HomeMy WebLinkAbout07-15-15 .'v
Neil W. Yahn,Esquire M
Attorney I.D.No. 82278 ?
JSDC Law Offices r~ F._,
P.O.Box 650 ._ w CT) r-1
r. V r ,-y
Hershey,PA 17033 <
Attorneys for Petitioner r=, . � `n it
C.0 r= M
IN RE: CALENE M. CLOUSE, ) IN THE COURT OF COMMON'PLEA$,, ,
an alleged incapacitated person ) CUMBERLAND COUNTY, PENNSYEVANIA7
ORPHANS' COURT DIVISION
On the Petition of )
J. Edward Clouse ) NO. 21-15-93
PETITIONER'S RESPONSE TO THE PRELIMINARY OBJECTION IN THE NATURE
OF A DEMURRER/MOTION TO DISMISS FILED BY CALENE M. CLOUSE
AND NOW comes the Petitioner, J. Edward Clouse (herein"Edward" or"Petitioner"),
by and through his attorney,Neil Warner Yahn, Esquire, of JSDC LAW OFFICES, who upon
valid information and belief hereby submits the below Response to the Preliminary Objection in
the Nature of a Demurrer/Motion to Dismiss filed by Calene M. Clouse (herein"Calene") as
follows:
1. Admitted in part and denied in part. It is admitted that the matter before this
Court began with the filing of said Petition, however, Calene's capacity began to decline
significantly in or about August of 2014 (and likely before) whereby she was admitted for a stay
at Haven Behavioral Hospital.'
2. 20 Pa.C.S.A. § 5511(a) is a writing which speaks for itself. As such, no
responsive pleading is required. To the extent a response is required, all averments herein are
specifically denied. Strict proof thereof is demanded at trial. By way of further answer, Petitioner
1 By way of further response,Petitioner hereby incorporates all facts,averments,references and exhibits from his
Petition to Adjudicate Incapacitated and Appoint Plenary Guardian of the Person and Estate(herein the"Petition"),
the Motion for Status Conference and the Motion for Hearing and Evaluation previously submitted before this
Honorable Court as if fully set forth in full herein.
specifically denies the averment or implication that the Petition herein should be dismissed.
Calene is confusing the factual contents of the initial Petition with the necessary evidential
support regarding capacity. See Responsive Paragraph 5 herein.
3. The cited cases are writings which speak for themselves. As such, no responsive
pleading is required. To the extent a response is required, all averments herein are specifically
denied. Strict proof thereof is demanded at trial. By way of further answer, Petitioner specifically
denies the averment.or implication that the Petition herein should be dismissed. Once again;
Calene is confusing the factual contents of the initial Petition with the necessary evidential
support regarding capacity. See Responsive Paragraph 5 herein.2
4. 20 Pa.C.S.A. § 101 is a writing which speaks for itself. As such, no responsive
pleading is required. To the extent a response is required, all averments herein are specifically
denied. Strict proof thereof is demanded at trial. By way of further answer, Petitioner avers that
Calene is an"incapacitated person" as defined in 20 Pa.C.S.A. § 101 consistent with the medical
evaluation completed by Dr. Robert Howse, MD (herein"Dr. Howse") on or about October 23,
2014 and memorialized in his report dated June 12, 2015 as set forth in the attached Exhibit"A".
See Responsive Paragraph 5 herein.
5. Denied as a conclusion of law to which no responsive pleading is required. To the
extent a response is required, all averments are specifically denied. Strict proof is.demanded at
2 It should be noted that Calene neglects to inform this Honorable Court that even in the cited caselaw(Estate of
Wood,533 A.2d 772,775 (Pa. Super. 1987))the Court therein held a hearing with respect to the competency(or lack
thereof)of the alleged incapacitated person.At said hearing,both lay individuals as well as a licensed psychiatrist
presented testimony regarding the health and circumstances of the alleged incapacitated person.Calene's present
Preliminary Objection/Motion to Dismiss seems to set forth an erroneous conclusion that the initial petition should
be the only conclusive evidence of incapacity which is wholly inapposite to the process and procedures of
guardianship matters. In short,the.adjudication of Calene's capacity(or lack thereof)is a matter to be addressed by
this Honorable Court after a hearing in which testimony is presented by the necessary professionals(Dr.Howse,Dr.
Royer,etc.).
