Finding Peace of Mind Now (and Later) with Discussing Your End of Life Care Wishes

Ben Franklin is known to have said that "but in this world nothing can be said to be certain, except death and taxes.” And just as we will pay our taxes on or before April 15th, the next day we recognize the importance of death, or at least, the importance of discussing End of Life care decisions.  

April 16th is the National Healthcare Decisions Day. 

This article will discuss a tool to let your wishes be known. I hope to persuade you to record your healthcare wishes for your loved ones, and to help them record their wishes.

There are understandable reasons to avoid 'The Conversation.' Death is a difficult topic to bring up, so we put it off to another day or never have the talk.

Just speaking in practical terms, when you decide not to have this conversation, you let someone else decide your level of comfort.

Did I say 'decide'?  I meant 'guess.'

That does not seem fair to you. After all, you have preferences.

Then consider being on the guessing end for a loved one who never expressed what they wanted at the end of life?  What if they told you, but you cannot remember because you are now scared and upset?  What if one family member disagrees with your memory of Mom's wishes and you cannot prove it?  Much of this stress can be avoided.

There can be a sense of dread, stress, and torment for someone trying to decide on behalf of a loved one.  Conversely, there can be a sense of comfort for a family when they can honor the wishes of a loved one.

A 2012 meta-synthesis of family interviews in the Journal of Hospice and Palliative Nursing by Jackson et al found "The discussion around Advanced Directives and End of Life preferences with family members prior to and during decline was strongly suggested by the majority of the families. Families did report that the more detailed the loved one's wishes were, the easier it was to make decisions at the end of life. The removal of the decision-making burden from families was noted as being one of the most important benefits of having Advanced Directives..." (Jackson 2012)

There are three common tools in advanced directives:

• Durable Healthcare Power of Attorney- Allows you to appoint who will make healthcare decisions when you are able. See an attorney for this service.

• Living Will - You can see my home state's document here. It's a government form. Need I say more? All kidding aside, take a look and compare it to my preference and focus...

• The Five Wishes document from Aging with Dignity- This is a wonderful document that I encourage everyone to consider completing to express their answers to 5 important questions:

1. Who is the person I want to make care decisions for me when I can't? (In legal terms - Durable Healthcare Power of Attorney)
2. What kind of medical treatment I want or do not want? (In legal terms- Living Will)
3. How comfortable do I want to be?
4. How do I want people to treat me?
5. What do I want my loved ones to know?

The Five Wishes is a rich guide to promoting discussion of some very meaningful decisions. Do I want my loved ones to pray by my bedside even when I am not awake? Sure! Had not occurred to me, but I'd love that. This document is accepted in 42 states (and D.C.), with 4 states requiring notarization.  The actual form does cost $5, but it's an invaluable guide and, the fee supports their mission of promoting advanced healthcare decision making. It can also be completed online. Two persons over 18 must sign as a witness to your Five Wishes, and there is a list of persons who cannot be witnesses (e.g. your doctor, a blood relative, spouse, or adopted child). Of course even with a Five  Wishes in place, there can still be some uncertainty. Having one will greatly reduce the uncertainty compared to not having one at all.

How did I complete the Five Wishes?

I completed my document with Post-It  Notes.  Over 7 days, I visited it once a day, making changes, replacing notes, and considering many options. In this process, I was able to brainstorm and not feel the pressure of completing the document in one day.  I spoke with my loved ones about my wishes, especially those who are named as healthcare decision-maker and the backup decision- makers.

Considering Your Loved Ones

While these are your choices, it is still important to consider the people who will help you carry out the wishes.  Remember your death is an emotional time for your loved ones who will do their best to carry out what you write down.  I tested some of my wishes.  For example, would my wife be upset that I preferred cremation?  Turns out she does not mind, but I would have reconsidered my choice if it bothered her. 

So here's a Blank Sample of the Five Wishes Document

Take Action

If you complete a 5 Wishes document, subscribe to the Peace with Dementia Blog, and email me that you have completed 5 Wishes by May 16, 2016, you will have a chance to win a $25 Amazon gift card. Your chances are probably very good! (No need to send your document)

If you feel this is worth sharing, please do so via email, Twitter, FaceBook, etc.

Interested in more info on Five Wishes?  Check out this interview with Aging in Dignity President, Mr. Paul Malley.

