Which led to the second reason the package was remarkable. There was no need to overnight the documents. Judge Paulson had given Keystone until the end of the week to turn them over. Today was Tuesday. Showalter could have saved his client some money and put them in the regular mail or sent them ground. But, instead, he’d paid extra for early morning delivery. After dragging its heels for months, suddenly, Keystone was in a big hurry for her to get the documents. Baffling. That was the only way to describe Showalter’s behavior.
The games Keystone was playing around the timing of the document production seemed senseless. And, thus far, her review of the e-mails hadn’t shed any light on the issue. She’d seen nothing but e-mails that set forth the mundane minutiae of a typical commercial landlord-tenant relationship: the activation procedure for VitaMight new hires’ access badges; the after-hours heating and cooling policy; a request from the landlord that no one park under a diseased oak tree so it could be removed from the lot; an invitation to a pizza lunch Keystone had sponsored for one of the candidates for county council; the e-mails scrolled across her screen in a seemingly endless parade of irrelevant information. Whatever was there, she wasn’t seeing it.
She finished her coffee and stood looking at the computer screen. Then, she put down the mug and powered off the screen. Noah used to say when you can’t see the forest for the trees, get out of the blasted forest.
* * * * * * * * * *
Sasha sat in the gerontologist’s waiting room and tried to make sense of the magazine selection. Doctors’ offices, perhaps the last refuge of the magazine industry. She understood the presence of Reader’s Digest, of course, and AARP Magazine. She had to wonder, though, how many of Dr. Kayser’s patients were fans of Wired and Bride. Unless those were aimed at adult children shuttling their parents to appointments.
The door from the outside corridor opened and an elderly woman shuffled in. She nodded a greeting to Sasha, then eased herself into the chair nearest the door and placed her large pocketbook near her feet. She unwound her scarf and folded it into a neat rectangle but did not remove her jacket. Sasha watched the woman get comfortable and made a silent bet as to which magazine she’d choose.
The woman ignored the magazines. She reached into her bag and took out a glasses case and an iPad. She snapped the case open, put on her glasses, and powered up her tablet. Sasha smiled to herself. Maybe magazines’ days were numbered here, too.
Sasha checked the time. The receptionist on the phone had told her Dr. Kayser’s last appointment was at 3:30 and that he’d give her a half an hour after that. It was now close to four o’clock. If he was running late, she’d come back. Sitting and waiting wasn’t her strong suit.
“Ma’am, are you here to see Dr. Kayser?”
The woman looked up from her device. “No, honey, Dr. Jenner.” She smiled and then bent her head back over the screen.
Intrigued, Sasha craned her neck subtly to see the screen. The old lady was updating her Facebook status.
The interior door swung open into the waiting room and an elderly man came through the doorway followed by a nurse wearing Scottie dog-patterned scrubs.
“You have a nice evening, Mr. Chatsworth,” she called to the man’s back in a loud, singsong voice.
She turned to Sasha and spoke in a normal tone. “Ms. McCandless? Dr. Kayser asked me to have you join him in his office.”
Then, her voice rose again and she addressed the old woman. “Dr. Jenner will be right with you, ma’am.”
“Okay, dearie,” the woman responded without looking up from her Facebook wall.
“Kids today and their electronics,” Sasha cracked as she followed the nurse through the doorway and past two exam rooms. At the end of the short hallway, the nurse delivered her to the doctor’s office without so much as a fake chuckle at the joke.
Dr. Alvin Kayser set aside his paperwork and rose to greet her.
“It’s good to see you, Sasha,” he said, shaking her hand. His eyes were magnified by his round, rimless glasses. He looked kind, almost jolly, like a balding, beardless Santa Claus.
“I really appreciate your taking the time to see me today,” she told him.
He waved her into a chair and shrugged off her thanks.
“It’s my pleasure. Your late grandmother was very fond of you. And proud of you, I should add. She said for a tiny thing you really held your own with your strapping brothers from the time you were a child. And, look where it got you, she used to say.”
Sasha smiled. Her maternal grandmother had always seemed mildly horrified by Sasha’s tomboy adventures as a child and her unladylike pursuits as an adult, but Nana Alexandrov was never shy about bragging about her grandchildren. She’d seen Dr. Kayser for the last several years of her life—with increasing frequency, as her frail body deteriorated over time—so, the doctor had probably learned more than he ever needed to know about the McCandless clan. Especially toward the end, when their doctor-patient relationship had deepened into a true friendship. For over a year, the doctor had brought her grandmother a burnt almond torte from Prantl’s Bakery every Sunday, and the two of them had worked on the crossword puzzle between bites.
He reclaimed his leather desk chair and leaned back, folding his hands over his belly. “Now, what can I do for you?”
“As I told your receptionist when I called, I’ve been appointed to represent a gentleman at an incapacitation hearing up in Clear Brook County. Elder law isn’t an area I’m familiar with, so I’m starting from scratch here. Anything you can tell me will be a help.”
The doctor nodded. He had testified in more incapacitation hearings than he could count.
