03/31/18

You’ve Detailed Your Last Wishes, but Doctors May Not See Them

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This is not how it was supposed to happen.

I was working overnight when my pager sounded, alerting me to an admission to the intensive care unit. I logged on to the computer and clicked on the patient’s chart, scanning the notes that tracked his decline. First there was a cancer diagnosis, too far gone for cure, then surgery, recurrence, surgery, and finally, a discharge home. The elderly man had been found there earlier that evening, pale, feverish and too confused to communicate.

Now he was in the emergency department, his breaths ragged. “There’s no family around. We’re probably going to have to intubate,” the emergency room doctor told me when I called him to learn more about the patient. I sighed, wondering what this man would have wanted, if only he could tell us.

I was surprised when, a few seconds after I hung up the phone, one of the doctors in training tapped me on the shoulder and pointed urgently at the computer screen. There was something important there at the very end of an otherwise unremarkable progress note from the patient’s outpatient oncologist. Just a few weeks before, doctor and patient had talked about how they were at the end of the road, without further therapies to slow the growth of the cancer. Facing a prognosis on the order of months, the elderly man had requested that when things got worse, there would be no breathing tubes or chest compressions. Only comfort and quiet.

But now he was unable to speak for himself. Too busy with X-rays and ultrasounds and medications, the emergency team hadn’t seen the note. I sent a page off to the attending taking care of the patient to alert him to the patient’s wishes, and my resident gathered his papers to run down to the emergency room.

This patient had done everything we could have asked. He’d been brave enough to talk with his doctors about his cancer and acknowledge that time was short. He had designated a health care proxy. But there he was, surrounded by strangers, the intubation he never would have wanted looming and the record of that conversation buried in his electronic record.

Something had gone wrong. And though it would be easy to blame the oncologist for not sending the patient home with a legally binding directive documenting his end-of-life wishes, or the emergency doctors for not searching harder in the chart, it’s not that simple. As it usually is with a surgery performed on the wrong side of the patient’s body or a medication that’s prescribed despite a known allergy, the problem here is not about individuals, but instead about a system that doesn’t sufficiently protect patients from getting care they do not want.

Increasingly, doctors like me are trained to have frank, hard conversations with our patients about prognosis and care goals. Outside the hospital, people with serious illnesses are encouraged to discuss these issues with their friends and family. But what happens after?

It’s tempting to assume that if you tell one doctor what you want at the end of your life, that’s enough — what you want will be clearly documented and retrievable when it is needed, and the record will follow you wherever you go. Yet this critical information is sometimes not documented even when conversations do happen, or scattered through our electronic records, only intermittently accessible (and often only with time-consuming searching), with few standards or best practices to guide us.

For the past year, I delved into the unexpectedly interesting world of advance care planning and electronic health records, interviewing clinicians with on-the-ground experience recording and retrieving these conversations and representatives from the companies behind some of the most widely used electronic records.

As a doctor working in the I.C.U., I knew firsthand the frustrations of searching the electronic record for notes and scanned documents. But I had no idea how common this problem was.

Through my interviews, I heard stories of patients who had been transferred to nursing facilities without their advance directives and returned to the hospital intubated when that was explicitly not what they wanted. Others told me about patients of theirs who’d grown ill on vacation only to end up in a hospital they’d never been to, with an entirely different electronic medical record, where no one was able to access any prior documentation. Others described situations in which last minute “saves” through extreme diligence or chance, such as the one I experienced, had led to a good outcome.

There are few existing regulations here, as the Centers for Medicare and Medicaid Service are relatively silent on advance care planning. In contrast to the rules around allergies, which mandate that all patients have an active med allergy list, electronic records simply need to have the capacity to show whether or not a patient has an advance directive, somewhere. They don’t even need to make the directive retrievable.

In the absence of nationwide standards, there’s significant variability among hospitals and among electronic records. Some have worked to make end-of-life documentation more easily accessible. At my hospital, for example, clicking on an “Advance Care Planning” tab will bring you to a record of all advance care planning notes, health care proxy forms, scanned directives and code status orders. This is a start, but it wasn’t enough for that elderly man in the emergency room. Habits are hard to break, and without a clear set of incentives, training and ongoing education, doctors (myself included) continue to record information about end-of-life conversations in progress notes, where they are not readily available, particularly when they are urgently needed.

Recently, a handful of start-ups have stepped in, trying to offer a solution to the fact that different electronic records can’t communicate with each other. There’s software and clever patient apps that work outside the electronic record, promising to build a repository of directives, proxy forms, even conversations. Just imagine, your E.D. doctor is fumbling to find your information in your chart, but you have an advance directive that was safely uploaded onto your smartphone. This most likely could have helped my patient that day — if he had a smartphone and was able to show it to his doctors, or if his hospital had committed to buying the necessary software.

What could really make a meaningful difference, I heard time and time again, is standards for sharing, or “interoperability” across all electronic records that would benefit every patient, everywhere. At least, all related advance care planning documentation should be in one place in the medical record and accessible with one simple click of the mouse. Beyond that, maybe all health systems could require identification of a health care proxy for all patients, so we would know who should make decisions if the patient can’t. Maybe patients should be able to access their health records through a patient-facing interface, send in their own directives, or even update related notes. Ideally, the electronic record isn’t just a clunky online version of a paper chart but actually a tool to help us do our jobs better.