In the future, I will cover POLST  (LaPOST in Louisiana) for advanced stages of diseases. For now, the Five Wishes is something all of us over 18 should do.

NB: I have no affiliation with Aging with Dignity, publisher of Five Wishes. Just a big fan!

In Peace,

Matt

Follow me on Twitter @mwestrade PeaceWithDementia

Matt Estrade, MBA, CAPS is the Founder and Chief Mentor at Care Partner Mentoring, LLC in Covington/New Orleans, LA, USA. A more extensive biography can be found here.

Literature cited:
Jackson, J., Derderian, L., White, P., Ayotte, J., Fiorini, J., Hall, R. O., & Shay, J. T. (2012). Family Perspectives on End-of-Life Care. Journal of Hospice & Palliative Nursing, 14(4), 303-311. doi:10.1097/njh.0b013e31824ea249

Genetics and Your Risk of Alzheimer's

In my classes and support groups, I am often asked how family history affects the risk of Alzheimer's Disease (AD).  It's not a cheerful topic since we cannot change our genes, but it's a fair question that certainly deserves some discussion.

Keep in mind, what do you do if you are genetically considered a higher risk?  Will you change your lifestyle to reduce your risk? Will you live with life to the fullest and take more chances?  Will you plan your future more carefully to make the best of it?

I am not a geneticist, so it's my pleasure to reintroduce Dr. Frank Longo from Stanford who first appeared in the actionable blog post on employing regular exercise to halt brain shrinkage.

In Alzheimer's, it is known that there are two categories:

1. Early Onset AD (or Young Onset or Familial)

• Less than 2% of all AD cases
• Development of AD before age 65; onset in 40's and 50's

2. Late Onset AD

• More than 98% of all AD cases
• Development of AD at 65 or older

Genetic Risk: Young Onset 
Dr. Longo uses the novel and film "Still Alice" as a popular reference of Young Onset AD. In the story, Alice develops AD symptoms at the age of 50.  For a person with Young Onset, their children have a 50% chance of developing the horrible disease.

He goes on to discuss the more probable Late Onset AD. I will explain the handy dandy slide that is pictured below.

Genetic Risk: Late Onset 

Keep in mind that we all have 23 pairs of genes for a total of 46. The 2 ApoE genes can vary between the E2, E3, or E4, with E4 associated with Alzheimer's Disease.

No Family History (hx)

The left box on the above slide, as you can see, is for those individuals with no parent, grandparent, etc., with AD.  My grandfather Milton experienced symptoms of dementia, but we suspect that it was related to alcohol damage rather than AD.  There is no way for me to know for certain.

• Average risk of 15% over lifetime
• Without the infamous "E4" version of the ApoE gene, a 9% risk
• With the E4 version, a 30% risk

One Parent with AD

Following the chart, Dr. Longo offers three options when having one parent with AD:

• You have no copy of the E4, 30% risk
• You have 1 copy of the E4,  45% risk
• You have 2 copies of the E4,  60% risk

Do You Want to Know if You Have the ApoE4 genes?

There are tests to find out if you have the E4 version of the ApoE pair of genes.  Dr. Longo mentions the company 23andMe who will allow you to send a sample of alive for a genetic analysis.  At the time of the presentation in 2015, 23andMe was shutdown by the FDA. Even though they are now allowed to resume genetic testing, they will not offer analysis of the ApoE gene pair if you are from Canada.  If you would like to see a Canada ApoE sample report with plenty of disclaimers, click here.

While I am currently not interested in knowing if I have the E4 version, I can see how some would like to know.  It's important to consider your potential benefits and potential disadvantages.  A clean diet and regular exercise are two prudent ways to potentially reduce the risk of AD and many other diseases. 

Now you...I'd love to hear your comments - would you want to know what variants of the ApoE gene that you have and what drives your answer?

In Peace, 

Matt 

*PS- Subscribe and share this blog article (then let me know at Matt@CarePartnerMentoring.com) and I'll email you links to more videos and information on genetics and dementia.   

Matt Estrade, MBA, CAPS is the Founder and Chief Mentor at Care Partner Mentoring, LLC in Covington/New Orleans, LA, USA. A more extensive biography can be found here. 

Could the Key to Reversing Dementia be Challenging but Attainable?

