An Overview of Filial Responsibility Laws

By Rebecca Lake

Taking care of aging parents is something you may need to plan for, especially if you think one or both of them might need long-term care. One thing you may not know is that some states have filial responsibility laws that require adult children to help financially with the cost of nursing home care. Whether these laws affect you or not depends largely on where you live and what financial resources your parents have to cover long-term care. But it’s important to understand how these laws work to avoid any financial surprises as your parents age.

Filial Responsibility Laws, Definition

Filial responsibility laws are legal rules that hold adult children financially responsible for their parents’ medical care when parents are unable to pay. More than half of U.S. states have some type of filial support or responsibility law, including:

  • Alaska
  • Arkansas
  • California
  • Connecticut
  • Delaware
  • Georgia
  • Indiana
  • Iowa
  • Kentucky
  • Louisiana
  • Massachusetts
  • Mississippi
  • Montana
  • Nevada
  • New Jersey
  • North Carolina
  • North Dakota
  • Ohio
  • Oregon
  • Pennsylvania
  • Rhode Island
  • South Dakota
  • Tennessee
  • Utah
  • Vermont
  • Virginia
  • West Virginia

Puerto Rico also has laws regarding filial responsibility. Broadly speaking, these laws require adult children to help pay for things like medical care and basic needs when a parent is impoverished. But the way the laws are applied can vary from state to state. For example, some states may include mental health treatment as a situation requiring children to pay while others don’t. States can also place time limitations on how long adult children are required to pay.

When Do Filial Responsibility Laws Apply?

If you live in a state that has filial responsibility guidelines on the books, it’s important to understand when those laws can be applied.

Generally, you may have an obligation to pay for your parents’ medical care if all of the following apply:

  • One or both parents are receiving some type of state government-sponsored financial support to help pay for food, housing, utilities or other expenses
  • One or both parents has nursing home bills they can’t pay
  • One or both parents qualifies for indigent status, which means their Social Security benefits don’t cover their expenses
  • One or both parents are ineligible for Medicaid help to pay for long-term care
  • It’s established that you have the ability to pay outstanding nursing home bills

If you live in a state with filial responsibility laws, it’s possible that the nursing home providing care to one or both of your parents could come after you personally to collect on any outstanding bills owed. This means the nursing home would have to sue you in small claims court.

If the lawsuit is successful, the nursing home would then be able to take additional collection actions against you. That might include garnishing your wages or levying your bank account, depending on what your state allows.

Whether you’re actually subject to any of those actions or a lawsuit depends on whether the nursing home or care provider believes that you have the ability to pay. If you’re sued by a nursing home, you may be able to avoid further collection actions if you can show that because of your income, liabilities or other circumstances, you’re not able to pay any medical bills owed by your parents.

Filial Responsibility Laws and Medicaid

While Medicare does not pay for long-term care expenses, Medicaid can. Medicaid eligibility guidelines vary from state to state but generally, aging seniors need to be income- and asset-eligible to qualify. If your aging parents are able to get Medicaid to help pay for long-term care, then filial responsibility laws don’t apply. Instead, Medicaid can paid for long-term care costs.

There is, however, a potential wrinkle to be aware of. Medicaid estate recovery laws allow nursing homes and long-term care providers to seek reimbursement for long-term care costs from the deceased person’s estate. Specifically, if your parents transferred assets to a trust then your state’s Medicaid program may be able to recover funds from the trust.

You wouldn’t have to worry about being sued personally in that case. But if your parents used a trust as part of their estate plan, any Medicaid recovery efforts could shrink the pool of assets you stand to inherit.

Talk to Your Parents About Estate Planning and Long-Term Care

If you live in a state with filial responsibility laws (or even if you don’t), it’s important to have an ongoing conversation with your parents about estate planning, end-of-life care and where that fits into your financial plans.

You can start with the basics and discuss what kind of care your parents expect to need and who they want to provide it. For example, they may want or expect you to care for them in your home or be allowed to stay in their own home with the help of a nursing aide. If that’s the case, it’s important to discuss whether that’s feasible financially.

If you believe that a nursing home stay is likely then you may want to talk to them about purchasing long-term care insurance or a hybrid life insurance policy that includes long-term care coverage. A hybrid policy can help pay for long-term care if needed and leave a death benefit for you (and your siblings if you have them) if your parents don’t require nursing home care.

Speaking of siblings, you may also want to discuss shared responsibility for caregiving, financial or otherwise, if you have brothers and sisters. This can help prevent resentment from arising later if one of you is taking on more of the financial or emotional burdens associated with caring for aging parents.

If your parents took out a reverse mortgage to provide income in retirement, it’s also important to discuss the implications of moving to a nursing home. Reverse mortgages generally must be repaid in full if long-term care means moving out of the home. In that instance, you may have to sell the home to repay a reverse mortgage.