Yet as it is, we’re playing catch-up. Which is how my patient ended up in the hospital that night, with a team of well-meaning doctors readying to do something to him that he never would have wanted, and a resident racing down to the emergency room because he’d happened upon a note.

When the resident arrived outside my patient’s room, he was relieved to see that the elderly man was still breathing on his own. The E.D. attending had held off. The patient’s family was on the way. Up in the I.C.U., we treated him gently with fluids and antibiotics and oxygen. He never did get strong enough to make it back home, but I think he was quiet and comfortable in the end, as he had wanted.

At the time, that felt like success. But looking back, I realize that we were just lucky — and that’s not enough.

Complete Article HERE!

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03/30/18

10 Questions to Consider When Preparing for the Death of a Loved One

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By John O. McManus

Death represents a significant and vulnerable point in time for both the individual facing it and his or her loved ones. As part of its Educational Focus Series, McManus & Associates, a top-rated estate planning law firm celebrating more than 25 years of success, today identified “10 Questions to Consider When Preparing for the Passing of a Loved One.” During a conference call with clients, the firm’s Founding Principal and AV-rated Attorney John O. McManus offered guidance on how to ensure optimal end-of-life care for oneself and loved ones. To hear his recommendations, go to http://bit.ly/2COi3R1.

“Death is an uncomfortable topic for many people, but it should be accepted as a natural part of life,” commented McManus. “While everyone would prefer to focus on life, a significant amount of stress related to death can be reduced by proper planning.”

10 Questions to Consider When Preparing for the Passing of a Loved One

  1. Know one’s options: What is the difference between hospice and palliative care?

Both hospice and palliative care provide end-of-life care, including symptom management and comfort for an ill patient while he prepares for death. Both also offer end-of-life care in the home or in a facility and have a team of specialists who deliver this care. However, there are a few differences:

2. Dot your i’s and cross your t’s: Are all the necessary legal documents in order?  

While competent, one’s loved one should express her wishes to guide family members in the event she cannot make decisions for herself. This includes directions as to what type of care she wants; whether she would like to donate her organs and when that should be communicated to medical professionals; preferred end-of-life care (hospice or palliative care) and location. This can be included in a health care directive or in a separate letter to the family but should be done with a greater level of formality – such as with the help of an attorney – to communicate the legitimacy of the loved one’s wishes.

  1. Health care directive/proxy: In this document, the loved one will appoint a surrogate decision-maker or proxy to make medical decisions for her once she is no longer considered able to make competent decisions and provide informed consent. Without this in place, family members will not be able to make medical or care decisions for their loved one; they will have to go through the courts to attain permission. This process can be time-consuming and expensive, detracting from the care of the patient.
  2. Living will: This document tells family members and surrogate decision-makers whether the loved one would like to receive additional measures of care. This includes instructions for extraordinary measures such as respirators, resuscitation, antibiotics, and withholding or withdrawing life-sustaining treatment. This is also a good place for the patient to instruct whether she would like her organs donated after her death.
  3. Health Insurance Portability & Accountability Act (HIPAA): This document protects the privacy of the patient’s medical records and other information. This is especially important if the loved one is unable to make competent decisions, allowing family members to get second opinions and to transfer her between facilities.

3. Broach the subject: Has there been a discussion with the loved one to understand what his or her wishes are? 

Ultimately, the loved one should be in control of her death and family members should know what that means for her. When the time comes that she is no longer mentally competent to make her own decisions, her surrogate decision-maker will step in to be the voice of the patient. It is important for the surrogate decision-maker to keep in mind the patient’s wishes. This is by no means an easy conversation but can help bring peace of mind to the loved one knowing what a good death means to her is understood.

4. Nail down the timeline: When does the loved one want end-of-life care to begin? 

Studies have found that there are many people who put off end-of-life care. This is often because the patient is still fighting his illness and does not want to receive end-of-life care until he is done receiving preventative treatment. This can minimize the benefits of end-of-life care, as he has less time to prepare for death. To be eligible for hospice care, patients must be within their last six months of life. If the loved one is not yet done fighting his illness, hospice may not be the right decision. If he wants to continue receiving preventative treatment, palliative care may be the better option. It is important to note that when hospice care starts, the loved one will no longer see his regular doctors, and will only be under the care of the hospice staff. However, if a new treatment becomes available while the loved one is receiving hospice care, he can leave hospice to receive life-prolonging treatment.

5. Research reputation: Has one discovered all that can be discovered about the potential care facilities being considered?   

Not all facilities offer the same benefits. One should look at the reputation of each facility, and ask for references from them, in addition to looking up reviews online. One should also ensure that they provide quality care and do not have a history of promising services that were not delivered, and find answers to questions like, “Do they have a history of withholding pain medication from patients due to fear of addiction? Do they have a history of ethical or staff issues?” Additionally, one should ask when the last time the facility was inspected by the state or federal government, which should reveal if there were any issues. If there were, one should be sure that they were resolved.

