Health Care Agents: What They Are, How They Help, and How to Choose

What Is a Health Care Agent?

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In this Article

In this Article

Most of us want to make our own decisions about our bodies and medical care. But sometimes that’s not possible. That’s where a health care agent comes in.

This is a person you allow to make decisions for you in case you can’t make them yourself. For example, if you were in an accident that left you unable to speak, your agent could make choices that honor how you want to be cared for.

A health care agent may also be known as:

  • An attorney-in-fact
  • A health care proxy
  • A representative
  • A surrogate

Should I Get One?

Having a health care agent can be a big help. Even if you have a living will, you can’t plan for everything that might arise when you need care. And you may not be well enough to make choices for yourself.

With a health care agent and a living will, you’re more likely to have your wishes honored. You can also ease stress on your family. They won’t have to guess at what you might want.

Whom Should I Choose?

You can pick almost any adult to be your agent. It could be a family member or friend, a lawyer, or perhaps someone from your faith group. In most states, you can’t choose your doctor or someone who works for your doctor, hospital, or nursing home to be your health care agent.

You want to pick someone you trust and who knows you very well. Look for someone you can talk to about hard decisions and who will support your choices.

Your agent may have to ask doctors a lot of questions and push hard for what you want. Try to pick someone who you think can take that on.

When you have someone in mind, talk a lot with each other. You need to be very clear and honest about what you want. No matter how well you think someone knows you, people have very different ideas about what to do in situations like these.

You can talk about your values and beliefs. You need to speak openly about life-support decisions, like whether you’d want CPR or a feeding tube and in what circumstances.

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You can’t cover every possible detail. Your agent may have to make treatment choices that never came up when you talked. Cover enough ground so that she gets a really good feel for what you want and believe. That will help her make the best decisions for you.

You’ll also want to choose a backup agent. Sometimes, doctors need to make quick decisions about treatment. If your first choice can’t be reached, they can check with your alternative agent.

What Can They Decide?

Your health care agent can speak for you only about health care, not money or other legal issues. Also, they can only make decisions for you if you can’t make them yourself.

Laws about what a health care agent can decide vary by state. Usually, they can make choices about life support and more routine care. This could mean the choice to start, stop, or try a different treatment.

Your health care agent helps make sure doctors follow your living will. If you don’t have a living will, she tries to make the same choices you’d make for yourself.

How Do I Make It Legal?

You put her name in a form called a “health care power of attorney.” You might also hear it called:

  • Appointment of a health care agent
  • Durable power of attorney for health care
  • Health care proxy

You don’t need a lawyer to create this. You can get them online, from your local or state government, and possibly at your doctor’s office or hospital. Normally, you also need two witnesses — people not related to you who watch you sign and date the forms.

Keep in mind that various states have different laws governing this.

If you live in two states — one in the summer and one in the winter, for example — you’ll need to make sure your health care power of attorney works in both places. This could mean you need to fill out forms for each state. If you’re not sure what to do, a lawyer can help.

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Finally, keep your finished form in your files but not in a safe deposit box. You want to make sure people can access it.

Give a copy of your health care power of attorney to your doctors, your agent, your backup agent, and your family and friends.

Sources

National Institute on Aging: “Planning for End-of-Life Care Decisions.”

See also:  4 Steps to a Healthy Lifestyle

National Hospice and Palliative Care Organization, CaringInfo: “End-of-Life Decisions,” “Communicate Your End-of-Life Wishes.”

Memorial Sloan Kettering Cancer Center: “What You Need to Know About a Health Care Agent.”

Stony Brook Medicine: “Health Care Proxy/Living Will.”

www.webmd.com

Rocky Mountain Spotted Fever (RMSF)

Agent

RMSF is most often transmitted by the American dog tick in the Eastern, Central and Western United States; by the Rocky Mountain wood tick in the Rocky Mountain states; and by the brown dog tick in the Southwestern United States, along the U.S.-Mexico border. RMSF can be rapidly fatal if not treated within the first 5 days of symptoms. Before tetracycline antibiotics were available, case fatality rates ranged from 20–80%.

Where Found

Although RMSF cases have been reported throughout most of the contiguous United States, five states (North Carolina, Oklahoma, Arkansas, Tennessee, and Missouri) account for over 60% of RMSF cases. RMSF has become increasingly common in certain areas of Arizona over the last several years; between 2003 and 2016, over 360 cases and 21 fatalities occurred.

Incubation Period

  • Typically appears 2–5 days after onset of symptoms; approximately 10% of RMSF patients never develop a rash.
  • Decision to treat should not be based on presence of rash.

Early Rash

  • Maculopapular: Small, flat, pink, non-itchy spots (macules) initially appear on the wrists, forearms, and ankles then spread to the trunk and sometimes palms and soles.