Filial responsibility laws could hold you responsible for your parents’ medical bills if they’re unable to pay what’s owed. If you live in a state that has these laws, it’s important to know when you may be subject to them. Helping your parents to plan ahead financially for long-term needs can help reduce the possibility of you being on the hook for nursing care costs unexpectedly.

  • Consider talking to a financial advisor about what filial responsibility laws could mean for you if you live in a state that enforces them. If you don’t have a financial advisor yet, finding one doesn’t have to be a complicated process. SmartAsset’s financial advisor matching tool can help you connect, in just minutes, with professional advisors in your local area. If you’re ready, get started now.
  • When discussing financial planning with your parents, there are other things you may want to cover in addition to long-term care. For example, you might ask whether they’ve drafted a will yet or if they think they may need a trust for Medicaid planning. Helping them to draft an advance healthcare directive and a power of attorney can ensure that you or another family member has the authority to make medical and financial decisions on your parents’ behalf if they’re unable to do so.

Complete Article HERE!

Death doulas help the dying meet their end with affirmation

Death doula Anna Adams sits in an office at Holistic Hospice in San Antonio on Oct. 28, 2020. Just as birth doulas help expectant parents bring new life into the world, end-of-life doulas help the dying cope with their next journey. They help the dying and their survivors face death with empowerment and affirmation instead of fear and anxiety.

By RENÉ A. GUZMAN

Andrea Aycock can only sometimes look at the photos of her hands clasped with her mother’s just before she died in May. But she’ll always cherish the helping hand she got from Anna Adams, an end-of-life doula in San Antonio who preserved that personal moment and so many more for Aycock in her mother’s dying days.

“Anna came and took care of her,” said Aycock, a call center operator in San Antonio. “(She) just mainly comforted me.”

Just as birth doulas help expectant parents bring new life into the world, end-of-life doulas help the dying cope with their next journey. They help the dying and their survivors face death with empowerment and affirmation instead of fear and anxiety.

Also known as death doulas, these trained professionals provide the terminally ill and their families physical and emotional support before, during and after death, the San Antonio Express-News reported. These are nonmedical services that often include relaxation exercises, funeral planning, educating the family on their loved one’s condition and just simple companionship.

Adams sees death awareness becoming more commonplace in the United States in the way that Día de los Muertos (Day of the Dead) celebrations have grown more mainstream and that there are more calls for services of end-of-life doulas.

“Cultures like the Mexican culture that have these beautiful traditions of staying in connection with that (dying) process are so admirable and so beautiful. Doulas want to make sure that is available to all people,” said Shelby Kirillin, an end-of-life doula in Richmond, Va., and program development manager for the International End of Life Doula Association (INELDA) in Jersey City, N.J.

Kirillin sees the rising awareness of death doulas as part of what she calls a “death positive movement,” where more people are getting back to supporting their dying loved ones at home and engaging with their death more up close and personal, much as their ancestors did.

“In the last 100-plus years in our Western culture, that has been taken away from us,” Kirillin said. “How to be with someone who was dying, how to touch them. That was something that we knew how to do.”

INELDA is one of just a handful of death doula organizations in the nation and was launched just five years ago. Co-founder Henry Fersko-Weiss created the first end-of-life doula program in the United States at a New York City hospice in 2003.

Kirillin estimates INELDA has around 40 certified death doulas across the country, yet has trained around 3,000 individuals in death doula care. Many just sign up to learn more about facing death and don’t pursue death doula work, she said, while others branch off to do their own training.

Most death doula services come in three phases.

The first is planning and preparation, which involves getting a terminal patient’s affairs in order and asking some tough questions that call for honest answers. Where does that person want to die? Who do they want present for those final moments? What so they absolutely need to say or do before they’re gone?

Kirillin said that first phase often addresses the dying individual’s regrets and unfinished business, as well as any advance directives, wills, etc. Often referred to as “legacy work,” such planning makes it easier for family to understand and respect the dying person’s wishes.

Fran Morgan is in that early stage with her dying mother Rosalee, who receives hospice care at the private residence of a family friend.

“With Anna in the picture, she will be advocating for all of the things that need to happen,” said Morgan, a retired telecommunications company manager in San Antonio. “It will release me from those responsibilities, and I can just be with my mom and cherish those final moments.”

That second phase is called the vigil, usually the last four or five days of the dying person’s life where end-of-life doulas and family members spend more time at their bedside.

“I call them my angel vigils,” Adams said.

During her doula vigils, Adams, 38, often creates a soothing space for the dying with soft music and dim lighting. Sometimes she’ll add a favorite scent with aromatherapy. Most times, she just gently massages her client’s arms and holds their hands.

And in those final moments as they take their last breaths, Adams comforts them with what they most want to hear, be it Bible verses, soothing music or just someone to say it’s going to be OK.

The final phase of a death doula’s work addresses survivors’ grief. Kirillin said that involves circling back with the family a few weeks after their loved one’s death to check on their emotional well-being.

