Repatriation For Us Employee

[CWMcMurray]

I am looking for some advice...

I fellow employe of the company I work at had a Heart Attack/Stroke and has been in ICU for the past 5 months. His family came to Thailand and wrote a letter stating that they gave our boss full control to make medical decisions and would not be finacially responsible for anything.

They then signed and notorized this letter and gave to the hospital and they haven't been heard from since.

Our boss did not ask for this responsibility and feels that in terms of his medical care and decisions should be controlled by his family (I completely agree)

He has been in the ICU for 5 months and only has another month until his 180 days are up on Social security and the doctors feel that he should be released from the hospital.

The question is where does he go??? His family in the US pretty much just signed him off and he doesn't have any family here in Thailand. I met with the doctor today and the Doc was not sure what should be done.

The first choice would be to have him repatriated back to the US, but he doesn't have any insurance, also since his family won't take care of him he will need to be made a ward of the State upon arrival.

If he stays here no one to take care of him and he will be put into a Thai nursing home...

In my opinion neither is a good solution but it looks like either Award of the US government or a ward of the Thai government.

I will be going to the US Embasy to ask about what can be done but I am not sure what they will be able to do to help.

I do not know this person very well, but I am concerned about him and I would like to find a way to get him back to the US if possible.

Any ideas out there????

[Sheryl]

Definitely, bring the Embassy into this, as soon as possible.

Would help if you could tell me a bit about his condition:

1) is he conscious at all? Of course on a ventilator he cannot speak, but if conscious he would be able to open and close his eyes on command, squeeze hand etc, nod yes or no. This is important as we need to establish if he, himself, is at all able to make decisions.

2) Do the doctors anticipate him being able to get off the ventilator? In short what is his prognosis long-term?

3) What nationality is the boss who has been given power of attorney? Is he also American or Thai or what?

4) I'm confused by the reference to social security. Is he over 65? Does he qualify for Medicare? Even if he does Iam not aware that Medicare will reimburse Thai hospitals. I suspect iot must be soemthing else that is about to expire, maybe private health insurance? Or is he somehow covered under Thai social security?

The Thai government is not going to pay for the long term care of a noncitizen, can be sure of that.

Actually from the sounds of his family it is probably not a good idea that they make any decsisiions on his behalf since they obviously don't have his welfare at heart. But someone is going to have to. . There is a doctor affiliated with the US Embassy ("regional Medical Advisor") and I imagine they'll have him go check out the situation. Possibly the family could give the power of attorney to someone at the Embassy. But a lot really depends on the man's prognosis and whether he is able to in any way make his wishes known.

If he is unconscious and unlikely to regain consciousness then taking him off the ventilator is a consideration, the issue becaomes who will take responsibility for that decsion. Possibly the Embassy could call the family and sort out something whereby they gave consent for that from a distance -- but only after evaluating him and determining that he is in fact unable to express his wishes and unlikely to recover, if that is the situation.

[CWMcMurray]

Definitely, bring the Embassy into this, as soon as possible.

I am going to the Embassy tomorrow morning 07:00 as soon as they open.

Would help if you could tell me a bit about his condition:

1) is he conscious at all? Of course on a ventilator he cannot speak, but if conscious he would be able to open and close his eyes on command, squeeze hand etc, nod yes or no. This is important as we need to establish if he, himself, is at all able to make decisions. He is consious and seemed to recognize his name when I called him but I asked him to blink twice if he could hear and understand me and he just continued to look at me. He could squeeze my hand but I am not sure if he was completely under control of that or not because his hand movement and squeezing seemed somewhat spazmodic and ramdom. When I asked the nurse if he could make his wishes known by answering yes or no questions by closing his eyes or blinking she said that he was't that conscious...but he could smile on comand... if the nurse asked him to smile he made a quick smile. His family also said that he told them that he wanted to be burried here in Thailand and so they said that he should stay here, not go back to the US. If he had died this seems ok to me, bury him where ever he wanted to be burried, but he didn't die... so now it should be about where should he go so that he can receive the best care possible. When I asked the doctor about what would happen to him if he stayed here, they said he would probably be put into a nursing home and he was very up front in saying that these are not nice places. I am paraphrasing a bit here but it sounded like he would most likely be put into a bed and would be given food and water until he died. He said in Thailand these type of places are only for the truly destitute who have no money and no family.

