U.S. economy adds 157,000 jobs in January

U.S. employers added 157,000 jobs in January and hiring was stronger over the past two years than previously thought, providing reassurance that the job market held steady while economic growth sputtered.

The mostly upbeat Labor Department report Friday included one negative sign: the unemployment rate rose to 7.9 percent from 7.8 percent in December. The unemployment rate is calculated from a survey of households, while job gains come from a survey of employers.

The hiring picture over the past two years looked better after the department's annual revisions. Those showed employers added an average of roughly 180,000 jobs per month in 2012 and 2011, up from previous estimates of about 150,000. And hiring was stronger at the end of last year, averaging 200,000 new jobs in the final three months.

Stock futures rose after the report was released.

One notable change in the job market is the stronger contribution from construction firms. They added 28,000 jobs in January and nearly 100,000 in the past four months. The gains are consistent with a rebound in home construction and a broader recovery in housing.

Last month's hiring should cushion the impact of the higher Social Security taxes that most consumers are paying this year. And it would help the economy resume growing after it shrank at an annual rate of 0.1 percent in the October-December quarter.

Higher Social Security taxes are reducing take-home pay for most Americans. A person earning $50,000 a year will have about $1,000 less to spend in 2013. A household with two high-paid workers will have up to $4,500 less. Taxes rose after a 2 percent cut, in place for two years, expired Jan. 1.

Analysts expect the Social Security tax increase to shave about a half-point off economic growth in 2013, since consumers drive about 70 percent of economic activity.

The hit to consumers is coming at a precarious moment for the economy. It contracted in the fourth quarter for the first time in 3 1/2  years. The decline was driven largely by a steep cut in defense spending and a drop in exports. Analysts generally think those factors will prove temporary and that the economy will resume growing.

Still, the contraction last quarter points to what are likely to be key challenges for the economy this year: the prospect of sharp government spending cuts and uncertainty over whether Congress will agree to raise the federal borrowing cap.

Most analysts predict that the economy will grow again in the January-March quarter, though likely at a lackluster annual rate of around 1 percent. They expect the economy to expand about 2 percent for the full year.

Two key drivers of growth improved last quarter: Consumer spending increased at a faster pace. And businesses invested more in equipment and software.

In addition, homebuilders are stepping up construction to meet rising demand. That could generate even more construction jobs.

And home prices are rising steadily. That tends to make Americans feel wealthier and more likely to spend. Housing could add as much as 1 percentage point to economic growth this year, some economists estimate.

Auto sales reached their highest level in five years in 2012 and are expected to keep growing this year. That's boosting production and hiring at U.S. automakers and their suppliers.

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Hagel to stress opposition to a nuclear Iran in Senate testimony

WASHINGTON -- President Obama’s nominee for secretary of Defense, former Sen. Chuck Hagel, will stress at his confirmation hearing Thursday that he opposes letting Iran acquire nuclear weapons and will focus on developing military options to set back Tehran’s program, according to a U.S. official familiar with his planned testimony.

It will be Hagel’s first chance to explain his views publicly since his selection last month ignited fierce opposition from several former Republican colleagues and pro-Israel groups. They contend Hagel was not tough enough on Iran during his two terms as a GOP senator from Nebraska, and warn he might not push for a U.S. attack on Iran if one is needed.

“He’s going to be very clear that he fully supports the president’s policy of preventing Iran from getting a nuclear weapon,” said the U.S. official, who spoke on condition of anonymity because Hagel had not yet testified. “His job as secretary of Defense is to ensure that the military is prepared for any contingency, and he believes all options should be on the table, including military options.”

Hagel’s willingness to back the use of force against Iran is likely to be the key area of questioning during what is expected to be a daylong hearing with the Senate Armed Services Committee.

After a shaky start, Hagel’s nomination has picked up increasing support from Democrats, and the first Republican, Sen. Thad Cochran of Mississippi, announced Monday that he would vote for Hagel.

White House officials say they expect more Republicans to back Hagel and predict that when the full Senate votes, he will win more than the 60 votes necessary to avoid the threat of a filibuster.