6. Find out who is behind the mask: How well does one know the loved one’s care providers?  

Few medical professionals have explicit training in death and dying. Talking to the loved one’s doctor may help form a more personal relationship and make the loved one feel more comfortable. Learning about the communication habits between the doctor and her colleagues is extremely important; one should be assured that all staff coming and going knows what has been done before they arrived and why. Also, as mentioned above, when the goal of end-of-life care is to provide comfort, reports of staff withholding pain medication can be an important concern. Finally, some facilities use volunteer services who interact with patients and their families, and learning what screening and training they have had can bring peace of mind. 

7. Do due diligence: Has one done his or her own research? Have all factors that could influence one’s decision been explored?

Not all facilities are created equal. Hospice and palliative care have facilities across the nation; however, their standards vary. One should ask the facilities being considered for references. If anyone who has been in a similar situation is known, one should ask him or her how he or she was treated by the particular facility’s staff and if they followed through with their promises. Also, one should ask care providers to share what can be done by the patient’s loved ones to help. Most importantly, one should ensure that he or she is well-informed on the ethical issues in this area of care.

8. Learn the ins and outs: Is in-patient or out-patient care best for the loved one and family?

The physical location for end-of-life care is a significant decision for the loved one. It is important that she feels comfortable in her environment during the final days of her life. Unfortunately, this is not always possible to achieve, since some families may not be physically equipped to care for their loved ones at home (out-patient care) and some are not financially able to allow their loved ones to stay in a facility (in-patient care).

9. Prepare Plan B: Does one have a backup plan?  

This may be most important for those who have decided to use out-patient care. Despite what promises are made by the end-of-life care provider, families should always have a backup plan. Recently, stories in the media have drawn attention to negative hospice and palliative care experiences. The reasons have ranged from poor communication to organizations not delivering on their promises. A common complaint is that staff does not treat the needs of patients who are in pain as time-sensitive, and the loved one’s doctors and nurses were unreachable. For situations such as these, it is important to have an alternative.

One option that many have found helpful is to have a comfort kit, which includes two pain relievers that can be administered to the loved one, should he be in pain when help is unable to come in a timely manner. One should ask for a comfort kit from the loved one’s care providers and shown how to properly administer the medication to the loved one.

10. Ask for help: Could the loved one and his or her family benefit from counseling?

Death is a highly stressful process for the person who is dying and her friends and family. It is extremely important for all parties to feel informed about what they are undergoing. The loved one should be able to reach a point of finitude, coming to grips with eventual death – this is a long process that can occur on many levels. On a surface level, this can begin with preparing any necessary legal documents, and on a deeper level, this can include reminiscing, enjoying positive moments, saying goodbyes, passing on sentimental items of significance, and legitimizing her life how she sees fit.  This should not solely be left for the loved one to realize on her own. When faced with a terminal diagnosis and death, people have many different reactions. It is important to offer the loved one guidance during this time. This will allow the loved one to have a death filled with control, dignity, peace, and finitude.

While this process has an end for the loved one, the family members must continue to live their lives. Rituals after death such as religious traditions, a funeral and/or a memorial service can be helpful, serving as a distraction and time to celebrate the loved one. However, at the end of this ritual period, family members will no longer have any distraction from their grief and may need guidance. It is important for those left behind to understand healthy coping techniques and the stages of grief they are experiencing.

“It is important to talk about death with loved ones – there are emotional benefits to reflecting on a life spent together, and expressing gratitude and admiration,” explained McManus. “It is also crucial to ask difficult questions so that the topic receives adequate attention and preparation

Complete Article HERE!

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03/29/18

How the world of death and funerals has become fashionable through digital culture

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‘Tearleading’ – the process of publicly sharing condolences after someone famous has died – has become an internet phenomenon. It’s made grief trendy and has digitised the only one true certainty in life: death

Public mourning: Céline Dion pauses at the casket of her late husband René Angélil – his funeral was livestreamed

By Oliver Bennett

It’s one of the more blood-curdling things about Facebook – the social media death notice. You know the score: the recently deceased star of Top of the Pops, sitcom or stage is commemorated by way of a YouTube video and a deluge of weepy RIPs and “part of my life” eulogies, a phenomenon derided as “tearleading”. The high-water mark for this was who “taught us how to live, then taught us how to die” two years ago. 

Of course, entrepreneurs have noticed this spectacle, which writer and psychologist Elaine Kasket brackets as “the data of the dead”. It’s part of a digital-led revolution in dying and death and it’s changing the way we see people pass into the ineffable digital afterlife. “We’re developing an entirely new mentality about death and dying,” she says. 

​Kasket (yes, she knows) is the author of an upcoming book about digital death called All the Ghosts in the Machine, and has observed a huge rise of interest. “I was at a recent SXSW festival and was introduced to someone who put on a super-serious voice and told me: ‘I’m in the death-tech space’.” As a subject, dying has become fashionable, with investors pouring money into startups, bolstering thought leadership and inspirational TED Talks on “new ways to think about death”. 

