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Four years ago my Dad (84) had completed an advanced medical directive with the assistance of his attorney and in my mother's presence. My brother, who was a physician, insisted on not following my father's wishes, I took care of my father at each hospital, vent care unit, rehab center, etc. I went daily over the next 8 months after a day of teaching special needs children, was 55, and received support from the hospitals but absolutely none from my family. My father had been declared competent to make his own decisions after 3 months of recovery of a massive stroke, was initially intubated against his specific written instructions by my brother at the hospital where he worked, and Dad finally told the doctors and nurses that I was to be in charge. My mother was busy enjoying her first freedom - they had been married for 63 years. She rarely visited. She and my brother made very poor decisions that had a serious negative impact on Dad's health. In the end, I was the only person there when he died. My other siblings were not. This site gave me so much comfort. My brother lost his license as a consequence of ethics violations for three years after forty years of practicing. In Georgia, he could have been charged with a third class felony. Georgia follows the AMA's ruling 8.19 which prohibits a doctor from treating his own family unless there are no other doctors present. My brother was not close to my father, and rarely visited him. I am the only one who lives near my parents farm. My brother has now been given back his license, and he is now treating my mother for aches and pains and her health needs. She had a traumatic brain injury six years ago and has struggled with emotional and memory needs. As a special needs teacher, neurological issues were my specialty for 35 years. She needs a specialist and is ill now and refuses to go to her doctor because she "has my brother to tell her what she needs" to do or not do. Do I just ignore this ? I do not want to go to court. What is your advice ? My older brother will not speak to me.

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Emjo and Countrymouse, you have given me a great deal to think about today. I realize I am fighting two formidable forces - my brother and my mother. My other siblings get frustrated and walk away almost immediately. There has not been a sudden move toward hoarding and drinking on the part of my mother. I looked at pictures today and realized this has been occurring for the past 25 years. I cannot help her anymore than my father could. I am also weary of the ugly comments from both of them, and I must draw my own boundaries. It is only becoming worse for me, not better. I know my father would understand. So, I am going to allow social services to step in and will let them know to talk to the last hospital he was at. People in our tiny community know mother has issues. They just do not know how bizarre they have become. The hospitals where my father stayed came to understand family dynamics and called me during a crisis. My mother avoided meetings and stated that my brother was going to do what he wanted to anyway. She told caseworkers she was busy. As a result, I would be Dad's one advocate and usually lost. I have been in counseling for the past two years with a diagnosis of PTSD. Some of the reasons have been due to my father's illness. A great deal of it has been due to a childhood that was chaotic despite its perfect outside appearance. I had to grow up way too fast and was really the mother figure in the household. It has to stop now. My mother has made her choices. I will love her as much as she will allow, but I will leave her and my brother to the experts. My counselor would agree with this, has been pushing me toward this avenue, but she does not understand the way most people on this website seem to understand. It is time to let go and hand it over to the experts. You have both been a blessing . Thank you !
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Shadowchild, I think you want to do the right thing. I wish it were easier to see what the right thing to do is, that's all.

Do I have this right? Your greatest fear (among lesser others) is that your brother's inappropriate professional intervention will prolong your mother's life artificially and subject her to, possibly, years of institutionalised, humiliating dependence on others?

Your best case scenario is attractive for a person who likes the quiet arcadian life, which you do, which is good. But. Your mother is not comfortable with your input, is she? Hasn't she already made it clear that she - quite irrationally - places all of her faith in your older brother and will not listen to your advice? The idea that you could do good for her by stealth, being present but not visible from her home… This is not healthy. It is not a sound basis on which to operate. Pretending you're not there and she's managing on her own? Your having to pretend anything is not a good sign.

What is it about your local social services that makes you dread their influence on her life? As far as I know, the role of social services is to support clients in leading their own lives as far as possible, and I've never personally experienced anything different from them. What's wrong with that? Have there been previous run-ins with social workers, perhaps somewhat officious ones?

With regard to your brother, as you say: "he's at it again." Have you considered consulting the AMA about what possible steps might persuade him to desist from treating your mother without having an adverse impact on what remains of his reputation and career? You could give them a call without naming names, perhaps, and not take it further unless you really have to. Your mother needs, as you say, to see a specialist. If your brother is blocking that, he must be removed.

This does lead me to wonder, though, whether actually, on the contrary, you are afraid that your mother's life will be prematurely cut short through neglect of her medical needs; as though you and your brother have swapped places in terms of interventionism. But either way, your brother needs to "resign." If he won't see that himself, and your mother clings to him as her doctor, then you will have to pursue other courses of action. You won't get any thanks for it.

Another reason for scepticism about your plan to care for your mother yourself is that you are not the only child she has ostracised - you're just the only one she hasn't *successfully* ostracised: the others - how many? - have taken the hint. I think you might be in danger of making a huge sacrifice in memory of your father which will do no good to any one living: not your mother, not you, not your husband or son, not your brother. In your place, I'm afraid, I'd have social services round to her place in a heartbeat. I realise that isn't what you'll be happy to read, but it is the conclusion I keep coming back to.