Late Rash

  • Petechial: Red to purple spots (petechiae) are usually not seen until day 6 or later after onset of symptoms.
  • Petechial rash is considered a sign of progression to severe disease. Every attempt should be made to begin treatment before petechiae develop.

Signs and Symptoms

Early (1–4 Days)

  • High fever
  • Severe headache
  • Malaise
  • Myalgia
  • Edema around eyes and on the back of hands
  • Gastrointestinal symptoms (nausea, vomiting, anorexia)

Late (5 Days and Beyond)

  • Altered mental status, coma, cerebral edema
  • Respiratory compromise (pulmonary edema, ARDS)
  • Necrosis, requiring amputation
  • Multiorgan system damage (CNS, renal failure)

Confirmation of the diagnosis is based on laboratory testing, but antibiotic therapy should not be delayed in a patient with a suggestive clinical presentation. Antibiotics are more likely to prevent fatal outcome from RMSF if started within the first 5 days of symptoms.

General Laboratory Findings

  • Thrombocytopenia
  • Elevated hepatic transaminases
  • Hyponatremia

NOTE: Laboratory values are often within normal limits in early illness.

Laboratory Diagnosis

  • Demonstration of a four-fold change (typically rise) in IgG-specific antibody titer by indirect immunofluorescence antibody (IFA) assay in paired serum samples. The first sample should be taken within the first week of illness and the second should be taken 2 to 4 weeks later.
  • Detection of DNA in a skin biopsy specimen of a rash lesion by PCR assay or in an acute phase whole blood specimen. Additionally, new pan-Rickettsia and R. rickettsii-specific PCR assays are available at some local and state health departments.
  • Immunohistochemical (IHC) staining of organism from skin or tissue biopsy specimen.

NOTE: Antibody titers are frequently negative in the first 7–10 days of illness. Acute antibody results cannot be independently relied upon for confirmation

NOTE: IgM antibodies are less specific than IgG antibodies and are more likely to generate false positives. IgM results alone should not be used for laboratory diagnosis.

Treatment

Anaplasmosis, ehrlichiosis, and spotted fever group rickettsioses are treated with doxycycline. Clinical suspicion of any of these diseases is sufficient to begin treatment. Delay in treatment may result in severe illness and even death. The regimens listed below are guidelines only and may need to be adjusted depending on a patient’s age, medical history, underlying health conditions, pregnancy status, or allergies. Consult an infectious disease specialist in cases of pregnancy or life-threatening allergy to doxycycline.

Rocky Mountain Spotted Fever treatment regimen

Age Category Drug Dosage Maximum Duration (Days)
Adults Doxycycline 100 mg twice per day, orally or IV 100 mg/dose Patients should be treated for at least 3 days after the fever subsides and until there is evidence of clinical improvement. Minimum course of treatment is 5-7 days.
Children weighing NOTE: Use doxycycline as the first-line treatment for suspected RMSF in patients of all ages. The use of doxycycline to treat suspected RMSF in children is recommended by both the CDC and the American Academy of Pediatrics Committee on Infectious Diseases. Use of antibiotics other than doxycycline increases the risk of patient death. At the recommended dose and duration needed to treat RMSF, no evidence has been shown to cause staining of permanent teeth, even when multiple courses are given before the age of eight.

References

Centers for Disease Control and Prevention. Diagnosis and management of tickborne rickettsial diseases: Rocky Mountain spotted fever and other spotted fever group rickettsioses, ehrlichioses, and anaplasmosis—United States: a practical guide for health care and public health professionals. MMWR 2016;65 (No.RR-2).

Demma LJ, Traeger MS, Nicholson WL, et al. Rocky Mountain spotted fever from an unexpected tick vector in Arizona. N Engl J Med 2005;353:587–94.

Elghetany MT, Walker DH. Hemostatic changes in Rocky Mountain spotted fever and Mediterranean spotted fever. Am J Clin Pathol 1999;112:159–68.

Holman RC, Paddock CD, Curns AT, et al. Analysis of risk factors for fatal Rocky Mountain spotted fever: evidence for superiority of tetracyclines for therapy. J Infect Dis 2001;184:1437–44.

Kirkland KB, Wilkinson WE, Sexton DJ. Therapeutic delay and mortality in cases of Rocky Mountain spotted fever. Clin Infect Dis 1995;20:1118–21.

Massey EW, Thames T, Coffey CE, et al. Neurologic complications of Rocky Mountain spotted fever. South Med J 1985;78:1288–90, 1303.

Paddock CD, Alvarez-Herandez G. Rickettsia rickettsii (Rocky Mountain spotted fever). In: Principles and Practice of Pediatric Infectious Diseases. 5th ed. Philadelphia, PA: Elsevier; 2017. p. 952-957.

Regan JJ, Traeger MS, Humpherys D, et al. Risk factors for fatal outcome from Rocky Mountain spotted fever in a highly endemic area—Arizona, 2002–2011. Clin Infect Dis 2015;60:1659–66.