Some pro-Israel groups have greeted Hagel’s nomination with opposition or lukewarm support. Even Democrats who back Hagel are determined to press him for greater clarity on how long diplomatic pressure and sanctions on Iran should be given to work before a military strike becomes necessary.

Sen. Carl Levin (D-Mich.), chairman of the committee, said “most Democrats are leaning very strongly” for Hagel, including himself. “That doesn’t mean I don’t have questions,” he added.

Many Republicans have not forgiven Hagel for publicly criticizing the George W. Bush administration for its handling of the war in Iraq, and they are likely to be considerably harsher in tone.

Sen. John Cornyn (R-Texas), speaking on the Senate floor Wednesday afternoon, said Hagel’s nomination had “already done damage to the United States’ credibility” in dealing with Iran.

“I realize that Sen. Hagel is now repudiating many of his past actions and statements,” he added. “But we’ve seen this before.”

Like Obama, Hagel has long called for a mix of negotiations and international economic sanctions to pressure Iran, insisting that military action should be considered only as a last resort. As he has sought support for his nomination, Hagel has emphasized that unilateral U.S. sanctions and even military action could be required.

“If Iran continues to flout its international obligations, it should continue to face severe and growing consequences,” Hagel said in response to written questions from the committee. ‘‘While there is time and space for diplomacy, backed by pressure, the window is closing. Iran needs to demonstrate it is prepared to negotiate seriously.’’

Ironically, the pressure on Hagel to come out strongly for a possible military strike against Iran comes as some Israeli officials, who have long pressed the Obama administration to consider a preemptive attack, say Iran appears to have backed away, at least for now, from what the West believes is a program to develop a nuclear bomb.

Sen. James Inhofe (R-Okla.), the top Republican on the panel, said last week that he and Hagel were “too philosophically opposed on the issues" for Inhofe to support his nomination, citing Hagel’s support for defense budget cuts and for cutting nuclear stockpiles. Inhofe was one of three Republicans who voted Tuesday against confirming Sen. John F. Kerry (D-Mass.) as secretary of State.

Senate Minority Leader Mitch McConnell (R-Ky.) on Tuesday declined to rule out the possibility that Republicans would require a 60-vote threshold for confirming Hagel.

“Sen. Hagel hasn't had his hearing yet, and I think it's too early to predict the conditions under which his nomination will be considered,” McConnell said.

Sen. Lindsey Graham (R-S.C.) has said he would block Hagel’s nomination from coming to a vote unless the current Pentagon chief, Leon E. Panetta, agrees to testify about the Sept. 11, 2012, attack on the U.S. compound in Benghazi, Libya. A White House official downplayed the possibility that Hagel’s nomination could be blocked, saying negotiations were underway to let Panetta testify.

david.cloud@latimes.com

michael.memoli@latimes.com

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Facebook slumps as mobile ad growth fails to impress

(Reuters) – Shares of Facebook Inc were set to open 7 percent lower on Thursday as a surge in fourth-quarter mobile advertising revenue failed to live up to Wall Street’s high expectations.

Three brokerages downgraded the stock of the No. 1 social network, which has struggled to develop a full-fledged mobile advertising business.

Facebook has long established itself as one of the most important websites, but investors have worried that until the company’s mobile advertising strategy takes off, revenue growth will remain shaky.

The company reported a better-than-expected fourth-quarter profit on Wednesday and said its mobile advertising revenue doubled to $ 306 million, suggesting it was making inroads into handheld devices such as smartphones and tablets.

Investors were looking for at least $ 350 million in mobile advertising revenue, Piper Jaffray analyst Gene Munster said in a note to clients.

“While the trajectory of mobile growth may not be as steep as some investors were hoping, the theme of mobile as the future of Facebook remains intact,” he said.

BMO Capital Markets analyst Daniel Salmon, who downgraded the stock to “market perform” from “outperform”, however said Facebook’s 2013 stock performance would not be dictated by its ability to generate mobile ad dollars.

He said new catalysts were necessary to drive Facebook’s stock price up.