2) Do the doctors anticipate him being able to get off the ventilator? In short what is his prognosis long-term? I need to correct my previous statement, he is no longer on a ventilator. He had a trachiotomy but he has been taken off the ventilator. The doctor says the long term prognosis is uncertain... He had previuous problems with his heart and during the stroke, they believe that some brain damage has occured. The doctor said that with rehabilitation he may improve or he may remain as he is now for the next month, year or decade.

3) What nationality is the boss who has been given power of attorney? Is he also American or Thai or what? The boss is Thai, but has not been given any offical power of attorney just a informal typed letter notorized and signed by the patients brother and nephew. The boss does not want to be responsible for making these decisions and is afraid that someone from his family may decide that what she decided was wrong and sue her.

4) I'm confused by the reference to social security. Is he over 65? Does he qualify for Medicare? Even if he does Iam not aware that Medicare will reimburse Thai hospitals. I suspect iot must be soemthing else that is about to expire, maybe private health insurance? Or is he somehow covered under Thai social security? He was covered under Thai Social Security medical coverage through our company but the benefit only covers 6 months of hospitalization. It is also important to note that our boss has already laid out quite a bit of money for things not covered by Social Security.

The Thai government is not going to pay for the long term care of a noncitizen, can be sure of that.

His visa will expire shortly as well, I know that he can apply for an extension based on his medical condition but will they allow this if no one is paying his medical here in Thailand? Would they deport him? If they did this who normally pays for the deportation? Would they medical evac him back to the US and make him a ward of the state?

Actually from the sounds of his family it is probably not a good idea that they make any decsisiions on his behalf since they obviously don't have his welfare at heart. But someone is going to have to. . There is a doctor affiliated with the US Embassy ("regional Medical Advisor") and I imagine they'll have him go check out the situation. Possibly the family could give the power of attorney to someone at the Embassy. But a lot really depends on the man's prognosis and whether he is able to in any way make his wishes known.

Do you know who the regional medical advisor is for Thailand? Would I just go into American Citizen services and ask to see him? What information would I need to bring with me?

If he is unconscious and unlikely to regain consciousness then taking him off the ventilator is a consideration, the issue becaomes who will take responsibility for that decsion. Possibly the Embassy could call the family and sort out something whereby they gave consent for that from a distance -- but only after evaluating him and determining that he is in fact unable to express his wishes and unlikely to recover, if that is the situation. The other thing his family did send was a DNR, but the doctor here in Thailand says that he can not honor such a document. He said that it is not allowed to let someone die if he can save them. He said that he is bound to try his best to save every patient.

[CWMcMurray]

I just got off of the phone with the Embassy and I was able yo get some aswewrs to my questions above.

They said that in order to arrange for his repatiration, the family would have to push for this.

They also said that considering his condition, he may qualify for social security benefits but that the family would have to apply for this.

They also said that his family would need be in charge of making all decisions unless an official power of attorney was given to someone else.

They said that they are already familiar with this case but there is really nothing they can do but inform the family of what the options are and it is upto them to decide what to do.

The only thing they did mention is that if repatriation was conducted without the support of the family, a representative from social services would be sent to meet him at the airport and they would put him into a medical facitlity in the US.

Any one out there have any idea what type of health care he would receive if this happened? She said that it would be similar to the healthcare someone in his condition would receive if they were homeless in the US.

This seems to be a bad situation all around, it looks like he will receive either the worst care Thailand has to offer or the worst care that the US has to offer. Anecdotally I believe that the care he would receive in the US would be better, but I don't really have any idea.

Anyone have any ideas?

[Sheryl]

Oh my goodness. This really sounds like a deplorable situation. I hope you got some response at the Embassy.