Smithee L, et al. Public health reporting and national notification for spotted fever rickettsiosis (including Rocky Mountain spotted fever). Council of State and Territorial Epidemiologists, Infectious Diseases Committee, 2009 Position Statement. Cdc-pdf [PDF – 11 pages] External

Todd SR, Dahlgren FS, et al. No visible dental staining in children treated with doxycycline for suspected Rocky Mountain spotted fever. J Pediatr 2015;166(5):1246-51

Traeger MS, Regan JJ, Humpherys D, et al. Rocky Mountain spotted fever characterization and comparison to similar illnesses in a highly endemic area—Arizona, 2002–2011. Clin Infect Dis 2015;60:1650–8.

www.cdc.gov

Anaplasmosis

Agent

Anaplasmosis was formerly known as Human Granulocytic Ehrlichiosis (HGE), and A. phagocytophilum was Ehrlichia phagocytophilum.

Severe and life-threatening illness is less common with anaplasmosis compared to other rickettsial diseases, such as Rocky Mountain spotted fever (RMSF) or E. chaffeensis ehrlichiosis. While the case-fatality rate among patients who seek care for the illness is

CONFIRMATION OF THE DIAGNOSIS IS BASED ON LABORATORY TESTING, BUT ANTIBIOTIC THERAPY SHOULD NOT BE DELAYED IN A PATIENT WITH A SUGGESTIVE CLINICAL PRESENTATION.

General Laboratory Findings

Typically observed during the first week of clinical disease:

  • Mild anemia
  • Thrombocytopenia
  • Leukopenia (characterized by relative and absolute lymphopenia and a left shift)
  • Mild to moderate elevations in hepatic transaminases

Visualization of morulae in the cytoplasm of granulocytes during examination of blood smears is highly suggestive of a diagnosis; however, blood smear examination is insensitive and should never be relied upon solely to rule anaplasmosis in or out.

  • Detection of DNA by PCR of whole blood. This method is most sensitive during the first week of illness; sensitivity may decrease after administration of tetracycline-class antibiotics.
  • Demonstration of a four-fold change (typically rise) in IgG-specific antibody titer by indirect immunofluorescence antibody (IFA) assay in paired serum samples. The first sample should be taken within the first week of illness and the second should be taken 2 to 4 weeks later.
  • Immunohistochemical (IHC) staining of organism from skin, tissue, or bone marrow biopsies.

NOTE: Antibody titers are frequently negative in the first 7–10 days of illness. Acute antibody results cannot independently be relied upon for confirmation.

NOTE: IgM antibodies are less specific than IgG antibodies and are more likely to generate false positives. IgM results alone should not be used for laboratory diagnosis.

Treatment

Anaplasmosis, ehrlichiosis, and spotted fever group rickettsioses are treated with doxycycline. Clinical suspicion of any of these diseases is sufficient to begin treatment. Delay in treatment may result in severe illness and even death. The regimens listed below are guidelines only and may need to be adjusted depending on a patient’s age, medical history, underlying health conditions, pregnancy status, or allergies. Consult an infectious disease specialist in cases of pregnancy or life-threatening allergy to doxycycline.

Anaplasmosis Treatment Regimen

Age Category Drug Dosage Maximum Duration (Days)
Adults Doxycycline 100 mg twice per day, orally or IV 100 mg/dose Patients with suspected anaplasmosis infection should be treated with doxycycline for 10-14 days to provide appropriate length of therapy for possible incubating co-infection with Lyme disease
Children weighing NOTE: Use doxycycline as first-line treatment for suspected anaplasmosis in patients of all ages. The use of doxycycline to treat suspected anaplasmosis in children is recommended by both the CDC and the American Academy of Pediatrics Committee on Infectious Diseases. Use of antibiotics other than doxycycline increases the risk of patient death. At the recommended dose and duration needed to treat anaplasmosis, no evidence has been shown to cause staining of permanent teeth, even when multiple courses are given before the age of eight.

References

Bakken, Johan S., and Dumler JS. Human granulocytic anaplasmosis. Infect Dis Clin North Am 2015:341–355.

Centers for Disease Control and Prevention. Diagnosis and management of tickborne rickettsial diseases: Rocky Mountain spotted fever and other spotted fever group rickettsioses, ehrlichioses, and anaplasmosis—United States: a practical guide for health care and public health professionals. MMWR 2016;65 (No.RR-2).

Gelfand JA, Vannier E. Ehrlichia chaffeensis (human monocytotropic ehrlichiosis), Anaplasma phagocytophilum (human granulocytotropic anaplasmosis) and other ehrlichiae. In: Mandell GL, Bennett JE, Dolin R, editors. Mandell, Douglas, and Bennett’s Principles and Practice of Infectious Diseases. 6th ed. Philadelphia, PA: Churchill Livingstone; 2005. p. 2310–2318.