In 2014, Dale Bredesen, MD published a paper documenting a study of 10 people following a non-pharmaceutical regimen to improve their "memory loss associated with Alzheimer's disease (AD), amnestic mild cognitive impairment (aMCI), or subjective cognitive impairment (SCI)" (Bredesen 2014). Among the many elements of the regimen, included a low grain diet, 8 hours of sleep nightly, exercise most days of the week, and several over-the-counter supplements.

Let me point out that this is considered an anecdotal study even by Dr. Bredesen, meaning that it was not designed with the scientific rigor of a prospective randomized control trial (RCT).  I discuss RCTs in this post on the positive impact of exercise on your brain health. In his summary, Dr. Bredesen mentions the need for more research in this area, including a controlled trial.

Of the 10 study participants, all of whom exhibited symptoms of memory challenges, 9 of them showed "subjective or objective improvement" after 3-6 months (Bredesen 2014).  Six of the participants who had to exit the workforce because of their condition were able to return to work after treatment. One person of the nine showing improvement never left the workforce and continued to work effectively.  Three of the ten were not working and did not seek employment. The one person who did not show improvement had severe dementia.

The diet described in this novel study sounds very close the Primal Blueprint (PB) diet from Mark Sisson of Mark's Daily Apple.  This lifestyle encourages eating similar to what our ancestors consumed prior to processed foods.  The diet includes wild-caught fish, grass-fed animals and their products, healthy fats, vegetables and fruit, a night's good sleep, and exercise. Of course, there are other popular diets that have a similar sugar-limiting feature.  I just know the most about the PB.

It's March of 2016 and there is no significant treatment for Alzheimer's or related dementias.  I encourage you to bring the article to the attention of your physician and discuss how it may help you.  My hope is that he or she encourages you, given the fact that there are little to no side effects to sleep, exercise, and a diet absent of processed foods.  The no- or low-grain part can still be controversial as well as healthy fats, but I encourage you to do your own research as I have, and choose for yourself.  After all, I am not a dietician.

This lifestyle described in Dr. Bredesen's study is challenging to follow, but I am excited to see how future studies will inform us.  It seems to me that this has the potential to reverse cognitive decline in dementia for some people, and perhaps be a key to prevention or a reduction in risk for many of us.  This has motivated me to modify my eating habits for the past 40 days. Losing excess body fat and feeling better...I'll take these as side effects.

Bredesen, D. E. (2014). Reversal of cognitive decline: A novel therapeutic program. Aging Aging, 6(9), 707-717. 

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In Peace,

Matt

Matt Estrade, MBA, CAPS is the Founder and Chief Mentor at Care Partner Mentoring, LLC in Covington/New Orleans, LA, USA. A more extensive biography can be found here.

Book Review: A View from Within: Living with Early Onset Alzheimer's

A Review of "A View From Within: Living with Early Onset Alzheimer's"

Title: A View from Within: Living with Early Onset Alzheimer's

Author: Dr. Thaddeus M. Raushi, Ph.D.

Publisher: Northeastern New York Chapter of the Alzheimer's and Related Disorder's Association, Inc. 2001

What is it like to have probable Alzheimer's Disease? Not just what are the signs, but what is it like? How does it feel? When he wrote this powerful book, Dr. Thaddeus Raushi was in the early stages of probable Alzheimer's at age 57 (which is young for AD), as well as someone with Waldenstrom's macroglobulinemia (an incurable lymphoma cancer) since age 55. Until retiring because of his condition, Dr. Rausi was a college counselor. After retiring and at the time of writing this book, he continued to coordinate regional cancer support groups and served as a volunteer with the Alzheimer's Association.

Who will benefit from this book?  First, persons who are experiencing dementia, especially those experiencing Young Onset/Early Onset, may feel validated when reading Dr. Raushi's experiences.  Care Partners of all types will also benefit by gaining insight into what AD is like for one person.  These insights could foster understanding of a disease that is so hard to appreciate from the outside.

A View From Within is heartfelt and well-written. I imagined as though I was next to Dr. Raushi having a dialogue with him. He would share a concept or example, I would think of a follow up question, and he would answer it in the next sentence or paragraph. This made the book very easy to read.