“Okay, now, understand, I am most familiar with Allegheny County, but the general process should be the same. Typically, the issue will arise when a family member or friend of the elderly person raises a concern or if a physician thinks there’s a problem. So, how did your client come to the attention of the court?”
“It’s not clear. The county Department of Aging Services is the petitioner. The petition just says they received a report. My guess—and it’s only a guess—is that a local doctor made a report after my client consulted her informally about a fall.”
Dr. Kayser nodded. “That’d be Dr. Spangler, I take it?”
Sasha blinked. “Well, yes. But, surely, she’s not really the only doctor in town?” She’d assumed Jed had been exaggerating.
“There are others in the general area, but I do believe she has the only office in the town itself. In any case, she seems to be, by far, the busiest general practitioner up there. There aren’t any geriatric specialists in that county, at least not to my knowledge, and the handful of other G.P.s up that way are always griping about the stranglehold she has on the client base at conferences and meetings. I assume the locals are loyal to her out of a sense of sympathy.”
Sasha stopped him. “Sympathy?”
He sighed, then said, “Dr. Shelly Spangler is a Spangler by marriage but a Wilson by birth.”
“A Wilson?”
“Yes. Clyde Wilson was a well-respected businessman in the area until the mid-70s. All before your time, of course. But, his business failed in spectacular fashion and it destroyed his family. Shelly is his daughter. From what I understand, after Clyde killed himself, his wife scraped out an existence. Shelly buried herself in her studies, and won a scholarship from the local Lions Club to college. She continued to apply herself and was accepted to medical school. People who know her story wouldn’t dream of changing doctors. She’s the hometown girl who made good.
Sasha thought about Dr. Spangler’s childhood home, condemned and bleak, standing across the street from Danny Trees’s place and could understand why the townspeople would support her.
“Okay, the county’s petition failed to provide any concrete evidence of incapacity. What should it have included? I mean, what would you have done?”
On comfortable ground, his answer came quickly and with authority. “Before I would pr
esume to classify one of my patients as incapacitated, I would do a thorough evaluation, starting with a complete physical examination. I’d also do a psychosocial information intake.”
Sasha jotted his answer on her notepad. “Let’s take those one at a time. What would you be looking for in the physical?”
“Signs of dementia, primarily. Any changes in existing conditions that might be caused by a patient’s failure to comply, for example, a diabetic who stops following an appropriate diet or someone who stops taking prescribed meds.”
“Okay, say, the patient hasn’t come in for a physical for years,” Sasha said. “So you have no baseline.”
He nodded. “I’d still do a workup. But, you’re right. It would be hard to draw any conclusions from the results. In that case, the psychosocial information might carry more weight.” He waited until she stopped scribbling. “Ready to discuss that?”
“Yes. Thanks.”
“Of course. At a minimum, I’d perform a MMSE—that’s a mini mental state examination. It takes about ten minutes. I’d ask the patient a series of questions intended to screen for cognitive impairment: what time it is; the date; who the president is, that sort of thing. Also some simple calculations. I’d ask the patient to repeat a list of words to test for recall. The highest possible score is 30 points. A score of 25 or higher would indicate no impairment. Between 21 and 24 would suggest a mild impairment. I’d be most concerned about a score of 10 to 20 points, which correlates to moderate impairment. Anything under 10 indicates severe impairment and, for a patient at that level, it would be fairly obvious that there was some age-related dementia or other problem.”
“That’s the standard accepted test?”
“Yes. There are others, of course, but most gerontologists will use the MMSE. Sometimes a social worker or other non-doctor will use an abbreviated MMSE. Some doctors will create their own unique tests. Pulling from the various accepted tests.” He paused here and pursed his lips to show his displeasure. “That’s not a best practice and it can skew results dramatically.”
Sasha wondered if anyone had performed a diagnostic battery of any kind on Jed Craybill and wrote herself a note to find out.
“Since Dr. Spangler isn’t a geriatric specialist, would it be appropriate for her to administer and score a test like this?”
Dr. Kayser sighed and pushed his chair back from his desk. He steepled his fingers together and looked up at the ceiling tiles before answering. “As I’m sure you can appreciate, that’s a difficult judgment to make. Is it appropriate for a general practitioner to administer the test and interpret the results? Certainly, just as it would be appropriate for a family doctor to perform a pregnancy test or to screen a patient for hearing loss. In my view, however, the next step, if any of those diagnostic tools indicated further care was warranted, would be to refer the patient to a specialist. There are physicians who are board certified in obstetrics, audiology, and, of course, geriatric medicine for a reason.” He drew his lips into a firm, thin line when he finished speaking.
“Of course.”
“Now, if I had a patient whose score on the MMSE concerned me, I would gather additional psychosocial information, such as the presence of formal and informal support systems, including membership in a church or club, relationships with neighbors, relatives, or friends; whether the patient already received any services; and if any recent psychological stressors were in play.”
“Like the death of a spouse?”
“Absolutely.”
“After gathering all this information, you would be comfortable making a diagnosis?”
Dr. Kayser straightened his back. “Some would. And, a diagnosis based on that information would be defensible. I, however, would not. We’re talking about wresting control of a person’s life.”
“What other steps would you take?”
