I’m an ICU nurse. I know I need an end-of-life directive.

So why can’t I bring myself to write it?

By Andrea Useem

I of all people should know how to do this. As an ICU nurse, I see every day how agonizing it is for families to make end-of-life care decisions for loved ones who have not made their wishes clearly known. I know what I want. I know what the legal options are. But when I sit down to fill out the papers, I stall.

The form remains incomplete.

All of my experience urges me to act. I think of the anguished adult son trying to decide whether his elderly, unconscious mother would want to live permanently connected to a ventilator.

“Pray for me that she dies before I have to make a decision,” he told me. If she had made her choices known before medical calamity struck, her son would have the peace of mind of carrying out her wishes, one way or another.

I think of another family, where two siblings — one of them a physician — came to blows in the hospital waiting room because they could not agree on whether to stop aggressive treatment for their father, given that his organs were shutting down, one by one.

Of course I want to reduce what’s called the “decisional burden” on my own family by making my choices clear in case I become too sick some day to decide for myself. I just can’t bring myself to translate my well-informed preferences into a legal document such as an advance directive.

I’m not alone. Although advance-care planning has other well-established benefits, including an increased chance that patients will receive the care they want, only one-third of Americans have any sort of advance directive, according to a 2017 study led by researchers at the University of Pennsylvania.

And health-care professionals like myself are no exception. In her 2017 book “Extreme Measures: Finding a Better Path to the End of Life,” physician Jessica Nutik Zitter explained why she avoided the task of translating her medical wishes into a series of yes/no check-boxes that make up many advance directive forms.

“My feelings are too complex, too nuanced, to fit into one little white square,” wrote Zitter, who is board certified in both palliative care and critical-care medicine.

So why is this undertaking so difficult? And how can we all get better at completing this vital task?

The first barrier to advance-care planning is often understanding what is involved. According to G. Kevin Donovan, director of Georgetown University’s Pellegrino Center for Clinical Bioethics, an advance directive is a document that usually includes two separate elements: naming a health-care surrogate and creating a living will.

A health-care surrogate or “proxy” is an adult who is legally empowered to make medical decisions for you when you can’t make them for yourself. Many think they have this base covered when they name a durable power-of-attorney. But a power-of-attorney directive does not automatically allow for decision-making power in the health-care realm.

“They can sell your stock, but they can’t take you off a ventilator,” Donovan said.

A living will offers you a way to say in advance what sorts of medical interventions you would want. For example, the form we offer at our hospital asks whether you would want “artificial nutrition” — meaning liquid nutrients delivered through a tube — if you were expected to die soon.

The problem with these forms is that they rarely capture the complexity of real-life medical decision-making, Donovan said.

In the intensive care unit where I work, we recently had a woman in her 60s whose cancer had come back with a vengeance. She was awake and talking with her family, but her vital signs were deteriorating quickly. We asked the patient and the family what they would want if she could no longer talk and make decisions, and they requested an advance directive form.

When I came to check on them later, I found the patient and family puzzling over the form’s questions, such as what kind of care she would want if she were in a “persistent vegetative state.” The abstract scenarios were almost irrelevant to their immediate situation.

I redirected the conversation to the concrete choices in front of them: Would she want a breathing tube put in her throat in the next 24 hours when her lungs began to fail? Or to have a large IV inserted in her neck to start dialysis after her kidneys stopped working? Thankfully for the family, the patient made her own decisions and shared these with our physicians. She said she didn’t want any “heroic” interventions, and she died 48 hours later, with her family at her bedside.

To me, filling out a living will as a relatively healthy person feels like ordering food for a meal I will eat in 20 years: It seems impossible to predict what I will want in that moment. Is it good to be vague and write, “I want to be kept comfortable?” Or better to be highly specific and say, “I never want to have a feeding tube inserted?”

Because living wills are difficult to translate into real-life decisions, many experts now advise focusing on not only naming the right person as your health-care decision-maker but also talking in depth with that person about what’s important to you.

“The best advanced directive is to name an educated person as your health-care surrogate,” said Douglas Houghton, an acute-care nurse practitioner and director of advanced practice providers at Jackson Health System in Miami. “You need to have a real conversation with that person, and not simply write down a name on a piece of paper that you keep in a filing cabinet.”

Zitter agreed that having conversations with loved ones is vital.

“A written document is a good first step, but it’s not the ultimate goal,” said Zitter, whose work around end-of-life decisions was profiled in the 2016 Netflix documentary, “Extremis.” “For me, the real work happens on Friday nights at the dinner table, when I talk with my family about illness, and death and what I would want at the end of my own life, even when my sons are rolling their eyes.”

But Zitter conceded that a major barrier stands in the way of these conversations: a fear of talking about death.

“Even for me, as a doctor who deals with death every day, I don’t want to think about my own end, it makes me very sad,” she said.

So what can help us all climb over this final existential barrier to end-of-life planning?

I recently witnessed a conversation at work between a palliative care doctor and a patient with severe heart failure, whose adult son and grandchild were at the bedside. The doctor gently reminded the patient that if she could give her preferences now while she was conscious, she would relieve the burden on her son, who otherwise would have to make hard decisions on her behalf. When she finally said she wanted to go home with hospice, her son was visibly relieved.

Framing end-of-life planning as a service to loved ones is a compelling idea. One critical-care doctor I work with suggested we link advance directives to Valentine’s Day. Show your love by sharing what you want. This idea is also what finally motivated me to overcome my own hesitations.

This month, I finally filled out “Five Wishes,” a downloadable document, where I named a health-care proxy and two backups. I wrote I don’t want to artificially prolong my life with machines, such as a ventilator, and if such treatments are started, I want them stopped. I had two neighbors witness the document, making it legally binding in Virginia, and placed it in our kitchen filing cabinet.

Talking about my wishes over dinner with my kids? I’m not there yet. Meanwhile, let me share my advance directive here, so at least my kids can Google it: When the time comes, keep me comfortable, let me go and know that I love you.

Complete Article HERE!

‘Good Death’

Choosing How to Live and How to Die

By Matt McMillen

Patty Webster heard her mom talk about death. A lot. So often that she and her sisters sometimes had to stop their mother from bringing it up. Her message got through, though.

Before her mom died of a stroke in 2016 at age 73, a previous stroke had already robbed her of her ability to communicate. But her family knew what she wanted at the end of her life because she had made it plain to them. That allowed them to share her wishes with her doctors and others so that she could die as she chose.