Kirillin stressed that end-of-life doulas do console families, but are not licensed grief counselors and will refer families to such resources if necessary.

When it came to caring for Aycock’s mother, Adams mostly helped with her bedside care and keeping her visiting nurses on task. Adams also explained to Aycock any of her mother’s diagnoses she didn’t understand.

Then there was that time Adams took those hand photos of Aycock and her mother. Difficult as it is for Aycock to look at those photos, much less share them, she still holds them close.

She holds Adams’s work even closer.

“It is the best help that you can get,” Aycock said. “They provide comfort not only for your loved one that is going through the transition, but for you.”

Morgan expects to experience more of that care from Adams. “I’m looking forward to the relationship that we’re going to have,” said Morgan, who started working with Adams around three weeks ago. “For now my initial experience (and) impression is she certainly has the heart for what she’s doing.”

Adams’s first experience comforting the dying came when she was 16. Fresh from certification as a nursing aid, Adams tended to a best friend’s cousin for several months at her home with bathing and conversation. That care continued when that cousin transferred to hospice care and well up to her death.

“So we just had a bonding moment. I gave her that sacred zone,” Adams said. “That kind of piqued my interest.”

Adams went on to pursue a career in hospice, then for the last four years worked as an EMS manager and dispatcher for a private company. But something pushed her back into working with the dying.

“I told my family, ‘God wants me to do this. God is keeping me in line with this,’ ” Adams said.

At the start of this year, Adams got her end-of-life doula certification. Then over the summer, she partnered with fellow certified doula Sonja Koenig to launch TX Doula Movement, an online training and certification course for death doulas, senior care doulas and doula consultants.

Adams knows of just a handful of death doulas in San Antonio right now, but she expects that number to double later this year when around five of her TX Doula Movement students complete their certification. Adams plans to launch her own doula training service next year.

Adams said the coronavirus has not deterred her from her work, save for having to incorporate more video consultations with families and masks and frequent hand-washings during visits. She has yet to provide end-of-life doula services to someone with COVID-19, but one of the hospice companies she works with takes in COVID-19 patients.

“I don’t have a problem working with COVID patients,” Adams said.

Adams said most hospitals still don’t work with death doulas, but hospice services are slowly warming up to them as adjuncts to their own care.

“It is relatively new, but we’re seeing it more,” said Rachel Hammon, executive director of the Texas Association for Home Care & Hospice in Austin.

Holistic Hospice Care is one of two hospice centers in San Antonio that works with Adams. Administrator Erica Sandoval said Adams has been a welcome bridge between families and clinical teams.

“She can get on (everyone’s) level,” Sandoval said. “And she’s very calm and very patient. And she just wins their trust and they feel very comfortable with her.”

Like Adams, Sandoval, too, sees parallels between death doulas and Día de los Muertos, such as the memory books the doulas make for their clients and the Day of the Dead tribute altars families make for their lost loved ones.

“I definitely think that there’s a good association to that because they are (both about) wanting you to cherish their memories and enjoy the last moments and everything that you can remember of the individual,” Sandoval said.

Complete Article HERE!

What to Do When a Loved One Dies

Advice to keep a sad event from becoming even more painful

By Consumer Reports

Responsibility for the various actions can be divided among family members and close friends of the deceased.

Immediately

1. Get a legal pronouncement of death. If no doctor is present, you’ll need to contact someone to do this.

  • If the person dies at home under hospice care, call the hospice nurse, who can declare the death and help facilitate the transport of the body.
  • If the person dies at home unexpectedly without hospice care, call 911. Have in hand a do-not-resuscitate document if it exists. Without one, paramedics will generally start emergency procedures and, except where permitted to pronounce death, take the person to an emergency room for a doctor to make the declaration. Keep in mind that do-not-resuscitate laws vary at the state level and if a person does not want to be resuscitated, “calling 911 is not necessary” according to the National Institute on Aging. “If the death is not unexpected, you might call the individual’s physician first,” says Lori Bishop, vice president of palliative and advanced care at the National Hospice and Palliative Care Organization.
  • 2. Arrange for transportation of the body. If no autopsy is needed, the body can be picked up by a mortuary (by law, a mortuary must provide price info over the phone if you ask for it) or crematorium.

    3. Notify the person’s doctor or the county coroner.

    4. Notify close family and friends. (Ask some to contact others.)

    5. Handle care of dependents and pets.

    6. Call the person’s employer, if he or she was working. Request info about benefits and any pay due. Ask whether there was a life-insurance policy through the company.

    Within a Few Days After Death

    7. Arrange for funeral, memorial service, and burial or cremation. Search the person’s documents to find out whether there was a prepaid burial plan. Ask a friend or family member to go with you to the mortuary. Prepare an obituary.

    8. If the person was in the military or belonged to a fraternal or religious group, contact that organization. It may have burial benefits or conduct funeral services.