trial. By way of further answer, Calene is confusing the factual contents of the initial Petition
with the,necessary evidential support regarding capacity. The Petition meets all of the essential
factual and content requirements of 20 Pa.C.S.A. § 5511(e). Evidence of incapacity can be
supported by"...testimony, in person or by deposition from individuals qualified by training and
experience in evaluating individuals with incapacities of the type alleged by the petitioner, which
establishes the nature and extent of the alleged incapacities and disabilities and the person's
mental,.emotional and physical condition, adaptive behavior and social skills" consistent with 20
Pa.C.S.A. § 5518. Accordingly, Petitioner has not only presented the opinion of Dr. Bowers,but
has also.obtained the evaluation completed by Dr. Howse who opines that Calene clinically lacks
the necessary capacity for decision making, rendering her unable to appreciate the consequences
of designating an agent under a power of attorney instrument as well as unable to comprehend
the contractual nature of changing her estate planning documents (see Exhibit"A"herein). In
addition, this Honorable Court,by Order dated June 22, 2015,has also ordered an independent
evaluation, consistent with 20 Pa.C.S.A. § 5511(d), to be completed by Dr. Christopher D. Royer
in advance of the Plenary Guardianship scheduled for August 21, 2015. As a result, for Calene to
now aver that evidentiary support for capacity is limited to the opinion of Dr. Bowers is absurd.3
3 By way of additional support,it is commonplace in guardianship proceedings to have multiple evaluations
performed,particularly when there are conflicting opinions by and amongst the medical professions.For example,in
Cunningham Estate(16 Fiduc.Rep. 509(Del.Orph. Ct. 1966)),where evidence as to incompetency was conflicting,
the Court therein selected an impartial physician to examine the alleged incompetent and relied upon his report to
eventually appoint a guardian.As outlined,Calene is confusing the factual contents of the initial Petition with the
necessary evidential support regarding capacity,which is not limited to the opinion of Dr.Bowers.
6. The Petition as well as the opinion of Dr. Bowers are writings which speak for
themselves. As such, no responsive pleading is required. To the extent a response is required, all
averments herein are specifically denied. Strict proof thereof is demanded at trial. By way of
further answer, see Responsive Paragraph 5 herein.
7. Denied as a conclusion of law to which no responsive pleading is required. To the
extent a response is required, all averments are specifically denied. Strict proof is demanded at
trial. By way of further answer, see Responsive Paragraph 5 herein.
8. The Petition as well as the opinion of Dr. Bowers are writings which speak for
themselves. As such, no responsive pleading is required. To the extent a response is required, all
averments herein are specifically denied. Strict proof thereof is demanded at trial. By way of
further answer, see Responsive Paragraph 5 herein.
9. The Petition as well as the opinion of Dr. Bowers are writings which speak for
themselves. As such, no responsive pleading is required. To the extent a response is required, all
averments herein are specifically denied. Strict proof thereof is demanded at trial. By way of
further answer, see Responsive Paragraph 5 herein.
10. The Petition as well as the opinion of Dr. Bowers are writings which speak for
themselves. As such, no responsive pleading is required. To the extent a response is required, all
averments herein are specifically denied. Strict proof thereof is demanded at trial. By way of
further answer, see Responsive Paragraph 5 herein.
11. 20 Pa.C.S.A. § 101 is a writing which speaks for itself. As such, no responsive
pleading is required. To the extent a response is required, all averments herein are specifically
denied.-Strict proof thereof is demanded at trial. By way of further answer, Petitioner avers that
Calene is an"incapacitated person" as defined in 20 Pa.C.S.A. § 101 consistent with the medical
evaluation completed by Dr. Robert Howse, MD (herein"DY. Howse") on or about October 23,
2014 and memorialized in his report dated June 12, 2015 as set forth in the attached Exhibit"A".
See Responsive Paragraph 5 herein.
12. Denied as a conclusion of law to which no responsive pleading is required. To the
extent a response is required, all averments are specifically denied. Strict proof is demanded at
trial. By way of further answer, see Responsive Paragraph 5 herein.
13. Denied as a conclusion of law to which no responsive pleading is required. To the
extent a response is required, all averments are specifically denied. Strict proof is demanded at
trial. By way of further answer, see Responsive Paragraph 5 herein.
WHEREFORE, Petitioner respectfully requests that this Honorable Court enter an Order
denying the Preliminary Objection/Motion to Dismiss with prejudice and continuing with the
Plenary Guardianship Hearing previously scheduled for Friday, August 21, 2015 at 9:00 a.m.
Respectfully submitted,
JSDC AW OFFICES
Date:
By:
NeJSipeAve
Esquire
o. 82278
13ue
HuPA 17036
(710
A etitioner
Lancaster General Health Physicians
Geriatrics
Neil Warner Yahn
James, Smith, Dietterick&Connelly
PO Box 850
Hershey, PA 17033
Email: NYahn@jsdc.com
Fax:717-533-7771
cc:Robert Howse MD
Dear Mr.Yahn,
Thank you for the opportunity to evaluate Calene M Clouse of 4 East Linden Drive, Carlisle PA
17015 at the same address on 1012312014.This is her home. 1, her husband Ed Clouse,and
Calene M Clouse were present. She is a left handed 74 year old with a date of birth of
1212911939. She completed 12 years of education.The client was cooperative.There was not
Interference from anyone with the evaluation. informed consent was offered. She did not
understand and did not remember the consent for the duration of the interview. No medical or
psychiatric records were available for my review.The Montreal Cognitive Assessment Score
was 18 of 30 consistent with her presentation of moderate dementia.The PHQ-9 score for
depression was zero.The AUDIT score for alcohol use was zero.The interview was 3 hours in
duration. No particular formal testing protocol is recognized as the gold-standard for capacity
evaluation.These tests were evaluated in conjunction with the interview, collaborative
information and medical information in order to form and an opinion about this client's capacity
for self-directlon with a commitment to the preservation of the personal dignity that is achieved
by the least restrictive level of supervision. These opinions are rendered with a reasonable
degree of medical certainty.