“We were her voice,” Webster says. “I didn’t know what a gift all of those talks had been until then.”

Webster works for the Conversation Project, an initiative of the Boston-based Institute for Healthcare Improvement. Founded in 2010, it encourages people to become comfortable talking about the type of care they want — and don’t want — at the end of their lives. A survey the group conducted in 2018 found that 95% of Americans are open to discussions about their wishes. But only about 1 in 3 have talked about what they would want. Five years earlier, however, that number had been closer to 1 in 4. More people, it seems, are talking about how they want to die. Some more than others.

“My family is tired of me talking about it,” Webster says, laughing.

But Webster wants those discussions to continue, and she wants the number of people having them to keep growing. She also wants to clarify: “Don’t talk about death but about how you want to live.”

Expressing your wishes for the end of your life and having them respected: Some call it “a good death.” Others may refer to it as “successful dying.” Ira Byock, MD, prefers “dying well.” A palliative care specialist and chief medical officer of the Institute for Human Caring at Providence St. Joseph Health in Gardena, CA, Byock is also the author of Dying Well: Peace and Possibilities at the End of Life.

“Every one of us as adults should be having this conversation,” he says.

In fact, Byock and his colleagues talk to high school seniors about advanced care planning: “We want to normalize this and make it a part of growing up.”

In a paper published in 2016, researchers reviewed 36 previously published studies to determine the “core themes” of a good death. They looked at the question from three perspectives: the person dying, the family, and health care providers. While 11 themes emerged, all three groups ranked three themes as most important:

  • Deciding how they wanted to die, including who would be with them and having their treatment preferences and funeral plans prepared
  • Approaching death without pain
  • Being emotionally well, meaning their psychological and spiritual well-being has been addressed

States Adapt to Change

In some parts of the country, the conversation includes drugs that end your life. Oregon became the first state to enact the Death with Dignity Act, which voters approved in a 1994 refereundum. After years of court challenges, the law took effect in 1998. It allows residents who are terminally ill, have 6 months or less to live, and are deemed mentally able to make their own decisions to end their lives. Ten years would pass before another state, Washington, would approve its own version. Maine became the most recent state to pass a version of the law. Gov. Janet Mills signed it on June 12. These are the other states where doctor-aided dying has been made legal and when the laws took effect:

  • California (2016)
  • Colorado (2016)
  • District of Columbia (2016/2017)
  • Hawaii (2018/2019)
  • New Jersey (2019)
  • Vermont (Patient Choice and Control at the End of Life Act, 2013)
  • Montana (Although no Death with Dignity law exists in Montana, the state’s Supreme Court ruled in 2009 that the practice was legal.)
  • The laws have sparked opposition. In Maine, for example, the state legislature passed the law by only four votes. In California, the law was overturned in court last year, but an appeals court put a hold on that ruling, and the state’s Supreme Court chose not to review the case. That leaves the law, known as the End of Life Option Act, in effect, though its future remains uncertain.

    Between 2009 and 2017, the most recent year for which statistics are available, 1,364 people in Washington had used the law to end their lives. Last year, in California, 337 people chose to die under the state’s End of Life Option Act. In Oregon, 2,217 terminally ill people have received life-ending drugs over the past 2 decades. Nearly two-thirds used those drugs, while the rest opted not to take them.

    “That’s been the case year after year,” says Peter Lyon, MD, medical director of End of Life Choices Oregon, a Portland-based organization that helps Oregonians navigate the Death with Dignity Act and other final decisions. “Some people just like to know that the medicine is there and available if their pain becomes too severe or their condition worsens a great deal.”

    On average, says Lyon, people do not reach out to his organization until they have about 3 to 4 weeks left to live. One reason: It’s so difficult for many people to think about, let alone talk about.

    “Talking about death is the hardest conversation that families can have,” he says.

    More Than a Medical Decision

    How you want to die is only partly about medical issues, Byock says. It’s also highly personal. And it will mean something different to you than it will to your spouse, your parents, your children, and others. To reach your own definition, Byock advises you take stock.

    “Ask yourself, ‘If I’m seriously ill, what would matter most to me?’” he says. “For the vast majority of us, it’s other people. We are hard-wired to matter to one another.”

    Your conversations, of course, should address practical matters, like life insurance information, how to access your safe deposit box, how to close your bank account — and your Facebook account — and more. Byock recalls how much that meant to him after his mother’s death.

    “She lived alone, we found that she kept a wooden box next to her phone with all the documents we needed,” he says. “Mom was still taking care of us.”

    You will also need to make decisions about key medical concerns. For example, do you want to be kept alive as long as possible, even if treatment causes great discomfort? Or do you prefer care that may allow you to enjoy better quality of life, though your death may come sooner?

    “Some people might worry that they’re not going to get enough treatment, while others might be afraid that they’ll get overly aggressive care,” says Kate DeBartolo, who directs the Conversation Project.

    Another crucial consideration: Who will speak for you if you are not able to voice your wishes? For many people, that may be a loved one, such as a family member, but it does not have to be.

    “I try to encourage my patients to think about who knows them best on their good days and bad days and who is readily available,” says palliative care doctor Christian Sinclair, MD, of the University of Kansas Health System in Kansas City.

    DeBartolo agrees: “I would love to expand the idea that it doesn’t have to be a traditional family member. Ask yourself: Who would you trust, and who do you think could really speak for you?”

    Such a person, known variously as a health care proxy or surrogate or agent, can be given power of attorney to make treatment decisions for you when you can’t make them for yourself. You also can –and should — put your wishes in writing. Legal documents, such as advance directives and living wills, are an alternative or may be used along with a proxy to make clear what you want.

    Sinclair, a co-author of the Institute of Medicine’s 2014 report Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life, says that over the last 15 years or so, conversations between patients and providers about end-of-life care have become more common as more doctors have been trained for such discussions.

    “Research shows that when these conversations happen and patients and clinicians are on the same page, there’s more likelihood that those patients will actually get the care that they want,” says Sinclair. “Having a good death is about making individual choices.”

    Complete Article HERE!

Emptiness and Filling Out Forms:

A Practical Approach to Death

Dying with compassion means having a plan in place for those left behind. A practitioner recounts how she navigated the process with her dharma friends.