Just a very cautious thought about you, too. You are a loving and dutiful person. But you are also one who has taken some very heavy blows from people you love. These must have been painful. If you have forgiven your mother and eldest brother for inflicting them, I applaud that; but nonetheless these people have hurt you and, more importantly, their behaviours harmed your father in a horrific way. Be careful not to pretend to yourself your feelings play no part in your thinking. Do be kind to yourself and practical about your mother's care.
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sorry - not sure how I double posted.
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Is your mother incompetent enough for you to go for guardianship? I hear your concerns regarding the treatment that your father got. Your mother and your brother are "enmeshed" enough that it doesn't look like you could influence either of them to change their course of action. Guardianship would give you legal right to make decisions, in your mother's interests, as I understand it.

Walking away is one alternative, but would be very difficult for several reasons, not the least of which is that you care for your mother and your brother and you see him walking them into another, as cm says, "can of worms".

I am a little concerned about the phrase "and make her happy". No one can make another person happy, We see others here try and get very distressed when they can't. You may be able to get her proper medical care, see that she is fed and dressed and kept clean perhaps. If she is a hoarder and an alcoholic, you may not even achieve all of these things, never mind keeping her happy.

You wrote about a pretty big change for your family - you and your husband building a home and moving out to your parent's farm. What does he think about this? I think it is crucial that you two are of one mind as there are many challenges in caregiving, and it sounds like your mother and brother offer a few extra challenges. How realistic is building a home when your mother is aging and her health will deteriorate eventually and she may eventually need more care than you can give her. She may need a facility at some point. Does this move affect anyone's job? Do read around this site to get see others experiences of caregiving.

What a very difficult situation, and heart breaking. After seeing what your father went through, I can see it is weighing on your mind. ((((((hugs)))))
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Thank you for your answer. I truly love my mother and have belonged to the little community all my life even though I do not live in it now. The best scenario is for me to build a small retirement house that Mom cannot see easily but is only a few steps from her back door. I would enjoy the peace of the lake, and Mom would enjoy a somewhat peaceful and independent life. If not, she is not facing gossip but is facing control from social services. My brother's behavior is known by most of the community which includes a state judge and other physicians. I love all of my family, but I know that my father considered my small family the best choice for Mom's care. My husband and I are retired teachers, and my son is a music minister and teacher. We are boring but stable. :) His request for me to take care of her is something I take seriously, but I will back off if it becomes too stressful. I would not mind caring for her if she is comfortable about the situation. She wants to pretend she is okay, but I see signs of either dementia or regression of her TBI status. You have helped a great deal. Thank you!
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Is your mother incompetent enough for you to go for guardianship? I hear your concerns regarding the treatment that your father got. Your mother and your brother are "enmeshed" enough that it doesn't look like you could influence either of them to change their course of action. Guardianship would give you legal right to make decisions, in your mother's interests, as I understand it.

Walking away is one alternative, but would be very difficult for several reasons, not the least of which is that you care for your mother and your brother and you see him walking them into another, as cm says, "can of worms".

I am a little concerned about the phrase "and make her happy". No one can make another person happy, We see others here try and get very distressed when they can't. You may be able to get her proper medical care, see that she is fed and dressed and kept clean perhaps. If she is a hoarder and an alcoholic, you may not even achieve all of these things, never mind keeping her happy.

You wrote about a pretty big change for your family - you and your husband building a home and moving out to your parent's farm. What does he think about this? I think it is crucial that you two are of one mind as there are many challenges in caregiving, and it sounds like your mother and brother offer a few extra challenges. How realistic is building a home when your mother's health will deteriorate eventually and she may eventually need more care than you can give her. She may need a facility at some point. Does this move affect anyone's job? Do read around this site to get see others experiences of caregiving.

What a very difficult situation, and heart breaking. After seeing what your father went through, I can see it is weighing on your mind. ((((((hugs)))))
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It is hugely inappropriate for your brother to be treating your mother. It would be normal and commonplace, however, for him to expect any other physician treating her to consult him. And my goodness they do get pretty pally about it, in my experience - that's doctors for you (I love them really).

Is your mother competent? If she is, you're a bit stuck. If you're confident that she is not: do you have any medically qualified candidates lined up to take over her medical care? Given the inevitable conflict that would ensue, you'd be asking a physician to tread heavily on the toes of another physician and they don't generally go for that.

You have rather an emotional can of worms on your hands, haven't you. What do you *want* to do?

Disregarding all external factors, would you choose to care for your mother?