There is not evidence of physical abuse.
There is not evidence of sexual abuse.
There is not evidence of emotional abuse.
There is not evidence of financial exploitation.
There is evidence of physical neglect. It is self-neglect.
There is not evidence of financial neglect.
Calene M Clouse's diagnosis Is most consistent with a diagnosis of Dementia of Alzheimer's
Type without behaviors. There are multiple cognitive deficits manifested by memory
impairment, and aphasia,apraxia, agnosia,,and disturbance in executive function showing
problems with planning, organization, sequencing and abstracting.These deficits are insidious,
progressive and have decremented this person's social and occupational functioning.
She may have, and is certainly at risk for, Lithium Induced Encephalopathy as a cause of
Dementia Not Otherwise Specified without Behaviors.This diagnosis should be considered
given her gait disorder, incontinence and long term lithium use. Magnetic Resonance Imaging
Non-Contrast brain and potentially subsequent PET scanning should be pursued to assist with
diagnostic accuracy.A review of her records to search for episodes of laboratory confirmed
2112 Harrisburg PHw,sine 312
Lancaster PA 17601 717-5443022 • 717-544.3021 Fax
www.LGHea1thPhys1dans.org
z�rz scot-z6-90 WdLE:LE:i:a 11,90VOLtL
Calene M Clouse
DOB: 1Z129f 1939
Page 2 of 11
toxicity, or long lapses in lithium level laboratory testing may yield clues to this diagnosis.
However,this level of accuracy is not needed for the determination of her decision making
incapacity.
The syndrome of irreversible lithium effectuated neurotoxicity(SILENT) consists of prolonged .
neurologic and neuropsychlatric symptoms following lithium toxicity. In typical cases of SiLENT,
neurologic toxicity develops along with an elevated lithium concentration, but symptoms persist
despite successful removal of the drug.
Cerebellar dysfunction, extrapyramidal symptoms, brainstem dysfunction, and dementia can
develop as part of SILENT. Other neurologic sequelae may include nystagmus, choreoathetoid
movements, myopathy,and blindness.A review of 90 published cases identified cerebellar
dysfunction as the most common sequelae, and proposed that demyelination at multiple sites in
the central nervous system may be the cause.SILENT can continue for months and in rare
cases effects persist for years.
I understand from you that her functional status has declined since my evaluation on
1012312014. 1 would be happy to re-evaluate her if you desire. However, a decline in functional
status would not be consistent with recovery of decision making capacity. I am unable to
provide you with the names of other persons who perform capacity evaluations, as i do not
know of any.
Her ability to make a choice is impaired.
Her understanding Is poor.
Her appreciation is nearly absent.
Her reasoning is variable, unreliable, easily swayed,inconsistent, idiosyncratic and sometimes
delusional.
Calene M Clouse lacks capacity for decision making permanently on the basis of this
diagnosis. I recommend the appointment of a plenary guardian of her person,finances, and
level of cane.Calene M Clouse will not recover decision making capacity in the future. In my
best medical opinion, Calene M Clouse lost this capacity by the time of her 08/2014 psychiatric
admission. Her functional status has not completely recovered since this time. I do not have the
exact date of her admission.
Calene M Clouse Is able to appear in court.
1 recommend a routinely scheduled guardianship. Calene M Clouse is not at high risk for
irreversible disability or death in her present circumstances. Stabilization of the situation can be
expected with ongoing supervision by a guardian. Her husband is ill,and has an uncertain
prognosis from prostate cancer,and may not be the best choice of guardian for this reason.
Other capable family members or a third party guardian could be considered.
Calene M Clouse was not able to answer the following questions regarding finances,a financial
agent and power of attorney.
Which bank do your use?She has no idea.
Which accounts to you have there?She has no idea.
Do you have an Income?She has no idea.
How much income to you have?She has no idea.
is this enough for you to live on?She has no idea.
What are your income sources?She has no idea.
2112 Harrisburg Pose.Suite 312
Lancaster PA 17601 . 717-544.3022 , 717-544.3021 Fax
www.LGHealthPhys!cians.org
Zt'E Sloe—Zi-90 w*d0S:je:Z0 11,90"011,1
Calene M Clouse
DOE: 12/29/1939
Page 3 of 11
Do you balance your checkbook?She rambles.
Do.you need help balancing your checkbook?She has no idea.
Who helps you.manage your checkbook?She has no idea.
What do they do to help you manage your checkbook? She has no Idea.
Hour do you balance you checkbook?She has no idea.
Do you have savings?She has no idea.
How much do you have in savings?She has no idea.
Do you have investments? "I have three million dollars I think."This is inserted in other
rambling.
How do you manage your investments?She has no idea.
Do you have bilis?She has no idea.
Which bills do you have?She has no idea.
How much are your bills?She has no idea,
Do you have debts?She has no idea.
Which debts do you have?She has no idea
How much debt do you have?She has no idea.