By Rena Graham

As a Tibetan Buddhist practitioner, I am constantly reminded that we never know when death might approach, but for years, I’d avoided dealing with one of the most practical aspects of death—the paperwork. I was not alone: Roughly half of all adults in North America do not have a living will. Then recently, I suffered a near-fatal illness that left me viscerally aware of how unprepared for death I was, and I made a pledge with two of my friends to get ready to leave our bodies behind for both ourselves and the people who survive us.

Bridging the end of December 2017 and the beginning of January 2018, I spent a month in a Vancouver, British Columbia hospital with a bacterial lung infection that had also invaded my pleural cavity—the first time I’d come down with a severe illness. After ten days in an intensive-care unit, I was moved to a recovery ward where I suffered a relapse. I spent my 62nd birthday, Christmas, and New Years with strangers in the hospital.

One night in the ICU, while I was partly delirious and falling in and out of sleep, I had a vision of a deceased friend reaching out to me. From what felt like disengaged consciousness, I looked down at my body on the hospital bed and realized I wasn’t ready to die. I hadn’t studied my lama’s [teacher’s] bardo teachings to navigate the intermediate state between death and rebirth, and did not want to take that journey without a road map. It didn’t matter whether this was a drug-fueled hallucination or an actual near-death experience. The important thing is that I rejected death, not out of fear, but through a recognition of the dreamlike nature of reality. After this experience, I felt that my attachment to this life and the things in it had diminished. I no longer wanted to ignore what came next. I wanted to be prepared. 

When I told my friends Liv and Rosie about this vision, we agreed to study the bardo teachings together once I’d had a couple of months of recuperation. By March, however, our plans shifted. Rosie had heard about a man (I’ll call him Ben) who had died on Lasqueti Island, an off-the-grid enclave in Canada’s Southern Gulf Islands that a local cookbook once described as “somewhere between Dogpatch and Shangri-La.” He had left his closest friends without any instructions. They had no idea if he had a family or where they might be.

“And he left an old dog behind!” Rosie said, “Can you imagine?”

“Not the bodhisattva way to die,” I replied, referring to the Buddhist ideal of compassion. I  also imagined what mess I might have left, had I not made it. 

Promising they would never leave others in such a quandary, Ben’s closest friends created a document called the Good to Go Kit, which detailed information required for end-of-life paperwork. (It is now sold at the Lasqueti Saturday market to raise funds for their medical center.)

“I’ve been wanting to make a will for 20 years,” said Liv, who would soon turn 70, “but research throws me into information overload, which adds to the emotional overwhelm I feel just thinking about it.”

“What if we did this together instead of studying the bardo?” suggested Rosie, who was in her early 50s.

Writing a will, figuring out advanced healthcare directives, and noting our final wishes didn’t have the mystical lure of bardo teachings, but we set that aside for a year while we took on this more practical area of inquiry. 

To use our time wisely, we set several parameters in place. We decided to meet one weekend a month to allow time for research and reflection between meetings, and we chose to keep our group small for ease of scheduling and to allow us to delve deeper into each topic.

 “I’d like this to be structured,” said Liv, “so it doesn’t devolve into a social event.”  

Rosie and I agreed but we knew better than to believe there didn’t need to be some socializing. She offered her place for the first meeting and said she’d cook. 

“We’ll get our chit-chat out of the way over dinner,” she said. “Since we can all be a little intimidated by this process, we have to make it fun.”

Later in March at Rosie’s garden suite, we sat down to dinner and Liv passed out copies of “A Contemplation of Food and Nourishment,” which begins with the appropriate words: “All life forms eat and are eaten, give up their lives to nourish others.” The prayer was written by Lama Mark Webber, Liv and Rosie’s teacher in the Drikung Kagyu school. (I also study with Lama Mark, although my main teacher, Khenpo Sonam Tobgyal, is in the Nyingma lineage.)  Turning our meetings into sacred practice seemed the obvious container to keep us on topic.

After dinner, Rosie rang a bell, we said a refuge prayer and recited the traditional four immeasurables prayer to generate equanimity, love, compassion, and joy toward all sentient beings.  

We traded our prayers for notebooks and reviewed our Good to Go Kit. Rosie smiled at the expected question of pets—including the name of the person who would be caring for the pet, the veterinarian and whether money had been set aside for their expenses. The form also asked whether we had hidden items or buried treasure.

Liv laughed and said, “People still bury strongboxes in their backyards?”

My answer was more prosaic: “Storage lockers.”

Rosie, Liv, and I are all single and childless. We are all self-employed and independent and have chosen Canada as our adopted homeland, meaning we have no family here. So we considered what roles friends might play and focused on those who were closer geographically than sentimentally. 

Pulling them in to act on our behalf seemed like such a “big ask” as Rosie said, but it was time to get real about our needs. The three of us shared our feelings about involving friends outside the dharma versus those within. 

When I was in the ICU, my friend Diane visited on several occasions and later told me she remained calm until she reached her car, where she cried uncontrollably. In marked contrast, my dharma friend Emma calmly asked what I needed and didn’t make much of a fuss. My Buddhist friends tend to view death as a natural transition from one incarnation to the next, while other friends may see it in more dire terms: as a finality or even failure. For end-of-life situations, asking non-Buddhist friends for limited practical support seemed kinder for all involved. 

We started to familiarize ourselves with the responsibilities of someone granted power of attorney for legal and financial proxy and enduring power of attorney for healthcare. Months later, we agreed our network of “dharma sisters” would be the perfect fit. While we hope to maintain our ability to make decisions for ourselves, should we require long-term care, we felt the baton could be passed between a dozen or so trustworthy women. We have since spoken casually about this with a number of these women and have made plans to organize a get-together and discuss our plans in greater detail, offering reciprocal support for what the Buddhist author Sallie Tisdale calls “the immeasurable wonder and disaster of change.” 

We concluded our five hours together by dedicating the merit and reciting prayers of dedication and aspiration. Long-life prayers for our lamas were offered, a bell rung, and heads bowed. Without the need for further conversation, we made our way into the chilly spring evening, silently reflecting on our new endeavor.