From what you describe he is conscious and may have some rehab potential. With the language and cultural barrier it is quite possible that there is untapped room for communicating more with him than has been developed. He really, really needs to get back to the US and into a long term care facility with good rehab services.

I don't know the name of the RMA. Actually his/her official role is to oversee medical care for US Giovernment employees in the region, not ordinary US citizens but in an extreme situation like this I would expect the Embassy to get him involved. If this does not happen you could call the main Embassy line and ask for the Regional Medical Office and see if you can get through; say it concerns a health emergency affceting a US citizen.

The doctor was incorrect re not being able to honor a DNR but as this man is off life support a DNR is not the issue at present (would be if he were to suddenly have a cardiac arrest, but otherwise not). A simple tracehostomy and feeding tube etc are usually not considered as advanced life support and would not be discontinued. Plus we really have no way of knowing want the patient himslef wants done. So these measures must continue along with proper medical care to avoid the various compications a patient like him is at risk of and above all aggressive rehabilitation including speech therapy in his own native language.

There is really no such thing as a "ward of the state" in the US as such but there are programs that can pay nursing home/long term care costs such as Medicaid. The big risk is that in the absence of caring family members he may get placed into a facility of low standard (altho probably better than what may await him if he remains here). It might be worth tryinmg yourself to get in touch wioth the family and alert them to the fact that he is off life support and in stable condition but in need of long term care and rehabilitation and thus, whether they like it or not, he is going to have to come back to the US and they ought to start looking for good facilities that accept Medicaid and get in touch with a social worker / the Medicaid office about procedures to get him enrolled.

How old is he and what is the relationship to these rleatives, are they siblings, children or what?

Chances are he was in am ore critical condition when they saw him here and they may have thought he wasdlikely to die, this place his preference to be buried in Thailand may have influenced their behavior, not that I am defending them. But they need to be clealry told that the situation is much changed. He is offf life support, he is conscious (altho with possible brain damage, unclear), his Thai insurance and visa are running out. A whole new ball game.

I am buried under work with a tight deadline right now but would be willing to do what I can to help next week if this is still unresolved. I would need to visit him in the hospital first and then would be quite willing to talk to the family by phone myself if you think that would help. Is he in a Bangkok Hospital or where?

Let me know, and bless you for your efforts. It really is inexcusable for his Thai boss to be saddled with this problem and if ever there was a case that the expat community -- particulaly but not only Americans here in LOS -- should be rallying round to help it sounds like this one.

[CWMcMurray]

I have talked to someone at the US Embassy and she will meet me tomorrow morning around 8:00am.

He had difficulties with his heart, I believe his heart was only working at about 10-20% before the stroke and that they have had to use the paddles on him a couple of times so far, so the DNR may still be an important issue.

I also do not want to judge his family as they have a very difficult decision that I do not envy, I believe that they thought that due to his quality of life, he would prefer to be let go.

He was already prepared to die but he had assumed that he would die from heart failure.

The embassy representative also agrees that this is not a good situation, she said that she has talked to the family but has not heard from them in a while either. Communication has broken down between our boss and the family and the Embasy said that they would help to relay information but that they can not preasure them our give them any advice, they can only inform.

He is currently in the ICU at Camellian Hospital in Thong Law.

I appreciate your offer to help and although I do not want to impose, I would like to take you up on your offer. If you want, we can meet at the Hospital when ever it is convenient for you. I will send you my cell number by PM.

Since there may be issues between the boss and the family I am sure I would only be seen as the bosses representative. The US embasy can only inform but not give any advice. I know that the family has tried to get information from the doctor but his English is not very good and the family just got frustrated and angry.

I believe that he is in his 50's and his closest relatives are his brother, sister and nephew. Never been maried, no chilren.

He has been with the company for 20 years and is very close with the owner but I agree that no matter how close of friends they have become over the years the family are the only ones that can make these difficult choices on his behalf.

Thank you again for all of your help.