Do you own your home?"Yes."Is there a mortgage?"No, I own it. It is mine."
Do you own a car?"Yes.I drive all the time. Or someone drives me. I don't drive so much
anymore. But I can if I want to. I am a good driver. I don't always want to drive."
Is anyone misusing your money?"No. I manage all my money without help."
Are you giving money to anyone?She has no idea.
Do you play the lottery?She has no idea.
Are you making donations to charities?She has no idea.
Do you have a power of attorney for your financial decisions?This had to be explained several
ways. "No. I can do that all by myself."What about when you are sick?"No, I can always do it.I
am not sick that much. If I am, I can tell someone to do it."And who would that be. "Whoever I
ask, because I don't need help.They will do what 1 say."How would they have access to your
accounts?"I would tell what to do and they would do it"Do you have any agreements with the
bank or your Investment companies that allow other people to withdraw money or pay bills for
you?"I don't need that."Did you ever create paperwork or documents that allow someone to
help with your accounts and bills?"No, I never did that. I don't need to. They will do what I say."
Who might you name as someone to make decisions about your finances if you ate too ill to do
so yourself?There was a long silence.Then there was rambling. I repeat the question."Maybe
my husband."
Do you trust him to act In your best interests?"Yes."
Why do you believe this person to be trustworthy?"Yes:'
Do you trust this person to make decisions you would have made for yourself if you were able
to do so?"Yes."
Have you discussed your wishes with your surrogate decision maker?"No."
When was the last time your discussed your WShes with your surrogate decision maker?"We
never discussed it"
Later in the interview she expresses distrust of her husband handling her affairs because she
believes he sold property of hers and put it in his name.
Power of attorney documents were not available for my review. She did not explain the creation
or absence of the documents.
Calene M Clouse Is not able to designate an agent and make a power of attorney nor can
2112 f1wisburg Pike,Supe 312
Lancas%t PA 17801 . 717-544-3022 • 71745443021 Fax
www.LGHeafthPhysiclons.org
Zt/4 StOt-tt'90 'ur'd40:Z£:ZO LMVOLIL
Calene M Clouse
DOB: 12/29/1939
Page 4 of 11
she change an agent or power of attorney.She is not able to choose between disparate,
potential courses of action. She is not able to understand their financial obligations and
opportunities. She is not able to appreciate the consequences of designating an agent and the
import of the power of attorney instrument. Her reasoning is not intact. She is not able to apply
her long term personal goals and values to these choices regarding an agent and a power of
attorney. in my best medical opinion,Calene M Clouse lost this capacity by the time of her
0812014 psychiatric admission. Her functional status has not completely recovered since this
time. I do not have the exact date of her admission.
Calene M Clouse was not able to adequately answer these questions regarding a testamentary
will:
Do you have a testamentary will?"Yes"
What are the legal ramifications of your will?"The people I want will get my things when I dle."
Who are your heirs?"My two daughters."
Why did you choose them as heirs?'"They are my daughters.Who else would I choose?"
What are your assets?"About 3 million dollars,and the house and the car."So what would that
add up to?She has no idea.
Who created and filed your documents?She has no idea.
How are the assets to be divided?"Well, now that one died, equally between the others. I may
have some other small parts to given to some charities or other people."Who would they be?"I
don't remember. Its been a long time since I looked at it."
Who is the executor? "My husband."
Why did you choose them as executor?"He is a businessman."
There is no collaborative information for me to review. Calene M Clouse has a weakened
intellect and Is prey to designing individuals.
Testamentary will documents were not available for my review. She did not entirely explain the
creation or absence of documents.
Calene M Clouse Is not able to make and change a testamentary will.She is perhaps able
to correctly identify her assets, suis juris heirs, and comprehend the contractual nature of the
instrument, but has a weakened intellect and is prey to designing individuals. In my best
medical opinion, Calene M Clouse lost this capacity by the time of her 0812014 psychiatric
admission. Her functional status has not completely recovered since this time.i do not have the
exact date of her admission.
Calene M Clouse is not able to handle small sums of money.Alternative arrangements
include the supervised use of small sums of money, supervised use of a debit card,
unsupervised use of non-essential income which can be misspent or lost,pre-payment of
regularly used personal items. It Is my opinion that she lost this ability by the time of her
0812014 psychiatric admission. Her functional status has not completely recovered since this
time. i do not have the exact date of her admission.
Calene M Clouse was not able to answer the following questions about their role as the agent
for another person.
Are you the representative payee,executor, power of attorney or guardian for anyone?"I don't
know."
2112 Harrlsburg Pike.sine 312
Lancaster PA 17601 717.544-3022 • 717-544-3021 Pax
www.LGHeafthPhysicians.org
ZLlS SLOZ-ZL-90 'W'dBl:tE:ZO LL90 OL LL
Calene M Clause
DOB: 12/29/1939
Page 5 of 11
Can you state the duties of an appointment?She has no idea.
What does it mean for you as an agent to act In the best Interests of the principal?She has no
Idea.
What does it mean for you as an agent to not mix your accounts with the principal's accounts?
