(The pdf for the issue in which this article appears is available for download: Vol. 37, Issue 5.)
Among the challenges faced by family caregivers is a tangled matrix of legal and financial issues that surround the practical care issues these caregivers cope with daily. The legal face of everyday caregiving can seem distant, obscure, or discomfiting. But, the key legal challenges are identifiable and manageable when one understands the basics.
Consider the following story. Ann works full time as a clerk at a local grocery store chain, and in much of her free time, cares for her mother and father, with whom she shares a two-bedroom apartment. Ann has one sibling, a brother who lives several hours away. Ann’s father has been diagnosed with Alzheimer’s Disease, but he is still able to recognize his loved ones most of the time, engage in simple conversation, and perform most daily activities, with some cueing. Her mother suffers from severe arthritis and emphysema and cannot handle most housework, but still adequately manages the couple’s finances. While at work, Ann receives a call from her neighbor: Her mother has had a fall in the apartment building’s lobby. The neighbor called 911 and Ann’s mother has been rushed to the hospital.
Hospital records noted that Ann’s mother is married, so when Ann arrives at the hospital, staff share only general information with her and ask how to contact her father. Upon explaining her father’s condition, hospital staff become somewhat more forthcoming. Treated for a broken hip, her mother is eventually transferred to a nursing home for convalescence. During this time, Ann takes extra, unpaid time off (begrudgingly provided by her employer) to care for her father and to manage her mother’s transfer to a nursing home, which is a considerable distance from home.
During his wife’s absence, Ann’s father becomes significantly more confused, agitated, and begins to wander. Ann recruits a neighbor to visit and keep an eye on her father a couple days a week, but one day, when no one is available to monitor him, Ann locks him in the apartment for his own safety while she is at work. When Ann’s mother returns home after four weeks, she is very frail physically and, though still fairly mentally capable, needs Ann’s help with virtually all household management and personal care tasks, including managing finances. Ann pays bills by writing checks from her parents’ bank accounts, on which they had her named as a joint owner. Ann also uses her personal bank account to pay some expenses, but because they are all one household, Ann tends to use the accounts interchangeably.
As Ann is adapting to this new care routine for her parents, she is suddenly fired from her job, because her supervisor assesses her performance as “lackadaisical” and “less competent and committed” to her work than is necessary for employment. In discussing what to do next with her mother, her mother insists that they pay Ann for her caregiving because it is so time consuming, and it is unfair to expect Ann to forego employment. They agree that Ann will be paid $2,000 per month. Some weeks later, her brother calls, concerned about their parents’ status. After an emotionally volatile conversation, he accuses Ann of taking financial advantage of their parents, and insists that both parents need to be in a residential care facility.
The predicament faced by Ann and her parents raises questions about appropriate access to support services, caregiver stress, financial management, and quality of care. But it also raises several legal conundrums and risks that can and should be addressed. This article discusses eight key law-related issues affecting family caregivers: decisional capacity; surrogate decision-making; caregiver access to health information; abuse and neglect risks; designating a financial decision-maker; designating a healthcare decision-maker; family responsibilities discrimination by employers; and, use of personal care agreements to pay family caregivers.
Decisional Capacity
Ann is facing issues regarding her parents’ capacity to make decisions for themselves. How does she know where the line lies between respecting a loved one’s decision-making autonomy and stepping in as decision maker? The starting point in understanding capacity is grasping the reality that capacity is task-specific and time-specific. One may have capacity to get dressed and prepare meals, but lack the capacity to manage finances. Or, one may have capacity to manage some finances in the morning, but not late in the day, or not after certain medications are taken.1
Though people can become totally and permanently incapacitated due to advanced illness, most cases fall into a broad and variable continuum. Ann’s parents still have some capacities at some times, but are gradually losing others. Ann needs help sorting out decisional capacity as a first step in determining how her parents’ needs can be met. This may be especially important in dealing with her brother, who seems to have judged their parents’ incapacity as being well beyond Ann’s caregiving abilities.
A second key to understanding capacity is distinguishing between legal and clinical notions. Legal incapacity is not the same as clinical incapacity, yet the concepts often are not clearly distinguished. Clinical incapacity is a functional conclusion based on an assessment of the particular cognitive, emotional, and physical faculties required to accomplish a specific task. Legal incapacity requires a finding by a civil court that the appointment of a guardian or conservator is necessary to manage some or all of one’s affairs. Questions of legal capacity normally will not arise if other legal tools have been thoughtfully put into place before one’s capacity declined—tools such as powers of attorney for finances and for healthcare decisions. For a court to find legal incapacity, it must be convinced not only that the individual lacks the clinical capacity to perform one or more essential functions, but also that the court’s intrusion into the individual’s life is necessary (i.e., there are no other options left to support the autonomy and well-being of the individual that are less restrictive than appointing a guardian). For Ann’s parents, the law still presumes legal capacity.