Facebook’s stock, which has lost over a quarter of its value since its botched debut in May, were down at $ 29.08 in premarket trading. The shares closed at $ 31.24 on the Nasdaq on Wednesday.

(Reporting by Neha Alawadhi in Bangalore; Editing by Saumyadeb Chakrabarty)

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Beyonce to finally face media in New Orleans

NEW ORLEANS (AP) — Beyonce is expected to face the media Thursday as she previews her halftime performance at the Super Bowl. But the focus will likely be on her performance at that other big event earlier this month.

The superstar hasn't spoken publicly since it was alleged that she lip-synched her rendition of "The Star-Spangled Banner" at President Barack Obama's inauguration last week. Her critically praised performance came under scrutiny less than a day later when a representative from the U.S. Marine Band said she wasn't singing live and the band's accompanying performance was taped. Shortly after, the group backed off its initial statement and said no one could tell if she was singing live or not.

It's expected that the halftime performance will be a main focus of her afternoon press conference, even though she'd likely rather concentrate on questions about her set list for Sunday and her upcoming HBO documentary, "Life Is but a Dream." The documentary is being shown for the media just before Beyonce speaks and takes questions, as expected.

There has been plenty of speculation about Beyonce's Super Bowl performance, including reports there would be a Destiny's Child reunion with Michelle Williams and Kelly Rowland (Williams has shot down such speculation). Some are also curious about whether her husband, Jay-Z, will join her onstage, as they often do for each other's shows.

Beyonce has teased photos and video of herself preparing for the show, which will perhaps be the biggest audience of her career. Last year, Madonna's halftime performance was the most-watched Super Bowl halftime performance ever, with an average of 114 million viewers. It garnered more viewers than the game itself, which was the most-watched U.S. TV event in history.

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Well: Waiting for Alzheimer's to Begin

My gray matter might be waning. Then again, it might not be. But I swear that I can feel memories — as I’m making them — slide off a neuron and into a tangle of plaque. I steel myself for those moments to come when I won’t remember what just went into my head.

I’m not losing track of my car keys, which is pretty standard in aging minds. Nor have I ever forgotten to turn off the oven after use, common in menopausal women. I can always find my car in the parking lot, although lots of “normal” folk can’t.

Rather, I suddenly can’t remember the name of someone with whom I’ve worked for years. I cover by saying “sir” or “madam” like the Southerner I am, even though I live in Vermont and grown people here don’t use such terms. Better to think I’m quirky than losing my faculties. Sometimes I’ll send myself an e-mail to-do reminder and then, seconds later, find myself thrilled to see a new entry pop into my inbox. Oops, it’s from me. Worse yet, a massage therapist kicked me out of her practice for missing three appointments. I didn’t recall making any of them. There must another Nancy.

Am I losing track of me?

Equally worrisome are the memories increasingly coming to the fore. Magically, these random recollections manage to circumnavigate my imagined build-up of beta-amyloid en route to delivering vivid images of my father’s first steps down his path of forgetting. He was the same age I am now, which is 46.

“How old are you?” I recall him asking me back then. Some years later, he began calling me every Dec. 28 to say, “Happy birthday,” instead of on the correct date, Dec. 27. The 28th had been his grandmother’s birthday.

The chasms were small at first. Explainable. Dismissible. When he crossed the street without looking both ways, we chalked it up to his well-cultivated, absent-minded professor persona. But the chasms grew into sinkholes, and eventually quicksand. When we took him to get new pants one day, he kept trying on the same ones he wore to the store.

“I like these slacks,” he’d say, over and over again, as he repeatedly pulled his pair up and down.

My dad died of Alzheimer’s last April at age 73 — the same age at which his father succumbed to the same disease. My dad ended up choosing neurology as his profession after witnessing the very beginning of his own dad’s forgetting.

Decades later, grandfather’s atrophied brain found its way into a jar on my father’s office desk. Was it meant to be an ever-present reminder of Alzheimer’s effect? Or was it a crystal ball sent to warn of genetic fate? My father the doctor never said, nor did he ever mention, that it was his father’s gray matter floating in that pool of formaldehyde.

