Part 5: Be Careful What You Wish For

by Shari (Zissie) Gitel
zissieg@walla.com

Those dreams for more help were realized, but at what a price! Now both my parents were awarded hours by Bituach Leumi—each at 9.75 hours per week. As time progressed so did their disabilities, and about two years ago, after several appeals for more caregiver hours, they both eventually reached the maximum number of hours that Bituach Leumi allowed (at that time 15.5 hours per week apiece). I finally had a lot more help. The flip side of the coin was the degree of how incapacitated my parents had become. If they were in bad condition before, now they were defined as totally house-bound (merutakei bayit) and requiring care for almost all their ADL’s.

This did come with several “perks”, though. It is indicative of my new perspective on what was important in life that I reached the point where I considered free house calls by the doctor and blood tests performed in the home by visiting nurses “perks”. My chauffeur services were somewhat reduced—though I was still making frequent trips to the kupat cholim to arrange for tests and get the proper paperwork done, not to mention regular visits where I met with the doctor and reviewed the medical situation with her to get medical advice, referrals and prescriptions. At least, I didn’t have to “schlep” my parents to the clinic—an ordeal neither they nor I enjoyed.

And now I would like to express a personal thank you to whoever invented the fax machine. This modern day device has been a Godsend. Many transactions with the kupat cholim (as well as other entities) can be conducted by this method, saving time both in travel and waiting in line. It is music to my ears when I hear the clerk tell me over the phone to fax the information to them for processing.

USE THE FAX TO SAVE PRECIOUS TIME

But what did this mean when you get down to brass tacks? Before my parents had been awarded the maximum allotment of hours, the caregivers (now we had a man coming several hours a week for my father, as well as a woman coming several hours a week for my mother) had been arriving early in the morning to take care of getting my parents breakfast and lunch, and getting them into bed for a nap. Then help arrived in the evening for bedtime. I set up a complicated schedule to make sure the hours did not overlap and to provide the best daytime coverage I could arrange for my parents during their waking hours. Once they received the maximum allotment of hours they were in no condition to be left alone. Great! Now what?

Advantages of staying at home
When we moved to Netanya to be closer to my parents (after having cared for my mother-in-law in Jerusalem for 10 years) we took into consideration the needs of my aging parents (and our own as well—we aren’t getting any younger, either). We purchased a home suited to the needs of the handicapped and elderly, i.e. there were no steps leading to the entrance of the house from our driveway; there was a bedroom on the entrance level as well as a bathroom across the hall from the bedroom. We installed a shower in the laundry room (off the bathroom) as soon as possible after my father had his stroke. For all intents and purposes we were physically set up to have them at our home. Indeed, during the holidays and on Shabbat my sister and I would take turns hosting them. So we got a taste of having them live with us for prolonged periods. Out of concern for their welfare we decided that staying in a home situation was better for them (we felt that individualized care and familiar surroundings were preferable to the more impersonal atmosphere and care afforded by a nursing home), as long as we could manage to continue providing the needed services for them. But the home where they would stay was not going to be ours.

WHAT EFFECT WILL A MOVE HAVE ON THE PATIENT? ON YOU?
Having your parents move into your home ideally should allow for the best supervision of their daily needs. Each person has to consider the risk/benefit factors of such a move. There are many considerations to take into account: invasion of privacy, clashes of temperaments, effect on your marriage, extra chores and meals, to name but a few. After much deliberation and despite the fact that I felt extremely guilty about not moving them in with us, we decided that for everyone’s sake it would be better to hire permanent full-time sleep-in help and keep my parents in their own apartment for as long as feasible.

Enter Foreign Worker Stage Left
Oh, if it were only so easy!! Applying for a foreign worker is a long, involved process and can be initiated only after the applicant has reached a certain number of points on the Bituach Leumi scale of requirements for extended nursing care. My father finally qualified. There are several stages in the application, first of which is acquiring the license for employing a foreign worker through the Ministry of Industry, Trade and Labor, Yechidat HaSemech L’Ovdim Zarim. To do this you have to contact a reputable employment agency that has experience in these matters. These agencies have all the forms necessary and can guide you through the process. Along the way there are many bureaucratic fees to pay, crowned by the fee that is paid to the employment agency itself for its services as intermediary. Until you have the license in hand, you cannot officially apply for the foreign worker.

Needless to say, this takes time. Once you have the license, if you are willing to hire a foreign worker that is already in the country (which generally means paying a higher salary than for a worker who has not yet entered the country), you may be able to find a suitable candidate in a relatively short time. If, however, you wish to hire a worker who has yet to arrive in the country, you could wait several months before this materializes. The contract for foreign workers from the Philippines may vary from company to company, but most of the terms as far as holidays and days off are basically the same. I am not familiar with contracts for workers from other countries.


