A well laid plan is a dialogue with the future…
Published January 13, 2023
The first part of this story is written by me, Deborah Bickel and the second half on avoiding a similar fate is by my colleague and friend, Wendy Jane Carrel who lives and works in the Lake Chapala area and does similar advocacy work to Be Well there. Both pieces are on the topic of falling, especially relevant here in Mexico where streets can be poorly maintained and are often treacherous. Many aging expatriates experience taking a fall for the first time in their lives. Falls can cause disability and even death for even the most cautious visitor, especially older expatriates.
The first article on prevention and management of falls is a recent true story of an expatriate who took a fatal fall in the Chapala area. Such a fall is just as probable in San Miguel de Allende. The advice about avoiding fall hazards is important. Just as timely is the story of how the medical profession robbed a newly-arrived expatriate of the dignified death he had desired and had detailed in his recent medical directive in the United States.
Preventing such an outcome in San Miguel de Allende is not difficult and Be Well urges all members to create a medical directive legal in the state of Guanajuato just as soon as they are able to focus on the easy paperwork. Be Well has streamlined the process, working with an excellent lawyer and notary in town. Be Well charges for this service, but the total expense for creating an advanced directive with us is far cheaper than what is charged by other lawyers, notaries, or advocates. You do not have to be a member of Be Well to use our services to create a binding and legal directive!
Mid-October, 2022
Over the last several days I have been trying to manage or at least CONTAIN a nightmare of a case unfolding in another part of Mexico, another haven for expatriates. This is unfortunately a very true story, and the client only just passed away after a brutal struggle to retain his rights to a humane death. It began for me when I received a call from Alan’s family (names and any other identifying information have been changed). Alan was an eighty-year-old expatriate on advanced life support in a small private hospital where he was the only patient.
Six days previous, Alan was walking with his wife when she saw a look of disorientation cloud his face, followed by a sound cracking as his head connected full force with unforgiving cement.
A fall, head trauma, or any other unanticipated or “early” death are sad and troubling events. However, this nightmare fully took shape when decisions and actions of the “care team” overrode all efforts to broker the peaceful and dignified death Alan and his wife had imagined. Indeed, those wishes are a part of a medical directive, on file in the United States.
The nightmare continued unabated for more than a week. Over the course of far too many hours to sustain any credible sense of urgency, the team managing his care in this small hospital decided to perform what can only be described as exploratory brain surgery “to assess the extent of any bleeding or injury if he had a reversible condition.” This was carried out even though actions aimed at limiting bleeding within the brain are only effective if done in a short window of time, far shorter than in this case. The team also put in a PICC line or “feeding tube” to deliver nutrients and insisted on replacing the first smaller line for a longer lasting and more durable one. Days stretched out to a week as the family tried every avenue to get Alan released. They finally engaged lawyers recommended by the “Death Café” (https://deathcafe.com/deathcafe/8346/ ) group based in the Lake region.
Meanwhile, with the help of many “accidental” advocates, the family identified a palliative care facility nearby, but just before the ambulance arrived, Alan made a few hand movements and opened his eyes. His gaze was vacant and the twitching movements he made are best described as involuntary. Thus, the nightmare continued:
Alan’s eyes closed once more, and his hand motions ceased. Despite a chart note indicating that Alan’s life expectancy was less than two weeks, the care team advised the family that any attempt to move the patient “might kill him”. They also hinted at legal problems that could ensue for his family should they discharge him against medical advice. More astonishing still was a recommendation to keep the dying man over the weekend in order to get a “cardiac evaluation” to address an abnormal EKG at a “more convenient hour”.
Five days after Alan fell, the family enlisted a lawyer who confirmed what I already knew: any planning carried out in the States, such as the creation of a medical advanced directive, is useless in Mexico. She also told them something I did not know and have not yet confirmed: Any hospital in Mexico must provide upon request a written record of diagnosis and a treatment plan including all associated costs in the patient’s native language.
Sharing essential information and then helping create plans of action in the event of a health crisis such as this one should be the bedrock of advocacy work. However, far too often my work over the past seven years most resembles that of a fire fighter. While astonishing levels of misinformation and greed characterize these ugly events, it was simple, albeit understandable ignorance and a failure to plan that left this family painfully vulnerable financially as well as emotionally.
Tools to Improve Medical Planning and Decision Making
It took five full days of my own efforts coupled with generous advice from my Be Well partner, Dr. Emilio Ramirez and two law firms to get Alan released from the hospital “against medical advice”. He was finally placed in a “palliative care” facility and died over the course of the next few days without regaining consciousness.
I find these events unbelievable and would not blame the reader for suspecting exaggeration added for shock value. Unfortunately, the only departure from the facts are those events that detail criminal behavior on behalf of members of the hospital team, left out of the narrative.
Now for the promised advice on how to prevent or prepare for similar miscarriage of the law and malpractice of medicine.
1) Make an advanced medical directive legal in whatever state in Mexico you reside. This document does not have to be expensive to prepare nor extensive in detail. Be Well San Miguel works with a firm of lawyers who offer a very fair price. Working with them, we can guide you through the process in a couple of meetings.
2) Once you have a directive in place, keep it, together with current medical records with you and make sure your physician has a copy and understands your wishes. Dr. Emilio Ramirez and I are willing to serve as signatories for a small fee.
3) As soon as you are hospitalized arrange to speak with the billing department to better understand the fees associated with your care. The lawyers I spoke with in the case above stated that by law, any hospital in Mexico must provide upon request a written record of diagnosis and a treatment plan including all associated costs in the patient’s native language.
4) Do everything in your power to have an advocate in your corner, be it a friend, family member or a professional patient advocate. Your advocate’s help can be invaluable to ensuring your interests are well represented.