Using the jarred brain as a teaching tool, my dad showed my 8-year-old self the difference between frontal and temporal lobes. He also pointed out how brains with Alzheimer’s disease become smaller, and how wide grooves develop in the cerebral cortex. But only after his death — and my mother’s confession about whose brain occupied that jar — did I figure out that my father was quite literally demonstrating how this disease runs through our heads.

Has my forgetting begun?

I called my dad’s neurologist. To find out if I was in the earliest stages of Alzheimer’s, he would have to look for proteins in my blood or spinal fluid and employ expensive neuroimaging tests. If he found any indication of onset, the only option would be experimental trials.

But documented confirmation of a diseased brain would break my still hopeful heart. I’d walk around with the scarlet letter “A” etched on the inside of my forehead — obstructing how I view every situation instead of the intermittent clouding I currently experience.

“You’re still grieving your father,” the doctor said at the end of our call. “Sadness and depression affect the memory, too. Let’s wait and see.”

It certainly didn’t help matters that two people at my father’s funeral made some insensitive remarks.

“Nancy, you must be scared to death.”

“Is it hard knowing the same thing probably will happen to you?”

Maybe the real question is what to do when the forgetting begins. My dad started taking 70 supplements a day in hopes of saving his mind. He begged me to kill him if he wound up like his father. He retired from his practice and spent all day in a chair doing puzzles. He stopped making new memories in an all-out effort to preserve the ones he already had.

Maybe his approach wasn’t the answer.

Just before his death — his brain a fraction of its former self — my father managed to offer up a final lesson. I was visiting him in the memory-care center when he got a strange look on his face. I figured it was gas. But then his eyes lit up and a big grin overtook him, and he looked right at me and said, “Funny how things turn out.”

An unforgettable moment?

I can only hope.

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Nancy Stearns Bercaw is a writer in Vermont. Her book, “Brain in a Jar: A Daughter’s Journey Through Her Father’s Memory,” will be published in April 2013 by Broadstone.

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Small surgeries, huge markups

A Southern California surgery center charged teacher Lynne Nielsen $87,500 for a routine, 20-minute knee operation that normally costs about $3,000.

Despite the huge markup, the Long Beach Unified School District and its insurer, Blue Shield of California, paid virtually all of the bill from Advanced Surgical Partners in Costa Mesa. Blue Shield mailed the $84,800 check to the high school Spanish teacher last month and told her to sign it over to the surgery center.

Nielsen said she was outraged and refused to send the check. Instead, she asked the California attorney general's office to investigate the matter. "This is insane," she said.

The 61-year-old is the latest patient caught up in a growing battle nationwide over billing by outpatient surgery centers. Industry experts say some of these surgery centers seek out well-insured patients such as Nielsen, sometimes by waiving their copays and deductibles, and then bill their insurers exorbitant amounts for out-of-network care.

All too often, critics say, insurers pay these large sums and then cite high medical bills for why insurance premiums keep rising for businesses and consumers.

"This bill is so outrageous it almost takes my breath away," said Gerald Kominski, director of the UCLA Center for Health Policy Research. "This is an example of what's wrong with our healthcare system, and employees and taxpayers of the school district are paying the price here."

In response to questions from The Times, Blue Shield defended its $84,800 payment as proper. Advanced Surgical Partners, through its lawyer, said the bill was excessive. Amid the scrutiny, the two sides agreed to a lower amount this week.

Nationwide, some insurers have begun to challenge these bills from outpatient centers. Last year, a unit of insurance giant Aetna Inc. sued several surgery centers in Northern California and accused them of overbilling the insurer more than $20 million. It has pursued similar actions against providers in New Jersey and Texas. Other insurers such as UnitedHealth Group Inc. have filed similar suits in California.

In one instance, Aetna said, a California surgery center charged $73,536 for a kidney stone procedure when the average in-network charge was $7,612. Aetna said it paid some of these bills before disputing them in court.

