Why you should plan your funeral

and how to do it

By Barbara Eisner Bayer

Let’s face it – you’re going to die at some point. And if you care about your money and your family, it will save a lot of grief if you create a funeral plan before the grieving starts. But according to a 2017 report by the National Funeral Directors Association (NFDA), only 21% of Americans discuss details about their funeral with loved ones.

Sure, when you’re gone, you’re gone, so it may not seem necessary to create a funeral plan. But it is – mostly because if you don’t, your loved ones will be making plans upon your passing while simultaneously mourning your loss. Do you really want them coping with decisions about casket types and music selections while their hearts are breaking?

Of course you don’t. Here are seven tips to help you prepare for this difficult but inevitable time.

1. Cremation or burial?

Ashes to ashes or dust to dust … do you want to be cremated or buried?

Cremation has been growing in popularity over the years. In fact, for the last four years, cremations have outpaced burials, and by 2040, they’re expected to lead burials 78.7% to 15.7%, according to a 2019 survey by the National Funeral Directors Association. The advantage of cremation is that it’s much cheaper, and you can distribute the remains wherever you please.

If you opt for a traditional burial, your costs can be high. When you price it, factor in the following fees: funeral planning, permits, death certificates, preparing the body, coordinating with the cemetery, embalming, a casket, obituary, etc. You’ll also need to purchase a burial site. After all, you don’t want to force your family to find one when they should be focusing on the service.

The median cost in 2017 for a funeral with all the trimmings was $8,755. That doesn’t include lots of stuff, though, like a grave marker and other miscellaneous expenses that always seem to pop up. The median cost for a cremation in 2017 was $6,260 if done by a funeral home. However, you can save tons of money by going for direct cremation (no service) – only about $1,100, according to the Cremation Research Council.

By choosing beforehand how you want to spend eternity, you’ll save your family from having to make this critical decision – and potentially save lots of money as well.

2. Decide how to pay

If you make your wishes known beforehand, you can set aside the funds in advance or prepay (see below). Otherwise, the costs of the funeral will fall directly onto your family, and they may not be prepared.

The funeral happens within days of your death, and your family may not have access to funds they’re going to inherit. And not everyone can come up with $8,000 or more within a few days or have that much available on a credit card.

3. Consider a prepaid plan

If you’re thinking of prepaying for a funeral, the general consensus is to never do this. And there are certainly many valid reasons for this advice: It’s expensive, you’re not earning interest on your money, the funeral home may go out of business, you may decide to relocate or change your mind, etc.

But if it will give you peace of mind, why not? If you have a funeral plan in advance, your family will know who to call when the inevitable occurs, and most of the significant choices will have been made – because you’ve already planned and paid for everything. It’s not always about dollars and cents.

If you decide to purchase a prepaid plan, shop around and find a funeral home that appeals to you. At the very least, you’ll learn about what choices need to be made and how much the costs will be, so even if you decide to self-fund or buy some type of small insurance policy that will cover your funeral expenses, you’ll have the info at your fingertips while you still have fingertips that function.

4. Create your funeral service

This will definitely be more fun (and only possible) for you to do when you’re alive – because when you’re gone, the choices won’t be yours. If you follow the steps above, your family will already know a lot of the other details that funerals entail. Now you can decide whether you want a large service in the funeral home or a small service by the graveside and a memorial service later on.

You can choose readings by your favorite poets and writers and the kind of music you’d like played. Jot down some thoughts or prerecord a tape that can be played at the service. It may bring people to tears to hear your voice, but it can also be deeply meaningful for them to hear your words and thoughts once you’re gone.

5. Write your obituary

Do you want to control how the world views your life when you’re gone? Then write your own obituary. It will be the final literary document of your life – but only if you can control what it says. This can be sent as a press release to your local newspaper, trade journals in your professional industry or alma mater.

Talk about your life’s challenges and how you overcame them. Do you have funny anecdotes or stories that define your sense of humor? Write them down. Dying is somber, and your capacity to make others laugh will be showcased as a memory of your personality.

Write about your history, your parents, your gratitude for the wonderful life you’ve lived, and the people who shared it with you. Include accomplishments and unforgettable moments, as well as lessons you learned that can be passed on to future generations. This exercise may seem sad, but the truth is that it will give you the opportunity to review your life and bring to the forefront all your special memories. It will also give you a deeper appreciation for the life you’ve been living.

6. Attend a ‘Death Cafe’

All of the above discussion may sound a bit morbid, but it shouldn’t. Death is a reality that everyone faces, and there’s no reason it should be a taboo subject. Imagine a place where people can gather and discuss end-of-life issues in a comfortable environment that takes the stigma away from dying. Welcome to the Death Cafe.

Created in 2004 by Swiss sociologist Bernard Crettaz, Death Cafes are nonprofit events organized across the globe for people to gather around tea, coffee and treats to discuss the reality and challenges of dying. Attending one gives you and/or your family the opportunity to have an objective and open conversation regarding feelings about death in a supportive and open space.

7. Discuss your plans with close family or friends

It would be a disservice to your loved ones not to talk to them about your plans for your final bow. Discuss all of the things above and what your wishes are. They can even help you fulfill many of your wishes if you’re unable to manage them by yourself.

Now you have the tools to circumvent the sadness of your death by creating an opportunity for your friends and family to celebrate your life with joy, unencumbered by the cloud of grief and funeral details that they may find overwhelming. Death is not a happy time, but by following the above steps and taking control of your funeral, you can give your family peace of mind, knowing that all is handled when that final moment comes.

Complete Article HERE!

Meet the former mortician who runs an at-home pet euthanasia business

By Ace Tilton Ratcliff

Derek and I stand in the driveway, hands clasped together. “May we end Jetson’s pain easily and quickly, and bring peace to the family,” I murmur. Derek squeezes my hand in amen, our rings rubbing metal against metal in our grip. I don’t believe in heaven or hell, but praying feels comforting. If there’s an afterlife where you get everything good your heart desires, surely dogs and cats have earned that reward.

“Let’s go do some good,” Derek says, his warm breath puffing clouds in the frigid nighttime cool.

“Let’s take care of this family,” I say at the same time. The bare skin of my shaved head chills as we laugh at our outburst.

Jill opens the door almost immediately after I knock. We’ve been friends online for years, but this is the first time we’ve ever met. Each plagued by rare chronic illnesses, our friendship was born on social media as we commiserated over being trapped in mutinous bodies. It fostered an intimacy that neither of us shares with many others.

We hug on the front porch, while Porkchop and Jetson, Boston terriers with big ears and even bigger personalities, weave between our legs in excitement. I know them from what feels like a million exchanged videos and photos. Porkchop is brindle and white, his gigantic ears pulling his eyebrows into a perpetual mask of concern. He’s always wearing a bow tie on his collar: always the gentleman. He’s also obsessed with balls in all forms: thrown, tossed, rolled, and — his very favorite — utterly destroyed.

Jetson’s abdomen has been invaded by cancer — “multicentric neoplasia,” in clinical vernacular. Jill and her parents have invited Derek and me here to euthanize him.


Derek and I co-own and operate an in-home pet euthanasia, hospice, and palliative care practice that serves Northern California’s Bay Area. Most of our work focuses specifically on euthanasia and the subsequent disposition of pets’ bodies. We also have a few patients we see to manage end-of-life care — making sure they’ve got the good drugs to stay comfortable when osteoarthritis has set in.

Derek’s a veterinarian and I’m a mortician who has shifted from human death care to pets. We started the practice two years ago after euthanizing our own dog, Harper, in our living room, though we’d assisted friends and family members through the deaths of their pets for at least a year prior to that. After having cared for Harper since puppyhood, I didn’t want to entrust her body to strangers, and we realized that the work was a calling after that experience.

Harper’s Promise isn’t a full-time job for us yet; the work is too variable and the cost of living here is astronomical. Some weeks pass with no calls, but occasionally we’ll pull back-to-back-to-back appointments with only enough time to stop for fast food in between. Derek still works shifts at a brick-and-mortar veterinary practice, and I’m perpetually freelance hustling as a writer and artist, to make sure rent gets paid. We dream of a future where this work occupies all of our focus.