    9. Secure the person’s home. Or ask a friend or relative to keep an eye on it, answer the phone, collect mail, throw food out, water plants, and keep minimal heat on to avoid frozen pipes if it’s winter in a colder climate.

    Up to 10 Days After Death

    10. Obtain the death certificate (usually from the funeral home). Get multiple copies; you’ll need them for financial institutions, government agencies, and insurers.

    11. Take the will to the appropriate county or city office to have it accepted for probate. Check your state’s laws, which may require you to file the will within a set period of time.

    12. If necessary, the estate’s executor should open a bank account for the deceased’s estate.

    13. Contact the following:

    • A trust and estate attorney, to learn how to transfer assets and assist with probate issues.
    • Police, to have them periodically check the deceased’s house if vacant.
    • An accountant or a tax preparer, to find out whether an estate-tax return or final income-tax return should be filed.
    • The person’s investment adviser, if applicable, for information on holdings.
    • Banks, to find accounts and safe deposit box.
    • Life insurance agent, to get claim forms.
    • The Social Security Administration (800-772-1213; ssa.gov) and other agencies from which the deceased received benefits, such as Veterans Affairs (800-827-1000; va.gov), to stop payments and ask about applicable survivor benefits. The SSA, like the VA, recommends immediately reporting the person’s death, though in many cases the funeral home will handle this.
    • Agency providing pension services, to stop monthly checks and get claim forms.
    • Utility companies, to change or stop service, and Postal Service, to stop or forward mail. Reach out to other companies to stop recurring bills and subscriptions. If home is vacant, contact the insurer to switch to a vacant policy. If home is under a mortgage, contact the lender.
    • The IRS, credit-reporting agencies, and the DMV to prevent identity theft.
    • Social media companies, such as Facebook or LinkedIn, to memorialize or remove an account.

    Know the Person’s Wishes

    For an elderly friend or relative:

    • Know the location of the will, birth certificate, marriage and divorce certificates, Social Security information, life-insurance policies, financial documents, and keys to safe deposit box or home safe. Ask the person to create an inventory of their digital assets (such as email, social networks, and digital files) and include a plan for these assets in their will.
    • Ask about the person’s wishes concerning funeral arrangements, organ and brain donation, and burial or cremation.
    • Have the person complete an advance directive, including a living will, which specifies wanted and unwanted procedures. The person should also appoint a healthcare proxy to make medical decisions if he or she becomes incapacitated. Some who are more seriously ill might also consider a Physician Orders for Life-Sustaining Treatment in addition to an advance directive.
    • Ask the person about end-of-life care, such as palliative and hospice care (which have key differences), and what their insurance will cover. Medicare, which covers most elderly Americans, will cover hospice care. Palliative care is growing in popularity, but “keep in mind that anyone with six months or less to live should have access to hospice,” Bishop says.
    • Have a do-not-resuscitate order drawn up if the person desires. That tells healthcare professionals not to perform CPR if the person’s heart or breathing stops and restarting would not result in a meaningful life.
    • Make sure the person gives copies of the documents to his or her doctor and a few family members or friends. Take the documents to the hospital if the person is admitted.

    Complete Article HERE!

Film ‘The Elephant in the Room’ Shines a Light on Palliative Care

By Holly Vossel

Public misperception is a barrier between patients and palliative care. Based on the true story of a nurse practitioner’s experiences with patients and families facing serious and terminal illnesses, the film “The Elephant in the Room” depicts the patient-centered interdisciplinary care that so many seriously ill patients need.

The film was written by Bonnie Freeman adapted from her novel, “Resilient Hearts: It’s All About the Journey,” based on true stories of her experience as a supportive care nurse practitioner for the Department of Supportive Care Medicine at City of Hope Medical Center located in Los Angeles. Shot throughout 2017 and directed by husband and photographer Allen Freeman, the book turned film brings an inside look into goal-concordant and patient-centered care through the eyes of those who provide it.

“Bonnie wanted to educate, that was her passion at the root of it all,” said Executive Producer William Dale, chair in Supportive Care Medicine at City of Hope. “She just wanted to make sure that our message got delivered. She had aspirations for us to break out of our little crowd that care about the cause, care about supportive care and palliative care.”

Dale also helped provide funding to support the film’s making.

According to producers, Freeman passed “unexpectedly and suddenly” before the film completed on April 26, 2018. She played an integral and hands-on role during filmmaking, working closely with Niko Vitacco, who played the lead role of nurse practitioner Michael Lafata. 

Films like the “The Elephant in the Room” could help to raise awareness and improve understanding of palliative care. The medical comedy-drama, walks viewers through end-of-life care through a provider’s lens, including goals-of-care conversations. The comical drama is currently available on Amazon Prime.

As many as 71% of people in the United States have little to no understanding of what palliative care is, including many clinicians in a position to refer patients to palliative care or hospice, according to A Journal of Palliative Medicine study.