Doctors and surgery centers say the criticism is unjustified. Surgery centers say they have helped reduce healthcare costs by offering convenient care at a fraction of what hospitals charge for colonoscopies, cataract surgeries and other outpatient procedures. These facilities now handle up to 40% of all outpatient surgeries, according to the Ambulatory Surgery Center Assn.

Nielsen went to Advanced Surgical Partners in November at the recommendation of her surgeon even though it was out of her insurance network. She checked beforehand with the facility and it assured her they would accept whatever Blue Shield offered to pay.

The surgery center's $87,500 bill was just for use of its facility and supplies. Nielsen's orthopedic surgeon and anesthesiologist billed separately and were paid about $1,200 combined.

Henry Fenton, an attorney for the surgery center, said this bill "was excessive and not correct. I'm sure they will be more careful in the future."

Blue Shield said its typical rate for this arthroscopic knee procedure in Southern California is about $3,000 among in-network providers.

"This surgery center is charging 30 times the average by remaining out of network to advance this outrageous and anti-consumer practice," said Blue Shield spokesman Steve Shivinsky. "This is a national problem."

Yet the company said it was obligated to pay nearly all of Advanced Surgical's bill because it is bound by the health plan rules set by the teacher's employer, the Long Beach school district. The school system is self-insured, meaning it pays its own medical bills and uses Blue Shield to administer its benefits and process claims.

In other situations involving out-of-network care, it's common for insurers to pay only about 60% of what's deemed to be "usual and customary" charges or some percentage of Medicare rates. Insurers and out-of-network medical providers routinely spar over what constitutes a reasonable amount.

Kominski, the UCLA professor, said he faulted both Blue Shield and the school district for "dropping the ball on this. There were lots of opportunities for red flags to go off on such an outlandish bill."

After defending its handling of the claim, Blue Shield reversed course this week and stopped payment on its $84,800 check. It told Nielsen that the surgery center had agreed to accept $15,000 instead.

"We are very pleased that Advanced Surgical Partners agreed to accept a more competitive rate," Shivinsky said.

Overall, Blue Shield said, it expects to have new measures in place by next month to better address these out-of-network billing issues for certain employer health plans. It also said employers should do more to encourage workers to use in-network facilities that are paid negotiated rates.

The Long Beach school district expressed frustration at the teacher's bill, but it echoed Blue Shield's explanation that it will incur additional costs at times because it has promised employees out-of-network benefits.

"This out-of-network issue regarding surgery centers is one that we want to explore with our employee groups in the next bargaining cycle," said Chris Eftychiou, a district spokesman.

Joe Boyd, executive director of the Teachers Assn. of Long Beach, said there is nothing in the employee contract to prevent the school district and Blue Shield from rejecting inflated medical bills.

"That's absurd. It isn't a requirement of the contract to pay fees that are five or 10 times what's customary," Boyd said. "We don't want the school district or our members ripped off."

Nielsen said she remains angry that Blue Shield declined to do anything when she first complained about the situation in December. She plans to continue pursuing the matter with the attorney general's office, which records show has begun an inquiry.

"Our insurance premiums wouldn't keep increasing," she said, "if they paid a fair amount for these procedures."

chad.terhune@latimes.com

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Economy unexpectedly contracts in fourth quarter

Holiday shoppers crowd the sidewalk outside Macy's department store in New York City. (Victor J. Blue / Bloomberg / December 23, 2012)

By Jim Puzzanghera

January 30, 2013, 6:25 a.m.

WASHINGTON -- The U.S. economy shrank at a 0.1% annualized rate in the last three months of 2012 amid fears about the fiscal cliff, the Commerce Department reported Wednesday.

It was the first time economic growth contracted since the end of the Great Recession in mid-2009 and showed how much the concerns about large tax hikes and federal spending cuts weighed on businesses as last year drew to a close.

A last-minute deal in Washington averted most of the tax increases and delayed the automatic spending cuts. Economists say they believe that will lead to economic growth in the first three months of 2013.

But Thursday's report -- the government's first estimate of fourth-quarter economic activity -- was a surprise.

QUIZ: Test your knowledge about the debt limit

Economists has projected that the gross domestic product -- the nation's total economic output -- would expand about 1% in the fourth quarter, a slowdown from the 3.1% growth in the July-through-September period.