It can be daunting to be a caregiver for a loved one whose capacity to handle ADLs [activities of daily living] and IADLs [instrumental activities of daily living] is uncertain. Neuroscience research tells us that financial capacity and judgment with respect to finances often decline before other functions, putting persons with mild impairment at risk for financial exploitation.2 It is advisable to get a professional assessment of capacity early on in cases of chronic, progressive illnesses accompanied by dementia. Assessment can help provide a clearer picture of the current level of functioning, underlying diagnoses, and likely progression of the condition(s); identify supports and accommodations to maximize capacity; and, confirm when to trigger legal arrangements that have been voluntarily set up for surrogate decision-making, such as powers of attorney.
The ideal resource for obtaining professional assessments is an interdisciplinary team specializing in geriatric assessment. This type of team assessment evaluates multiple issues including physical, cognitive, affective, social, financial, environmental, and spiritual components that influence the older adult’s health and then develops a coordinated plan to maximize health and functioning.3 If such a resource is not available, the most important criteria for an assessment is the professional’s (e.g., primary care physician or other clinical provider) depth of experience in geriatric capacity assessment, rather than the particular letters that follow that professional’s name. Resources available vary considerably by community. Ann’s best starting point for finding the resources available in her community is likely to be her local area agency on aging.
Surrogate Decision-Making
Even though Ann’s parents have not yet had a formal assessment of capacity, Ann clearly has stepped into the role of de facto surrogate decision-maker. But what is the basis of Ann’s authority to act as their decision maker, and what is the extent of that authority? Ann’s authority can come from any of the following three possible sources:
Delegated decision authority
This is accomplished through the use of legal advance planning documents created while the individual still has decisional capacity. The most common devices are powers of attorney that can be created for financial and healthcare decisions. Trusts also are a common planning instrument, but normally used in circumstances where there is a need to manage a significant amount of property, or property across multiple jurisdictions. In Ann’s parents’ case, none of these legal tools were used.
Judicially determined decision-making authority
A guardianship or conservatorship proceeding is the vehicle for obtaining this authority. The process, cost, and consequences vary by state, but almost always require legal assistance to navigate and can be expensive, time-consuming, and stressful. It is a solution of last resort. Once established, the individual appointed as guardian has only the authority specified in the guardianship order and serves under the supervision of the court.
Devolution of authority under state law
For health decisions, the majority of states (about forty-four) authorize a close family member to step in as surrogate decision-maker for treatment decisions.4 Typically, a next-of-kin hierarchy of permissible surrogates is specified, starting with one’s spouse, then adult children, and down to some level of kinship, defined by each state. About half the states include close friends as an alternative if no family members are available.5
The trigger for these default surrogate laws is a clinical finding (not a legal finding) of incapacity to make a treatment decision. Assuming Ann and her parents live in a state that includes default surrogacy, she could have authority to make healthcare decisions for her parents when they lose the capacity to make those decisions, but their incapacity must be determined and documented in the medical record, as prescribed by the health surrogacy law in their state. A complicating factor is that Ann’s brother will have equal authority with Ann with respect to healthcare decisions. If Ann and her brother don’t get along, it will undermine decision making. If her parents don’t live in a state with default surrogacy, then Ann’s options are more restricted and the importance of advance planning is all the more emphatic.
There are no equivalent default surrogate laws for financial decisions. Ann has no inherent authority to assume the role of financial decision-maker over her parents’ assets, even if she is going to be the beneficiary of those assets after her parents’ deaths. The one caveat is the joint bank account. While the money in that account may belong to her parents, her name on the account gives her the same practical control over the money as her parents had. Families commonly use joint financial accounts like this. However, such accounts have major risks. They muddle intended ownership: Ann’s parents may have intended her to serve only as helper to make sure bills were paid, and not as an owner of the account. Yet Ann now has the easy means, albeit improper, to use the money as she pleases and even empty the account. And Ann’s creditors may have the ability, through legal action, to reach that account to satisfy Ann’s debts. The arrangement may also contribute to suspicions and discord with her brother. Using a power of attorney (described later in this article) to manage her parents’ finances would have been the preferred course of action.