Some of the most meaningful topics to me include:

• Blessing of being diagnosed while he could still plan his life and care wishes
• What conversations with others are like and the exhaustion after trying to keep up
• What not to say when someone says they memory challenges
• The difference of forgetting keys-like everyone does-versus probable AD
• The unfortunate "Labeling" of AD and moving from "person to patient" ( p 62-63 )
• The need to grieve losses in order to deal with them appropriately, rather than to deny them
• Why he does not pray to have the disease removed

There are many more insights I could share, but the best person to do this is Dr. Raushi in his own words.

At the moment, this book is out of print and according to staff at the Northeastern New York Chapter of the Alzheimer's Association, there may be a few copies around the office. It is my intention to connect with the Chapter and encourage them to republish it in Kindle and other media. The book is worth finding used on Amazon.  If I learn of more copies and any interest in a Kindle version, I will update you.  I hope you will sign up for updates to the blog for the new developments.

Special thanks to Dr. Kathleen Rusnak, Ph.D. who brought it to my attention as I listened to the CD audiobook of her lecture "Before They Forget: Maximizing the Spiritual Possibilities of Alzheimer's" (2005 The Brick Wall 2, Inc.).

Take Action:

• Tell me what you think of this review - leave a comment
• Get the book and read it or share with someone who may appreciate it.
• Share, Like, and +1 this article.
• Like us on FB and visit our website for a list of local classes, discussions, and services.

In Peace,

Matt 

Matt Estrade, MBA, CAPS is the Founder and Chief Mentor at Care Partner Mentoring, LLC in Covington/New Orleans, LA, USA. A more extensive biography can be found here.

Why I am Here: The Social Model of Dementia Care

I prefer to keep my articles focused away from me and to place a spotlight on persons living with dementia (PLwD) and their care partners.  At the same time, I think a self-indulgent post may be in order to tell the reader why I have dedicated my life to helping others find "Peace with Dementia" as I like to call it. This is more of an opinion article; while the sample interventions are based in science, I will cite very few sources.

If you visit my website, you will see a dedication to my Grandfather Milton Ragas who had some type of dementia in his last years and my Mom, Yvonne who advocated for him and coordinated his care.

While this was a catalyst for my calling, it does not explain my philosophy of Peace with Dementia.

I started my graduate studies in Gerontology under the direction of Christopher Johnson, PhD who enlightened me to the social model of dementia care.  Dr. Johnson is doing amazing things in a new dementia program at Texas State University. In short, the social model focuses on the person with dementia as a whole person, still capable of joy, fear, pain, delight, and other feelings.  The social model does not contradict, but does differ from the biomedical model of dementia care that focuses on medical treatment and drugs.  Ideally, the two models work together, caring for the body (biomedical) and the mind and spirit (social).  The current system is built upon a biomedical model, leaving a need for some balance and an enormous potential for increased healing through the social model.

Examples of the social model, like non-pharmacological interventions, take time, effort, patience, and empathy.  Examples of these interventions are:

• Studying a person's life history and personality to discover meaningful activities to delight the PLwD;
• Understanding that "problem behaviors" are typically the PLwD communicating a need, not trying to annoy his care partners;
• Discovering the root cause of these behaviors, which could be physical (untreated pain or discomfort) or emotional (fear and confusion where their parents are; a veteran dealing with combat trauma); 
• Using personalized music (Gerdner) to sooth patients who are agitated or combative;
• Utilizing meaningful activities to engage PLwD who are an elopement risk (wandering risk);
• Utilizing Validation Therapy (Feil) with much older PLwD trying to resolve a traumatic past;
• Care partner support groups and groups for persons with early onset dementia;
• and more...

While the above sample do not include pharmaceuticals, they do not necessarily exclude responsible use of drugs. What they always do include is what I mentioned above:  time, effort, patience, and empathy.

The social model fascinates me and it is my calling to educate and collaborate with all care partners who are willing to make the effort: family, friends, professionals, and staff.  In this journey, I appreciate and give credit to those researchers who came before me to discover these methods and credit to practitioners and family members who use these interventions everyday, even though it means more effort. They "get it." I am very blessed to be able to email back and forth with some of these leading researchers and teachers.

The social model means some potential frustration and much trial & error for care partners. It means learning from each person with dementia, the expert.  When one method does not work, we try another. Time, effort, patience, and empathy. The upshot is that when care partners are successful in these methods, the satisfaction and accomplishment is incredible.  Another benefit is saving time.  If you can use non-drug methods to sooth a combative PLwD, you are looking at lower risk of injury (which is amazing alone), as well as not having to document an incident. Stated another way, you are going to spend time somewhere and it may as well be in prevention of combative behaviors rather than the aftermath.