But a drop in inventory investment by businesses, federal government spending and U.S. exports led to the first contraction since the economy shrank 0.3% in the second quarter of 2009.

Leading the drop in government outlays was a 22.2% drop in defense spending.

"The economy ended 2012 on a very sluggish pace, even though one-time factors put the number below the trend," said Kathy Bostjancic, director for macroeconomic analysis at the Conference Board.

"While the inventory runoff and the steep decline in defense spending in the fourth quarter made economic activity look weaker than it really was, the underlying demand from consumers and businesses kept moving forward at a moderate pace," she said.

ALSO:

U.S. economic growth in third quarter is revised upward

Scrap the debt limit, some lawmakers and economists say

Dow falls short of 14,000 but closes at highest level since 2007 [Video chat]

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Yandex puts mobile app blocked by Facebook on hold

MOSCOW (Reuters) – Russian internet company Yandex has put an experimental application that allows users to search social networking sites from mobile devices on hold after it was blocked by Facebook.

Facebook, which launched its own search tool earlier this month, blocked the Wonder app three hours after its launch on January 24 for U.S. users.

The application allows users to look for recommendations on, for example, music or restaurants based on information from their friends on social network sites.

Facebook believes Wonder violates its policies, which state that no data obtained from Facebook can be used in any search engine without the company’s written permission, Yandex said on Wednesday, adding access to Facebook would not be restored.

“Since this access was revoked, we decided to put our application on hold for the time being,” the Russian firm said, adding it would consider partnership with other social networks and services.

Existing Wonder users are still able to search in Instagram, Foursquare and Twitter, a Yandex spokeswoman said, but marketing and further development of the application is on hold.

(Reporting by Maria Kiselyova; Editing by Mark Potter)

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Justin Timberlake to perform at Grammys on Feb. 10

NEW YORK (AP) — Justin Timberlake will be rocking that suit and tie at the Grammy Awards.

The Recording Academy announced Wednesday that Timberlake will perform at the Feb. 10 awards show in Los Angeles.

The 32-year-old pop star returned to music earlier this month when he released the single, "Suit & Tie," which features Jay-Z. The song is a Top 5 hit on the Billboard Hot 100 charts.

His performance at the Grammys will be Timberlake's first musical appearance on television in years. Most recently, he's appeared in movies like "The Social Network" and "Friends With Benefits."

Timberlake's third solo album, "The 20/20 Experience," will be released March 19. His last album was the 2006 multiplatinum effort, "FutureSex/LoveSounds."

The Grammys will air live on CBS from the Staples Center.

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The New Old Age Blog: For Some Caregivers, the Trauma Lingers

Recently, I spoke at length to a physician who seems to have suffered a form of post-traumatic stress after her mother’s final illness.

There is little research on this topic, which suggests that it is overlooked or discounted. But several experts acknowledge that psychological trauma of this sort does exist.

Barry Jacobs, a clinical psychologist and author of “The Emotional Survival Guide for Caregivers” (The Guilford Press, 2006), often sees caregivers who struggle with intrusive thoughts and memories months and even years after a loved one has died.

“Many people find themselves unable to stop thinking about the suffering they witnessed, which is so powerfully seared into their brains that they cannot push it away,” Dr. Jacobs said.

Flashbacks are a symptom of post-traumatic stress disorder, along with feelings of numbness, anxiety, guilt, dread, depression, irritability, apathy, tension and more. Though one symptom or several do not prove that such a condition exists — that’s up to an expert to determine — these issues are a “very common problem for caregivers,” Dr. Jacobs said.

Dolores Gallagher-Thompson, a professor of psychiatry at the Stanford University School of Medicine who treats many caregivers, said there was little evidence that caregiving on its own caused post-traumatic stress. But if someone is vulnerable for another reason — perhaps a tragedy experienced earlier in life — this kind of response might be activated.

“When something happens that the individual perceives and reacts to as a tremendous stressor, that can intensify and bring back to the forefront of consciousness memories that were traumatic,” Dr. Gallagher-Thompson said. “It’s more an exacerbation of an already existing vulnerability.”