The cost of in-home services are slightly more expensive than visiting a veterinary office, but not by much. I’m haunted by years spent working for a corporate funeral home, where I had to meet a quota on my contracts or face a pink slip. The idea of fleecing people who are addled with grief-brain makes me feel ill. In-home euthanasia consultations cost $375. Communal cremation with the remains scattered in the mountains runs $115, while individual cremation with a cedar urn and a metal plaque is $225.

We’ve euthanized animals ranging from a tiny guinea pig to a full-grown, 200-pound domestic pig. Inevitably, every few months, a client will pursue a unique form of memorialization; taxidermy is popular. Once, we helped ship a dog to be cryogenically preserved, his owner desperate for a future where they could be reunited. We don’t judge what the heart wants when overwhelmed by grief; we simply work to make it happen.


At the house, we enter the dim back bedroom, dominated by a bed draped with a white comforter, contrasted with a startlingly red towel spread flat. On the dresser beside the bed, a digital screen scrolls through photos of Jetson. My memory is jarred — back to the mortuary and the ubiquitous slideshows that have become a routine part of directing funerals. The simultaneous experience of now and then is disorienting, but working in death care necessitates compartmentalization. I tuck that feeling into a box in my heart and focus on the work to come.

Jill’s mother, Kathryn, is also chronically ill. Jetson is her service dog, and at only 9 years old, his death strikes an unexpectedly early blow. The average Boston terrier lives to about 13. Jill and Kathryn seem resigned to the grim reality of their decision. They’ve done the research, spent hours on the phone with us, exhausted their vet visits and medical options. It is unfair, but there is a breeze of relief in the fact that dogs seem to have no concept of the impossible decision their humans have to make. They just want to lick your face and be loved by you.

As Derek prepares the first injection, a mix of sedatives, opiates, and antianxiety medications intended to relax Jetson into near-sleep, the family shares stories about adopting him. The medications usually take between two and 15 minutes to fully kick in, pets slipping into sedation as easily as they doze off in a sunbeam. Clients will often use this time to ply their pets with snacks as they share stories with us. One dog devoured an entire rotisserie chicken, bones and all, before succumbing to sedation. Big Macs are also a popular choice.

While Kathryn and her husband, Bryan, tell stories about their beloved dog, Derek slips the sharp end of the needle between Jetson’s shoulder blades, depressing the plunger and emptying the syringe. Jetson doesn’t even flinch.

Jetson wobbles when the meds make him sleepy. We move him on top of the red towel, and his head lolls, his big tongue floppy and loose. He gazes around the room, making direct eye contact with each of us. Bryan cries, cupping his hands around Jetson’s head and leaning against his muzzle.

Jetson licks my hand when I reach out. It feels as though he’s looking straight into my soul. It’s been a long time since I’ve felt the specific, quiet intensity of grief, an emotion that imbues funeral homes like spritzed perfume.

Jetson breathes steadily into the sedation. Jill sits on the bed beside him, Porkchop bundled beneath the covers and leaning against her. Derek holds my hand as we lapse into silence. My other hand rests lightly on Jill’s back as she touches Jetson and holds Kathryn’s hand; Kathryn holds Jetson, her fingers overlapping with Bryan’s. It feels sacred, existing in this veil between the worlds of the living and the dead, all of us connected as Jetson’s heartbeat slows.

When the medication makes Jetson’s eyes close, Kathryn reaches over to her bedside table and lifts up a small jar. “I saved the very last of the hand lotion I wear all the time,” she explains to Derek and me, unscrewing the cap and using one finger to scoop. She spreads the lotion across her hands with a deft, practiced motion. “I wanted it to be the last thing he smells.” She gently runs her hands over Jetson’s face and body, suffusing him with her scent as he lays relaxed. She lowers her voice, and though we can all hear her in the small room, the words are only for him. “Don’t forget this smell, Jetson. Don’t forget to find me.”

When the part of Jetson’s brain that recognizes us and responds to stimulus has gone quiet, I circle my right hand around Jetson’s thigh, watching the vein cast a shadow as it rises. Derek places the needle of the broad barrel of viscous pink euthanasia solution in the raised vein. The flashback of blood in the syringe is short and small. The headlamp encircling Derek’s forehead illuminates a full-moon halo against Jetson’s fur.

Because he’s so sick, his blood pressure is low. The vein blows; we waltz smoothly into new positions, shifting to Jetson’s front legs. Derek’s movements are efficient. This time, as the needle slides into Jetson’s flesh, the flashback of blood is a bright firework. The overdose of anesthesia slides in without resistance. Jetson is gone before Derek is finished, his heartbeat stopping beneath our collective palms.

When we are done, a tiny slip of pink tongue shows between Jetson’s lips. His body twitches and dances beneath Jill’s steady hand, a tarantella of nerves spasming with the last offshoots of his body’s electricity, even though his spirit is no longer there. I look up and see a photo of Jetson emblazoned above the bedside table: proud and handsome on a sand dune, his mouth open in a wide, happy pant.

We step outside of the room to let them sit with Jetson’s body. My hands shake as I trim roses from their stems to tuck around Jetson’s body before we leave with him. I can’t help but think of Harper again. She was the beginning of our mission, the connection we forged in that sacrosanct act, as we took the life that was already slipping away from her.


Harper had screamed a dramatic overreaction through the snap-pop first injection, as though we were killing her — which we were, but we didn’t want it to hurt. She took the sedation like a tank, eyes open and flickering long after she should have been peacefully whisked away in a hydrocodone dream. Waiting for the meds to kick in, I ran my hand over her flank while she panted, murmuring song lyrics to the top of her head because they say hearing is the last sense to go. After the final injection, I knew she was gone, even though her body was still warm beneath my hands and her tongue was twitching between her canines. She fought to the very end, and I was grateful to finally grant her peace and relief.

At first, euthanizing her felt like stealing something from her, like we should have let her body make the decision. But her broken heart was pumping harder than it should have to keep her alive, and the overexertion was eating away at her muscles. The meaty hocks I always swore teasingly I’d eat in an apocalypse had become easy for me to wrap my fingers around. Her hacking cough, her exhaustion, the image of white fur flopped on the cool tile. Her body told us it was either euthanasia or an inevitable, slow, painful collapse.

That day is divided into two sections: Harper’s death, and everything that came after.

After six years as a mortician, I was comfortable with the paperwork, with carefully winding our way between the gravestones that interrupted long stretches of grass at the pet cemetery, and with Derek asking if the smell of burning meat coming from the crematory was Harper’s body. (It was.) I knew what the door of the crematory would look like as it trundled up, how her limp body would flop when I lay her gently inside the retort, how her fragile bones would crumble into dust beneath the bristles of the broom sweeping her out after we returned an hour later.

But I was still surprised when my heart lurched in my chest as we got home and saw there were two leashes hanging beside our front door and only one dog to walk. The same tiny earthquake wound a hairline fracture through my heart at seeing two white bowls stacked for dinner but only one mouth to feed.

Harper was half of the furry brigade that undertook the hard work of keeping me afloat in the years after I was forced out of the mortuary industry because of my Ehlers-Danlos syndrome diagnosis. A rare connective tissue disorder, the disease causes my body to create collagen incorrectly. Collagen serves as the brick and mortar of the body. Symptoms are unique to each patient, but I deal with a myriad of issues, including unexpected joint dislocations; dysautonomia, which causes me to faint from standing for too long; and endometriosis, which invaded my abdomen and necessitated a hysterectomy. I’ve had at least a surgery a year since I was 26, and since the disease is degenerative, it’s only going to get worse.

Frightened I might injure myself, frightened of the lawsuit that would surely follow, and frustrated by the time I needed to take for doctor appointments and surgeries, my managers illegally limited my responsibilities and cut my hours. My last paycheck dipped below $1,000, barely enough to pay rent and definitely not enough to cover my copious medical bills.