The next meeting and those following included menus and discussions that varied widely. Our research grew monthly with documents from government agencies, legal and trust firms, and funeral homes. None of which felt specific to Buddhist practitioners, until Rosie told us about Life in Relation to Death: Second Edition by the late Tibetan teacher Chagdud Tulku Rinpoche. This small book is out of print, but I purchased a Kindle copy. In the introduction, Chagdud Tulku, a respected Vajrayana teacher and skilled physician, reminds us that “[t]here are many methods, extraordinary and ordinary, to prepare for the transformation of death.” A book of Buddhist “pith instruction,” it includes in its second edition appendices that above all I found most valuable. These include suggested forms for “Durable Power of Attorney for Health Care,” “Advance Directive for Health Care (Living Will),” “Miscellaneous Statements for Witnesses, Notary and Physician,” and “Letter of Instructions.” It even includes a wonderful note for adding your ashes to tza-tsas, small sacred images stamped out of clay. We loved that idea, though we couldn’t imagine asking friends to go to that extent to honor our passing. 

We decided to use a community-based notary public to draw up our wills, but with further research, Liv realized she could also hire them to act as her executor, rather than use her bank. She found someone experienced and enjoyed the more personable experience. In contrast, Rosie and I’ve decided to pay friends now that we’ve found ways to simplify that process for them. 

Memorial Societies are common in North America and help consumers obtain reasonably priced funeral arrangements. Pre-paying services at a recommended funeral home allows us to leave funds with them for executor expenses, should our assets be frozen in probate. End-of-life insurance “add-ons” we like include travel protection—should we die away from home—and a final document service to close accounts and handle time-consuming administrative tasks. 

In her book Advice for Future Corpses (and Those Who Love Them): A Practical Perspective on Death and Dying, Sallie Tisdale says, “Your body is the last object for which you can be responsible, and this wish may be the most personal one you ever make.” Traditionally in Tibetan Buddhism, the edict is to leave the body undisturbed for three days after death so your consciousness has time to disengage. Tisdale states that American law generally allows you to leave a body in place for at least 24 hours and that while a hospital might want to give you less time, you might be able to negotiate for more. 

We then turned to the thorny topic of organ donation, with Rosie and Liv both deciding against. Knowing someone would soon be taking a scalpel to your cadaver would not enhance the peaceful mind they hope to die with, while my view was just the opposite. Besides gaining merit through donation, that same scalpel image provides great motivation to leave the body quickly.

While reading Tisdale’s chapter titled “Bodies,” I began entertaining thoughts of a green burial, but after months of discussion, I ended up where we all started: with expedient cremations. Rosie wanted her ashes buried and a fragrant rose bush planted on top. Liv and I were more comfortable in the water and decided our ashes would best be left there, but not scattered to ride on the wind. We selected biodegradable urns imprinted with tiny footprints. Made of sand and vegetable gel, they dissolve in water within three days, leaving gentle waves to lap our remnants out to sea. 

By getting past the practical and emotional aspects surrounding death, Liv has found herself in a space of awe. 

“There’s a wow factor to dying that I can now embrace,” she said. 

Rosie no longer worries about who will care for her in later years. Without that insecurity, she’s left with a yearning to be as present for the dying process as possible. And I have found that my understanding of life’s importance as we reach toward enlightenment has been heightened. 

Our small sangha still meets monthly and is now studying bardo teachings in our ongoing attempt to create compassionate dying from compassionate living. As we have continued with our arrangements, we’ve reflected on what we gained from our meetings. We feel blessed for the profound level of intimacy and trust we now share. We have a deeper regard for other friendships and feel enveloped by an enhanced sense of community. And we all feel more cared for.

As Chagdud Tulku Rinpoche wrote in Life in Relation to Death: “Putting worldly affairs in order can be an important spiritual process. Writing a will enables us to look at our attachments and transform them into generosity.”

Complete Article HERE!

Planning Your Own Funeral & Memorial Service

by Anthony Martin

Planning your own funeral is not something anyone gets excited about. In all honestly, who would?

But you know what? There is great value in doing so.

Before we jump into the nitty-gritty, how about a funeral joke to lighten the mood?

Here’s a good one…

I was a little taken aback when I got my receipt from the funeral parlor. On the bottom of the receipt after the bill, it read, “Thank you. Please come again.”

In all seriousness, if you are considering planning your own funeral ahead of time we sincerely commend you. It takes courage to do so, and you will find it’s very rewarding once it’s done.

To help you on your quest, you’ll find in this article why you should plan your own memorial, how to do it, and discover four different ways you can ensure your funeral is paid for.

Why You Should Be Planning Your Own Funeral

The reason why you should plan your own funeral is quite simple.

If you don’t plan your own funeral, your family will have to while in their darkest hour.

Here’s the cold hard truth of it.

When you pass away, your family will be going through an incredibly dark time full of grief and sadness. They will miss you terribly.

Your loved ones having to make tough choices via planning your funeral only adds to the emotional stress they are enduring due to your passing.

Nobody likes to think of their own mortality, let alone plan for it. You should take the time to do it for your family, so they won’t have to while under the greatest emotional stress of their life.

Here’s some really good news.

Planning your own funeral is actually very easy! Not to mention, it won’t take as much time as you’d think to knock it out.

All you are really doing is documenting exactly how you would like to be remembered.

The best part is, once you’ve done it, you never have to do it again!

Taking a little time planning this ahead of time will pay huge dividends in the future. You’ll save your family from a lot of grief, and they will know how much you cared because of what you’ve done.

You Have To Document Your Plans Or They Do No Good

You could literally just use a blank piece of paper and that would suffice.

No matter how you do it, you must document your final wishes, or all your preparation is worthless.

Not to mention, however you choose to transcribe your funeral plan, you need to store them in a place where they are easily accessible by your family.

The idea is upon your passing, your family will naturally locate your final wishes, so they can follow your instructions. This will alleviate them from having to make these tough choices while they are grieving.

There are lots of free funeral planning guides online such as this one or this one, if you prefer to have something that pre-outlines everything.

Ultimately, it does not matter exactly how you document your final wishes. All that matters is that you do it, so your family can put it to use.

How To Plan Your Funeral

Planning out your own funeral has a process that will actually be very familiar to you.

No seriously, it will be.

Think of it this way.

Have you ever bought a vehicle? You likely have at some point in your life.