Caregiver Access to Health Information
Ann has already encountered resistance from healthcare providers in trying to access her mother’s health information. That is because most healthcare providers and facilities are bound to very detailed rules intended to protect the privacy of patients’ personal health information. The rules were established by the Health Insurance Portability and Accountability Act of 19966 and its regulations, one component of which is known as the Privacy Rule.7
The starting point of the Privacy Rule is that healthcare providers cannot disclose a patient’s personal health information without the patient’s consent. The HIPAA Rules (specifically, the Privacy Rule) enumerate several exceptions, most of which address the necessity to share information among the providers and suppliers involved in Ann’s mother’s care, or who regulate or pay for that care. Ann may have access to her parents’ health information in one of three ways. First, she could be their “personal representative.” This status is given to someone legally authorized to make healthcare decisions for the patient.8
As noted above, this can come about by virtue of a healthcare power of attorney (which Ann does not have), or by being appointed guardian with health decisions authority, or by virtue of the default surrogate decision-making law for health decisions under state law. The need to establish this status with documentation and a determination of her parents’ incapacity to make healthcare decisions is an extra challenge for Ann, but necessary to be recognized as a personal representative. As her parents’ personal representative, Ann would be entitled to the same access and the same rights to consent to, or limit access to, personal health information as each of her parents do themselves.
A second means of access is through a valid HIPAA authorization. There is no standard form for such an authorization, but it must be a document, signed by the patient, that identifies the information to be disclosed, to whom, for what purposes, and for what duration. An example may be found on the health decisions Web resource page of the ABA Commission on Law and Aging at http://ambar.org/healthdecisions.9 To complete an authorization, the patient must still have the capacity to knowingly and voluntarily execute a HIPAA authorization.10
The third means by which Ann may access information about her parents’ health is the family and friends discretionary rule. Where authority is lacking under the above two options, the healthcare provider may share limited information with family and friends who are involved in the patient’s health in some way. The simplest way for this to happen is for Ann’s mother to tell her healthcare provider, “It’s okay to talk to Ann.” Or, permission can be implicit by not objecting to the sharing of information in the presence of the provider. However, as is commonly the case, the patient may not always be present or may not have capacity to consent. In that situation, the Privacy Rule gives the provider broad discretion, based on professional judgment, to determine whether it is in the patient’s best interest to share information.11
Moreover, the information shared must be limited to the minimally necessary information that the person involved needs to know about the patient’s care or payment.12 For example, if Ann has to depend on the discretionary rule to request copies of diagnostic tests the hospital performed on her mother, the hospital might refuse, saying that summary findings are sufficient for purposes of her involvement in her mother’s care. Under the “minimally necessary” guideline providers follow, less is better. This is the situation in which the healthcare provider wields the most control, and where a caregiver may find herself obstructed. Again, this highlights the value of a healthcare power of attorney.
Abuse and Neglect Risks
Ann is desperately struggling to care for her parents, to keep them at home, and to stay employed. While her intent is good and even courageous, Ann may already have stepped over the line of neglect and abuse. Locking her father in the apartment even once and using her parents’ bank account interchangeably with her own are both actions that, on their face, raise neglect and financial-exploitation flags. Ideally, long-term services and supports (LTSS) would be available to help Ann understand and implement a plan of care for her parents, while enabling her to remain employed. However, with limited time and a lack of familiarity with available resources and LTSS, Ann did not have those supports at the time of her mother’s hospitalization. What is available depends upon where she and her parents live, and the institutions she deals with.
In managing their financial affairs, Ann has stepped into a role in which the law expects her to meet basic fiduciary standards, of which she may be oblivious. For example, she should maintain a strict separation between her money and obligations and those of her parents. As emphasized earlier, relying on a joint bank account is an easy but very risky way of managing another person’s money. A better strategy would be to designate a financial decision-maker through a financial power of attorney.
Designating a Financial Decision-Maker
Caregiving for anyone with diminished capacity is always easier when there has been advance care planning before the onset of serious illness. The goal is to have someone trustworthy in place in the event one loses capacity to manage financial and personal affairs. For financial tasks, a financial power of attorney is an essential—but too often misunderstood—legal tool. It often is perceived as a simple, standardized form document. In reality, powers of attorney need to be closely tailored to individual needs and circumstances. Without that, a power of attorney can be a blank check for financial exploitation.
A well-drafted power of attorney should clearly describe the powers given to the agent (Ann) and meaningful protections for the principal (Ann’s mother or father). For example, if there is a possibility that the agent may need to hire herself as a caregiver for the principal, that power should be explicitly stated in the power of attorney; otherwise, it may be seen as selfdealing if Ann were to pay herself.