Becoming a mortician had been my childhood dream; I read books about ancient Egypt and mummification. In my early 20s, I’d fought through an abusive marriage and the pain of my undiagnosed disease to graduate from mortuary college and complete a grueling two-year apprenticeship. I became a licensed funeral director, embalmer and crematory operator, and I was damn good at the work. I loved being able to make someone’s worst day ever at least a little bit easier. I’d expected to make a lifelong career working in the funeral industry, not to be forced into retirement well before I turned 30.

The death of my career had neatly followed divorcing my abuser. Losing it all in one fell swoop left me wild with grief, my bereavement all bared fangs and sharpened claws. I was plagued by debilitating panic attacks and existential terror about my own death. I was afraid my ex would show up unexpectedly, battering down the front door, his hands around my neck.

But Harper made me feel safe. The length of her furry form was always pressed tight along my thigh, her long, pink tongue licking away my tears. Tangling my fingers in her white fur brought me back to myself when I was spinning out. The necessary routine of feeding and walking her kept me grounded.

By the time I eventually met Derek, my life had become more balanced. Sure, I wasn’t doing what I loved anymore, but at least I hadn’t been swallowed into the black hole of my hurt. One day, Derek brought home his stethoscope so I could hear the comforting drumbeat pulse of Harper’s heart. I couldn’t identify the subtle lub-swoosh, lub-swoosh as a portent of congestive heart failure, but Derek could. Harper’s illness was terminal; death was not a matter of if, merely when.

The idea of bringing her to a clinic for euthanasia, giving her over to someone we didn’t know, never occurred to either of us.

Before the euthanasia, we had a new tag made for her collar, one with Derek’s last name on it too. She was part of our family. We took her out for a burger and a cup filled with whipped cream, and snapped photos of her with the redwoods as a backdrop before she was exhausted. When she was gone, we arranged her body in a cremation casket, white fur bold against a pink towel. Beneath her paw, I slipped a bouquet of pink roses, white Peruvian lilies, and a bone.

Later, after driving back from the crematory, as I cradled a small wooden box in my lap instead of my dog, we parked outside our apartment. Sunshine streamed in through the windshield and the sky was so blue it almost hurt my eyes. Derek cut the engine, and we sat in silence for only a moment before I turned to him and we spoke.

“I don’t know why we never thought about this before …” he started, glancing at me.

“We have to do this for other people,” I finished. “This was the best way for the worst thing ever to happen.”

“At home, in our arms, surrounded by familiar scents and sounds? Yeah, that’s how I wanna go.”

He nodded, and from the promise that a dignified death is an important part of a good life, our practice, Harper’s Promise, was born.


Jill and I sit together on the bed, swaddling Jetson’s body with the red towel and moving him over into a small basket Derek and I brought. We tuck the trimmed blooms of yellow roses around him, the color of friendship. Kathryn steps inside the bathroom to sob and collect herself, but her face lights up when she returns. She slips outside to collect rosemary and lavender from the yard in a small, fragrant bundle that she places beneath Jetson’s paw.

On the way out, Jill hands me a brown bag with a white envelope stapled to it, a thank-you card and home-baked dog treats for our pooches. Reading it out loud as we pull away from their neighborhood, I burst into tears. Derek holds my hand, and again we are connected — in this moment of service, this kindness, in Jetson’s death.

After the long drive home, Derek lifts the basket out of the back seat where we have it buckled in. Looking down at Jetson’s body, Derek’s eyes crinkle, clouding with tears. I love that even though he has carried a syringe full of Euthasol for an uncountable number of pets, he’s crying in our front yard over Jetson. I am more used to being there in the seconds after the grim reaper has left the room, curtains still wafting from his exit. It’s so strange that now the reaper comes in the form of this beneficent man I sleep next to at night.

Heading inside, I notice a text from Jill to both of us. “This is the first time I haven’t heard my parents bawling since we got the news about Jetson’s diagnosis.” I feel the acrid sting of tears rise again.

I have missed the way it feels to shepherd a family through the tumultuous experience of death. There is nothing quite like being the guiding light through this storm, basking in the deep sense of contentment combined with the adrenaline rush of success. When I left the mortuary, I had regretfully accepted the hurt of knowing I wouldn’t do this work again, yet here I am. I feel like I have stepped back onto the ferry, wrapped my hands around the rowing oar and felt the gentle waves of the river Styx lapping against the hull.

Complete Article HERE!

Physician-Assisted Dying…

Even When Legal, Difficult to Achieve

By Roxanne Nelson, BSN, RN

When Maine passes a law allowing physician-assisted dying (PAD), it will be joining nine other jurisdictions in the United States.

By October, one in five Americans (22%) will have a law that allows terminally ill patients, most of whom have cancer, to choose an end to their life with medical help from a doctor.

However, the practicalities of actually doing so are formidable, and patients who choose this option find there are many obstacles in the way.

First is finding a doctor who will participate. Many doctors have moral objections to PAD, refuse to participate, and will not refer patients.

This sounds familiar to Charles Blanke, MD, professor of medicine at the Knight Cancer Institute at Oregon Health and Science University in Portland, who has been participating in PAD since it was legalized there in 1997.

Blanke says patients have told him that after being turned down by their physician, they also were not given a referral; instead, they were told by their doctor that “they don’t know anyone, and good luck finding someone.”

I believe this is patient abandonment.
Dr Charles Blanke

“I believe it is patient abandonment,” Blanke told Medscape Medical News. “For some patients, it takes them months to find me, so it’s no wonder many are too ill by then to proceed.”

In general, eligible patients say that PAD was not offered to them, Blanke said, but he argues that “it is legal and should be put on the table.”

He emphasized that physicians should never be pressured to participate in PAD, but they should refer patients. “We need to make it more patient friendly and more accessible.”

For years, Oregon was the only state that allowed the practice.

In recent years, however, other states have passed similar laws — Washington in 2008, Montana in 2009, Vermont in 2013, California in 2015, Colorado in 2016, Washington, D.C. in 2017, Hawaii in 2018, and New Jersey just a few weeks ago.

Lack of Training

That some doctors do not want to participate in PAD is understandable; many have moral objections to the whole idea, citing the Hippocratic oath to ‘do no harm.’

But there are signs of a shift toward more acceptance.

For instance, a 2018 Medscape ethics report found that 58% of doctors who responded to the survey said physician-assisted death should be available to the terminally ill, similar to 57% in 2016, and up from 54% in 2014 and 46% in 2010.

However, doctors who are willing to participate find it difficult to do so.

“The law makes no provision for medical training, there is no formal system, and I believe that is one of the major barriers and a shortcoming of the law in every state where it is legal,” said Lonny Shavelson, MD, a California physician based in the San Francisco area who specializes in aid in dying. He founded Bay Area End of Life Options in 2016.

“I agree that sometimes there is a moral objection, and there is sometimes institutional resistance, but most commonly it is lack of training,” he said.

Doctors, as a rule, like to do things they’ve been trained in.
Dr Lonny Shavelson

“Doctors, as a rule, like to do things they’ve been trained in and don’t like to do things they haven’t been trained in,” he added.

He noted that his practice has received more than 800 requests for medical aid in dying from different patients throughout California.

“Every patient who comes to us does so because they can’t find another doctor,” he said. “Everyone thinks it’s because of moral objections or that the patients live in rural communities, but it’s not the case for most of the patients.”

Shavelson told Medscape Medical News that he always calls the patient’s doctor, and most of them are not morally opposed to participating in PAD. “But what they tell me is that they’ve never been trained and that they don’t know anything about it. They don’t know what medications to use, or anything about the paperwork or protocol,” he said.

Barriers To Access

“The great news is that we have 22 years of data in Oregon, and the law is protecting patients,” says Kim Callinan, CEO of Compassion & Choices, the largest national advocacy group for aid in dying.

“But we also have robust data showing that the law is not meeting its intentions and that we have erected too many barriers for many to access it,” she told Medscape Medical News.

Callinan believes that improvements are needed to allow the original intention of the law to take place. “We want to keep the right safeguards in place,” she said. “But we are seeing such small numbers of people using it, and in many cases it’s because they can’t get access.”