Think back to your last car buying experience. It probably went something like this…

  1. Calculated your budget
  2. Decided if you want a car, truck, van, etc.
  3. Identified which makes and models you were interested in
  4. Compared those models to see which one(s) you like most
  5. Selected a model
  6. Chose the color, interior & exterior options, etc.
  7. Bought the vehicle

The procedure to plan your own funeral will be just like that. The only real difference is A) You won’t take delivery of your product right now 😇 (at least we hope not), and B) you will be selecting options related to a funeral rather than a car.

Burial, Cremation, Or Donation

By far the biggest choice you will make is choosing to be buried, cremated, or donating your body to science.

Your budget may play a role in deciding which one of these you go with.

Remember, the cost of a funeral varies greatly among these three options. On average, a typical burial service will cost anywhere from $7,000-$10,000. At the same time, a cremation service will cost between $1,500-$5,000. Donating your body to science will usually cost nothing.

With the availability of affordable funeral life insurance plans to cover end-of-life costs, most people can adequately insure themselves for an amount necessary to cover whatever sort of memorial they prefer.

What To Do With The Remains If You Choose A Burial Or Cremation

If you choose to be buried, you then must select what you want done with the casket. If your wish is to be cremated, then you must choose where the urn or ashes are placed.

Believe it or not, there are quite a few options. There are pros and cons to each, so decide which one you think best suites you.

In Ground For A Burial

This is the stereotypical burial so to speak. The casket is placed inside a burial vault that is roughly six feet underground.

In Ground Lawn Crypt For A Burial

A lawn crypt is a pre-made tomb that is typically comprised of concrete and steel whereby multiple caskets can be stacked upon one another.

Lawn crypts are sometimes referred to as in ground mausoleums because they are essentially a completely enclosed shell that preserves the casket(s) far better than a burial vault will.

Above Ground Lawn Crypt For A Burial

This is identical to an in-ground lawn crypt, except that it’s above ground. It provides the proper water drainage to ensure the enclosed casket is preserved.

In A Private Mausoleum Above Ground For A Burial Or Cremation

A mausoleum is an above ground structure that is built specifically to hold the remains of single family. Private mausoleums are quite costly, but if you desire exclusivity and privacy for your whole family a private mausoleum is the way to get it done.

In A Community Mausoleum Above Ground For A Burial Or Cremation

Many cemeteries have mausoleums built that are public. This means anyone can elect to have their remains placed there. Usually those who elect this feature just don’t want their remains placed underground.

The most important thing to understand about a community mausoleum is that it’s public, so other people unrelated to you will also be stored alongside you.

Natural Burial

In this situation there are no embalming fluids, caskets, or burial vaults used. Instead, the remains are placed directly into the ground allowing the body to naturally decompose.

Sometimes with a natural burial, they will utilize some sort of biodegradable casket or shroud just as long as they don’t impede the decomposition of the remains.

Green Burial

This is almost identical to a natural burial with one key difference. For it to be a green burial, the cemetery where the remains will be buried must not use pesticides, and there must be no other bodies buried in the cemetery when embalming fluids or caskets were used.

Spreading Ashes For Cremation

For those who wish to be cremated, one of the most popular options is to have their ashes spread in a location of great significance.

Spreading ashes is certainly an option, but be sure to mind local and state laws. Every state is different, so don’t assume anything. Basically, some states and local ordinances allow it, and some don’t. In addition, those that do allow it often have restrictions regarding where you can spread the ashes, so be sure to double check before pursing this option.

Memorial Reef For Cremation

A memorial reef is a unique option whereby the ashes of the body can be infused with concrete and shaped into a statue of something (could be any shape you like) and placed on the ocean floor.

You will need to work with a business that provides these kinds of services. It’s not something you would want your family to do on their own.

Viewing Or No Viewing

Do you want your loved ones to have one final chance to visit your body? Some people do, and some people don’t. The choice is certainly yours, but it’s definitely something you must decide upon.

Viewings can take place at a funeral home, church, synagogue, or any other location of your preference (assuming the owner of the building agrees to it).

One thing to keep in mind is that if you prefer to donate your body to science and you want a viewing, you will be required to pay for the cost of the viewing.

Now Choose The Details To Round Out Your Plans

At this point, you’ve chosen between a burial, cremation, or donation. You’ve selected what to do with the remains, and you’ve decided whether or not to have a viewing.

All you have to do now is finalize the details such as location, flowers, music, etc.

Look the list below and decide which ones (if any) apply to you. Then document your preferences along with all the other stuff.

  • Memorial service location
  • Where the remains will be placed
  • Type of casket or urn
  • Flowers
  • Music
  • Attendees
  • Name(s) of those who you wish to make your arrangements
  • Open or closed casket for a service
  • Clothes, glasses, & jewelry to be worn for a viewing and/or final resting
  • Any military preferences for veterans
  • Marker/headstone preferences
  • Pallbearer suggestions
  • Obituary preferences (key points you want addressed in your obituary)
  • Post funeral reception preferences

4 Ways You Can Ensure Your Funeral Is Paid For

At this point, you’ve fully planned out your entire funeral which means your family won’t have to make these tough decisions while grieving your loss.

Now all you’ve got to do is put together a plan to ensure the expenses of your funeral don’t fall on your family.

Here’s the deal.

The greatest burden you can pass on to your loved ones is to saddle them with your unpaid funeral costs.

The truth is most families don’t have the cash needed to pay for the funeral outright. As a result, loved ones will resort to taking on debt in order to ensure you receive a respectable memorial service. Very often the debt they agree to takes years to pay off.

If you do nothing else, please make sure you financially prepare for your funeral to ensure your family doesn’t have to take on debt to do it for you.

Having said all of that, you have four basic options to pay for your final expenses.

1) Life Insurance

Life insurance to pay for burial expenses is a very popular option mainly because it affords immediate protection.

There are even life policies available that were designed specifically to cover end of life costs. They are often referred to as “burial insurance for seniors” or “final expense life insurance”.

They are small policies meant to provide just enough coverage to pay for final expenses. These policies are particularly helpful for folks over 80 who likely cannot qualify for a traditional life insurance policy. The cost of burial policies is generally affordable since the face amounts are low.

2) Save Money

This option should only be considered by those who are financially disciplined. In essence, you are electing to set aside a set amount each and every month until you have enough needed to cover all your final expenses.

The obvious drawback to this option is the fact that if you pass away before you’ve saved enough, your family will have to come up with the difference.