There are several powers that a principal may be advised to limit or not to confer upon the agent at all, such as the power to make unlimited gifts, to change beneficiaries on insurance policies, to change rights of survivorship on financial accounts, or create or amend a trust. Also, selected safeguards can help avoid financial misdirection, such as requiring a yearly financial accounting to another family member, or requiring the written consent of a designated person to engage in transactions over a specified amount. Powers of attorney are private consensual arrangements, so there is no routine outside scrutiny of them unless such oversight is written into the document.
To the extent that Ann’s parents’ income consists of Social Security and-or veterans benefits, she will need to make a request to those agencies to be appointed as their representative payee (for Social Security) or VA fiduciary (for veterans benefits) if her parents cannot manage those funds. If approved, her parents’ checks would be paid to her, to be managed on behalf of her parents. Monitoring of the appointment is done through an annual report that Ann must file with the agency.
As a designated agent or representative payee or VA fiduciary, Ann would legally be a fiduciary under the law and expected to comply with basic fiduciary duties. However, many (if not most) family members acting as agent have no familiarity with fiduciary duties. The Consumer Financial Protection Bureau makes available four simple, free guides13 for family members acting in any fiduciary capacity: one each for agents under powers of attorney, family trustees, guardians or conservators, and representative payees–VA fiduciaries. The guides explain four basic fiduciary duties that would apply to Ann: acting only in her parents’ best interests; managing their money carefully and avoiding conflicts of interest; keeping their property separate from hers; and keeping good records. Guides are available at https://www.consumerfinance.gov/consumer-tools/managing-someone-elses-money/.
Designating a Healthcare Decision-Maker
Just as with financial affairs, healthcare decision-making for anyone with diminished capacity is always easier when there has been planning before the onset of serious illness. For health planning, most people have at least heard of the legal documents that are available to use to direct their care: Living Wills and Health Care Powers of Attorney. These documents are known more generally as Health Care Advance Directives.
A Living Will is a document that spells out wishes or preferences about end-of life care, and a Health Care Power of Attorney is a document that legally appoints someone to make medical decisions for another (the principal), should the principal be unable to make them herself. Depending on the state, the person appointed may be called a “healthcare agent,” “proxy,” “surrogate,” or “attorney-in-fact,” among other titles. Both documents can be combined into one healthcare advance directive.
Of the two, the healthcare power of attorney is by far the more essential. Sound decision-making for Ann’s parents requires her to understand the medical circumstances and options faced by her parents in real time, and to make decisions in collaboration with their healthcare providers, based upon her parent’s most important values, priorities, and wishes. The latter task depends on Ann’s intimate knowledge of her parents’ wishes, which in turn depends on whether or not she and her parents have had direct and meaningful discussions about their goals and priorities. To that end, a growing number of tools for guiding reflection and conversation about healthcare advance planning are easily available,14 and can be accessed through the health decisions Web resource page of the ABA Commission on Law and Aging15 at http://ambar.org/healthdecisions. Ann should try to initiate these conversations, even at her parents’ advanced stage of illness.
Family Responsibilities Discrimination
Ann was fired from her job at the grocery store. Perhaps her supervisor’s negative assessment of her work performance was accurate. But possibly, Ann’s need to take periodic and sometimes unplanned time off to care for her parents was the reason. The latter phenomenon has been called family responsibilities discrimination, or FRD. FRD is employment discrimination against people based on their caregiving responsibilities— whether for children, elderly parents, or ill family members. It arises when an employer treats an employee with caregiving responsibilities based on stereotypes about how the employee will or should behave, rather than on that employee’s individual interests or performance.16 Ann may be perfectly competent and committed to her work, but her supervisor may equate her need to fulfill caregiving responsibilities as equivalent to lack of commitment to work or incompetence.
Surprisingly, most federal and state statutes don’t expressly prohibit discrimination based on family responsibility, although there is increasing attention to the topic. FRD–related claims challenging employer actions typically rely on other related discrimination causes of action, such as sex discrimination, hostile work environment claims, or discrimination based on association with a person with a disability. Ann can complain to the Equal Employment Opportunity Commission if she suspects discrimination on these grounds.