Recent reports confirm that the number of patients who have chosen PAD — and who have completed the process — remains small.

For example, data from Oregon show that from 1997–2018, prescriptions have been written for 2217 people, and 1459 patients have died from ingesting the drugs.

In California during a single year (2017), 577 individuals received prescriptions and 374 people died after ingesting the medication.

Shavelson feels the actual demand for PAD is not reflected in the current statistics, and the numbers would probably be much higher if there was more access to physicians.

He argues that a more accurate survey would be to identify how many patients have requested PAD but could not find a physician to help them, he said. Shavelson believes that number would be significantly higher than what has been documented.

Institutional Barriers

In some cases, it is not the physician making the decision but the healthcare system.

A recent survey of 270 California hospitals, conducted 18 months after implementation of the state’s End of Life Option Act, found that 61% of hospitals had a policy forbidding physicians to participate (JAMA Intern Med. 2019;179:985-987).

“We found that of the 164 hospitals in California that opted out, 56% allowed physicians to refer patients to another provider and 29% of hospitals did not provide any guidance on this question,” said lead author Cindy Cain, PhD, assistant professor in the Department of Sociology at the University of Alabama at Birmingham.

“I support the idea that a health system can opt out,” says Peg Sandeen, PhD, MSW, executive director of the Death with Dignity National Center, a nonpartisan, nonprofit organization. “As much as I don’t like it, and think physicians should be free to practice, the health system has that right to do so,” she said.

However, not referring patients is an entirely different issue. “The outright act of refusing to refer a patient puts the physician into an ethical quandary,” she said. “Referral is part of how medicine is practiced, but it is up to the individual physician to make that determination.”

Waiting Times Present Another Barrier

The whole PAD process requires two oral requests with a waiting time of at least 15 days between them, and also a written request using the statutory form included in the state’s aid-in-dying law.

There are slight variations among states (eg, Washington, DC also requires two witnesses). Many states also require a second waiting period, in which the physician must wait 48 hours from the time of receiving the written request to write the prescription.

Callinan believes that the waiting periods, as well as the need for two doctors to confirm eligibility, are redundant in some cases. “The eligibility is that a patient has 6 months or less to live, and 2 doctors have to certify that,” she said.

“But if someone is already enrolled in hospice, as many are, it has already been determined that they meet the 6-month criteria and that the decision has been made to forgo treatment. In this case, they should only need one doctor to authorize it,” she argues.

A new law in Oregon may cut some of the waiting time, as it allows physicians to make exceptions to the waiting periods if the patient is likely to die before completing them.

“Oregon law has not evolved since it was written 20 years ago,” said Blanke. “This new bill will eliminate the waiting period for those who are imminently terminal. It won’t affect very many people, but it will help a few get quicker access.”

Shavelson praised the new Oregon law. “I think the 15-day waiting period is obscene because it’s not 15 days,” he said, explaining that it may be more like 3 or 4 months, as patients have to find a doctor and then may have to wait weeks for an appointment.

“The idea was that it was supposed to be a period of contemplation, but many patients have been contemplating since they got their diagnosis,” Shavelson pointed out. “They didn’t start thinking about it when they first made their request — they have been thinking about this for a long time.”

Patients in this waiting period may be dying or losing the mental and/or physical ability required for self-administration of the drugs, he explained. In his own clinical practice, about 30% of patients die during the 15-day waiting period, he estimates.

This is a similar proportion to that found in recent study from Kaiser Permanente Southern California, where one third of patients became too sick or died before the process was completed (JAMA Intern Med. 2018;178:417-421).

Accessing and Taking the Drugs

Even for patients who do manage to get through the bureaucracy, there are challenges in the practical steps of actually obtaining the drugs. A physician can only write the prescription and it is up to the patient to procure the drugs.

When states began to first legalize PAD, the drugs of choice were oral pentobarbital and secobarbital. However, as of 2015, both of these drugs have been largely unavailable, as previously reported by Medscape Medical News.

Through trial and error, a group of physicians eventually developed a drug regimen (DDMP2), which contains diazepam 1 g, digoxin 50 mg, morphine 15 g, and propranolol 2 g. It is more complicated than the barbiturates but has been found effective.

Shavelson explained that an updated version known as D-DMA (no propranolol and amitriptyline 8 g added), which is both faster and more reliable than all other protocols, is in the process of replacing DDMP2.

Both formulations are compounded by a pharmacist and available as a powder, which then must be mixed with 4 oz of apple juice and taken as a liquid/suspension.

Shavelson noted that physicians may not know where a patient can fill the prescription.

“It’s not something that can be filled at the local CVS or Walgreens,” he said. “A regular pharmacy doesn’t have the ingredients on hand, and for the DDMP2 combination, it has to be compounded.”

In California, two pharmacists currently fill about two thirds of the prescriptions. “Pharmacists need training as well,” Shavelson contends. “They are an integral part of this process.”

Even the last step in the whole process, the actual ingestion of the drugs, can be difficult for some patients.;

State law requires that the lethal dose be self-ingested via the digestive tract (orally or through an nasogastric (NG) or gastrostomy tube). The restriction that the drugs must be self-administered was to help ensure no one could harm a patient against his or her will.

However, many terminally ill patients are so sick they can’t physically mix the solutions, pick up and take the medicine, or swallow the drugs. Blanke estimates that around 10% of the patients he has evaluated have swallowing issues, and they fear that they will be unable to swallow the medications when they are ready to die.

To get around these practical difficulties, a proposed bill in Oregon sought to allow patients to self-administer intravenous drugs.

“There are many people who cannot swallow or administer through an NG tube, so just pushing the button on a pump syringe would allow them to take the medication,” said Blanke. “The IV could be put in right before they used it.”

Putting in an IV is easier than an NG tube, he explained, and much less invasive than a gastrostomy tube. “There’s really no difference between them, as far as putting medication in,” Blanke said. Both require some intervention and hold the same risk that someone else can administer the drugs.

Although the bill passed through the Oregon House of Representatives, it stalled in the Senate and has not moved forward. Some opponents of the bill feared that it would move Oregon closer to allowing euthanasia, while others cited the high cost of pump syringes.

Blanke believes that much of the opposition was really directed at the concept of assisted dying. “The arguments were with Death with Dignity,” he said. “Not the idea of making changes in the law or the use of an IV.”

The practical difficulties of PAD in the United States contrast with a much simpler process in Canada. Since 2016, Canada has legalized medical assistance in dying, which allows for both physician-assisted euthanasia and self-ingestion of a lethal dose. Patients have overwhelmingly selected physician-assisted euthanasia, where the lethal dose is administered intravenously by a clinician. According to Health Canada, of the nearly 7000 Canadians who have chosen to end their lives since the law went into effect, only six people have opted to self-administer drugs.

Physician Education and Training Needed

The biggest barrier — and the most imperative need — is physician education and training in PAD, argues Shavelson.

“Traditionally, teaching happens at large institutions, medical schools, universities, academics — but they won’t touch this,” said Shavelson. “They don’t want their reputation so-called ‘sullied,’ and are frightened that their reputation will take a hit. I don’t think that’s true, and I think people would feel that it’s a good thing to have medical centers more involved in this.”

Academia has fallen down on their responsibility, he contends. “This is a legal medical procedure and there is not one medical institution in my state [California] that is doing formal training on this. It’s not part of any conferences or any continuing medical education.”

As an example, the University of California, San Francisco, forbids palliative care residents and fellows from participating in aid-in-dying practices. The end result is that there are palliative care fellows coming out of training who have no experience in this area.

“Their patients will be asking about it, since palliative care doctors get asked about it more than any other specialty except for oncology,” said Shavelson. “So we will have palliative care and hospice doctors who have no training in it, and that’s absurd. This is part of the realm of what they are going to have to deal with in their practice, and institutions have forbidden it.”

However, next year the first conference for clinicians on medical aid in dying will be held in Berkeley, California, and will really delve into the nuts and bolts of practicalities, Shavelson explained. “The topic has come up at conferences, and there have been other gatherings to discuss it, but the focus has been on policy and ethics.”