She has no idea.
What does it mean for the agreement to be legally binding?She has no idea.
What are the legal penalties if you fall to abide by the agreement?She has no idea.
Calene ilA Clouse does not have the capacity to act as an agent or surrogate for another
on the basis of this diagnosis.She Is not able to make choices as an agent. She is not able
to understand the duties of an agent. She is not able to appreciate the duties of an agent.She
is not able to reason as an agent. In my best medical opinion, Calene M Clouse lost this
capacity by the time of her 0812014 psychiatric admission. Her functional status has not
completely recovered since this time. I do not have the exact date of her admission.
Calene M Clouse was not able to answer the following questions regarding their medical care.
Who is your doctor?"Dr. Molla does my psychiatric care once a month. Dr, Harris at Grand
Medical in Newville."
When did you last see your doctor?"Often.When I am sick. Recently."
For which medical problems does your doctor treat you?"Bipolar. You can see my messy
house."The home is cluttered,hoarded,and mainly not functional. I only saw three of the many
rooms.There is too much clutter to effectively clean.A chair had to be cleared off for me to sit
through the interview.
Which medications are you on?"Lithium one daily at night."How many milligrams?She has no
idea. "Cymbalta 30 mg in the morning"I was not able to look at her medication bottles.
How do you get your medication?She has no idea.
How do you take your medication?She has no Idea.
Are you allergic to any medications?Denies.
Do you take over the counter medications?"No."
Do you take vitamins?"Over fifty vitamins."
What do your medications do for your health?She has no idea.
What would happen to you if you did not take your medications? "My bipolar."How long have
you had bipolar disease?She has no idea.
What do your medical problems mean for your overall health?She has no idea.
Tell me about your hospitalization from August 2014. "My husband thought I was a danger to
him. He had me arrested and taken in handcuffs to Reading. I almost liked the place. I could
help people. I opened someone"s milk for them."She continued for 10 more minutes of
uninterrupted and uninterruptible rambling well off the point of our discussion, progressively
becoming more verbally and physically agitated during this monologue.
Calene M Clouse is not able to direct her medical decision making.She is not able to
choose between disparate potential courses of action. She is not able to understand her
medical diagnoses and treatment options. She Is not able to reliably participate in informed
consent for medical procedures and decision making. She is not able to appreciate the
consequences of these diagnoses and treatments or their refusal. She is not able to
demonstrate Intact reasoning with which to apply her long term personal goals and values to
these choices. In my best medical opinion,Calene M Clouse lost this capacity by the time of
her 0812014 psychiatric admission. Her functional status has not completely recovered since
2112 Harrisburg Pike.Suite 312
Lancaster PA 17601 + 717-544-3022 • 717-644-3021 Fax
www.LGHea1thPhys1dans.org
2119 St0Z—Zt-90 ZE:ZE:Z0 1190"tLi1
Calene M Clouse
DOB. 22/29/1939
Page 6 of 11
tl�is time. I do not have the exact date of her admission.
Calene M Clouse was not able to able to answer the following questions regarding an
advanced directive:
Do you have a living will or advanced directive?"No."
What are your wishes regarding cardiopulmonary resuscitation if you are obviously at the end
of your life?"I don't want that"
What are your wishes regarding antibiotics If you are obviously at the end of your life?1 don't
want that."
What are your wishes regarding intravenous fluids if you are obviously at the end of your life?"1
don't want that."
What are your wishes regarding artificial feeding if you are obviously at the end of your life?1
don't want that."
What are your wishes regarding renal dialysis if you are obviously at the end of your life?"I
don't want that"
What does your advanced directive say?"1 don't want that."
Did you name someone to make decisions about your health care if you are too ill to do so
yourself?"No."
Who did you name as your decision maker?"I don't know. Maybe my husband. I trust him..He
would make decisions for me just like I make them myself."
Have you discussed your wishes with your surrogate decision maker?"No."
When was the last time your discussed your wishes with your surrogate decision maker or
family?"I don't think I ever did."
Living will, advanced directives and PaOLST documents were not available for my review,She
did not explain the creation or absence of such documents.
Calene M Clouse is not able to make a living will or make changes to their living WIIL She
is not able to choose between disparate potential courses of action. She is not able to
understand her medical diagnoses and treatment options.She is not able to reliably evaluate
and choose an agent who will act in a surrogate fashion on her behalf. She is not able to
appreciate the consequences of these diagnoses and treatments or their refusal.She is not
able to demonstrate intact reasoning with which to apply their long term personal goals and
values to these choices. It is my opinion that she lost this ability by the time of her 08/2014
psychiatric admission. Her functional status has not completely recovered since this time. I do
not have the exact date of her admission.
Calene M Clouse can no longer drive a motor vehicle, Do you drive?"Yes." Have you had
any accidents?"No."Do you get lost?"No."Has anyone ever told you not to drive?"No."Her
husband feels she should not be driving. She leaves the house, gets lost, calls him and he has
to go find her. She says she has a valid drivers license.I recommend immediate driving
cessation. I have fled the appropriate paperwork with PennDOT.Alternative private and public
transportation should be arranged for her.A Pennsylvania Photo Identification Card can be
obtained if necessary for proof of Identity within Pennsylvania,A valid United States Passport is
another alternate means of personal identification.
