing everything medically aggressive for her may cause more harm than good.

Consider Palliative Care for your mother. Also, Look up visiting podiatrists in your area as many, many areas have podiatrists that will go to the home to treat & Medicare pays for it (quarterly or semiannually perhaps if the person has a diabetic ulcer).

Why put mother through all the trauma of getting up and dressed and then transported via litter/ambulance outside in whatever the weather may be, exposing mother to the elements as well as contact with people who may be ill?
Palliative Care would be a great resource to pursue.
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Before mom went into the NH we found a podiatrist who made house calls. Medicare didn’t cover it since she wasn’t diabetic, so I just paid for it. I think it was about $60 per visit but Priceless to me. If your jerk of a doctor won’t even examine her in a wheelchair ( like the NH podiatrists do!) I’d get a different one.
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I took my mom to podiatrist she was also pretty much bedridden she was definitely a two person assist,She had bedsores to the bone on her toes , great care when my sister had her,NOT. She was able to go in wheelchair,sorry your mom can’t. My mom was in No so sometimes we rode in Nh bus or the data on demand .She also had hammer toe severe. My doctor was happy to treat in wheelchair she got right down and examined her feet. Went a few more times I can’t believe how tiring it was for me and her.As she became worse I had wound nurse take care of it . Nurses at NH made sure they were wrapped etc . Long story but my point is call another doctor that can and will bend over no need to be on table. Bless you for being a great caregiver and I really pray that you and mom .
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Yes that is definitely an issue as office staff will not help to get them on the exam table if your mother is unable to. They may minimally assist but I wouldn’t count on it.

Some people by necessity must be transported via stretcher.

Are there any visiting doctor agencies in your area? That may be an option for you as the ambulance cost for transport is expensive & I believe, an out of pocket expense.

As far as when to call an ambulance when she isn’t feeling well that’s not as clear cut. Err on the side of caution & call them if you need to.

I remember when this began to be implemented, maybe a decade ago, when office staff proclaimed they will lift no more. I guess I understand why - the possibility of employee injury.
But again, it’s yet another obstacle the CG has to navigate through that takes physical strength & puts the CG at risk. On the other hand, there are many immobile obese people in wheelchairs these days and most of the time the ancillary support staff in MD offices are MA’s or CNA’s who weren’t taught proper body mechanics and maybe in an office setting they are not required to lift to keep insurance and liability costs down.

But I so agree with you in being upset that you are responsible to get your mother up on an exam table. Another reason office staff also don’t have the time it takes to transfer someone as they are constantly seeing patients all day.
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I have found with my MIL who has short-term memory loss and cognitive issues, she often will tell me she has a pain one minute and then not the next. I'm not familiar with Parkinsons but good comments below.
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Your mom has many challenges. My mom has Parkinson’s too. With Parkinson’s you can’t second guess either. Mom’s neurologist and primary care doctor always says not to hesitate to take an ambulance to the ER with different or new symptoms. I recently had to do this. She did stay in the hospital for several days for observation and tests, then moved to the nursing home for skilled nursing rehab. Now on home health. Mom’s roommate was wheelchair bound and was doing a rehab program too. You never want to second guess and have the situation become worse. The elderly are always dealing with new issues that have to be addressed by medical professionals. When my mom went to the hospital she couldn’t walk.

My mom uses a walker and can no longer get on exam table either. Can’t they elevate her legs onto a stool of some sort?

My mom had the fungus thing before. What about home health? Ask if it will be covered under home health and if it is something a nurse can treat. The nurse mom had with home health treated certain skin issues. They may not but worth asking about. Medicare pays for home health.

There is a cream for it. Ask your pharmacist also.

Best wishes for you and your mom.
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I would try to find a podiatrist that does house calls, they do exist. But I would check out Google and see if you can treat it without a doctor.

As we age we have days that we feel punky, nothing specific just generally not feeling good. I would watch for symptoms before I called an ambulance. Unfortunately the older we get and the less mobile we are the more we tend to feel not well.

Have you talked to hospice yet? It may be time.
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