This new meeting, called the National Clinicians Conference on Medical Aid in Dying, will provide an opportunity for clinicians to learn about bedside practices and share information.

“We need this clinical conference,” Shavelson added. “We are going to make education happen.”

Complete Article HERE!

Water cremation and human composting…

The new, eco-friendly frontier of dying

by Eillie Anzilotti

We are running out of space to bury people, and cremation has an enormous carbon footprint. So people are finding new ways to dispose of the bodies of their loved ones.

Matt Baskerville has served as a licensed funeral director in Illinois for the past 24 years. In that time, he’s seen his industry—and what people want after their deaths—change dramatically.

For instance, when Baskerville entered the business in the mid-’90s, the cremation rate was roughly 10%. Now, when he looks at the records of recent years at his own businesses (he directs at four funeral homes in towns of 10,000 people or less), he sees that more than 40% of people are opting for cremation.

According to new findings from the National Funeral Directors Association, for which Baskerville serves as a spokesperson, the national cremation rate is projected to be around 54% (“The Midwest tends to be a bit more traditional,” he says). Burial, once the far-dominant option for end-of-life services, has dropped to just around 41%, and Baskerville expects it will continue to decline in popularity.

Many factors are driving this shift. For one, Baskerville says, “we’re a much more mobile society.” When families tended to live and die in the same place for generations, burial was a way to keep everyone together. But now, he’s seeing that in his hometown of Wilmington, Illinois, the younger generation is dispersing, and the ties to location are not as strong. Services like cremation better meet the needs of families who are spread out geographically. It’s becoming so much more commonplace that a new set of startups now exist to cater to families whose loved ones opt for cremation. One Portland-based company called Solace, for instance, operates as a direct-to-consumer cremation service that manages the transport, storage, cremation, and return of the remains for a flat fee.

There’s also a growing awareness that traditional burial is incompatible with the state of the planet. We are, quite simply, running out of space to devote plots of land to people who are no longer living. In cities, space for necessities like housing and parks is already in short supply, and many cities like Berlin are beginning to convert old cemeteries to other land uses. But even in places where space is not so crunched, like Baskerville’s hometown, there’s a growing recognition that the burial process—from the chemicals used to embalm a body to the wood used to create caskets—is environmentally damaging, and people are beginning to seek out alternatives.

“People like the concept of going green,” Baskerville says. But even traditional flame cremation does not exactly meet that need. Cremating a single body emits as much carbon as an 1,000-mile car trip.

So increasingly, people are seeking out greener alternatives for their afterlife. A process called alkaline hydrolysis is now legal in 15 states, including Baskerville’s home of Illinois. He describes it as “flameless cremation” because what it entails is using the gentle flow of warm water mixed with alkali (usually sodium hydroxide or potassium hydroxide) to naturally liquefy a body over the course of several hours. The process creates relatively little emissions and leaves behind no waste. The leftover liquid can be disposed down the drain, and the remaining bones and metal can then go in an urn, like a traditional cremation. In Baskerville’s businesses, around 40% of people who chose cremation are opting for the flameless process.

Another emerging alternative is human composting, which was legalized in Washington (the first state to do so) in spring 2019. Through exposure to microbes, bodies can be naturally broken down and turned into soil—around one cubic yard per person, to be precise. A Seattle-based company called Recompose is pioneering the service, which will be available as an option to Washington residents beginning May 2020. Katrina Spade, Recompose’s founder and CEO, previously founded the Urban Death Project to advocate for the practice as both more sustainable and more practical in terms of land use. Recompose has proposed memorial sites where family members could come visit the bodies as they were decomposing. The dirt could then be given to families to save or to use to grow trees or plants. The company plans to open its first site in 2020.

While body composting is limited to Washington for the time being, Baskerville would not be surprised if it became more widespread. “Trends in burials tend to begin on the west coast and spread from there,” he says. Cremation, for instance, first overtook burials in popularity on the west coast, and interest in greener options, he believes, will continue to grow.

Moving away from traditional burials also tracks with a shift in American attitudes toward death on the whole. The rising “death wellness” movement encourages a more open and accepting approach to death and mortality, whether that be through dinner parties built around the discussion of death, or through hiring “death doulas” to coach people as they approach the end of life. HBO recently released a documentary called Alternate Endings that explores the different ways in which people in the U.S. are opting to memorialize themselves. Certainly, the availability of a wider range of funeral options necessitates a more open conversation around end-of-life planning and what death and burial means to individuals. To Baskerville, this is a good thing. “In years past in the American culture, death has been a topic that was not talked about,” he says. Now, though, “end of life is more of an open topic of conversation in most families now.”

Complete Article HERE!

We’re All Gonna Die!

How Fear Of Death Drives Our Behavior

by , , , &

Many people tend to push frightening realities out of mind, rather than face them head on. That’s especially true when it comes to the terrifying event that no one can escape—death. Psychologist Sheldon Solomon says people may suppress conscious thoughts about their mortality, but unconscious ones still seep through.

In the book The Worm at the Core: On the Role of Death in Life, Solomon, along with psychologists Jeff Greenberg and Tom Pyszczynski, illustrate how death anxiety influences people’s behavior in ways they would never suspect. The fear of death is so overwhelming, they say, that people go to great lengths to seek security; they embrace belief systems that give them a sense of meaning—religion, values, community.

Through decades of studies, Solomon and his colleagues have shown that people suppress their fear of mortality by supporting those who are similar to themselves. “If somebody does something that’s in accord with your belief system then being reminded of death should make you like them more so,” Solomon says.

People don’t just respond by clinging to their in-group. They act in ways that make them feel better about themselves, whether that’s demonstrating their physical prowess or buying status goods. In short, Solomon says, “we shore up our self-esteem in response to existential anxieties.”

This week on Hidden Brain, we learn how the specter of death hovers in the background, shaping everything from the risks we take to the politicians we elect.

Hidden Brain is hosted by Shankar Vedantam and produced by Jennifer Schmidt, Rhaina Cohen, Parth Shah, Laura Kwerel, and Thomas Lu. Our supervising producer is Tara Boyle. You can follow us on Twitter @hiddenbrain, and listen for Hidden Brain stories on your local public radio station.

Additional Resources:

The Worm at the Core: On the Role of Death in Life, by Sheldon Solomon, Jeff Greenberg, and Tom Pyszczynski, 2015.

The Birth and Death of Meaning, by Ernest Becker, 1971.

The Denial of Death, by Ernest Becker, 1973.

These articles describe how death reminders influence the following behaviors and preferences:

Bond recommendations by municipal court judges

Germans’ preference for German vs. non-German items

Reckless driving

Tanning habits

Support for charismatic politicians

Desire to harm someone who doesn’t share your beliefs

Complete Article HERE!

The Cost of Dying in All 50 States

By Gabrielle Olya

There are many reasons to celebrate getting older, but having to think about the cost of death isn’t one of them.

For starters, funeral costs can add up fast. The National Funeral Directors Association cited the median out-of-pocket funeral expenses for 2016 — including viewing and cremation costs — at $7,360. On top of that, the average out-of-pocket expenditure for end-of-life necessities is $11,618, according to the National Bureau of Economic Research.

One of the biggest factors impacting funeral expenses — and the cost of dying, in general — is the state where the death certificate is issued. Just like the cost of living, the cost of dying depends on where you reside.

GOBankingRates calculated the average costs for end-of-life medical care and funeral expenses in each state by multiplying the national averages for those services by every state’s cost-of-living index. The study also considered 2018 inheritance tax and estate tax data, sourced from the Tax Foundation.

50. Mississippi — $18,509

Average funeral expenses: $6,684
Average end-of-life medical costs: $11,825

The cheapest state to die in, Mississippi, has no estate tax or inheritance tax. Average funeral expenses total $6,684, and average medical costs associated with dying come out to $11,825 — both well below the national average. This is unsurprising because Mississippi also has the cheapest cost of living in America, according to a separate GOBankingRates study.