Todd SR, Dahlgren FS, et al. No visible dental staining in children treated with doxycycline for suspected Rocky Mountain spotted fever. J Pediatr 2015;166(5):1246-51.

Wormser GP, Dattwyler RJ, Shapiro ED, et al. The clinical assessment, treatment and prevention of Lyme disease, human granulocytic anaplasmosis, and babesiosis: clinical practice guidelines by the Infectious Diseases Society of America. Clin Infect Dis 2006; 43:1089–1134.

www.cdc.gov

How to find a real estate agent

When you find a good real estate agent, you have more than just someone to unlock houses for you. The right person will be a trusted, responsive, knowledgeable ally who can help you understand the home-buying process , give you expert advice, and bring smart strategies to the table. You’re probably wondering how to find a real estate agent you can trust to meet your needs, and it’s a good question. We’ve got the goods.

Here’s how to find a real estate agent for you:

Understand why you even want an agent.

Knowing the reasons you’re bringing on an agent in the first place will help you pick the right one. Here’s why you want one:

  • An agent costs you nothing as a buyer, so there’s no need to go with a newbie or first available agent. Take your time and get the best agent out there.
  • Agents have access to info you don’t. The Multiple Listing Service is a private database where brokers share listings so real estate professionals can see what’s available.
  • The right agent will provide you with local expertise on the real estate market and will work hard on your behalf.
  • Agents are real estate teachers. If you’re a first-time buyer , make sure you pick an agent with serious teaching skills.
  • Experienced agents have seen it all. When surprises come up or negotiations get tough, they’ll know what the best move is for you.

Start your agent search early.

Give yourself plenty of time to figure out how to find a good real estate agent. Start your agent search before you fall in love with any listings, so you don’t feel any pressure to sign with anyone who can help you make a quick offer .

Learn the lingo.

Not all agents are the same. Learning an agent’s official title—and what it means—can help you understand the level of expertise and accreditation they have.

  • Real estate agent or salesperson — anyone with a real estate license.
  • Realtor® — a real estate agent who is a member of the National Association of Realtors®. This person has sworn to uphold the association’s standards and code of ethics.
  • Real estate broker — an agent with extra education who has passed a broker’s license exam. They can hire agents to work for them.

Make a list of needs.

Knowing what you want will help you choose the right agent. Agents have specialties. Many work in particular neighborhoods and some focus on condos, coastal homes, or fixer-uppers . Finding an agent with the right specialty will ensure they understand your needs and can respond to you quickly throughout the home buying process. Make a list of the following things to keep on hand as you start your search:

  • Type of home you’re looking for
  • Type of mortgage you may be interested in
  • Neighborhoods you like
  • House budget
  • Characteristics in a real estate agent, like a tough negotiator, thoughtful listener, or speedy communicator

Get referrals.

Start with friends and family and online reviews of real estate agents on Trulia , for example. Look at home-for-sale signs in a neighborhood you’re interested in and see which real estate agent’s name appears most often. That agent is likely to know the area inside out.

Trulia can help you connect with trustworthy agents who will work hard for you through their Premier Agents resource. You can request to be connected with a Premier Agent on any property listing. These agents meet Trulia’s high standard for quality service, so you know you’ll have a great home buying experience with their personal support.

Check background info.

Do a little sleuthing. Every real estate agent has a state-issued license. You can check with an individual state regulatory body online to verify their license. Or go to Arello, the Association of Real Estate License Law Officials and search by name and state.

Look on the agent’s Premier Agent or individual website to see if they’ve won any awards or have any special certifications. If they’re a member of the local Realtor® association, you can call to verify that the agent is a member in good standing. You can also find out how many years of experience the agent has.

Interview more than one agent.

You hire an agent, just like an employer would, so the process is similar. Set some interviews with agents that look promising. Ideally, they’ll treat the opportunity to interview with you just like a prospective employee would—eagerly and professionally. Bring a list of questions for the real estate agent you’ve developed in advance, and expect them to answer every one thoroughly. Make sure to ask them about their real estate background, but also about their personality and the way they work. You’ll be close partners with this person for months, so making sure you’ll enjoy working together is important.

Also, ask for references to past clients.

Follow up with their references.

It may seem like extra busywork to call satisfied clients the agent provided to you, but you can learn a lot from chatting with real people who worked with an agent. If they have anything negative to say off the bat, that’s a definite red flag. More likely, they’ll have nice things to say, but encourage them to answer some serious questions: What was communicating with this agent like? What’s one thing you would have done differently during your home purchase? What was the biggest challenge of working with this agent?

Once you’ve how to find a real estate agent, you may be tempted to start setting home viewings, but there’s one more very important thing to do first: Get pre-approved for a mortgage.

www.trulia.com

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