There are so many new death-tech sites that they break up into different types. There’s the price disruptors like Harbour Funerals, Beyond.life, and Funeral Zone, which offer price comparisons and sometimes, TripAdvisor-type reviews. Derrick Grant set up Willow when a close friend couldn’t afford his funeral expenses and found one-sixth of Britons struggle to pay for a funeral – the average cost of dying is £8,905. He now offers an against-deadline price check to help those who “couldn’t afford to die”: the ultimate poverty. “I found the industry hadn’t changed for 100 years,” says Grant. “People thought you had to pay a lot to do right.” Now it’s becoming more transparent, more open, and partly as a result, says Grant, “funerals have become less funereal”.

Starman: tributes at a Bowie mural in Brixton the day after the announcement of his death

Then there are the planning sites, which include Cake, a US company that has developed an app for end-of-life planning, and the UK’s DeadSocial.org which explains how to prepare your digital estate from the scattered confetti of Instagram, Facebook, Gmail et al. On SafeBeyond, users can create an online cache – including video and audio messages – to be shared posthumously with loved ones which founder and chief executive Moran Zur has called “digital relics” and “emotional life insurance”. My Last Soundtrack will develop your end-of-life Spotify playlist. More than half a million people die every year in the UK, and market analyst IBISWorld says the UK funeral sector is worth £1.7bn. No wonder there’s been significant funding from angel investors in that “death-tech space”.

This stuff enthuses Peter Billingham, a celebrant and “digital death adviser” who founded the website Death Goes Digital. “The world of death and funerals has really been disrupted by digital culture,” he says. “What was stable for hundreds of years has changed enormously in the last five years. We’re more open about death than ever before and technology is helping to reframe what death means.”

Baby boomers, now moving into the death demographic, are leading the way. Milestones include the 2016 livestreaming of funerals, including those of Lemmy Kilmister and Céline Dion’s husband René Angélil; and of course Bowie, who as ever in the avant-garde, favoured a direct cremation, where the body is cremated before the funeral. There’s a growing inventiveness in eco-death options too: recomposition, where the body becomes compost, and aquamation, a kind of a water cremation – even a “mushroom burial suit”. There are death celebrities, notably Caitlin Doughty, a “mortician and activist” who founded “death acceptance” collective The Order of the Good Death, spearheading the “death positive” movement.

But it is the tech spiritualism that is perhaps the most fascinating part of the digital death otherworld. Many readers will recognise the curious and unsettling scenario whereby a dead friend or relative pops up zombie-like on Facebook, perhaps in a prompt to recognise a birthday.

Modern trend: Dave Grohl delivers a speech at Lemmy Kilmister’s televised funeral

This has led to a huge leap in the way we approach the afterlife. In the past, says Elaine Kasket, attitudes to the dead divided into two main global tendencies: cultures of memory, and cultures of care, roughly zoned into west and east: in China, for example, there’s a tradition of believing that one’s ancestors remain active, while here we honour their memory with photographs and grave visits.

“Now, with digital culture the dead are becoming more vocal and socially influential and the West is moving towards a care culture,” adds Kasket. “They are increasingly in the places of the living.” Digital representations of dead persons won’t be confined to cemeteries. They will haunt different spaces: perhaps even become a rights lobby: the “transdimensional”, perhaps. They will be what Kasket calls the “active dead”, and what Billingham calls “present not absent”. Many people have online conversations with the dead on Facebook, which introduced a legacy contact option in 2015, and Billingham says that we’re already seeing the emergence of a new kind of professional: the “posthumous legacy curator”.

There are far reaches of death-tech that encroach upon sci-fi. Eternime, founded by MIT fellow Marius Ursache, is about creating an eternal posthumous avatar: animated by your digital footprint and given life by artificial intelligence, and is building a database of like-minded people who gain the chance for grandchildren to interact with their unmet great-grandparents. Also in the US, Muhammad Aurangzeb Ahmad, a computer scientist and specialist in personality emulation, is engaged in a project to create simulations of the dead people so as to keep our loved ones “alive”. These avatars will start on the screen, move into virtual reality and augmented reality, then potentially become life-size simulations. Ahmad, who was inspired to work in the area when his father died, sees it becoming reality between 2030 to 2050. “It’s not if, it’s when,” he says. And to those who say it sounds like Black Mirror: well, go back and have a look at the “Be Right Back” episode. 

Open-ended: a woman in ‘Black Mirror’ gets an AI version of her husband after he died

Ahmad thinks that cultures like Japan, with its animist traditions and a neophilic acceptance of robots, will be the early adopters. But he doesn’t see why (bar a few surmountable religious barriers) it shouldn’t take hold everywhere as we become used to it. “It means my daughter will have the chance to interact with my father,” he says. “It will deepen our relationships with our dead loved ones and offer a living memorial that can bring ‘emotional enrichment’.” We’ll be less likely to visit graves, perhaps, and more likely to summon Gran like a digital Doris Stokes.