In addition to the monthly salary for the foreign worker there are other benefits the patient (employer) must provide. These include health insurance, Bituach Leumi payments, overtime, accommodation and food, a weekly allowance, vacation/holiday pay, sick pay, rest and relaxation pay (d’mei havra’ah), severance pay under certain circumstances, and fees for repatriation of the foreign worker for a variety of conditions.

I never promised you a rose garden.

SALARY IS ONLY A SMALL PART OF THE COST FOR A FOREIGN WORKER

While you’re anxiously awaiting the arrival of the mystery foreign worker, you might consider some shortcuts to shopping for medications and groceries—although I myself never took advantage of them. Internet shopping for groceries is an option with delivery to the door of the patient (here is the Supersol link, and I am sure there are other major chains that provide the same service). Some pharmacies and kupot cholim also advertise that they will send a courier to the home to pick up prescriptions and send the medications back to the home of the patient. No doubt there is a fee involved, but it may be worth your while to look into this option.

Don’t believe everything you hear
Well, we filled out the inevitable forms to process the arrival of a foreign worker, and paid the inevitable fees involved. Of course, as luck would have it, our scheduled worker’s flight kept getting postponed for one reason or another. Our original application for a license was made at the beginning of November. We received the license at the end of November and were told that within three weeks or so the worker would arrive. The worker actually arrived in mid-January. According to the employment agency all their workers attend a course in basic spoken Hebrew and are taught the laws of keeping kosher. We found this to be an exaggeration in the extreme. But we did receive a very capable, bright and energetic worker and managed to continue with home care for close to two years.

Be prepared, if you do decide to go this route, that there are many days off (besides the weekly day off) that the worker is allowed, and if the worker agrees to work on those days off you will have to pay a hefty overtime rate for this service. If the worker takes vacation days (highly recommended for the worker’s sanity and well-being), you are left on your own to care for the patient/s or to find alternate help. The website for the Philippine Embassy has a list of the national and religious holidays to which their citizens are entitled. The hours that Bituach Leumi has awarded the patient/s can be used towards the salary of the foreign worker. (Note: Bituach Leumi does not pay the caregiver of a patient during days that the patient is hospitalized. This applies whether the caregiver is a local worker or a foreign worker. Many times, however, it is possible to reassign the hours to a different date in the case of a patient who is cared for by a full-time foreign worker. If all parties agree and there are enough hours left in the month for a part-time caretaker to make up the lost salary, the caregiver may choose to work extended hours to recover the money lost due to the patient’s hospitalization.)

MAKE SURE TO HAVE THE PATIENT'S VITAL INFORMATION READILY AVAILABLE

I must have been doing something right
To ensure proper dosage of medications and performance of medical procedures accurately I prepared many lists. All the medical information relating to my parents was stored in my head, and if I were unavailable for whatever reason, without these lists everyone else would be at a loss for how to deal with them. Among the lists I prepared for each of my parents individually were:
Each of their medications including the strength of the medication, how many times a day and at which hours to take them, as well as whether they were to be taken with a meal or not.
All their diagnoses, lists of their hospitalizations, and answers to frequently asked questions when being admitted to the hospital, e.g. date of birth, date of aliyah, country of birth, Holocaust survivor?, allergies, next of kin and contact information for close family members both in Israel and abroad.
Information on how to reach their family doctor, dentist, barber, pharmacy, supermarket, etc.
Sample menus for their meals.

Can you tell I’m a Type A personality? Born under the sign of Virgo? But knowledge is power, and you never know when the information might come in handy. I’m a little neurotic, so what? When out of the blue my parents’ family doctor sent the district geriatric specialist team to pay a home visit to my parents, they took one look at the organized listing of medications and the set-up in the home and said we had everything under proper control. If only my head felt that way, too, I’d have been in good shape.

So, one more milestone was reached, and another sigh of relief was heaved. But not to worry—the saga continues.

Guide to Services for the Aged and Disabled in Israel
© Copyright-2008
This work is protected by copyright law. Use of this work or any portion thereof, including photocopying, publication, public production, distribution, translation, broadcast, allowing public access to it, and utilizing portions derived from it for other purposes, without prior written permission from the author is prohibited.

Part 4 The Energizer Bunny Syndrome

by Shari (Zissie) Gitel

email: zissieg@walla.com

Remember the TV commercials for Energizer batteries? That one bunny rabbit just kept on going and going and going. Well, it may work with bunnies, but it sure doesn’t work with humans. This column is devoted to pitfalls I encountered when I thought I could be Superwoman and various resources available to help both the patient and caregiver get through difficult times.

Progress and the conservation of energy
About four weeks after my father’s stroke, my daughter, son-in-law and their three children moved in with us during the period between vacating their rental apartment and waiting for their apartment under construction to be inhabitable—including my parents that made nine, but who’s counting? Right about then I came down with the flu (flu-shot notwithstanding) and I came to the realization that this old machine just can’t keep going at its present pace.