While no standardized definition exists for “palliative care,” the U.S. Centers for Medicare & Medicaid Services (CMS) defines the term as “patient and family-centered care that optimizes quality of life by anticipating, preventing and treating suffering. Palliative care throughout the continuum of illness involves addressing physical, intellectual, emotional, social and spiritual needs and to facilitate patient autonomy, access to information and choice.”

Roughly half of community-based palliative care providers in the United States are hospices, according to the Center to Advance Palliative Care (CAPC). While a growing number of hospices are diversifying their service lines to include palliative care, many struggle to sustain and grow programming due to a widespread lack of awareness. These services remain relatively unknown and misunderstood among the general public, as well as within medical communities.

“Bonnie knew that storytelling was a way to help improve end-of-life care,” said Vitacco, actor and co-producer of Absolution Films. Vitacco read the following quote Freeman initially wrote to pitch the film. “‘I realized many health care providers did not know what we provided and the community was even less informed. I felt a film would reach a broader audience and could be a tool to promote discussions about effective ways to communicate the need for compassion and show the difference a dedicated palliative care team can make in the lives of each other, their patients and their families.’”

The film strikes a strong chord as the world comes face-to-face with a deadly pandemic. The COVID-19 outbreak has brought serious illness to the forefront, with the World Health Organization reporting more than 1.6 million lives lost globally since its onset.

“Something within this script resonated so strongly with me. I saw it as an opportunity to help people on a larger scale, to share a story that was meaningful and bigger than me,” said Vitacco. “Even more so now in a world where humanity can sometimes feel lost, this film can show the type of the side of people that we all want to become but sometimes struggle to be.”

Despite heightened focus, palliative services remain underutilized throughout the globe. The World Health Organization reported in August that only 14% of people who need palliative care currently receive it. Many countries ranked low in an international review of length of palliative care received by people with life-limiting and terminal conditions, including the United States and Australia.

Increasing awareness around the benefits of serious illness care was a stated goal for the filmmakers.

“Palliative care is still considered new within the medical world,” said Vitacco. “Our mission was to make it universally known and share it with not only the professionals, but the public as well to show them what is readily available to them.”

Initially released in Middle Eastern countries, “The Elephant in the Room” came out in Australia, Canada, Germany, India, the United Kingdom and the United States on Amazon on Aug. 21, 2020, representing a broader reach for the film’s universal message.

“The subject is universal and we just wanted to release it wherever we could,” said co-producer Tamir Gedalia of Absolution Films. “For me, the message was that we need to change the way we treat terminally ill patients. It’s universal in every country. There is no country that doesn’t have this kind of love and treatment, there is no relation to a village.”

The film’s use of the term “supportive care” to describe end-of-life care was deliberate. The term is becoming more common in the field as providers seek to avoid stigma associated with the words “palliative” and “hospice.” Numerous organizations rebranded in recent years to remove those words from their company names.

Scenes show providers both engaging with patients and behind closed doors in interdisciplinary team meetings. The film’s team includes the supportive care department chair, oncologist, neurologist, pediatrician, pharmacist, nurse practitioner, social worker, chaplain and a staff psychologist who collaborate from the point of the patient’s admission through his passing. The social worker role of Valerie Howard was played by Rupinder Sidhu, a licensed social work program specialist at City of Hope.

Filming took place onsite for 12 days at City of Hope to minimize disruption to patients and operations, according to Dale, who expressed reluctance at opening the medical center’s doors to filming but ultimately valued an authentic setting.

“My hope is that people elsewhere understand the field and get entertained, but then also imbibe this message that it’s about how you take care of each other and take care of yourself,” said Dale. “We’ve all had those moments as providers when we’re in too deep with patients and families and we’ve gone across that line. The team did an amazing job dramatizing that, and I think that’s what Bonnie wanted and it’s my deepest goal for the field and for the film. This is more than we could have expected and we couldn’t have hoped for a better product that’s actually getting seen.”

Complete Article HERE!

How To Analyze 4 Common Dreams About Death & Dying

By Catharine Allan

How many times have you had a dream that involved death? Have you ever dreamed about someone you loved dying or been visited in a dream by someone who has passed away? Though we don’t often talk about them, I’d say that death is a common dream theme—especially this year.

Dreams are, after all, a way for us to process life. And dreaming about death is often a way to process the fear of the unknown. Morbid dreams can show up when we are in the middle of a job transition, a divorce, an identity crisis, or any other kind of major shift. In 2020, we are all going through a transformation on some level. We are all connected, so on some level, we are all affected.

Generally speaking, dreaming about death is likely a sign that you are in a period of change, but here’s how to further interpret this type of dream based on the details.

If you dreamed about a loved one dying:

If you’ve ever had a dream of a loved one dying, you know how utterly upsetting they can feel. You wake up wondering if it’s a premonition, a warning of an accident—you name it. Once this panic is activated, it becomes extremely hard to be objective.