Of course Ahmad has critics. “People bring up the idea that we need ‘closure’,” he says. “But it goes towards solving the ‘if only I’d said this or that’ problem to an extent.” Still, he concedes there are plenty of legal and ethical issues. What if the simulation were sanitised, with difficult opinions edited out? How should their ageing be represented? Does their voice sound right? Ahmad thinks that the development of digital trusts will emerge, and with artificial voice synthesis, the latter will get better. “But these are uncharted territories. It will affect the way we see identity. Adding emotions may be a challenge.” Will Death 2.0 bring on unintended consequences? It’s a dead cert.

Complete Article HERE!

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03/28/18

Learning how to think about death changed how I live

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Viewing death as unrelated to life, or antithetical it, does a disservice to the days we have, because we don’t know how to value them, says John Leland. The journalist and author explains how an elderly friend changed his perspective on the importance of acknowledging our mortality.

Read the Full Transcript

Judy Woodruff:
New York Times reporter John Leland began following a group of men and women in 2015 who ranged in age from 87 to 92.
What he learned shattered his expectations about aging and death, as he explains in his Humble Opinion.

John Leland:

People are always telling us to live each day as if it’s our last, but we don’t really do it, and for two good reasons.

The first is that, if you really thought today was your last day, you wouldn’t pay the utility bill or save for retirement, and, before you know it, you’re in the dark warming a can of beans over an open flame.

And the second reason is that we don’t like to think about death or dying, except as something that happens to other people.

A few years ago, I met a man named John Sorensen, who taught me how to think about death, and it changed my outlook on life. He was 91, and he missed his partner of 60 years. And every time I visited him, he said he wanted to die. He wasn’t depressed or even sad.

In fact, talking about dying always got him in a good mood. Wanting to die, for John, was the best reason to live.

And what I mean is this. He loved opera and he loved old movie musicals. And wanting to die meant acknowledging that this might be the last time he heard Jonas Kaufmann sing Wagner or watched Gene Kelly singing in the rain. This made each time more worthy of his attention.

And the same went for visits with friends. It’s a textbook economics of scarcity. His days weren’t fleeting. They were saturated with pleasures of his own choosing.

In our culture, we have come to think of death as a kind of failure of medicine or an affront to the self, rather than seeing mortality as built into all of our days, the first as much as the last.

Viewing death this way, as unrelated to life or antithetical to it, does a disservice to the days we have, because we don’t know how to value them. We enjoy a movie more knowing it’s going to end in a couple hours.

That ski run in the Swiss Alps, it’s only fun because you know there’s a bottom. The end of the run gives meaning to each curve on the way down, even when you’re still near the top of the mountain.

I have heard this acceptance of the end from most of the older people I have spent time with.

But you don’t have to wait until we’re 91 to enjoy it. We should rethink what it means to live every day as if it’s your last. The way I learned it from John, it means embracing that part of the end that exists in this moment, and then in the next.

You don’t have to quit your job or stop paying your utility bill. There’s enough to live for in the things you’re already doing. Each brush with a stranger, each moment with friends, each kiss or caress, there’s a little bit of our mortality in all of them. But their ours for now.

And that is reason to be happy.

Complete Article HERE!

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03/27/18

Coming to terms with the end of life

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by Penny Heneke

Being well ensconced in my senior years, I am faced with the daunting prospect of my mortality. An article I read recently commented that people are afraid to face and to speak of this pending permanent change of address. For me death lurks in the dark like a boogey man under the bed. An elderly, crabby aunt I boarded with as a teenager scanned the death notices each day. She positively cackled with delight when she discovered an acquaintance she had outlived.

Nor is death and dying a scintillating topic to introduce for conversation in an evening entertaining friends. While seniors are renown for recounting “organ recitals” of their many health problems in great detail, death itself is a taboo subject. For some, life is a painful battle against debilitating health issues and for most of us it is trying to find strategies to deal with the everyday evidence of our evaporating capabilities along this final stage of our life journey.

Perhaps a sense of humour is a valuable tool to deal with our aversion to death. A friend on his 90th birthday decided to deal with his advancing age by walking around with a sticky note plastered on his forehead announcing, “expiry date: overdue.”

In the meantime, seniors have to cope with the everyday incomprehensible things we seem to do as we amble along to this dead end. If the solution were only as simple as one friend remarked: “Oh, for some happy pills.”

One morning, my husband, Ken emerged from the unlit walk-in closet attired in my fluffy, light blue, terry housecoat. It fitted him to a tee, as today my hubby is a shell of his former robust five-foot-10. Shrinkage of over 4 inches has occurred due to arthritis. When he realised his faux pas, he looked sheepish and commented: “I’m really losing it.”

I couldn’t laugh too loud as I find myself in the same category. At my recent optometrist appointment, I was squinting through the phoropter the optometrist was using to test my eyesight, not wishing to admit that the finest print was a blur. I had always had 20/20 vision. In an attempt to improve the images, I closed one eye. As the consultation continued with the instrument going back and forth, I suddenly could not see anything in the one lens — just blackness. My optometrist was puzzled and made some lens adjustments.

“Can you see now?” she asked.