With Care Partner Mentoring, LLC,  I see my mission as four-fold:

1. Listening to the care partner; 
2. Educating & training with the care partner; 
3. Persuading the care partner to take action;
4. Encouraging the care partner when times are tough.

Persons with Dementia are whole persons, not a 'shell of a person' as we are conditioned to believe.  They were care-free children once, most raised families, many founded businesses and served others, and were community leaders. They deserve our love and attention.  As a care partner, you will have good days and bad days like they do.  Perhaps if you end up in the same position, someone will care for you this way.  If you agree with my perspective, we are on the same team and I hope you stay connected with me.  If you do not share my perspective, I hope you read more to consider these ideas.  

We need a very large team.

Thank you for reading my story and hope you will subscribe for updates and like my FB page for other updates.

In Peace,
Matt

Action Items:

• Add a comment or question.  Do you "get it" ?
• Share, Like, and +1 this article.
• Like us on FB and visit our website for a list of local classes, discussions, and services.

Matt Estrade, MA, MBA,  is Gerontologist and Founder/Chief Mentor at Care Partner Mentoring, LLC in Covington/New Orleans, LA, USA. A more extensive biography can be found here.






  

Fluctuating Awareness in Dementia and Why It Matters to Care Partners

Persons Living with dementia (PLwD), with their fluctuating memory, can confuse and frustrate even the most patient care partner. One day their loved one with dementia correctly recognizes them as their daughter. Days (or even moments) later, they think their daughter is their (now 86 year old) sister, or deceased mother. It can be heart breaking as when my grandfather did not recognize my mother Yvonne when he had dementia in the late 1990’s. Some days he knew her and other days did not. I can only imagine how frustrating this was for my Mom.  

If we as care partners experience this roller coaster, it can be easy to think that our loved one with dementia is doing it on purpose or can snap out of it if we just correct them.

In the April/March 2000 issue of the American Journal of Alzheimer's Disease, my mentor Dr. Chris Johnson and his wife Dr. Roxann Johnson published an important way of looking at why persons with a dementia do this. In their article “Alzheimer's Disease as a Trip Back in Time, ” Drs. Johnson and Johnson discuss that a person with dementia can turn back the clock in their mind, with their state of memory regressing to that of their 60’s, 50’s, 40’s and so on until in their mind they are children.  What makes the Johnsons' model unique is that the regression of memory is not a straight line moving backwards in time only, but contains loops to mean your loved one with dementia can travel back and forth in time.  

As mentioned in their paper, Drs. Johnson and Johnson are building upon the previous work of Paiget, Thornbury, Reisberg, and Kuhn.

Why is this model or perspective matter? 

• It is significant because if care partners understand that their loved one is on a trip back in time, they may better be able to join them on their journey.  It is not realistic or practical to try and get them to leave their journey and meet you. This correcting can bring about increased frustration, agitation, and further confusion. Their brain is impacted in a way that not even our best lecturing will overcome. Perhaps correcting makes us feel better because we do not know what else to do.

• The model also can help care partners understand that there can be variations in their loved one's perspective of time. Perhaps, this understanding can lead to more flexibility on part of the care partner and remind them that the "only constant is change."

• As stated in the article, this model may "caution against overestimating or underestimating the capabilities" of PLwD. It's very easy to assume that they can do something correctly because they did it correctly yesterday. This assuming may now be overestimating their abilities today. The same can be said if we assume that the PLwD cannot do something today because yesterday they could not. While it's difficult to truly understand unless you are a care partner, it is probably easy for the reader to sense that the constant changing of abilities and unpredictability can be frustrating.

So how do you join them on their journey when they are not in the present day? 

Here are a few quick tips to get you started. Look for more details posts in the future.

• Avoid contradicting or correcting them.
• Find ways to validate the PLwD and set them up for succeeding in what they do.
• Ask open-ended questions about the topic that they are talking about - let them do most of the talking.
• Jot down their phrases and track their time travel over a week or more. When you are not frustrated, review and think about ways you could have respond so you are prepared for next time.
• Be ready for some tough requests or questions, such as “Where is my mother?” when she died 20 years ago or “I want to go home,” when they are home. In short, your loved one is expressing a need to feel the security of a parent like they did when they were young.  A good first effort is to get them to talk about their mother or home (whichever home they mean).