So the first thing I would do if I dream of someone I know dying would be to ask myself if I am afraid of losing that person. If the answer is yes, this dream may have served as a wake-up call about how much this relationship means to me.

Start there and see if your body drops the tension and you stop obsessing over that dream.

If you dreamed about yourself dying:

This can be a very scary dream or a very tranquil dream, depending on its quality. I’ve heard of people who have dreamed that they’ve died and been met by spirits, angels, ancestors, or guides and experience peace. I’ve also heard from people who dream of painful deaths that occur under scary circumstances. So it’s complex, and ultimately the only person who can decode the meaning behind this dream is you. But here is an example of how I would approach a dream like this:

Let’s say I had a dream that I died in the water, drowned when I fell into the sea. If I felt peace and calm in my dream and like my spirit was at rest, I might come to the conclusion that this dream was about a past life.

If I had the same dream but I struggled for air, felt alone and in despair, this would obviously be a bad death. In this case, I would try to remember some more details of the dream. What was the scenario that caused me to fall overboard? Was I pushed? Were large waves washing me away?

I would look for more clues about what the message could be and how this dream could be signifying a different kind of “drowning” in my own life.

If you had a nonsensical dream about death:

When we are processing many emotions at once—fear, sadness, loss, frustration, desire, longing, etc.—our dreams often become giant mashup scenarios. They don’t make much logical sense. One minute, it’s the 1980s and you’re wearing the pants you bought online last week. The next minute your ex from five years ago is there, and suddenly you see your dying fall.

When timelines are mixed, people past and present are juxtaposed, and you can’t put the dream in any logical order, that’s your psyche processing your waking life. That’s the one for the analyst’s couch or the dream books. Its message is always personal and only clear after a lot of inner reflection. If you die in this kind of dream, it’s likely pure fear of change or loss.

If you dream of someone you love dying in a similarly haphazard way, the same criteria apply. If the story is convoluted and the steps are mixed up in time and space—and especially if you wake up instantly emotional and confused—this is not a predictive dream. You might just be feeling scared to lose this person, literally or emotionally.

(I do believe that some highly intuitive people can have predictive dreams, but these tend to be very matter-of-fact, detailed, and orderly. You wake up with a clear, concise flowing story, and you don’t feel emotional about it.)

If you dreamed about someone who has passed away in real life:

If the dream is confusing, has mixed-up timelines, and causes you to wake up feeling sad or confused, it’s likely you processing their loss.

If that person is happy and at peace in the dream, maybe talking to you or showing you something, and you wake up feeling calm, it could have been a visitation from them. And those are the best dreams of all.

Dreams are a common way for us to process our waking life. So most of the time dreams about death are not about literal death but the challenges and unknowns we are facing. Pay attention to the details of your death dreams and how they make you feel for further insights into their messages.

Complete Article HERE!

What you need to know if you or a loved one requires end-of-life care

By Ben Poston, Kim Christensen

Conceived as an end-of-life option for terminally ill patients, hospices provide palliative care, medications, nursing services and counseling for those diagnosed with six months or less to live.

The number of U.S. hospices has roughly doubled in the last 20 years, as more for-profit providers vie for a share of $19.2 billion a year in Medicare spending that covers hospice care. More than 1.5 million Medicare beneficiaries now receive care from some 5,000 hospices, nearly a quarter of them in California.

While hospice has been a godsend for millions of dying Americans and their families, a Times investigation found that intense competition for new patients has spurred billing fraud and other illegal practices, including falsified diagnoses and kickbacks to unscrupulous doctors and recruiters who target prospective patients at retirement homes and other venues.

The Times also found hundreds of instances in which California hospice patients were harmed, neglected or put at serious risk, their mistreatment sometimes exacerbated by serious gaps in government oversight.

What are the benefits of hospice care?

Hospice is intended to provide comforting, compassionate care and a range of support services for terminally ill patients and their families. In addition to nursing and medical care that includes pain management, prescription drugs and supplies, patients receive spiritual and emotional support, help with personal hygiene and respite care for family caregivers.

Most hospice patients receive care in their homes, including assisted-living settings and nursing facilities.

How do I choose a hospice?

There’s no set formula for choosing a hospice, although experts suggest discussing options with your personal physician and seeking recommendations from friends and relatives whose loved ones have had good experiences.

You should also interview any prospective hospice, asking questions about its licensing, which is required by the California Department of Public Health; whether it is certified by Medicare; when it was last inspected and whether violations were found; the range of available services; the makeup of the hospice care team and the roles of its doctors, nurses and others; and the role the hospice expects family members to play in a patient’s care plan.

Several industry and advocacy groups offer online guidance, including the National Hospice and Palliative Care Organization, which provides a worksheet and a list of questions.

How do I know if a hospice is reliable?

There is no one place where consumers can go to make a comprehensive comparison of local hospices — a gap that patient rights advocates have long criticized.