“No, it’s still pitch black,” I replied. “I can’t see a thing.”

She sounded puzzled and moved the machine aside. After a moment’s hesitation, she placed a hand gently on my shoulder and remarked: “My dear, you have your eye closed!”

While my vision might be fading fast, Ken suffered a mini-stroke and lost the use of his right eye. Family and friends responded sympathetically by telling him of someone they knew with the same predicament and yet was still legally able to drive. Neither Ken nor I felt reassured learning how many one-eyed people are out there on the roads driving.

I don’t think it was his eyesight that caused Ken to panic as he was leaving for a doctor’s appointment. He patted his pockets frantically looking for his car keys until I pointed out that he had them in his hand.

Never mind the missing death discussion, aging itself takes a great deal of adjustment. My recurrent nightmare of losing my teeth has been replaced by one of losing clumps of my hair and going bald.

After spending a life time amassing material objects, I have reversed the procedure by decluttering. Now I am fine tuning the unburdening of my “stuff.” I am in the last stage, which I am calling, “closure.” This is as close to the “D” word as I can get.

Preparing for the end, I announced to my children that I was drafting my own obituary notice. I don’t trust them to get the facts right. This resulted from my perusal of the obituary notices each day in the daily newspaper. My first feeling is one of sadness looking at all the smiling faces of people who have passed. However, I am also struck by a few who have had unflattering photographs placed with their notice. In order to avoid this dilemma, I have picked a photo — admittedly a good few years younger — of myself for my obituary. My daughters love to tease me by saying that I will have no control over the whole issue. At least I would have tried.

The lyrics from the English punk rock band, the Clash, “Should I stay, or should I go” underscore that we really have little choice in the timing of our departure so it’s best to make the most of what you still have left of life.

Complete Article HERE!

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03/26/18

Thinking About Having a ‘Green’ Funeral? Here’s What you need to Know

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A typical American funeral usually involves a few hallmarks we’ve come to expect: an expensive coffin, lots of flowers, an embalming for the deceased and a number of other add-ons.

But how necessary are those embellishments? Enter the “green burial.”

The specifics of a green burial vary widely, but typically they require far fewer resources for the care of the body and skip a number of the traditional steps, making them better for the environment. Plus, they can save families on funeral costs.

Interest in these pared-down, eco-friendly options has grown as people look for ways to cut their carbon footprint. Nearly 54 percent of Americans are considering a green burial, and 72 percent of cemeteries are reporting an increased demand, according to a survey released earlier this year by the National Funeral Directors Association.

Death planning may not be at the top of your mind, but if you’re curious about looking into a green burial, here’s what to know.

What exactly is a green burial?

The Green Burial Council’s steps for minimizing negative environmental effects include forgoing embalming, skipping concrete vaults, rethinking burial containers and maintaining and protecting natural habitat. Choices can be made at each step of the death care process to limit waste, reduce the carbon footprint and even nourish the local ecosystem.

Embalming, vaults and coffins can be expensive, with the national median cost of a funeral reaching upward of $8,500, according to the N.F.D.A. Replacing them with other options or scrapping them altogether can save money as well as the environment, since you’re not spending on extraneous items or putting them into the ground.

The extent of how “green” a burial can be is up to the individual; the service can be as simple as wrapping the deceased in a cotton shroud before lowering them into the ground. The services can also become more complicated, involving a memorial ceremony and burial in a conservation park like Washington’s Greenacres, where families can choose to plant a variety of plants, flowers and shrubs on the grave.

These aren’t entirely new ideas — the funeral traditions of many religions, for example, are in line with these steps.

Why would I want one?

Death planning is a deeply personal and often unpleasant topic, so reasons for choosing one type of burial over another are as varied as you can imagine. But for many people who opt for a green burial, it can come down to cost, environmental impact and legacy.

Since burial costs vary not just state to state but cemetery to cemetery, hybrid cemeteries — or those offering both conventional and green burials — offer a balanced look at the financial aspect of death. According to the Green Burial Council, a nonprofit that encourages environmentally sustainable death care, most hybrid cemeteries report that graves intended for green burial cost “the same or somewhat less” than their conventional counterparts; after the costs of vaults, coffins and embalming are factored in, the savings a green burial offers are “significant.”

The reason others choose green burial is right in the name: It’s environmentally friendly. Green burials do away with both the embalming chemicals and the extraneous cement, steel or other non-biodegradable materials conventional burials put into the earth, and lack the carbon footprint of cremation, which has been calculated to be the equivalent of a 500-mile car journey.

Perhaps the most personal reason of all is one where the idea of green burial simply speaks to a person. They might find comfort in their body “returning to nature,” or want to take part in a conservation burial, where burial fees are also used to cover land protection, restoration and management. “Not only does conservation burial help protect land, but the burial area becomes hallowed ground, restored to its natural condition and protected forever with a conservation easement,” explains the Prairie Creek Conservation Cemetery. “Citizens who support conservation are offered a more meaningful burial option with the certainty that protected land is the ultimate legacy to leave for future generations.”

But isn’t embalming necessary?