The one federal law that directly addresses caregiving is the Family and Medical Leave Act (FMLA), which applies to employers with more than 50 employees. Ann’s employer, a grocery chain, is almost certainly covered. Ann has also worked there more than a year, another requirement of the Act, so under the FMLA she is entitled to up to 12 weeks of unpaid, job-protected leave per year to care for her parents or a spouse or child. Unfortunately, less than 60% of the workforce is covered by the FMLA.17 And, if one is caring for a non-covered relative, such as a grandparent, in-law, or sibling, the FMLA doesn’t apply. Violations of the FMLA provide a basis of a legal claim if the employee can establish that the employer interfered with, restrained, or denied the exercise of FMLA rights. The Wage and Hour Division of the U.S. Department of Labor receives FMLA claims. In all instances, the filing of a civil action in state or federal court is likely necessary because administrative enforcement is weak unless the claim is egregious. The Center for WorkLife Law reports that the number of FRD cases filed between 1999 and 2008 (2,207 cases) was nearly five times the number of cases filed between 1989 and 1998 (444 cases).18
National policy that supports workers with caregiving responsibilities falls far short of today’s social realities, given the high prevalence of caregivers in the workforce, as well as the increase in the aging population needing LTSS, and the dependency upon family caregivers for the lion’s share of care for that population. Proposed solutions abound, such as providing greater flexibility in work hours; expressly prohibiting FRD in federal law; expanding the coverage of the FMLA; requiring paid FMLA; mandating minimum sick leave for all employees; or, establishing paid family and medical leave under a mandatory social insurance model.19 All of these face obstacles on a national level, even though state-level and private-industry examples have been shown to be successful.20
Personal Care Agreements
Ann was forced into a trade-off between working and caring for her parents. She’s not unique in facing that dilemma. A recent survey21 by the National Alliance for Caregiving and the AARP Public Policy Institute found that 60% of caregivers were employed at some point in the past year while also caregiving; and, among employed caregivers who are not self-employed, 11% reduced work hours or took less demanding jobs, and 5% gave up working entirely. Without employment, Ann faces not only the loss of income, but also the loss of the Social Security work credit and of employee benefits such as healthcare coverage or future pension benefits, if these were provided by her employer.
Being paid by her parents to provide personal care services can be a win-win situation for all, because her parents prefer Ann over paid caregivers who are unknown to them, it will enable them to remain at home, and it will provide Ann with an income. However, the legal trap here is trying to do this without a formal personal care agreement (PCA), prepared in consultation with legal counsel. Ann has already run into the wrath and distrust of her brother, as he perceives her to be making up her caregiving role, as circumstances change, without any clear assessment or plan. Forming a PCA provides an opportunity to bring family members together with a professional and the care recipient to discuss and explore options, and devise a plan everyone will support.
The legal issues of a PCA include employment tax and reporting responsibilities, estate-planning issues (because anyone with siblings will face potential disputes over inheritance from the parents’ estate), and Medicaid issues. Ann’s parents may never have imagined needing to rely on Medicaid, but as their care needs increase, many Americans find that their comfortable middle-class incomes and estates are insufficient to cover long-term-care costs, and they turn to Medicaid. Medicaid rules vary considerably by state, but all states view family PCAs with skepticism and may impose several restrictions.
Unless there is an acceptable PCA in place before services are provided, all states will presume those services were intended to be provided without compensation, and any transfers of money or property to the caregiver will be seen as transfers of assets that disqualify the care recipient from Medicaid coverage for a period of time, tied to the size of the transfers. The transfers also may be viewed as possible financial exploitation by authorities. If care was being provided gratuitously for a period of time, a decision to switch to paying the family caregiver faces even greater scrutiny and distrust by Medicaid officials.
At a minimum, the PCA between Ann and her parents must be in writing and signed by the parties before services are rendered. It must define the services to be provided and their duration, and define the compensation to be paid. Care needs change, therefore some process for changing the amount, type, or level of services to be provided should be considered. For example, changes could be triggered by periodic assessments of care needs by a geriatric care manager or other health professional. The involvement of a geriatric care manager at the inception of a PCA will help definitively establish the need for and level of services specified in the PCA. In many states, Ann will also need to compile evidence of the fair market value of the services to be provided, and once services begin, she will need to keep a detailed daily log of caregiving services.22 Guidance on paying employment taxes and income reporting also is important; consult the IRS Publication 926, Household Employer’s Tax Guide.23
In the end, Ann’s success in balancing her needs and her parents’ increasingly demanding care needs requires planning ahead for both health and financial contingencies, connecting with and maximizing available long-term-care services and supports, and getting good clinical and legal guidance. It may be disquieting to find that legal issues so pervasively permeate the world of family caregivers, but that is the world we live in. With determination, it can be mastered . . . or at least help to put Ann, and others like her, on a footing that better serves her parents’ and her own needs.