49. Arkansas — $18,681

Average funeral expenses: $6,746
Average end-of-life medical costs: $11,934

The cost of dying in Arkansas is similar to that in Alabama. Funeral expenses in Arkansas average $6,746, while medical costs associated with dying hover around $11,934. The state has no estate tax or inheritance tax.

48. Oklahoma — $18,702

Average funeral expenses: $6,754
Average end-of-life medical costs: $11,948

Medical costs associated with dying in Oklahoma are typically around $11,948, and the average cost of a funeral is $6,754 — notably below national figures. You won’t have to pay inheritance or estate taxes when you die in Oklahoma.

47. Missouri — $18,724

Average funeral expenses: $6,762
Average end-of-life medical costs: $11,962

In Missouri, the cost of a funeral averages $6,762, and the medical costs related to dying average $11,962. Neither estate taxes nor inheritance taxes are imposed.

46. New Mexico — $18,810

Average funeral expenses: $6,793
Average end-of-life medical costs: $12,017

The cost of a funeral in New Mexico averages $6,793, while medical expenses related to dying typically total $12,017. New Mexico doesn’t levy an estate tax or an inheritance tax.

45. Tennessee — $19,068

Average funeral expenses: $6,886
Average end-of-life medical costs: $12,182

Funeral costs average $6,886 in Tennessee, and medical costs related to dying are normally around $12,182. One of the most tax-friendly states for retirees, Tennessee doesn’t have an estate tax or an inheritance tax.

44. Michigan — $19,111

Average funeral expenses: $6,902
Average end-of-life medical costs: $12,209

As the seventh-cheapest state to die in, Michigan doesn’t impose an estate or inheritance tax. The average cost of a funeral in the state is low at $6,902, and medical costs associated with dying are typically around $12,209.

43. Kansas — $19,132

Average funeral expenses: $6,909
Average end-of-life medical costs: $12,223

The cost of a funeral in Kansas averages $6,909, and medical expenses related to death total approximately $12,223. No inheritance tax or estate tax is collected in the state.

42. Georgia — $19,175

Average funeral expenses: $6,925
Average end-of-life medical costs: $12,250

Falling below the national average, the standard cost for funeral expenses in Georgia is $6,925, while medical costs associated with dying are usually around $12,250. Georgia has no estate tax or inheritance tax.

41. Alabama — $19,197

Average funeral expenses: $6,933
Average end-of-life medical costs: $12,264

The average cost of a funeral in Alabama is $6,933, and medical costs associated with dying typically total $12,264. Like the other members of the 10 cheapest states to die in, Alabama doesn’t have an estate tax or an inheritance tax.

40. Wyoming — $19,197

Average funeral expenses: $6,933
Average end-of-life medical costs: $12,264

The average cost of a funeral in Wyoming is $6,933, and medical expenses associated with dying total $12,264, on average. Neither an estate tax nor an inheritance tax is collected in Wyoming.

39. Indiana — $19,347

Average funeral expenses: $6,987
Average end-of-life medical costs: $12,360

Medical costs related to dying in Indiana average $12,360, and the standard for funeral expenses is $6,987. There’s no inheritance tax or estate tax in Indiana.

38. Iowa — $19,369

Average funeral expenses: $6,995
Average end-of-life medical costs: $12,374

Iowa has no estate tax, but unlike many other states, it does have an inheritance tax of up to 15%. The average cost of a funeral is $6,995, and medical expenses related to dying hover around $12,374.

37. Nebraska — $19,519

Average funeral expenses: $7,049
Average end-of-life medical costs: $12,470

If you’re inheriting from a deceased family member in Nebraska, you’ll be taxed at a rate between 1% and 18%. However, the state doesn’t impose an estate tax. The cost of a funeral in Nebraska averages $7,049, and medical expenses associated with dying are typically around $12,470.

36. Ohio — $19,519

Average funeral expenses: $7,049
Average end-of-life medical costs: $12,470

Coming in below the national average, funeral costs in Ohio run approximately $7,049, and medical costs associated with dying total $12,470, on average. Ohio doesn’t have an estate tax or an inheritance tax.

35. Kentucky — $19,541

Average funeral expenses: $7,057
Average end-of-life medical costs: $12,484

Funeral costs in Kentucky total approximately $7,057, while medical expenses related to dying average $12,484. The state doesn’t have an estate tax, but its inheritance tax can be as much as 16%.

34. West Virginia — $19,584

Average funeral expenses: $7,072
Average end-of-life medical costs: $12,511

Dying in West Virginia will cost close to the national average, at around $12,511 in medical costs and $7,072 in funeral expenses. There’s no estate tax or inheritance tax in West Virginia.

33. Texas — $19,669

Average funeral expenses: $7,103
Average end-of-life medical costs: $12,566

The average cost of a funeral in Texas is $7,103, while medical costs associated with death are typically around $12,566. Texans don’t pay an estate tax or an inheritance tax.

32. Idaho — $19,841

Average funeral expenses: $7,165
Average end-of-life medical costs: $12,676

You won’t be charged an estate tax or an inheritance tax in Idaho, which is good news if you are the executor of a will. Plan for around $7,165 in funeral costs and approximately $12,676 in medical expenses associated with dying.

31. Louisiana — $20,185

Average funeral expenses: $7,290
Average end-of-life medical costs: $12,896

There’s no estate tax or inheritance tax in Louisiana. Medical costs related to death average $12,896, and funeral expenses run approximately $7,290.

30. Illinois — $20,314

Average funeral expenses: $7,336
Average end-of-life medical costs: $12,978

Like most states, Illinois doesn’t have an inheritance tax. However, estates worth more than $4 million are taxed at a rate of 0.8%-16%. Funeral costs average $7,336, and medical costs related to dying are typically around $12,978.

29. North Carolina — $20,400

Average funeral expenses: $7,367
Average end-of-life medical costs: $13,033

In North Carolina, there’s no estate tax or inheritance tax, so you won’t have to worry too much about what might happen to your money after you die. The average cost of a funeral is $7,367, and medical expenses associated with dying tend to total $13,033.

28. South Carolina — $20,615

Average funeral expenses: $7,445
Average end-of-life medical costs: $13,170

In South Carolina, the average cost of a funeral is $7,445, and medical costs associated with dying average $13,170. There’s no estate tax or inheritance tax.

27. Arizona — $20,852

Average funeral expenses: $7,530
Average end-of-life medical costs: $13,321

There’s no estate tax or inheritance tax in the Grand Canyon State. The average cost of a funeral is $7,530 in Arizona, and medical expenses related to death tend to add up to $13,321.

26. Wisconsin — $20,916

Average funeral expenses: $7,554
Average end-of-life medical costs: $13,363

Funeral costs in Wisconsin tend to total around $7,554, while medical expenses associated with dying average $13,363 — which are both on the cheaper side for the U.S. as a whole. No inheritance tax or estate tax is instituted, but Wisconsin is one of the most expensive states to file taxes, in general.

25. Florida — $21,045

Average funeral expenses: $7,600
Average end-of-life medical costs: $13,445

The cost of a funeral in Florida is typically around $7,600, and medical expenses associated with death average $13,445. No estate tax or inheritance tax is levied in the Sunshine State.

24. Utah — $21,153

Average funeral expenses: $7,639
Average end-of-life medical costs: $13,514

Still under the U.S. benchmark, medical costs associated with dying in Utah average $13,514, and funeral expenses are approximately $7,639. The state doesn’t impose an inheritance tax or an estate tax.

23. North Dakota — $21,239

Average funeral expenses: $7,670
Average end-of-life medical costs: $13,569

North Dakota doesn’t have an inheritance tax or an estate tax. Medical expenses associated with dying are usually around $13,569, and the average cost of a funeral is $7,670.

22. South Dakota — $21,454

Average funeral expenses: $7,748
Average end-of-life medical costs: $13,706

No estate tax or inheritance tax is imposed in South Dakota. Funeral expenses average $7,748, and medical costs related to dying are typically around $13,706 — just above the U.S. average.

21. Virginia — $21,647

Average funeral expenses: $7,818
Average end-of-life medical costs: $13,830

There’s no estate tax or inheritance tax in Virginia. Medical costs related to death hover around $13,830, and funeral expenses average $7,818.