“For one, I would have a social worker perform a safety assessment of the living environment. Does the patient’s home have fire alarms, adequate lighting, sturdy stairs, or grab bars in the bathroom? Is the home clean and uncluttered? That sort of information.”
He stood and paced behind his desk, his hands clasped together behind his back. “Then, I would consider what services might be appropriate to provide support to enable the patient to continue to function independently. Would a walker be helpful? A medical alert necklace? Would an alarmed pill box that dispenses the patient’s medication in the correct dosage and provides reminders be useful? Could Meals on Wheels deliver food to the patient? Could the patient’s banking be automated, both for deposits and bill payment?”
He turned and faced her. “There is a wealth of services and products intended to help people age in place with dignity. In my view, these should be exhausted first. If, after all that, it is clear the patient cannot function safely without a guardian, then and only then would I get on the stand and testify that this patient is incapacitated.”
He sat back down, with a sheepish smile, like he realized he’d been up on a soapbox.
“This is very helpful background,” Sasha reassured him, then asked, “How often in your practice do you ultimately conclude that a patient needs a guardian? I mean, out of the times that someone files a petition?”
He rubbed his belly while he considered the question. “More than half the time. Sometimes, it’s just clear as day. The patient is in full-blown dementia, say. Sometimes, we can put off the determination of incapacitation for months or years by devising an appropriate care plan, but ultimately, independent daily living becomes too much for the patient. And, sometimes, a patient like your grandmother will function independently until she dies in her sleep. Of course, in her case, your mother was there to help her, if needed.”
He smiled at the memory of her grandmother, who read The New York Times every day, up to and including the day she died, and was always ready to talk politics.
Sasha smiled back, then asked the money question. “Have you ever testified in opposition to an incapacitation petition?”
He cocked his head and thought. “No. I don’t believe I have.”
“Will you?”
CHAPTER 10
Tuesday evening
Cold Brook County Commissioners’ Meeting
Drew Showalter checked the notes on the podium in front of him. Speaking at these commissioners’ meetings could be more nerve-wracking than arguing in front of an appellate panel. At least with judges, he could predict the questions and issues with some accuracy. But the county commissioners were a retired banker, a minister, and the owner of a trucking company. He never had any idea what they were going to ask him.
He snuck a look behind him. The audience was thin, at least. He saw the politics editor of the paper, the hapless Danny Trees and a handful of his people, and a cluster of retirees with nothing better to do on a Tuesday night. Maybe they’d get out of here at a decent hour for once.
Lately, the monthly meetings had been running on for hours, what with every red-faced homeowner in the county wanting to yell about too much fracking, not enough fracking, chemicals in their water, the noise, the smell, the too-lax regulations, the too-strict regulations. It was worse than the year they’d done real estate reassessments.
The acid started to rise in his throat just thinking about it. He popped an antacid and told himself to put it out of his mind. Being county solicitor was a civic duty. And a guaranteed forty grand a year.
The commissioners filed in together, whispering and gossiping. They took their seats behind the long table.
After the Pledge of Allegiance, they got down to business. It was clear sailing until they got to the declaratory judgment actions that Big Sky had filed.
Big Sky. Those guys didn’t mess around. A day didn’t go by that they weren’t suing somebody over something or other. And, of course, they used big law firms to do all the work and just hired someone in town as local counsel to shepherd the cases through the court. So, it was motion after motion, preliminary objections, and endless
discovery requests. It was like their strategy was to bury the town under paper.
Cort Garland, the retired banker, started with the questions right away.
“How can they keep filing these frivolous lawsuits? Don’t they understand we don’t have the resources to respond to all these cases?”
The business owner, Heather Price, snapped at him. “Don’t be naive, Cort. Of course they understand that. That’s why they’re filing all these lawsuits. Right, Drew?”
Heather could be a real ball buster, but he imagined being a woman in the trucking industry was no picnic. Especially a woman as drop-dead gorgeous as she was.
He cleared his throat. “I tend to agree. They’re trying to keep us on the defensive. It’s only going to get worse, I’m afraid, now that you’ve voted to consider the drilling moratorium.”
Cort jumped in, “I want the minutes to reflect that I was the lone dissent on that vote.”
Heather rolled her eyes.
Troy Benjamin, the minister, spoke up in the rich baritone that made him so popular behind the pulpit. “Now, let’s not revisit settled issues. We agreed that we need to examine whether we’re being good stewards of the bounty of resources the Lord gave us. Let’s be at peace with that decision.”
Heather rewarded Troy with one of her dazzling smiles, and he ducked his head in embarrassment.
Drew had once remarked to his wife how Heather sure could wrap her fellow commissioners around her fingers when it suited her. Betty had roared with laughter and said, “Counselor, your house is made of glass.”
Ever since then, he was self-conscious around Heather, worried that he came across like a love-struck schoolboy. It made these meetings even more trying.
Heather turned her violet eyes his way. “Counselor, what’s the process for these declaratory judgments? Are they fast-tracked or what?”
He peeked at his notes even though he knew the procedure cold. “Well, Judge Paulson has both sides’ briefs. On the moratorium issue, he also has the amicus brief filed by PORE.”
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