Calene M Clouse was not able to answer these questions regarding voting privilege:
Do you vote?"No."Why not?"I'd vote for the wrong guy. It didn't matter which one I voted for. it
2112 Harrisburg Pike,Su#e W2
Lancaster PA 17601 0 717-544-3022 • 717-544-2021 Fax
www.LGHeafthPhoicians.org
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Calene M Clouse
DOB: 12/29/1939
Page 7 of 11
would be the wrong guy."
What will happen on the next election day?She has no idea.
What will you do on the next election'day?She has no idea_
How will a decision be made on the next election day. She has no idea.
Would you vote for more taxes and more services or less taxes and less services?Why?She
has no idea.
Calene M Clouse does not retain the capacity to vote.She is not able to distinguish
between candidates and parties.She is not able to choose between opposing candidates and
ideas. She does not understand nature of voting and the effect of voting. She is not able to
correctly use voting privileges without,cuing. She is prey to designing persons because of her
inability to resist coercion and suasion and voter fraud is possible. in my best medical opinion,
Calene M Clouse lost this capacity by the time of her 08/2014 psychiatric admission. Her
functional status has not completely recovered since this time. i do not have the exact date of
her admission.
Supporting Data:
Problem List
Diagnosis
Health maintenance examination
10/23/2014
Hearing: mild loss clinically, she denies this.She should be evaluated by her
audiologist'within 90 days.She will not benefit from augmentation. Her canals are
free of cerumen. Debrox 5 drops each ear twice a week should keep them cerumen
free.
Vision:glasses. She should be evaluated by her ophthalmologist within 90 days.
Driving: Without accidents or citations, Husband says she gets lost and calls him to
come find her. He feels she should not drive.
Dental: Yearly recommended. Dentures to be evaluated at least yearly.
Exercise: none
Diet:Ad lib.
Falls:denies, but family says recurrent.
incontinence: denies urinary and fecal incontinence
Screening Cognition: Montreal Cognitive Assessment See attached scan for
detailed findings. MOCA total score: 18
Screening Depression: PHQ9
Screening Stool Occult Blood x 3:this is overdue
Screening Colonoscopy: this Is overdue
Screening Mammogram:this is overdue
Screening DEXA:this is overdue.
Immunizations: There is no immunization history on file for this patient.
Immunizations may not be up to date. I recommend DtaP 0.5 ml Intramuscular,
Prevnar immunization not In the same year as the also recommended adult
pneumococcal vaccine 0.5 ml intramuscular, yearly influenza vaccine, and a single
Zoster vaccine live 0.65 ml intracutaneously administered not within 30 days of
influenza vaccine.
Multifactorlal gait disorder
10/23/2014 Strength 3/5 in bilateral legs and thighs. Unstable gait,turns and
transfers. Sedentary. Physical therapy, occupational therapy recommended.
2112 Harrisburg Pike,Suite 312
Lancaster PA 17B01 • V7444-302 • 717-544-3021 Fax
www.LGHealthPhysicians.org
ZtlB St0Z—Zt-90 w*d to:E6:Zo LLOOVOLLL
Calene M Clouse
DOB: 12/29/1939
Page 8 of 11
• Patient incapable of making informed decisions
10123!2014 Lacks decision making capacity.
• Urinary incontinence, mixed
10/23/2014 Has urge symptoms during the day,stress and functional symptoms at
night.There is a bedside commode.A urology referral is recommended.
• Bipolar disorder
Wears dentures
10/23/2014 Upper Dentures.She has dentures.They are several years old.They
do seem fit well with without adhesive.They do not cause oral pain. They are
cleaned routinely. They are due to be evaluated for fit and should be replaced if
necessary. Dentures routinely improve nutrition, social confidence and
communication. Dentures usually have a 2 year life span. Loss of fit occurs from
recession of the alveolar ridge from aging and tooth loss and cannot be
compensated for by adhesive,which works well only with well-fitting dentures.
o Bilateral sensorineural hearing loss
10/23!2014 She denies this, but it is clinically evident. She should be evaluated by
her audiologist within 90 days. She will benefit from augmentation. Her canals are
free of cerumen. Debrox 5 drops each ear twice a week should keep them cerumen
free.
- Xerostomia
10/23/2014 Medication induced
• History of blood transfusion
Review of systems: She is unable to give a reliable review of systems because of her
dementia.
No headache, earache,visual loss,hearing loss, nasal congestion or discharge, sore throat,
dysphagia, dysphonia, dysarthria.
No neck pain or lymphadenopathy.
No cough, hemoptysis, dyspnea, shortness of breath at rest or exercise. No chest pain,
diaphoresis, palpitations, syncope or dizziness.
No nausea, vomiting,diarrhea, hematemesis, melena or bright red blood per rectum. No
constipation. No indigestion or reflux.Appetite intact.
No hematuria, pyuria, dysuria, hesitancy, urgency or retention.