20. Minnesota — $21,841

Average funeral expenses: $7,887
Average end-of-life medical costs: $13,953

Slightly above the national average, standard funeral costs in Minnesota come out to $7,887, and medical expenses associated with dying are approximately $13,953. The state has no inheritance tax, but if the value of your estate is above $2.4 million, you will be subject to an estate tax between 13% and 16%.

19. Pennsylvania — $21,862

Average funeral expenses: $7,895
Average end-of-life medical costs: $13,967

Pennsylvania doesn’t have an estate tax, but it does levy up to 15% in inheritance taxes. Medical expenses related to dying total approximately $13,967, and the average cost of a funeral is $7,895.

18. Colorado — $22,701

Average funeral expenses: $8,198
Average end-of-life medical costs: $14,503

There’s no need to stress about an estate tax or inheritance tax in Colorado, as neither is imposed. Funeral costs average $8,198, and medical expenses correlated with dying generally total $14,503.

17. Montana — $22,980

Average funeral expenses: $8,299
Average end-of-life medical costs: $14,681

The standard cost of a funeral in Montana is approximately $8,299, while medical costs related to dying typically average $14,681. You can keep any gold and jewels passed down to you in the Treasure State free of estate or inheritance taxes.

16. Delaware — $23,238

Average funeral expenses: $8,392
Average end-of-life medical costs: $14,846

You won’t pay an inheritance tax or estate tax in Delaware. Funeral costs average $8,392, and medical expenses related to death tend to fall around $14,846.

15. Nevada — $23,324

Average funeral expenses: $8,423
Average end-of-life medical costs: $14,901

Expect to spend about $8,423 on funeral costs in Nevada. Typical medical expenses involved with dying are $14,901, and there’s no estate tax or inheritance tax. Nevada is also one of the states with no income tax.

14. New Hampshire — $23,582

Average funeral expenses: $8,516
Average end-of-life medical costs: $15,066

Medical costs related to dying in New Hampshire average $15,066. Funeral expenses add up to $8,516, on average, but there’s no estate or inheritance tax in the Granite State.

13. Washington — $23,797

Average funeral expenses: $8,594
Average end-of-life medical costs: $15,203

In Washington, funeral expenses average $8,594, and medical expenses related to dying typically hover around $15,203. There’s no inheritance tax, but estates worth more than $2.19 million are taxed between 10% and 20%.

12. Vermont — $24,614

Average funeral expenses: $8,889
Average end-of-life medical costs: $15,725

Vermont has a 16% tax on estates worth more than $2.75 million. There’s no inheritance tax, but funeral costs average $8,889, and medical expenses related to death are typically around $15,725.

11. Maine — $25,259

Average funeral expenses: $9,122
Average end-of-life medical costs: $16,137

Maine estates valued at more than $5.6 million are taxed between 8% and 12%. There’s no inheritance tax, but the average cost of a funeral is $9,122, and $16,137 is the standard for medical expenses associated with end-of-life care.

10. Rhode Island — $25,667

Average funeral expenses: $9,269
Average end-of-life medical costs: $16,398

The average cost of a funeral in Rhode Island is $9,269, and medical expenses associated with death typically amount to $16,398. There’s no inheritance tax, but a 0.8%-16% tax is levied on estates worth more than $1.54 million.

9. New Jersey — $26,892

Average funeral expenses: $9,712
Average end-of-life medical costs: $17,181

In New Jersey, the standard funeral costs $9,712, and medical expenses correlated with dying average $17,181. There’s no estate tax, but you’ll face an inheritance tax of up to 16%.

8. Connecticut — $27,451

Average funeral expenses: $9,914
Average end-of-life medical costs: $17,538

In Connecticut, funeral costs are typically around $9,914, and medical expenses related to end-of-life care average $17,538. There’s no inheritance tax, but a 7.2%-12% tax is levied against estates valued at over $2.6 million.

7. Maryland — $27,881

Average funeral expenses: $10,069
Average end-of-life medical costs: $17,812

Funeral expenses in Maryland average $10,069, and medical bills associated with dying typically add up to $17,812. Maryland is one of the few states with both an estate tax and an inheritance tax. Inheritances are taxed up to 10%, and estates worth more than $4 million are taxed at a 16% rate.

6. Alaska — $27,924

Average funeral expenses: $10,084
Average end-of-life medical costs: $17,840

The average cost of a funeral in Alaska is $10,084, while medical expenses associated with dying hover around $17,840 — both of which are much higher than the national average. On the plus side, the state doesn’t have an inheritance tax or an estate tax.

5. Massachusetts — $28,290

Average funeral expenses: $10,216
Average end-of-life medical costs: $18,073

At around $10,216, funeral costs in Massachusetts are well above the national average. Medical expenses related to end-of-life care average $18,073. No inheritance tax is levied in Massachusetts, but estates worth more than $1 million are taxed at a 0.8%-16% rate.

4. Oregon — $28,849

Average funeral expenses: $10,418
Average end-of-life medical costs: $18,430

There’s no inheritance tax in Oregon, but if you own property in the Beaver State, plan your estate carefully — those worth more than $1 million will be taxed at a 10%-16% rate. Funeral expenses average $10,418, and medical costs related to death tend to be around $18,430.

3. New York — $29,902

Average funeral expenses: $10,799
Average end-of-life medical costs: $19,103

In New York, you won’t pay an inheritance tax, but estates worth more than $5.25 million are taxed at a 3.06%-16% rate. Funeral expenses average $10,799, and medical costs correlated with dying are $19,103.

2. California — $32,611

Average funeral expenses: $11,777
Average end-of-life medical costs: $20,834

Though it’s the second-most expensive state to die in, California doesn’t levy an estate tax or an inheritance tax. The standard cost of funeral activities is around $11,777, and medical expenses related to dying average $20,834.

1. Hawaii — $41,467

Average funeral expenses: $14,975
Average end-of-life medical costs: $26,492

Death in Hawaii is by far the priciest among all the states, as funeral costs average $14,975 and the benchmark for medical expenses correlated with end-of-life care is $26,492. The Aloha State doesn’t have an inheritance tax, but estates worth more than $11.2 million are taxed at a 10%-15.7% rate.

Where You Die Impacts the Financial Burden You Leave Behind

Fortunately for people who have to face the death of a loved one, many states don’t add an additional financial burden on the deceased’s family by levying taxes. However, this wasn’t always the case, as many states have removed estate and inheritance taxes in recent years. Others have left taxes in place but raised the exemption levels:

  • Indiana repealed its inheritance tax in 2013.
  • Tennessee repealed its estate tax in 2016.
  • New York raised its exemption level to $5.25 million and will match the federal exemption level in 2019.
  • New Jersey fully phased out its estate tax in 2018.
  • Delaware repealed its estate tax in 2018.

Overall, the cheapest places to die are Mississippi, Arkansas, Oklahoma, Missouri and New Mexico. The most expensive places to die are Hawaii, California, New York, Oregon and Massachusetts.

Complete Article HERE!

What happens as we die?

As with birth, dying is a process. How does it unfold? Can you prepare for it? And why should you keep talking to a dying person even if they don’t talk back?

By Sophie Aubrey

We’re born, we live, we die. Few things are so concrete. And yet, while we swap countless stories about the start of life, the end is a subject we’re less inclined to talk about.

Conversations about death – what it is, what it looks like – are scarce until we suddenly face it head on, often for the first time with the loss of a loved one.

“We hold a lot of anxiety about what death means and I think that’s just part of the human experience,” says Associate Professor Mark Boughey, director of palliative medicine at Melbourne’s St Vincent’s Hospital. “Some people just really push it away and don’t think about it until it’s immediately in front of them.”

But it doesn’t need to be this way, he says.

“The more people engage and understand death and know where it’s heading … the better prepared the person is to be able to let go to the process, and the better prepared the family is to reconcile with it, for a more peaceful death.”