[Sheryl]

Fine, do what you can with the Embassy and you can also tell them that an American RN ha offered to go have a look at the patient and talk to the family. One of the things we need to knwo from the Embassy is what they can do in terms of arranging the logistics of medical transfer back to the US and also expediting his enrollment for Medicaid which eh will need to cover his costs once in the US. I don't know whether or not Medicaid can cover the ciosts of his medical evacuation. From the sounds of things he can go by commercial flight but would need some equipment (oxygen, suction), special seating arrangments and a medical attendant. All ofwhich will come to some $$$.

If you can, get Jan's number so that I can follow uop with her. I'll plan on coming to see him sometime next week and give you a call when I know the day.

Once I can say that I have seen his situation for myself I will be better placed to try to talk with the family.

[CWMcMurray]

Thank you for your help

I will make sure to bring up all of the points you mentioned with Jan and try to get her direct number tomorrow. I do have her email, I will PM it to you.

What ever time is most convenient for you let me know and I will meet you there.

[CWMcMurray]

I wemt to the embassy yesterday and was able to speak with Jan, the vice consulate.

She was very kind and while it was very aperant that she empathized greatly she was sum what limited in what she could do.

She took down all of the information about Mike and where he is staying and said that she would call his family.

She did say that he should be eligable for SSI disability benefits and gave us the application packet and said that she would send an email to the SSI office in the Philipines to try and get an unofficial estimate of possible benefits. This estimate would then allow everyone to better compare the level of quality he could receive here and in the US.

This may not be correct but right now we are not sure if he would survive the trip back to the US, he has had a few cardiac incidents already.

In terms of the DNR, do you know what format this would need to take in order to be legally binding in Thailand? I know that the family said previously that they wanted a DNR but Mike's condition has improved since then and I am not sure in what format they made their wishes known to the doctor.

I am certain that if it was only in an email the doctor could not follow it, it would probably need to be some in offical format that would need to be certified by the embassy as a true copy; translated into Thai and certifed as a correct translation. (this is just an educated guess on my part)

At first she said that all of this would need to be done by Mike's family, but if the family abandons Mike and is not willing to make a claim for benefits we could submit it on his behalf. If we do this then in addition to his application and the letter from the doctor explaining his condition we should also include a letter from the company explaining our relationship to Mike and the reason why we are submitting the application on his behalf and the notorized letter that the family gave to the doctor stating that they did not want to be responsible for making any decisions about his care or for any medical bills.

We just received an email from Mike's family and they have said that they have started the process of applying for his social security benefits, but that it will take at least 3 months to get things started. This is good news, with his family doing this it will significantly simplfy things.

I do not think that they will push to have him brought back to the US, in their email they stated that he has lived he for over 20 years and this is his home abd they don't think that he would want to be brought back to the US.

I need to call Jan back today to see if she was able to get a hold of his family.

[girlx]

how very sad that an acquaintance is doing more to help this man than his family. enjoy your good karma!

[Sheryl]

They are probably right that he wouldn't ideally want to leave Thailand but I'm just not sure that we can find a place in Thailand that provides what he needs....long-term care with a good rehab department and speech therapy with a native English speaker, these last to improve the quality of however much time he has left and enable him to communicate his needs.

If anyone out there knows of a good nursing home/ long-term care facility in Thailand please speak up.

There is also the wuestion of whether his SSI would be enough to cobver costs at such a place even if we can find one. If in the US he could get either Medicaid or Medicare benefits....

re the DNR Ifor sure an email won't do it. Usually in Thailand these matters are handled through verbal communication between the family and the doctor and without paperwork. Without any face to face with family members they are going to feel hesitant. A notarized letter plus verbal communication from the Embassy might do the trick if the only problem is the hospital being concerned about getting in trouble (and might need yo go through someone in Hospital Administartion as this is probably not a situation they deal with everyday...I mean the farang and no family here angle, not the DNR part). But if the doctor in charge has issues of his own with honoring a DNR that complicates things. Anyhowas soon as I can get down there I'll try to talk with the staff and see if I can find out what it would take.

I'm still snowed under with work but will get in touch with you early next week.