No joint pain or gait disorder.
No concerning skin lesion.
No memory loss, sleep disorder,depression, anxiety,hallucinations or delusions.
Allergies: She'has No Known Allergies.
Current Medications: "Lithium one daily at night."How many milligrams?She has no idea.
"Cymbalta 30 mg in the morning." I was not permitted to inspect her medication bottles. I have
no collaborative medical history.
Past Medical History:She has a past medical history of Psychiatric problem (08/2014).
Past Surgical History: She has past surgical history that includes ovarian cyst removal
(Bilateral); appendectomy; and knee replacement(Bilateral).
Social History: She reports that she has never smoked. She has never used smokeless
tobacco. She reports that she does not drink alcohol or use illicit drugs.
Family History: Her family history includes Coronary Heart Disease,early onset in her father
and mother.
Immunizations:
There is no immunization history on file for this patient.
2112 Harrisburg Pike,Suite 312
Lancaster PA 17601 • 717.644-3022 • 717544-3021 Fax
www.LGHealthPhysidans.org
ZIJ6 SIOZ-ZL-90 'w'd BI:EE:Zo MOGMIL
Calene YL Clouse
DOB: 12/29/1939
Page 9 of 11
Physical Examination:
Head, Ears, Nose and Throat: Normocephalic,atraumatic, pupils equal, round reactive to light,
extraocular movements intact. Sclera anicteric. Conjunctiva pink and moist.Tympanic
membranes pearly and mobile without occluding cerumen. Nares without erythema purulence
or discharge. Dentition intact. Pharynx without erythema purulence or discharge. Neck supple
without lymphadenopathy. Carotid pulses 2+without bruit. Hearing loss is clinically evident, but
did not interfere with the evaluation. She wears glasses and has clinically adequate visual
acuity to participate in formal testing.
Chest: Normal excursion, resonant, without kyphosis,clear to auscultation and percussion.
Heart:Without heaves or thrills, rate and rhythm regularwithout murmurs, rubs or gallops. S1
and 82 normal. No S3, no S4.
Abdomen: Obese, soft, non-tender,without hepatosplenomegaly.
Extremities: Without cyanosis, clubbing or edema. Peripheral pulses absent.
Skin: Intact
Lymph: No cervical, supraclavicular, or axillary lymphadenopathy. No femoral or popliteal
lymphadenopathy.
Neuro: Cranial II-XII intact. Finger-to-nose intact. Sensory intact to light touch and
proprioception. Motor 4/5 throughout except in the bilateral thighs and legs where it is only 3/5.
Her gait is unstable,transfers are unstable,turning is unstable. There is not evidence of
Parkinsonian features.
Judgement is not intact. Insight is not intact.Anosognosia is present.
Orientation:To person is intact. To place is intact.To time is not intact. Concentration is not
intact.
Delusions are present. Do you remember what happened before you went to the psychiatric
hospital recently?"Ed sold a property of one of my babies and put it in his own name."Ed
denies this. "I went to the movies, but was greeted by the police on the way out. Then I got
back. I wanted powdered milk because my milk is always sour and i went to see those police to
tell them to see the movie called, 'You Wanna Be a CopT it was hilarious.And instead they
arrested me and took me to Reading. I had a shot.They told me if I didn't get it I would have to
stay a month. There was a guy who dropped his pants and peed on the television. One fell In
love with me and slept outside my door, but then he went into a rage like I have never seen and
I stayed away from him. Mostly there were women abandoned by their husbands stuck there in
limbo with no place to go,
Hallucinations:Visual hallucinations are not present.Auditory hallucinations are not. Olfactory
hallucinations are not present. Gustatory hallucinations are not present. Formication is not
present. Derealization�is not present
There is social disinhibition.There is not verbal disinhibition.There is not sexual disinhibition.
There is not urinary disinhibition, but there are functional elements to her urinary incontinence.
There is not fecal disinhibition.There is not hyperorality.
Eating:There is not polydipsia.There is not polyphagia.There is not anorexia.
Sleeping. is not normal, is not excessive,is diminished, is interrupted. "My sleep is terrible.
That's why I see Dr. Mullah, but the last two to three nights are better on the Cymbalta. I had
been off it because It made me too high. But that was in the spring. Now i am sleepy. My
energy level is low right now. In the spring and summer it is very high. 1 plant trees and flowers.
I go on spending sprees in the spring and summer. My energy level changes overnight." Denies
periods of sleeplessness. "Even when I am high I sleep at night."
Mood is happy, is not elated, is not sad, is not depressed.
2112 Harrisburg Pike,Suite 312
Lancaster PA 17601 717-544-3022 • 717,544-3021 Fax
www.LGHeal(hPhysic4ons.org
ZLIOI SIDE-ZL-90 'w'd LE:EE:ZO LAD109VILL
Calene M Clouse
DOB: 12/29/1939
Page 10 of 11
Affect is not happy,is not sad, is sornewhat flat, is somewhat inappropriate.
Motor agitation is not present. Motor retardation is present.Abnormal posturing is not present.