Dr. Judy Stone, the physician who was willing to share her mother’s end-of-life experience and her powerful reaction to it, fits that definition in spades.

Both of Dr. Stone’s Hungarian parents were Holocaust survivors: her mother, Magdus, called Maggie by family and friends, had been sent to Auschwitz; her father, Miki, to Dachau. The two married before World War II, after Maggie left her small village, moved to the city and became a corset maker in Miki’s shop.

Death cast a long shadow over the family. During the war, Maggie’s first baby died of exposure while she was confined for a time to the Debrecen ghetto. After the war, the family moved to the United States, where they worked to recover a sense of normalcy and Miki worked as a maker of orthopedic appliances. Then he died suddenly of a heart attack at the age of 50.

“None of us recovered from that,” said Dr. Stone, who traces her interest in medicine and her lifelong interest in fighting for social justice to her parents and trips she made with her father to visit his clients.

Decades passed, as Dr. Stone operated an infectious disease practice in Cumberland, Md., and raised her own family.

In her old age, Maggie, who her daughter describes as “tough, stubborn, strong,” developed macular degeneration, bad arthritis and emphysema — a result of a smoking habit she started just after the war and never gave up. Still, she lived alone, accepting no help until she reached the age of 92.

Then, in late 2007, respiratory failure set in, causing the old woman to be admitted to the hospital, then rehabilitation, then assisted living, then another hospital. Maggie had made her preferences absolutely clear to her daughter, who had medical power of attorney: doctors were to pursue every intervention needed to keep her alive.

Yet one doctor sent her from a rehabilitation center to the hospital during respiratory crisis with instructions that she was not to be resuscitated — despite her express wishes. Fortunately, the hospital called Dr. Stone and the order was reversed.

“You have to be ever vigilant,” Dr. Stone said when asked what advice she would give to families. “You can’t assume that anything, be it a D.N.R. or allergies or medication orders, have been communicated correctly.”

Other mistakes were made in various settings: There were times that Dr. Stone’s mother had not received necessary oxygen, was without an inhaler she needed for respiratory distress, was denied water or ice chips to moisten her mouth, or received an antibiotic that can cause hallucinations in older people, despite Dr. Stone’s request that this not happen. “People didn’t listen,” she said. “The lack of communication was horrible.”

It was a daily fight to protect her mother and make sure she got what she needed, and “frankly, if I hadn’t been a doctor, I think I would have been thrown out of there,” she said.

In the end, when it became clear that death was inevitable, Maggie finally agreed to be taken off a respirator. But rather than immediately arrange for palliative measures, doctors arranged for a brief trial to see if she could breathe on her own.

“They didn’t give her enough morphine to suppress her agony,” Dr. Stone recalled.

Five years have passed since her mother died, and “I still have nightmares about her being tortured,” the doctor said. “I’ve never been able to overcome the feeling that I failed her — I let her down. It wasn’t her dying that is so upsetting, it was how she died and the unnecessary suffering at the end.”

Dr. Stone had specialized in treating infectious diseases and often saw patients who were critically ill in intensive care. But after her mother died, “I just could not do it,” she said. “I couldn’t see people die. I couldn’t step foot in the I.C.U. for a long, long time.”

Today, she works part time seeing patients with infectious diseases on an as-needed basis in various places — a job she calls “rent a doc” — and blogs for Scientific American about medical ethics. “I tilt at windmills,” she said, describing her current occupations.

Most important to her is trying to change problems in the health system that failed her mother and failed her as well. But Dr. Stone has a sense of despair about that: it is too big an issue, too hard to tackle.

I’m grateful to her for sharing her story so that other caregivers who may have experienced overwhelming emotional reactions that feel like post-traumatic stress realize they are not alone.

It is important to note that both Dr. Jacobs and Dr. Gallagher-Thompson report successfully treating caregivers beset by overwhelming stress. It is hard work and it takes time, but they say recovery is possible. I’ll give a sense of treatment options they and others recommend in another post.

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