If you’ve read my previous postings you know that I try to maintain a lively sense of humor to get myself through the day and advocate the same for everyone else having to endure a crisis such as this. But make no mistake. I do not take this situation lightly. We had a rocky road ahead of us, and my batteries were running down. How could I provide the maximum amount of care for my parents, if I myself could barely function?

Things had improved somewhat with my father to the point that he had “graduated” to having physical and occupational therapy at the kupat cholim, rather than at my home. He also started speech therapy, and as much as possible we tried to coordinate the appointments to minimize the number of times we would have to travel to the clinic.

Coordinate appointments to minimize hardships on patient.

Although this was a milestone, it further complicated my schedule—now I could add chauffeur to my long list of occupations. It actually was a two-person job to transport him anywhere, as he had to be dropped off near the entrance to the building with one person accompanying him and another parking the car afterwards. In addition, it took two people to get him into and out of the car. This situation can be circumvented by ordering special transport services in vans equipped to handle wheelchair-bound patients. Besides the YadSaraVan service, there are other places that provide similar transportation options. One that I know of is Ezer MiZion. Though these services are certainly helpful in getting the patient into and out of the vehicle, they do have at least one drawback—they are not always available to suit your schedule, unless you don’t mind going to the appointment a couple of hours early and being picked up a couple of hours late. For some people this may not be a problem, but my schedule was so tight already, and my father was in no condition to be hanging around sick people for hours on end, that we rarely availed ourselves of these services.

Another option is for the patient to apply for handicapped parking privileges. I myself never did this, however, and have no experience with the procedure. I would venture a guess that pretty much the same type of medical information that is requested for Bituach Leumi would be requested here. There may also be restrictions as to who bears ownership of the vehicle.

Could things possibly get any worse?
I’m sure it will come as no surprise to you that things can always get worse--especially when dealing with chronic illnesses and conditions. We would like to hope and pray for full and speedy recoveries for our loved ones, but often, barring some miracle or medical breakthrough, the reverse is often the case.

For awhile we were making good progress with my father’s recovery. He dutifully went to all his therapy sessions for several months, during the course of which time my mother’s condition deteriorated. By this time they had returned to their apartment, and my father was receiving additional hours from Bituach Leumi. We divided up the allocated hours between a woman who came a few hours a week to deal with household chores and a man who came to deal with my father’s personal hygiene issues. My husband and I dealt with everything else—shopping, doctors, medications, therapy, finances, all types of medical tests, apartment repairs—we were on call 24/7. If only someone would lend a hand, I kept saying to myself, maybe I could get through the week in a better state of mind.

During his hospitalization for the stroke and for the first few weeks afterwards, friends and family came to visit my father regularly. As time wore on, however, the number of people that came to visit dwindled. There simply was not much for my parents to look forward to at home, and leaving the house was such a difficult project that they preferred to just stay put. This dreary existence further complicated by deterioration in my mother’s condition started them down the slippery slope to depression. There are organizations (Yad Sarah and Ezer Mizion come to mind) that have outreach programs with volunteers that make home-visits to shut-ins. It has just come to my knowledge that even Bituach Leumi has volunteers for this purpose through their Department of Counseling Service for the Elderly (in a recent advertisement in the Jerusalem Post Lifestyle Magazine they advertise the service with a National Hotline number to call: 02-646-3404). In our situation we made an attempt to recruit visitors, but did not succeed in finding English-speaking volunteers.


Outreach programs are available to boost the patient’s spirits.

As my mother worsened, my father’s spirits declined, and he started displaying signs of depression. The fighting attitude he had at the beginning of the ordeal was being eroded by having to cope with the painful deterioration in my mother’s mental and physical condition coupled with additional hospitalizations for pneumonia that he had suffered. He no longer had the will to work at improving himself physically and gave up hope of ever getting better. Things were looking pretty bleak.

How to deal with Hachmarat Matzav
When my mother was initially assessed by Bituach Leumi, her claim was denied. My father, on the other hand, was awarded 9.75 hours per week of care. We were ready to appeal to Bituach Leumi for a re-evaluation on both of them (a process we went through at least twice, as the situation warranted it). In order to apply for re-evaluation one must complete a form claiming hachmarat matzav (worsening of the situation/condition). There is a portion for the family doctor to complete indicating the nature of the deterioration, and there is a portion for the patient or caregiver to complete with basic information (since the initial application had already supplied detailed information).

Appeal to Bituach Leumi for more

hours if the situation warrants.