Speech is not always fluent, is not pressured, is not slow,is spontaneous, is not slurred.There
is paucity. There are word choice errors.There are word use errors.There are syntax errors.
There are comprehension errors.
Conversation is not always coherent, is rambling, is tangential, is confabulatory, is not logical.
Reading ability: Comprehension is not intact.Vocabulary is not intact. Fluency is not intact.
Memory: Immediate is not intact. Short Term is not intact. Long Term is not intact. Procedural
Is not intact for IADL.
Calene M Clouse perceives herself to be Independent of ADL and independent of IADL.
Calene M Clouse as evaluated by me is dependent of toileting of ADL and dependent of
transportation, finances,cleaning, chores, and personal safety of IADL.
Life expectancy is estimated to be 12 years by actuarial and clinical means. Presently, actuarial
data is considered to be the best means of estimating life expectancy except in clinical
situations that are clearly mortal in character.These include various forntis of advanced cancer,
heart failure, lung failure, kidney failure, liver failure and dementia.
Calene M Clouse is appropriate for assisted living care.She requires assistance with
instrumental activities of daily living and would benefit from the services provided by an
assisted living facility. These services can be provided in the community with a combination of
personal,family, private and community resources bearing in mind that this is often difficult for
caretakers to manage, arrange,and routinely provide. Back-up systems are particularly difficult
to arrange and manage. It is important to remember and consider that caretakers who are
obligated to provide direct care beyond their personal abilities suffer an increased risk of
morbidity and mortality after six weeks of over-extension. Caretakers who are over-extended
are at increased risk for acute medical problems, hospitalization, depression and dementia.
Underlying chronic medical issues, poor coping skills, a low perception of personal agency'and
depression further increase these risks and the risk of failure to provide adequate care. Respite
care plans and a day off per week are minimally required for ongoing caregiver health. She is
very likely to need skilled care within the next two years. She may have the monetary resources
necessary to achieve this in her home, but this may not be the best choice for her well-being,
and well-reasoned consideration of the options for skilled dementia care should be evaluated at
the time a transition is made.
Persons with dementia have a uniformly poor chance of meaningful long term recovery after
cardiopulmonary resuscitation.Although published literature indicates a one In six or fifteen
percent chance of immediate post-resuscitation survival,far fewer patients survive the next
sixty day period. There is literature to indicate a less than 3%survival rate in elders with
dementia. This time of hospital stay is invariably fraught with Indignity, pain, and suffering with
invasive procedures, intravenous lines, artificial feeding, mechanical ventilation and prolonged
intensive care unit treatment. i recommend Do Not Resuscitate orders for patients with this
terminal, progressive disease.Likewise, I do not recommend artificial feeding for dementia
patients who are declining, spending greater than 18 hours a day in bed,who are eating and
drinking poorly and losing weight. Percutaneous gastrointestinal artificial feedings do not
improve weight, survival, or comfort in advanced dementia patients. They are invariably
associated with multiple uncomfortable visits to the hospital for replacement of the device when
2112 Harrisburg Pate,Sutie 312
Lancaster PA 17601 • 717-544-3022 - 717.5443021 Fax
www.LGHeafthPhysiclarts.org
Wit SLOZ—EL-90 wdLt+:EE:e0 LL909WIL
Calene M Clouse
DOB: 12/29/1939
Page 11 of 11
confused patients pull them out. They increase the risk of aspiration pneumonia in severely
demented elderly patients.They are associated with an increased risk of death compared to
comfort feeding regimens.
Thank you for the opportunity to serve Calene M Clouse. I trust my recommendations will help
her age with dignity and as much Independence as possible.
Sincerely,
Robert Howse, M.Q.
2112 Harrisburg Pike,Suite 312
Lancaster PA 17501 • M-5443022 - 717-644-3021 Fax
www.LGHenithPhysideno.org
UM StOZ-Zt-9O 'urdfO:VE Z0 Lt5FOV4trLtL
Neil W.Yahn,Esquire
Attorney.LD.No.82278
JSDC Law Offices
P.O.Box 650
. Hershey,PA 17033
Attorneys for Petitioner
IN RE: CALENE M. CLOUSE, ) IN THE COURT OF COMMON PLEAS
an alleged incapacitated person ) CUMBERLAND COUNTY, PENNSYLVANIA
ORPHANS' COURT DIVISION
On the Petition of )
J. Edward Clouse ) NO. 21-15-93
CERTIFICATE OF SERVICE
AND NOW, this iG qday of July, 2015, I,Neil W. Yahn, Esquire,do hereby certify that I
served a true and correct copy of the foregoing Response to the Preliminary Objection in the
Nature of a Demurrer/Motion to Dismiss upon the following below-named individuals by
depositing the same in the U.S. Mail,postage pre-paid at Hershey,Dauphin County, Pennsylvania:
SERVED UPON:
Daniel L. Sullivan, Esquire
Robert C. Saidis, Esquire
Saidis, Sullivan &Rogers
26 West High Street
Carlisle, PA 17013
Attorney for Calene Clouse
T�ErL WA NER YARN, ESQUIRE
Attorney I. #82278