3) Pre-Need Contract

A pre-need policy is contract between you and a specific funeral home. Basically, you completely design your funeral service with them, and they tell you how much it will cost.

The policy is backed by a form of life insurance, but it’s a different kind of life policy compared to the one you obtain on an individual basis. The main difference between a pre-need life policy and an individually purchased life policy is that one day you will stop making payments on the pre-need policy.

Funeral homes that sell pre-need policies will try to get you pay off the balance of your funeral over the course of 3-5 years. Because of this, the monthly payments on a pre-need policy can be costly. They frequently end up being $100-$500 per month depending on the total cost and how long you give yourself to pay it off.

4) Funds From The Deceased’s Estate

Although not recommended, you could rely on your family liquidating your house, investments, or other valuable property as means to pay for your final expenses.

There’s no question that this is an option.

However, it should honestly be off the table for the most part.

Here’s why we say that.

It takes a lot of time for your family to be able to liquidate your estate. For one, the probate process can easily take months. That alone will condemn your family with having to temporarily generate funds to pay for your funeral.

Even after the probate process is complete, they would still need to sell off whatever valuables you own which takes even more time.

Again, this is an option, but because of the time involved, it should be a last resort.

Put Together A Will Or Living Trust

A will or living trust will address the legal matters associated with your death which is why it’s important you not leave this step out.

Now, whether you go should go with a will or living trust is purely a personal preference that will likely be determined by the complexity of your estate. This article gives a good outline about the pros and cons of each one.

The best thing to do is to consult with a wills and trust attorney, and let them help you decide which is best for you.

However, if you are the independent type and want to set up a will on your own that’s perfectly okay. Truthfully, a lot of people do with much success.

There are many online resources available to help you setup a will. If followed properly, it can be relatively simple and accurate.

If you do elect to setup a will without the assistance of an attorney, at least use a guide to ensure you do it properly.

On the other hand, a living trust is far more complex, and should be done with the assistance of a professional. From implementation to structure, they are very different and subject to different laws which is why professional legal help is suggested.

You might be wondering… Why do I need a will or trust anyways?

The reason is simple.

You want a will or trust to shore up the legal matters associated with death.

Just like all the other elements of your funeral, if you don’t prepare for the legal ones, you condemn your family with having to deal with them.

Complete Article HERE!

How to talk to your friends and family about death and dying

It’s a conversation nobody really wants to have because it’s about a subject none of us wants to face…

By Donna Fleming

It’s important, nevertheless, to talk to people close to us about death and dying, so that when the time does come we know what their wishes are and how best to support them.

Also, telling family members what you want when it comes to that end-stage of life can make a difficult time easier for them.

Funeral directors constantly see families grappling with grief and having to make decisions when a special person to us has passed, and say having had “that conversation” can take away some of the pressure.
Dean Maxted, assistant manager at H Morris in Northcote, Auckland, says it not only helps with the logistics of organising a funeral, but also opens the door to getting people talking about matters that are important and have perhaps been left unsaid.

“Talking about personal preferences and what you would like when it comes to your funeral can be a really good conversation starter to all sorts of other big stuff,” says Dean. “It can lead to really valuable discussions that you might not have had otherwise.”

In some cases, it can help people come to terms with facing the inevitable and it can also strengthen bonds or mend fences. It may also be a chance to let go of long-held secrets that can weigh someone down.

And whether you’re having the conversation with someone living with a terminal illness or the subject has been raised because you know it is something that will have to be dealt with one day, it is important to pay attention to what the other person has to say.

“Death and dying is not a rational topic and people don’t always react how you think they will,” says Dean, who has seen people respond to facing death and the loss of someone they care about in just about every way possible during his years in the funeral business.

Then there are the huge range of emotions people can experience when they’re faced with dying. These include fear of what will happen and anger that their lives are being cut short, through to disappointment that they have not achieved what they wanted to. Some people are so worn down by illness and old age that they can’t wait to go. Others are very grateful for the care they’ve had and feel satisfied with their lot.

“No matter how they are feeling, the important thing is that you are talking about what they are going through and that they know they matter enough for someone to listen to them,” says Dean. “Taking that on board is as generous a thing as you can do for anyone.”

Tips on having a conversation about a tough subject

• Be sensitive to the needs of the other person. Raise the subject at an appropriate time and don’t be pushy if they don’t want to talk about it.

• If you find it difficult to handle having the conversation yourself, maybe there is someone else who can do it instead, for example a relative or friend, a minister or pastoral carer, or a counsellor.

• Write down their wishes. This is not only helpful for later on, but also shows that they are being listened to.

• Be respectful and calm.

Complete Article HERE!

More elderly and fewer children…

who will make final decisions in the future?

By Angela Y. Lee

With an aging, childless future, who’s going to take care of us when we get old? Who’s going to make those end-of-life decisions for us when we can no longer decide for ourselves?

A recent global report from Axios, “The Aging Childless Future,” shows that in the U.S., a fertility rate below the “replacement rate,” according to the Centers for Disease Control, occurs at the same time as the rise in global life expectancy. In 2015, the global life expectancy of about 70 years old will rise to 83 years old in 2100, according to U.N. data.

The report states, “Except in Africa, by 2050 about a quarter of the world population will be 60 or older. At about 900 million now, their numbers will rise to about 3.2 billion in 2100. By 2080, those 65 or older will be 29.1 percent of the global population — and 12.7 percent will be 80 or over, Eurostat reports.

A troubling takeaway from the report is that there simply will not be enough workers to support the elderly, In the U.S., there are fewer than four workers per retired person. In seven European countries, there are three and in Japan, there are two workers per retired person.

The implications of this population shift affect public policy, health care, elder care, end of life decisions, the overall economy and every family in America and across the world.

I understand this firsthand. My mother is 96 years old and has Alzheimer’s. Two months ago she suffered a massive stroke and was in a coma for two weeks. Her heart rate slowed down to the 50s and 60s; her blood pressure dropped to 70/44. Her body was not ingesting the food she was fed through a feeding tube.

My siblings and I decided to remove the tube to make her feel more comfortable. We were preparing for her departure; and the priest (who was a former student of hers) came to administer the Annointing of the Sick. And one of us was always there with her.

Gradually her heartbeat got stronger, her blood pressure started to climb and she was able to breathe without the support of the ventilator.