A variety of online sources provide information about hospice care, but each has limitations. Medicare’s hospice comparison site allows consumers to search for providers by ZIP Code or name, but has scant information about quality-of-care issues and inspections.

The California Department of Public Health has a searchable tool called Cal Health Find Database, which provides users with inspection reports when serious violations are uncovered back to 2017. It also allows consumers to compare quality metrics of up to three hospices at a time, but it doesn’t provide a rating system for providers. The results of inspections by accrediting agencies are not included on the site — a significant problem for consumers in California, where more than 80% of hospices contract with accrediting agencies rather than the state to conduct certification inspections once every three years.

Another resource that is more difficult to navigate is an interactive site maintained by the Centers for Medicare and Medicaid Services. The site includes copies of complaint investigations and a look-up function that allows users to compare the number of serious violations at hospices in California and other states.

What red flags should I look for?

Be on the lookout for any hospices that have been cited in recent years with serious violations. In the language used by Medicare, these include “condition-level” deficiencies or “immediate jeopardy” situations, which are considered the most severe. Also, hospices can be cited for failing to certify that patients are terminally ill, which is an indication of possible fraud.

If you have the name of a hospice administrator, which can be found on the state public health department’s website, you can find out if that person has been excluded from receiving federal healthcare payments on a site run by the U.S. Department of Health and Human Services’ Office of Inspector General.

If I’m not happy about my hospice, where do I complain?

If you can’t resolve your issues with the hospice, the California Department of Public Health investigates complaints, which can be filed online — but not necessarily with satisfying results.

You may also file a complaint about Medicare providers directly with the federal agency or with the California Senior Medicare Patrol, a federally funded statewide hotline to help Medicare beneficiaries prevent, detect and report fraud.

What Is Death?

How the pandemic is changing our understanding of mortality.

By BJ Miller

This year has awakened us to the fact that we die. We’ve always known it to be true in a technical sense, but a pandemic demands that we internalize this understanding. It’s one thing to acknowledge the deaths of others, and another to accept our own. It’s not just emotionally taxing; it is difficult even to conceive. To do this means to imagine it, reckon with it and, most important, personalize it. Your life. Your death.

Covid-19’s daily death and hospitalization tallies read like ticker tape or the weather report. This week, the death toll passed 300,000 in the United States. Worldwide, it’s more than 1.6 million. The cumulative effect is shock fatigue or numbness, but instead of turning away, we need to fold death into our lives. We really have only two choices: to share life with death or to be robbed by death.

Fight, flight or freeze. This is how we animals are wired to respond to anything that threatens our existence. We haven’t evolved — morally or socially — to deal with a health care system with technological powers that verge on godly. Dying is no longer so intuitive as it once was, nor is death necessarily the great equalizer. Modern medicine can subvert nature’s course in many ways, at least for a while. But you have to have access to health care for health care to work. And eventually, whether because of this virus or something else, whether you’re young or old, rich or poor, death still comes.

What is death? I’ve thought a lot about the question, though it took me many years of practicing medicine even to realize that I needed to ask it. Like almost anyone, I figured death was a simple fact, a singular event. A noun. Obnoxious, but clearer in its borders than just about anything else. The End. In fact, no matter how many times I’ve sidled up to it, or how many words I’ve tried on, I still can’t say what it is.

If we strip away the poetry and appliqué our culture uses to try to make sense of death — all the sanctity and style we impose on the wild, holy trip of a life that begins, rises and falls apart — we are left with a husk of a body. No pulse, no brain waves, no inspiration, no explanation. Death is defined by what it lacks.

According to the Uniform Determination of Death Act of 1981 (model legislation endorsed by both the American Medical Association and the American Bar Association, meant to guide state laws on the question of death), you are dead if you have sustained “either irreversible cessation of circulatory and respiratory functions” or “irreversible cessation of all functions of the entire brain, including the brain stem” — in other words, no heartbeat and no breathing, which is obvious enough, or no brain function, which requires an electroencephalogram.

These are the words we use to describe one of the most profound events in human experience. Most states have adopted them as the legal definition of death. They may be uninspired, and they surely are incomplete. Either way, a doctor or nurse needs to pronounce you dead for it to be official. Until then, you are legally alive.

If we stay focused on the body, the most concrete thing about us, it becomes difficult to say whether death exists at all.

From the time you are born, your body is turning over. Cells are dying and growing all day, every day. The life span of your red blood cells, for example, is about 115 days. At your healthiest, living is a process of dying. A vital tension holds you together until the truce is broken.

But your death is not the end of your body. The chemical bonds that held you together at the molecular level continue to break in the minutes and months after you die. Tissues oxidize and decay, like a banana ripening. The energy that once animated the body doesn’t stop: It transforms. Decay from one angle, growth from another.

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Unfettered, the decay process continues until all that was your body becomes something else, living on in others — in the grass and trees that grow from where you might come to rest, and from the critters who eat there. Your very genes, little packets of stuff, will live indefinitely as long as they found someone new to host them. Even after interment or cremation, your atoms remain intact and scatter to become other things, just as they pre-existed you and became you.