Action Items:

• Read the abbreviated article here with the author's permission.
• Read the full article here with the author's permission.
• See Dr. Chris Johnson's profile here.
• Add a comment or question. 
• Share, Like, and +1 this article.
• Like us on FB and visit our website for a list of support groups and services.Matt 

Matt Estrade, MA, MBA is the Founder and Chief Mentor at Care Partner Mentoring, LLC in Covington/New Orleans, LA, USA. A more extensive biography can be found here.

Delighting Persons with Dementia with TimeSlips Storytelling

If there was an activity that you could offer your loved one or offer a client with dementia that would bring them delight and potentially improve their mood, would you do it?  

I am glad you said “Yes!” because there is such an activity if you are ready to learn the process, prepare for the activity, and have some fun.  It is called TimeSlips (TS) and was created by Professor of Theatre, Anne Basting at the Peck School of the Arts, the University of Wisconsin-Milwaukee in 1998.

In full disclosure, I am a bit biased as the first and now 1 of 2 Certified TimeSlips facilitators in my state of Louisiana (LA). I think we need 25, then 50, then 100 facilitators here even if that means less TS freelance opportunities for me. I will not possibly keep up with the demand when residences and facilities catch on to this. So, I encourage others to join our ranks - family members, volunteers, and professionals alike.

To see the TimeSlips Storytelling activity in your mind, imagine a room (free of distractions) with 6-12 persons with a dementia - varying ages and varying levels of cognition. The “storytellers” are seated in a half circle with a facilitator at the front of them, equipped with a white flipchart pad on easel and some markers.  Everyone has a nametag sticker on.  To start the session I distribute a picture printed on 8.5 x 11 paper (cardstock when possible) to each storyteller.  The Leaping Cowboy in this post is an example of a picture I use. I simply explain that we are going to create a story based on the picture. “I will ask you some questions and write down all of your answers with names of the contributor.  There are no wrong answers :) Let’s have fun.” For the next 20 minutes, the storytellers are engaged. They are laughing. They are joking.  They are happy.  In the end we have the flipchart page filled with a story that they are proud of.   As facilitator, I have put them in charge in creating something special.  After 1 or 2 stories, I shake each storyteller's hand and thank them for their input.  The smiles and reciprocated thank you’s are gold for a facilitator. 

You can enjoy my fun stories from my storytellers here.

Why does TimeSlips have this delightful effect on these groups that are so diverse, but who also have much in common? As the the TimeSlips staff will tell you, the activity does several things:

• Presents a fun challenge
• Returns a role back to people who have had so many roles taken away by dementia and then by society
• Strengthens the relationships of the storytellers
• Strengthens the relationships between the storytellers and staff, when the staff see the abilty of the storytellers.
• The Storytellers are engaged with a purpose and have their ideas validated.

Please check out this 2014 research article in the American Journal of Alzheimer's Disease and Related Dementias on TimeSlips Storytelling. 

Stay tuned to a future post describing my experiences as a Certified TimeSlips Facilitator, including some of the feedback from the Storytellers and Staff. In the meantime, please take action with this information. It is not enough to fill your head with interesting stuff!

Action Items:

• Watch this TEDx event with founder Anne Basting. 
• Read the stories that I have facilitated.
• Hear a 5 interview with facilitator Liz Nichols as she explains TimeSlips.
• Consider becoming a TimeSlips facilitator to make a difference in your family or in your facility.
• If you are a staff member, read more about TimeSlips and approach your leaders about becoming Certified Facilitator. Share the research article.  If management somehow says "no," be a leader for change and do it anyway on your time and on your dime.  Introduce it to your residents, invite the leaders, and show them it works. It can have a high impact and is not costly.  
• If you are a Family member with a loved one in a facility, ask management if they will bring TimeSlips to the residence. If not, ask why.  Be persistent. I hope that one day this is a program that residences can use to demonstrate how dementia-friendly they are. 

• Add a comment or question. 
• Share, Like, and +1 this article.
• Like us on FB and visit our website for a list of support groups and services.

Matt Estrade, MBA, CAPS is the Founder and Chief Mentor at Care Partner Mentoring, LLC in Covington/New Orleans, LA, USA. A more extensive biography can be found here.