Generally speaking, no. Embalming — the preservation of human remains for public display through the use of a chemical mixture that delays decomposition and makes the body “look natural” — is more of a cosmetic procedure than a public health safeguard.

“The easy elimination in traditional funerals is embalming,” said Amber Carvaly, a service director at California’s Undertaking LA, referring to how to lessen a funeral’s environmental impact.

“It’s almost exhausting at this point to argue with people in the industry on whether it is good or bad,” she said. “You took a body that would have decomposed naturally, you put chemicals in it and a huge part that is left out is that most of the chemicals don’t stay in the body: They are flushed down the drain when they are let back out of the body’s arterial system.”

Still, popular culture tends to reinforce the idea that embalming is a necessary step: Just about 48 percent of people are aware that embalming isn’t needed for a cremation service, according to the N.F.D.A.’s consumer survey.

Jeff Jorgenson, who owns Elemental Cremation and Burial in Washington, said forgoing embalming is a crucial part of green burials.

Instead, he suggested asking for dry ice or Techni-ice, a refrigeration unit, or a nontoxic embalming agent. You can also keep (or bring) the body home and cool it with fans, cooling blankets or open windows.

“Traditional funeral directors will frequently talk about how mom or dad won’t look very good” if the bodies aren’t embalmed, Mr. Jorgenson said. Instead, he has found that families are thankful that his company doesn’t perform embalming “because it feels like there is more room for closure.”

Cremation or burial?

Here is what Americans put in the ground each year through traditional burials: 20 million feet of wood, 4.3 million gallons of embalming fluids, 1.6 million tons of reinforced concrete, 17,000 tons of copper and bronze, and 64,500 tons of steel, according to the Green Burial Council.

Green burials eliminate much of this waste by leaving out almost all of those materials; most bodies are simply wrapped in shrouds made from a biodegradable material like cotton and placed in the ground. And although cremations often have the reputation as being an eco-friendly option, they tend to have an outsize carbon footprint.

(A third option, called alkaline hydrolysis or aquamation, in which water pressure accelerates the decomposition of soft tissues, uses less energy than cremation but is only legal in 14 states.)

Each option has its pros and cons, and it’s important to consider your situation. If you’re attentive to your carbon footprint, cremation in your hometown might still be a better choice than using a green cemetery hours away, and certain funeral homes have ways to offset the environmental hit, like working with organizations on strategic reforestation processes, Mr. Jorgenson said.

Should you go with cremation, there is one final factor to consider: What to do with the remains.

“Even scattering small amounts can be hazardous in a delicate environment such as an alpine environment or vernal pool,” said Michelle Acciavatti of Ending Well, a service that guides families all over the country through their end-of-life options.

Instead of scattering, try Let Your Love Grow, a product that turns ashes into plantable soil for a memorial flower or tree. Another option is Eternal Reefs, which hold cremated remains in an underwater cement ball and create new marine habitats for fish and other sea life.

A ‘green’ burial by any other name

While cremation is a straightforward option, a green burial encapsulates a wider range of decisions, from how to where. If there aren’t green cemeteries where you live, there are still plenty of ways to minimize the burial process’s environmental impact.

Substitute concrete vaults and toxic burial containers for coffins made with sustainably harvested wood and organic liners, and check if products or components were transported over long distances, which can increase the carbon footprint.

You also shouldn’t feel limited by what a funeral home is selling you — by federal law, they’re required to accept a coffin provided by the customer at no extra charge. Or skip the coffin altogether. A shroud made from organic, biodegradable cotton can be purchased through your funeral home or online, or even at the local fabric store.

A growing movement

When it comes to green burials, funeral professionals say the biggest challenge is a lack of awareness and resources.

“Thinking about the impact of disposition on the environment is a new idea,” Ms. Acciavatti said. “And, I would say the other big issue is access: Even though there are over 150 green cemeteries in the U.S. and Canada, there still aren’t enough.”

Ms. Acciavatti and many others in the industry believe that educating the public as well as continuing to invest in green practices helps not just the environment, but humans, too.

“It’s always really rewarding when someone says, ‘I’d really like to return to the earth.’” she said. “And I get to say, ‘I can help you do that.’”

Interested? Start here

The Green Burial Council’s website has information, a list of providers and additional resources for people interested in green burial.

The Order of the Good Death, a collective of funeral professionals, academics and artists, has an informative page about green burials.

Looking for a green burial for you and your pet? Visit the Green Pet-Burial Society.

Complete Article HERE!

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03/25/18

An Alternative to Burial and Cremation Gains Popularity

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An alkaline hydrolysis unit at a funeral home in Windom, Minn. This week, California became the 15th state to outline commercial regulations for the disposal of human remains using the method.

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What do you want done with your body after you die?

It is an unnerving but important question, and for most Americans there have long been only two obvious choices: burial or cremation.

But a third option, a liquefaction process called by a variety of names — flameless cremation, green cremation or the “Fire to Water” method — is starting to gain popularity throughout the United States.

This week, California became the 15th state to outline commercial regulations for the disposal of human remains through the method, chemically known as alkaline hydrolysis.