1 American Bar Association (ABA) and American Psychological Association (APA). 2005. Assessment of Older Adults with Diminished Capacity: A Handbook for Lawyers. Washington, DC: American Bar Association.
2 Widera, E., et al. 2011. “Finances in the Older Patient with Cognitive Impairment.” Journal of the American Medical Association 305(7): 698–707.
3 Elsawy, B., and Higgins, K. E. 2011. “The Geriatric Assessment.” American Family Physician 83(1): 48–56.
4 Wynn, S. 2014. “Decisions by Surrogates: An Overview of Surrogate Consent Laws in the United States.” Bifocal 36(1): 10–4. http://www.americanbar.org/publications/bifocal/vol_36/issue_1_october2014/default_surrogate_consent_statutes.html. Retrieved August 4, 2015.
5 ABA Commission on Law and Aging. 2015. “Health Decisions Resources” (periodically updated). http://www.ambar.org/HealthDecisions. Retrieved June 29, 2015.
6 Health Insurance Portability and Accountability Act of 1996 (HIPAA). 1996. PL 104–91.
7 45 C.F.R. Part 160 and Subparts A and E of Part 164 (2013) (The Privacy Rule).
8 45 C.F.R. § 164.502(g) (2015) (Personal Representatives).
9 ABA Commission on Law and Aging. 2015. “Health Decisions Resources” (periodically updated). http://www.ambar.org/HealthDecisions. Retrieved June 29, 2015.
10 45 C.F.R. § 164.508 (2015) (Uses and Disclosures for which an Authorization Is Required).
11 45 C.F.R. § 164.510 (2015) (Uses and Disclosures Requiring an Opportunity for the Individual to Agree or to Object).
12 45 C.F.R. § 164.502(b) (2015) (Standard: Minimum Necessary).
13 Consumer Financial Protection Bureau (CFPB). 2013. Managing Someone Else’s Money: Help for Agents Under a Power of Attorney. https://www.consumerfinance.gov/consumer-tools/managing-someone-elses-money/. Retrieved August 4, 2015.
14 Sabatino, C. P. 2014. “Advance Care Planning Tools that Educate, Engage, and Empower.” Public Policy and Aging Report 24(3): 107–111.
15 ABA Commission on Law and Aging. 2015. “Health Decisions Resources” (periodically updated). http://www.ambar.org/HealthDecisions. Retrieved June 29, 2015.
16 Williams, J. C., and Bornstein, S. 2008. “The Evolution of ‘FRED’ Family Responsibilities Discrimination and Developments in the Law of Stereotyping and Implicit Bias.” Hastings Law Journal 59: 1311–58.
17 Feinberg, L. 2013. Keeping Up with the Times: Supporting Family Caregivers with Workplace Leave Policies. Washington, DC: AARP Public Policy Institute.
18 Calvert, C. T. 2010. Family Responsibilities Discrimination: Litigation Update 2010. San Francisco, CA: UC Hastings College of Law, Center for WorkLife Law.
19 Feinberg, L. 2013. Keeping Up with the Times: Supporting Family Caregivers with Workplace Leave Policies. Washington, DC: AARP Public Policy Institute.
20 Bornstein, S., and Rathmell, R. J. 2009. Caregivers as a Protected Class?: The Growth of State and Local Laws Prohibiting Family Responsibilities Discrimination. San Francisco, CA: UC Hastings College of the Law, Center for WorkLife Law. www.worklifelaw.org/pubs/LocalFRDLawsReport.pdf. Retrieved August 18, 2015. See also Equal Employment Opportunity Commission (EEOC). 2009. Employer Best Practices for Workers with Caregiving Responsibilities. www.eeoc.gov/policy/docs/caregiver-best-practices.html. Retrieved August 18, 2015.
21 National Alliance for Caregiving and the AARP Public Policy Institute. 2015. Caregiving in the U.S. 2015. www.aarp.org/ppi/info-2015/caregiving-in-the-united-states-2015.html. Retrieved August 18, 2015.
22 Peck, K., and Law, R. L. 2013. Alzheimer’s and the Law: Counseling Clients with Dementia and their Families. Chicago: American Bar Association.
23 Internal Revenue Service (IRS). 2014. Household Employer’s Tax Guide. Publication 926 (revised periodically). www.irs.gov/publications/p926/index.html. Retrieved August 18, 2015. ■