The doctors’ prognosis was bleak — our mother would inevitably get pneumonia, or some infection. We had discussed and all agreed that we would not want to prolong her suffering. So no resuscitation, no reattaching to the ventilator and no antibiotics.

What about the feeding tube? One option was not to reintroduce nutrients through the feeding tube and essentially let her waste away. The other option was to reintroduce nutrients and wait for some infection to happen (which according to the doctors was just a matter of time). Starving mother to death might be a more humane decision, but it was immediately rejected by my sister who is a Buddhist. She thought our mother wanted to live and we should honor her wish and give her a chance.

Mother did not have a living will. We were all trying to make a decision on her behalf — based on what we thought she wanted, based on what we thought was best and on what we personally would like to happen if we were in her situation.

Our mother had on occasions before the stroke complained that she was bored and life was not worth living. But that didn’t necessarily mean that she wanted to die. Her complaint could be her way of telling us that she wanted us to visit more often.

Families all across the globe are faced with similar scenarios. In a future where perhaps children are not there to facilitate these decisions, how will these life and death decisions be decided and by whom? Leaving these decisions to chance, or to administrators, health-care workers and other strangers is a frightening possibility.

Everyone should have a living will — in order to depart this world with dignity, free from prolonged pain and suffering. However, an end-of-life decision made as young and healthy people may not be the same end-of-life decision when older, weaker and perhaps unable to communicate.

Research in affect forecasting — or  the ability to accurately predict future emotions– has consistently shown that people are reliably inaccurate in predicting how they would feel in different situations

In one study, younger participants with a mean age of 25.5 years and older adults with a mean age of 74.3 years have been shown to make different predictions about how they would feel if they win or lose money.

Older adults reported feeling less negative than younger adults when they lost money. Who is to say that end-of-life decisions made when we are young are the right decisions for us when we are old?

My own research has shown that when people are cognitively depleted or physically tired, they feel more vulnerable and are more likely to engage in self-protection. Across different studies, depleted participants reported being less likely to engage in risky behaviors such as having unprotected sex and more likely to engage in risk-reduction behaviors such as getting tested for kidney diseases and chlamydia.

When people are not able to think properly or reason logically, they revert to relying on instincts. And the survival or self-preservation instinct is a very strong instinct. So if we are trying to make an important end-of-life decision for ourselves when we can still think properly by anticipating what we would want when we could no longer think properly, we may be off the mark.

If our mother’s will to live is what enabled her to come out of the coma and get off the ventilator, then withholding nutrients and let her waste away is equivalent to murdering her.

Many people have a will,  a legal document that specifies the distribution of one’s assets after death. People change their will as circumstances change and they re-decide who should inherit how much of their assets.

People should also have a living will, a document that allows people to state their wishes for end-of-life medical care, in the event they become unable to express their decision. Health-care providers are usually the ones to suggest or remind patients to have a living will.

But more than just having a living will may be the best practice. Given the frequency of poor performance on affect forecasting and given that perspectives and sentiments often change as we age, perhaps perhaps there needs to be a system in place to prompt regularly revisiting the terms of the living will.

Our mother is in a hospice/rehab facility. She takes pleasure in the daily visits and phone calls of her five children. We are doing our best.

Everyone needs to learn more about end-of-life experiences in order to make better end-of-life decisions for ourselves and for our loved ones.

Perhaps there can be a public policy on not just who has the legal authority to make end-of-life decisions, but also with guidance on how to make these decisions.

In the not too distant future, for people who are childless, these decisions are best not left to chance.

Complete Article HERE!

A Graceful Exit: Taking Charge at the End of Life

How can we break the silence about what happens when we’re dying?

By

I was standing in my cubicle, a 24-year-old fact-checker envisioning a publishing career of glamor and greatness, suddenly shaking as I read the document my mother had mailed. It detailed her wish that I promise never to keep her or my father alive with artificial respirators, IV-drip nourishment, or anything else she deemed “extreme.”

I was horrified, and slightly angry. My mom was a 54-year-old literature professor who’d spent the 1970s eating whole grains and downing vitamins. She was healthier than anyone I knew. Why get so dramatic now? It seemed ghoulish, not to mention premature. But I scrawled my signature at the bottom of the page and shoved it into an envelope, my mother’s voice in my head, prodding me along.

As with the whole wheat and vitamins, my mother—back in 1990—was onto something long before it became conventional wisdom. But these days, Americans’ approach to aging and death is rapidly evolving, pushed both by the numbers and the grim reality behind them: In 40 years, 19 million Americans will be over 85, all at high risk of losing the ability to care for themselves or dwindling away because of organ failure, dementia, or chronic illness. (The days of a sudden fatal heart attack are fading; by 2008, the death rate from coronary heart disease was down 72 percent from what it was in 1950.)

So while many seniors now live vigorous lives well into their 80s, no one gets a free pass. Eating right and exercising may merely forestall an inevitable and ruinously expensive decline. By 2050, the cost of dementia care alone is projected to total more than $1 trillion.

My mom’s decision to face her end came not from any of these facts, but from the nightmare of watching her own mother’s angry decline in a New York nursing home. “You’re all a bunch of rotten apples,” Grandma growled at visitors, the words erupting from her otherwise mute lips. And there she sat for three years, waiting to die. “Why can’t you just get me some pills so I can go?” she would sometimes wail.

The slide toward death was only slightly less awful for my father’s mother. Grandma Ada would greet me with a dazed smile—though it was impossible to know whether she recognized the person standing in front of her wheelchair—before thrashing with involuntary spasms. An aide would come to restrain her, and then my dad and I would leave.

This cannot be right. This cannot be what we want for our parents—or ourselves.

In denial

Despite our myriad technological advances, the final stages of life in America still exist as a twilight purgatory where too many people simply suffer and wait, having lost all power to have any effect on the world or their place in it. No wonder we’re loathe to confront this. The Patient Self-Determination Act, passed in 1990, guarantees us the right to take some control over our final days by creating advance directives like the one my mother made me sign, yet fewer than 50 percent of patients have done so. This amazes me.

“We have a death taboo in our country,” says Barbara Coombs Lee, whose advocacy group, Compassion & Choices, pushed Washington and Oregon to pass laws allowing doctors to prescribe life-ending medication for the terminally ill. “Americans act as if death is optional. It’s all tied into a romance with technology, against accepting ourselves as mortal.”