It may seem markedly different from the traditional means of digging graves or burning the dead. A machine uses a chemical bath to dissolve protein, blood and fat, leaving only a coffee-colored liquid, powdery bone and any metal implants, like dental fillings.

Alkaline hydrolysis has been used to dispose of human cadavers and dead pets since the process was modernized in the 1990s. About 10 years ago, the machines became available for ordinary funerals, and now families are requesting it more frequently. Some are motivated by environmentalism or cost, as cemeteries fill up. Others find the process more comforting than cremation, which recently edged past burial in the United States, according to the National Funeral Directors Association.

The California bill was sponsored by Assemblyman Todd Gloria, who represents much of San Diego, after he was contacted by executives from Qico Inc., the company that advertises the process with the trademark “Fire to Water.”

Assemblyman Gloria said that he supported the bill partly to advocate for a constituent but also because he thought that people should have more choices.

“It was definitely new to me,” he said. “I think like most people I don’t talk a lot about death. I don’t think about it a great deal; I probably shy away from it. But when the concept was brought to me, of course I needed to understand it better.” He added, “It’s pretty fascinating stuff.”

Alkaline hydrolysis was patented in the United States in 1888 “for the treatment of bones and animal waste” and modernized by Dr. Gordon I. Kaye and Dr. Peter B. Weber, two professors at Albany Medical College about a century later.

t works like this: An alkali, or salt derived from an alkali metal or an alkaline earth metal (usually sodium hydroxide, potassium hydroxide or a combination of the two), is combined with water in a specially made machine.

About 65 percent of the human body is already water, while another 20 percent or so is protein, including blood, muscle and collagen, which is found in tissue and bone. The alkali breaks down the body’s proteins and fats. The machine produces sterile brown effluent made up of minerals, salts, amino acids, soap and water, as well as weakened bones that can be crushed into an ash, and any metal in the body.

Bio-Response Solutions is one of the few working manufacturers of such machines in the United States. Joe Wilson, its chief executive, said the field is so new, people do not yet agree on what to call the machines. He sells two models: the High-Temperature 28 and Low-Temperature 28. The first sells for $220,000 and can dissolve a body in as little as three hours; the second costs $150,000 and takes up to 16 hours. Some competitors sell far costlier models. (The number refers to the diameter of the cylinder, 28 inches.)

An alkaline hydrolysis unit at Bio-Response Solutions in Danville, Ind. The company is one of the few working manufacturers of such machines in the United States.

One of his competitors sells a $500,000 model. “It’s a very high-end unit, like a Rolls-Royce,” he said. “And Rolls-Royces are nice but you don’t see many of them around. I watched it for a couple years and finally decided to do a Chevrolet.”

Flameless cremation seems to have caught on among younger funeral directors.

Ryan Cattoni, 28, who graduated from mortuary school in 2010, said that he learned about the method from a trade magazine and thought it was probably “the wave of the future.”

He opened AquaGreen Dispositions in South Holland, Ill., in September 2012, about a year after the state legalized the process. He offers a flameless cremation package covering the paperwork, an urn (filled with powder from the bone) and transport for $1,795. He said that he performs hundreds of them a year. A simple nonceremonial cremation in Chicago can cost as much as $3,000.

The environmental benefits of alkaline hydrolysis are significant. Its carbon footprint is about a tenth of that caused by burning bodies. Mr. Wilson said liquefaction uses a fraction of the energy of a standard cremator and releases no fumes.

Funeral directors thought the machines would be popular for their environmental benefits, but they were surprised to discover other motives.

“When it’s a family that has just lost Mom or Dad, they’re in a more emotional state and they look at it and say it seems more gentle,” said Jason Bradshaw, the president and chief executive of a funeral and cremation service with six locations in the Twin Cities.

One of his customers was Judy Kastelle, 68, a resident of Hudson, Wis., who has found herself averse to burial. Both her grandparents were buried, she said in an interview, and she thought it seemed wrong to put their bodies in coffins encased in concrete.

When her mother, Marcella Okerman, died at 95 earlier this month, Ms. Kastelle had already arranged for flameless cremation.

“I just liked the gentleness, of her kind of being dissolved away,” Ms. Kastelle said. “I didn’t think a lot about that. I knew cremation was the thing, and it just seemed like an option that felt kinder, to me.”

Not everyone feels this way. Some critics recoil, in part because the effluent is released into local sewage systems.

“They say ‘soylent green’ or ‘throw mama down the drain’ or all that stuff,” Mr. Wilson said.

But experts note that the fluid is sterile and contains nutrients, so much so that it can be and is used as a fertilizer. Rick Vonderwell, who manages Tails Remembered, a pet crematory in Delphos, Ohio, uses the effluent at his farm, as do several large universities.

In some places where flameless cremation is available, it has quickly overtaken the alternative. Mr. Bradshaw, who has been offering both services for five years, says that more than two-thirds of families seeking cremation choose the new method when it is offered.

“Burial is dead,” Mr. Wilson said. “It’s going to go away. It’s not sustainable. Too many people and not enough land.”

Complete Article HERE!

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