5) Appoint a power of attorney that can act in your behalf in Mexico as well as your country of origin. If Alan’s family had someone in this role, they could have brought greater weight to bear on care decisions, ensuring that the hospital would honor the patient’s wishes.
Tips for Preventing Falls
Below is a reprint of Wendy Jane Carrel’s excellent essay taken from her blog https://wellnessshepherd.com
A Note to Expat Retirees: Avoid Falling in Mexico (or anywhere)
One hour south of Guadalajara, Mexico’s second largest city, is the quaint village of Ajijic, a Pueblo Magico. For those of you who have visited or lived there, you have may have heard or read that the village is also known as the “City of Fallen Women.”
The Fallen Women are (most often) foreigners. Foreigners who have tripped on river rock, rough cobblestone, or lone pieces of steel rebar. They have broken hips, femur bones, wrists, or sadly lost their lives with complications from falls. Fewer men fall. As I write it is reported that one older adult male was walking in Chapala Centro, three miles from Ajijic, at 8:19 a.m. Sunday, September 26. According to a witness, he fell, hit his head, and died.
A few years ago, I felt just as sorrowful when I learned a similar story. I think of it often. A 60-year-old male fell in Ajijic, impaled his head on river rock, and died. Someone reported he was fit and had no health conditions. That may be true or not. No matter what, surviving a fall or dying from a fall is sad and painful, an event to be avoided no matter where you live. But if you are in Mexico it’s good to have a plan if you do fall and to walk with awareness even though it is easy to get distracted.
The worst-case scenario is falling and dying alone. In Mexico your body will be transported to the closest SEMEFO (Servicio Medico Forense or Medical Forensic Service) for an autopsy and your family and friends will have quite a challenge retrieving your corpse. Even if your government makes a call to assist, your government does not interfere or have influence with the Mexican government SEMEFO unless you get lucky.
Several ladies I’ve met at Lake Chapala have fallen on the street or at home. Fortunately, they were in company or had cell phones to call for help. They also had immediate access to doctors. They or companions had pre-organized for such an event, just in case. Recovery was rarely easy but thankfulness for rescue is the continued message.
Current statistics related to older adults falling in the U.S. (and Mexico):
The U.S. Center for Disease Control (CDC) and innumerable other studies report the following:
♦ 1 in 4 older adults fall each year
♦ 1 in 4 falls result in an increased level of care
♦ Every 19 minutes an older adult dies from a fall (in the U.S.)
♦ Persons with Alzheimer’s and other forms of dementia fall more, and person-centered care is critical for them
♦ Falls are the leading cause of both fatal and non-fatal injuries for older adults
♦ The cost of falls is $50 billion per year across the U.S. health system – emergency rooms, hospitals, rehab, and more.
♦ With care and attention most falls can be prevented. When they are prevented, they save you and healthcare systems financial, physical, and emotional costs.
What should anyone of any age, especially an older adult, pay attention to now?
1. Assess your fall risk. Protect your bones. Many older adults are not aware they may be walking around with osteoporosis, also known as the “silent disease”. The cost of a bone density test in Mexico is reasonable (for most). Discuss the results with your physician, chiropractor, or naturopath. Read about diet, exercise, supplements and more.
2. Join an exercise program focused on building balance and strength. Expat communities throughout Mexico offer pilates, yoga, training at gyms, and specialized classes for older adults at senior centers known as “centros geriatricos.” As mentioned, physical therapy may also be helpful.
3. Dress sensibly. Wear clothing you will not trip on. Wear sensible shoes that support and cushion your feet. Flip flops, for example, are not the best choice of sandal at a certain age. It’s easy to twist an ankle or to slip.
4. Check your vision, hearing, and medications. Some medications may cause weakness, fogginess, forgetfulness. Be aware.
5. If you do fall, yes, there could be an emotional toll. You may feel shame or anxiety. Even if the fall is unwitnessed, it is best to share the information with chosen healthcare professionals and friends. It is fine to self-recover, but letting someone know what happened will create a history to refer to and will assist healthcare professionals should you fall again (hopefully not).
6. Consider using a cane or walking stick. No need to stay inside. Movement is important. Walk in safe places free of skateboards, bicycles, and other moving forces that could harm you.
7. Consider making where you live safe and barrier free by following universal living design standards. Wood floors and linoleum are preferred as the materials cushion falls to some degree. Avoid slippery or wet floors. Ensure well-lit rooms and corridors. Install grab bars. See links below in Resources for ways to create an environment friendly to falls and most disabilities.
8. Companions or buddies to keep an eye on you. Whether you are a solo ager, married, or with a significant other, it is wise to have at least two persons you can call for rescue. Make that three, with your doctor. As the National Council on Aging suggests, “make fall prevention a team effort.”
Wishes for your wellness and no falls! Please be careful.
Resources:
National Council on Aging. https://ncoa.org/
Safely You is a San Francisco-based company focused on preventing falls in senior living and skilled nursing. Their well-documented report “The 2022 State of Falls” is available for download on their website. https://www.safely-
Universal Design Standards for aging and disabilities https://
Dr. Leslie Kernisan’s blog about medications that may cause falls https://
Wendy Jane Carrel, MA, is a Spanish-speaking senior care specialist and consultant from California. She has travelled Mexico for several years researching health systems, senior care, and end-of-life care in order to connect Americans, Canadians, and Europeans with healing options for loved ones. She has investigated hundreds of senior housing choices in 16 Mexican states. Her web site is http://www.
Reporting from San Miguel de Allende,
Deborah Bickel, BeWell San Miguel
Deborah@BeWellSanMiguel.com
January 12, 2023
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