In researching this column I learned that the forms can be ordered online. Again these forms can be submitted directly into the Bituach Leumi mailbox outside their offices to avoid waiting in line. Place them in the envelope provided by Bituach Leumi and complete the necessary information on the outside of the envelope to identify the patient, the liaison for making appointments, and the office to which the form is intended (in this case siyud). Bituach Leumi will contact you to set up a date for the re-evaluation. As before, there is a waiting period of a few weeks until the committee’s decision is available. It is highly recommended to phone Bituach Leumi periodically to see if a decision has been reached. Call your local branch (this response line is usually available only for about two hours in the morning) to check on progress with your claim. With verbal notification over the phone you can begin utilizing the added hours, without having to wait for the written verification, which is often delayed in the mail.

Each time there is a significant change in the patient’s condition you can go through this procedure. Conversely, Bituach Leumi can decide to send someone to re-evaluate the situation on their own to determine whether the patient is still eligible for the number of hours they have been awarded. If the situation has improved, they can decide to reduce the number of hours previously granted.

The importance of being earnest

Let me say at the outset that I am not a medical practitioner, and cannot nor will I recommend any particular medical treatment. I am just reporting on my experiences. Should you feel you need medical intervention you should see a competent licensed medical practitioner to assess your individual case.

Needless to say, the worsening of the situation was taking a toll on my health. I was in a state of denial about requiring the anti-depressants that my doctor recommended—no one was going to fool around with my head, if I could help it. So I began trying alternative treatments to reduce the tension, sleep disturbances, aches and pains and depression I was experiencing.

Reflexology helped with many of my symptoms (and it was during the evaluation by the doctor at the alternative medicine department of my kupat cholim that I was diagnosed with fibromyalgia—a disease I apparently had had for many years, based on my symptoms, but which had been exacerbated by the traumatic and tense situation I was dealing with currently). I also tried the Bach remedies, with no significant results. I tried meditation and conscious relaxation techniques. I had so many conversations with God (one-sided—don’t worry, I don’t hear voices! yet!) that I was starting to bear a close resemblance to Tevye from Fiddler on the Roof. In short, I tried just about anything I could to postpone the inevitable. When I finally reached rock bottom, I realized that in order to get through this period of my life I was going to need some pharmaceutical help. I made an appointment with my family doctor and walked out with a prescription for an anti-depressant. It took a few weeks before it began to take effect, but my coping mechanism has certainly improved. I also rely on sleeping pills now.

Take immediate action upon signs of depression and suicidal thoughts.

I’m starting to sound like a member of Drug-Takers Anonymous, but there are two points I am trying to make:
1) For anyone out there who thinks they are SuperCareGiver—you cannot do it all by yourself and expect to maintain your health. If you need help, do not hesitate to seek it. There are support groups (see end of article for partial list of links) for family members of patients with all types of diseases. Don’t be ashamed to admit that you might need to take medications to help you get through the crisis.
2) If you think you, as a caregiver, are depressed, can you imagine what effect the illness or condition is having on the patient him/herself? He/she has lost his independence and control of his/her environment and is now totally reliant on others for his/her every need. This is a drastic life-change to say the least. Be on the lookout for signs of depression or suicidal indications in the patient. Run, don’t walk, to the patient’s doctor to notify him of these signs and to get prescriptions for the appropriate medications and/or referrals for psychiatric care. It goes without saying that if the patient expresses suicidal thoughts you must get him/her to the hospital immediately. I am not personally familiar with the Israel Mental Health Association, but you can certainly check out their site for useful information if needed.

Without going into details, suffice it to say that I speak from experience. Professional intervention in cases of severe depression is not a luxury, it is an absolute necessity.

“If I am not for myself, who is for me?
And being only for my own self, what am I?
And if not now, when?”
Hillel, Ethics of the Fathers

Looking out for Numero Uno
I hope that I have managed to sufficiently scare you into being alert to both your health needs as well as those of the patient. I must reiterate how important it is to take a break from the routine. What they say about taking care of frail parents all falling on the shoulders of one child is no exaggeration. For whatever reason, this is usually just how it is. So don’t forget to treat yourself regularly to time-out—at one point my husband and I went on a two-week cruise where we were unavailable by phone or email, forcing other family members to bear the responsibility. That may sound pretty drastic. But a gal’s gotta do what a gal’s gotta do to recharge her batteries.

I welcome your comments.

Related Links:
Eran for emotional first aid
Mental Health Services of Ministry of Health
Guide for the Disabled in Israel
Support Groups for Neurological Diseases
Israel Society for Fighting Pain
Israel Cancer Society
Israel Lupus Association
Bookmarks of Ministry of Foreign Affairs for a comprehensive listing of useful sites

Guide to Services for the Aged and Disabled in Israel
© Copyright-2008
This work is protected by copyright law. Use of this work or any portion thereof, including photocopying, publication, public production, distribution, translation, broadcast, allowing public access to it, and utilizing portions derived from it for other purposes, without prior written permission from the author is prohibited.