For proof of this, consider that among venture capitalists the cutting edge is no longer computers, but life-extending technologies. Peter Thiel, the 45-year-old who started PayPal and was an early investor in Facebook, has thrown in with a $3.5 million bet on the famed anti-aging researcher Aubrey de Grey. And Thiel is no outlier. As of 2010, about 400 companies were working to reverse human aging.

Talking about death

The reason for this chronic avoidance of aging and death is not simply that American culture equals youth culture. It’s that we grow up trained to believe in self-determination—which is precisely what’s lost with our current approach to the process of dying. But what if every time you saw your doctor for a checkup, you’d have to answer a few basic questions about your wishes for the end of life? What if planning for those days became customary—a discussion of personal preferences—instead of paralyzing?

Dr. Peter Saul, a physician in Australia, endeavored to test this approach by interviewing hundreds of dying patients at Newcastle Hospital in Melbourne about the way they’d like to handle their lead-up to death—and how they felt discussing it. He was startled to find that 98 percent said they loved being asked. They appreciated the chance to think out loud on the subject. They thought it should be standard practice.

“Most people don’t want to be dead, but I think most people want to have some control over how their dying process proceeds,” Saul says in his widely viewed TED lecture “Let’s Talk About Dying.”

Nevertheless, when his study was complete, Newcastle went back to business as usual, studiously ignoring the elephant in the room, acting as if these patients would eventually stand up and walk out, whistling. “The cultural issue had reasserted itself,” Saul says drily.

Slow medicine

It’s hardly surprising that medical personnel would drive this reexamination of our final days. Coombs Lee, who spent 25 years as a nurse and physician’s assistant, considers her current advocacy work a form of atonement for the misery she visited on terminal patients in the past—forcing IV tubes into collapsed veins, cracking open ribs for heart resuscitation.

“I had one elderly patient who I resuscitated in the I.C.U., and he was livid,” she says. “He shook his fist at me, ‘Barbara, don’t you ever do that again!’ We made a deal that the next time it happened we would just keep him comfortable and let him go, and that’s what we did.”

It bears pointing out, however, that many doctors dislike discussing the ultimate question—whether patients should be allowed to choose their moment of death by legally obtaining life-ending medication. Several have told me that the debate over this overshadows more important conversations about how to give meaning to what remains of life. In Europe, the term of art is euthanasia—the practice of injecting patients with life-ending drugs—which remains illegal in the United States. But whatever the method, many physicians would prefer to avoid the entire topic.

“I don’t think euthanasia matters,” Saul says. “I think it’s a sideshow.”

While arguments flare around this, Dennis McCullough, a geriatrician in New Hampshire, has noticed a quieter answer taking shape among his own patients. Many are themselves retired doctors and nurses, and they have taken charge of their last days by carefully mulling the realities of aggressive medical intervention. Rather than grasping at every possible procedure to stave off the inevitable, they focus instead on accepting it. In place of scheduling never-ending doctor’s visits, they concentrate on connecting with others.

McCullough has termed their philosophy “slow medicine,” and his book about it, My Mother, Your Mother, is starting to attract attention around the world.

“If you go to a doctor to get a recommendation for having some procedure, that’s probably what’s going to happen. Doctors are driven by revenue,” he said in an interview. “But many of the things that we can do to older people don’t yield the results we’ve promised—medicine can’t fix everything. ‘Slow medicine’ is being more thoughtful about that and staying away from decisions based on fear.”

This attitude is gaining traction. In November, several hundred physicians plan to gather in Italy to discuss slow medicine (a name lifted from the similarly anti-tech slow food movement), and McCullough’s book is being translated into Korean and Japanese.

“What’s the last gift you’re going to give your family? In a sense, it’s knowing how to die,” he says. “Staying alive is not necessarily the goal.”

Death with dignity

I consider my mother-in-law, a practicing Catholic and right-leaning political moderate, a barometer for this slowly shifting national consciousness. She is in her mid-60s and healthy, but has already written directives specifying that Bach be played at her bedside and perfume scent the air, if her health deteriorates to the point where she cannot say so herself.

Personally, I’m relieved. Unlike my 24-year-old self, I now find it comforting to plan these things, rather than living in fear of them. But I would still be mired in denial were it not for former Washington Gov. Booth Gardner, whom I wrote about in 2008 when he was pushing for a Death with Dignity law and I was a newspaper reporter.

Shaking with Parkinson’s disease, he tried to spark conversation about legalizing physician-assisted aid-in-dying while attending a luncheon in downtown Seattle with a small circle of business friends: “I have a real tough time understanding why people like us, who’ve made tough decisions all their lives—buying, selling, hiring—do not have the right to make such a fundamental decision as this,” Gardner said, referencing his wish to take life-ending medication when his illness becomes unbearable, to gather his family and die when he chooses.

The men sipped their soup. They did not approve. They did not even want to discuss it. Yet that stony opposition—which mirrors the position of the Catholic church, groups representing the disabled, and hospice workers dedicated to maintaining “studied neutrality”—has, ironically, begun to nudge talk of death into the open.

Gardner, to my mind, had articulated the central concern: Wherever you come down on end-of-life decisions, the question is one of control—and who is going to have it over our bodies at the last moments.

Thus far, only Washington and Oregon have passed Death with Dignity laws, though a voter initiative is scheduled for the November election in Massachusetts. In Montana, the courts have ruled that physicians who prescribe life-ending medication for the terminally ill are not subject to homicide statutes; in New Mexico, two doctors have filed a suit challenging prohibitions against “assisting suicide.” And in Hawaii, four doctors willing to prescribe life-ending medication have geared up for a similar fight.

Yet after 15 years of legalized aid-in-dying in Oregon, the biggest news is how seldom people actually invoke this right. Since 1997, fewer than 600 terminal patients have swallowed doctor-prescribed drugs hastening their ends, though 935 had prescriptions written. Did 335 people change their minds at the last minute? Decide in their final days to cling to life as long as possible?

If so, that might be the best thing to come out of Compassion & Choices’ campaign: a peace of mind that allows us to soldier on, knowing we can control the manner of our death, even if we never choose to exercise that power.

My own immediate family ranges in age from 3 to 84, and I envision a dinner in the not-too-distant future when we will gather, talk about how to make my parents’ final journey as meaningful as all that has come before, and raise a glass to the next stage. Maybe at Thanksgiving.

Complete Article HERE!