I'm curious, not contradicting: given that you seem to be a reasonably forthright and assertive person, why are you especially troubled by the expectations of the nearest small town? I take it they wouldn't actually burn you in effigy, would they, if you were to explain to the key gossip mongers that your mother had rejected your help?
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Please stop arguing about this. I sat through two court hearings over it. You are not sticking to the point. The point is my mother's care and my brother's issues as a physician which caused him to lose his license for three years and go through a special program dictated by an ethics board. He is still acting very odd. Please remove yourself from this discussion. It's not about whether or not you are right. It is not about you at all. It is about helping me with correct, useful, and caring information that will decide an elderly lady's future and my brother's future. I still love him. If DFACS does a home health care investigation, she will lose her cover of a fully functioning person, and her future will be decided by others. If I need to walk away, it is much more difficult than people realize. The nearest small town will expect me to care for her. I am younger than my brother and can build a house on the farm with my husband on my share of the land.I will work with a geriatric psychologist to help me understand Mom and make her happy. I just do not know if that is fair to any of us.
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The Georgia Composite Medical Board has not issued a rule on the subject, but it has stated that it does not believe physicians should treat immediate family members. That is opinion, not law.
Medicare bars payment for items and services rendered by physicians to immediate relatives of the physician, to the physician’s partner in a partnership, or to members of their household. “Immediate relatives” is defined to include husband and wife; natural or adoptive parent, child and sibling; stepparent, stepchild, stepbrother, and stepsister; father-in-law, mother-in-law, son-in-law, daughter-in-law, brother-in-law, and sister-in-law; grandparent and grandchild; and spouse of grandparent and grandchild. Medicare Benefit Policy Manual, Chapter 16, Section 130. Perhaps that is what you are referring to.
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This is to Pam: please realize the AMA ethics are different from state-to-state. Your answer was incorrect. My brother lost his license for three years for violating AMA8.19 and was warned by 7 hospitals to cease and desist. There is an 800 you can find online to verify the info from each state.
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Actually, AMA 8.19 is a law in Georgia. The opinion part is listed so each state has the right to follow the option or reword it. The consequences are also decided in each state. GA has selected to follow this "opinion" and has very stiff consequences. It is a third class felony. My mother needs specialized care. Please understand that my brother was fired by the medical center he helped to start in 1978 because of odd behavior, lack of functioning in a timely manner, and was four years behind in paperwork. I love my brother, but I know he has limitations. The advanced directive was what my father drew up with a lawyer to protect himself. My brother violated it, and my father begged to allow him to die. In the end my brother was to go before the ethics board at the hospital, and I was asked to help him avoid that by his physician friends. My mother needs help. She is demonstrating signs of dementia, she is hoarding, living in a dirty environment, and is withdrawing from people that might insist on helping her. She is on the family farm in a 3,000 square foot house built in 1851 with no neighbors and avoids visits from people. This is a rural county, my brother lives far away, and she needs to be evaluated. I have an Ed.S in neurological and stroke impacted children and adults: I go to specialists for help when I am dealing with a child who has needs outside of my realm of specialties. I am not just guessing at what may be a problem. It is a problem, and I don't want my mother to suffer like my father. My brother could not find a job for 2 years after he was fired by the board for the clinic he helped to create. He was then fired by his next two jobs. I love him, but he is not a specialist in any area although he is/was an excellent family physician. It is clearly against what Georgia considers ethical to treat immediate family members unless there is not other doctors present. I have been asked if my problem is with my brother treating my mother. I do not believe an 86 year old woman with serious medical issues including alcohol abuse should be treated by someone who is not a geriatric specialist and a neurologist. She has never told any doctor the truth about her emotional issues. I raised a younger brother starting at the age of 12 when my baby brother who was 2 and a half. We had a well to do family and the family tried to cover up many of her problems. I dearly love my mother, but I don't want her to suffer like my father did. He actually grabbed my blouse at one point and said to tell everyone to stop keeping him alive. My brother ignored this. The nurses had already started complaining about his irrational behavior from the first day. He has numerous emotional problems and disappears at times. That is why his second wife, a nurse, left him. He is older and heading for seventy. I feel like I am banging my head against a brick wall. He deliberately downplayed my father's illness to "protect" my mother. She thought he would get well and was devastated that she left the hospital 15 minutes before he died. I told her the truth, but she would not believe it because my brother told her otherwise. An example is that my brother told her Dad had not coded, but the pulmonoligist and I told her the truth.She was furious and only believed my brother. She cries now that my Dad was ill for 8 months and she ignored him and she deliberately hid his Advanced Directive. The hospital my brother was working at obtained a copy of the directive. That is why he was taken in front of a board of his peers for an ethics hearing. I tried to tell him because his friends (and mine) warned me. He rarely visited my parents, criticized them, and was not realistic about their ages. My mother is ill at this time and should see her doctor. So. no this is not about my brother. I am fine if he does not try to keep mother from obtaining appropriate help. This is not about money. Things are divided and in a trust fund. It is about protecting my brother from himself, and taking care of my mother in a better way than I did for my father. My other siblings are not involved and won't be involved.
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Mother is free to choose, even to choose unwisely.
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Your mother has the right to choose unless she is incompetent. AMA 8.19 is an Opinion, not a law, or even a regulation. Let it be.
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shadowschild - is your main concern your mother's care or lack thereof because your brother is her doctor, and she reslly needs to see a neurologist, or that your brother is once again violating the AHA's ruling?

Could you ask advice from your own doctor how to address either issue? You are in a difficult situation.
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If your mother is happy with your brother's care and she paid no mind to your dad when he was ill, why are you getting involved in her care? Why not leave them all to themselves and move on? This is a serious question, NOT a rhetorical one.
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