For revelation of the mysteries of an afterlife, or of the forces that kicked off this wondrous circus in the first place, we might look to religion. What is described above is plainly observable science. Yet science doesn’t do the question justice. It won’t tell us why, or what’s behind its laws. The body houses more than we can express; you are more than your body. Becoming a blade of grass is a sweetness that doesn’t compensate for all the heartache death connotes.

Of course, we’re sad and afraid of losing ourselves and people we love, but for many of us a fear of death as the Great Unknown has been overtaken by our fears of what we know — or think we know — about dying.

Nowadays, being dead sounds like a lullaby compared with the process of dying. Given a steadily awful diet of stories about breathing machines and already-disenfranchised people dying alone, we’re told to imagine the worst, before cutting to commercial. Our choices seem to be either to picture a kind of hell — that could be mom or me, breathless and alone — or to distance ourselves from the people living those stories, not just in body but in every way, to de-identify with our fellow human beings.

But this is how we make hard things harder. Maybe our fear of death has more to do with our perceptions of reality than with reality itself, and that is good news. Even if we can’t change what we’re looking at, we can change how we look at it.

We do have fuller ways of knowing. Who doubts that imagination and intuition and love hold power and capacity beyond what language can describe? You are a person with consciousness and emotions and ties. You live on in those you’ve touched, in hearts and minds. You affect people. Just remember those who’ve died before you. There’s your immortality. There, in you, they live. Maybe this force wanes over time, but it is never nothing.

And then there’s consciousness — spirit, if you like — and of this, who can say? You may have your own answer to this question, but we do not get to fall back on empiricism. Whatever this mystery is, it blurs all the lines that seem at first glance to separate death from life. And if death isn’t so concrete, or separate, maybe it isn’t so frightening.

The pandemic is a personal and global disaster, but it is also a moment to look at the big picture of life. Earlier this week I had a patient lean into her computer’s camera and whisper to me that she appreciates what the pandemic is doing for her: She has been living through the final stages of cancer for a while, only now her friends are more able to relate to her uncertainties, and that empathy is a balm. I’ve heard many, in hushed tones, say that these times are shaking them into clarity. That clarity may show up as unmitigated sorrow or discomfort, but that is honest and real, and it is itself a powerful sign of life.

So, again, what is death? Talking about and around it may be the best we can do, and doing so out loud is finally welcome. Facts alone won’t get you there. We’re always left with the next biggest question, one that is answerable and more useful anyway: What is death to you? When do you know you’re done? What are you living for in the meantime?

For some of us, death is reached when all other loved ones have perished, or when we can no longer think straight, or go to the bathroom by ourselves, or have some kind of sex; when we can no longer read a book, or eat pizza; when our body can no longer live without the assistance of a machine; when there is absolutely nothing left to try. Maybe the most useful answer I ever came across was the brilliant professor who instructed his daughter that death was what happened when he could no longer take in a Red Sox game.

If I had to answer the question today I would say that, for me, death is when I can no longer engage with the world around me. When I can no longer take anything in and, therefore, can no longer connect. At times, social distancing has me wondering if I’m there already, but that’s just me missing touching the people I care about. There are still ways to connect with others, including the bittersweet act of missing them. And besides, I get to touch the planet all day long.

These are helpful questions to consider as you weigh serious medical treatment options, or any time you have to choose whether to mobilize your finite energy to push, or use it to let go. Our answers may be different, but they are always actionable; they are ends around which we and our inner circles and our doctors can make critical decisions.

They also have a way of illuminating character. They are an expression of self, the self who will one day do the dying and so gets to say. What is it you hold dear? Who are you, or who do you wish to be? You can see how death is better framed by what you care about than by the absence of a pulse or a brain wave.

Beyond fear and isolation, maybe this is what the pandemic holds for us: the understanding that living in the face of death can set off a cascade of realization and appreciation. Death is the force that shows you what you love and urges you to revel in that love while the clock ticks. Reveling in love is one sure way to see through and beyond yourself to the wider world, where immortality lives. A pretty brilliant system, really, showing you who you are (limited) and all that you’re a part of (vast). As a connecting force, love makes a person much more resistant to obliteration.

You might have to loosen your need to know what lies ahead. Rather than spend so much energy keeping pain at bay, you might want to suspend your judgment and let your body do what a body does. If the past, present and future come together, as we sense they must, then death is a process of becoming.

So, once more, what is death? If you’re reading this, you still have time to respond. Since there’s no known right answer, you can’t get it wrong. You can even make your life the answer to the question.

BJ Miller is a hospice and palliative medicine physician, author of “A Beginner’s Guide to the End: Practical Advice for Living Life and Facing Death,” and founder of Mettle Heath, which provides consultations for patients and caregivers navigating serious illness.

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