Of course, not everyone ends up in palliative care or even in a hospital. For some people, death can be shockingly sudden, as in an accident or from a cardiac arrest or massive stroke. Death can follow a brief decline, as with some cancers; or a prolonged one, as with frailty; or it can come after a series of serious episodes, such as heart failure. And different illnesses, such as dementia and cancer, can also cause particular symptoms prior to death.

But there are key physical processes that are commonly experienced by many people as they die – whether from “old age”, or indeed from cancer, or even following a major physical trauma.

What is the process of dying? How can you prepare for it? And how should you be with someone who is nearing the end of their life?

What are the earliest signs a person is going to die?

The point of no return, when a person begins deteriorating towards their final breath, can start weeks or months before someone dies.

Professor Boughey says refractory symptoms – stubborn and irreversible despite medical treatment – offer the earliest signs that the dying process is beginning: breathlessness, severe appetite and weight loss, fluid retention, fatigue, drowsiness, delirium, jaundice and nausea, and an overall drop in physical function.

Simple actions, such as going from a bed to a chair, can become exhausting. A dying person often starts to withdraw from the news, some activities and other people, to talk less or have trouble with conversation, and to sleep more.

This all ties in with a drop in energy levels caused by a deterioration in the body’s brain function and metabolic processes.

Predicting exactly when a person will die is, of course, nearly impossible and depends on factors ranging from the health issues they have to whether they are choosing to accept more medical interventions.

“The journey for everyone towards dying is so variable,” Professor Boughey says.

What happens in someone’s final days?

As the body continues to wind down, various other reflexes and functions will also slow. A dying person will become progressively more fatigued, their sleep-wake patterns more random, their coughing and swallowing reflexes slower. They will start to respond less to verbal commands and gentle touch.

Reduced blood flow to the brain or chemical imbalances can also cause a dying person to become disoriented, confused or detached from reality and time. Visions or hallucinations often come into play.

“A lot of people have hallucinations or dreams where they see loved ones,” Professor Boughey says. “It’s a real signal that, even if we can’t see they’re dying, they might be.”

But Professor Boughey says the hallucinations often help a person die more peacefully so it’s best not to “correct” them. “Visions, especially of long-gone loved ones, can be comforting.”

Instead of simply sleeping more, the person’s consciousness may begin to fluctuate, making them nearly impossible to wake at times, even when there is a lot of stimulation around them.

With the slowing in blood circulation, body temperature can begin to seesaw, so a person can be cool to the touch at one point and then hot later on.

Their senses of taste and smell diminish. “People become no longer interested in eating … they physically don’t want to,” Professor Boughey says.

This means urine and bowel movements become less frequent, and urine will be much darker than usual due to lower fluid intake. Some people might start to experience incontinence as muscles deteriorate but absorbent pads and sheets help minimise discomfort.

What happens when death is just hours or minutes away?

As death nears, it’s very common for a person’s breathing to change, sometimes slowing, other times speeding up or becoming noisy and shallow. The changes are triggered by reduction in blood flow, and they’re not painful.

Some people will experience a gurgle-like “death rattle”. “It’s really some secretions sitting in the back of the throat, and the body can no longer shift them,” Professor Boughey says.

An irregular breathing pattern known as Cheyne-Stokes is also often seen in people approaching death: taking one or several breaths followed by a long pause with no breathing at all, then another breath.

“It doesn’t happen to everybody, but it happens in the last hours of life and indicates dying is really front and centre. It usually happens when someone is profoundly unconscious,” Professor Boughey says.

Restlessness affects nearly half of all people who are dying. “The confusion [experienced earlier] can cause restlessness right at the end of life,” Professor Boughey says. “It’s just the natural physiology, the brain is trying to keep functioning.”

Circulation changes also mean a person’s heartbeat becomes fainter while their skin can become mottled or pale grey-blue, particularly on the knees, feet and hands.

Professor Boughey says more perspiration or clamminess may be present, and a person’s eyes can begin to tear or appear glazed over.

Gradually, the person drifts in and out or slips into complete unconsciousness.

How long does dying take? Is it painful?

UNSW Professor of Intensive Care Ken Hillman says when he is treating someone who is going to die, one of the first questions he is inevitably asked is how long the person has to live.

“That is such a difficult question to answer with accuracy. I always put a rider at the end saying it’s unpredictable,” he says.

“Even when we stop treatment, the body can draw on reserves we didn’t know it had. They might live another day, or two days, or two weeks. All we know is, in long-term speaking, they certainly are going to die very soon.”

But he stresses that most expected deaths are not painful. “You gradually become confused, you lose your level of consciousness, and you fade away.”

Should there be any pain, it is relieved with medications such as morphine, which do not interfere with natural dying processes.

“If there is any sign of pain or discomfort, we would always reassure relatives and carers that they will die with dignity, that we don’t stop caring, that we know how to treat it and we continue treatment.”

Professor Boughey agrees, saying the pain instead tends to sit with the loved ones.

“For a dying person there can be a real sense of readiness, like they’re in this safe cocoon, in the last day or two of life.”

Professor Boughey believes there is an element of “letting go” to death.

“We see situations where people seem to hang on for certain things to occur, or to see somebody significant, which then allows them to let go,” he says.

“I’ve seen someone talk to a sibling overseas and then they put the phone down and die.”

How can you ‘prepare’ for death?

Firstly, there is your frame of mind. In thinking about death, it helps to compare it to birth, Professor Boughey says.

“The time of dying is like birth, it can happen over a day or two, but it’s actually the time leading up to it that is the most critical part of the equation,” he says.

With birth, what happens in the nine months leading to the day a baby is born – from the doctor’s appointments to the birth classes – can make a huge difference. And Professor Boughey says it’s “absolutely similar” when someone is facing the end of life.

To Professor Hillman, better understanding the dying process can help us stop treating death as a medical problem to be fixed, and instead as an inevitability that should be as comfortable and peaceful as possible.

Then there are some practicalities to discuss. Seventy per cent of Australians would prefer to die at home but, according to a 2018 Productivity Commission report, less than 10 per cent do. Instead, about half die in hospitals, ending up there because of an illness triggered by disease or age-related frailty (a small percentage die in accident and emergency departments). Another third die in residential aged care, according to data from the Australian Institute of Health and Welfare.

Professor Hillman believes death is over-medicalised, particularly in old age, and he urges families to acknowledge when a loved one is dying and to discuss their wishes: where they want to die, whether they want medical interventions, what they don’t want to happen.

“[Discussing this] can empower people to make their own decisions about how they die,” says Professor Hillman.

Palliative Care Nurses Australia president Jane Phillips says someone’s end-of-life preferences should be understood early but also revisited throughout the dying process as things can change. With the right support systems in place, dying at home can be an option.

“People are not being asked enough where they want to be cared for and where they want to die,” Professor Phillips says. “One of the most important things for families and patients is to have conversations about what their care preferences are.”

How can you help a loved one in their final hours?

Studies show that hearing is the last sense to fade, so people are urged to keep talking calmly and reassuringly to a dying person as it can bring great comfort even if they do not appear to be responding.

“Many people will be unconscious, not able to be roused – but be mindful they can still hear,” Professor Phillips says.

“As a nurse caring for the person, I let them know when I’m there, when I’m about to touch them, I keep talking to them. And I would advise the same to the family as well.”

On his ICU ward, Professor Hillman encourages relatives to “not be afraid of the person on all these machines”.

“Sit next to them, hold their hands, stroke their forehead, talk to them about their garden and pets and assume they are listening,” he says.

Remember that while the physical or mental changes can be distressing to observe, they’re not generally troubling for the person dying. Once families accept this, they can focus on being with their dying loved one.

Professor Boughey says people should think about how the person would habitually like them to act.

“What would you normally do when you’re caring for your loved one? If you like to hold and touch and communicate, do what you would normally do,” he says.

Other things that can comfort a dying person are playing their favourite music, sharing memories, moistening their mouth if it becomes dry, covering them with light blankets if they get cold or damp cloths if they feel hot, keeping the room air fresh, repositioning pillows if they get uncomfortable and gently massaging them. These gestures are simple but their significance should not be underestimated.

What is the moment of death?

In Australia, the moment of death is defined as when either blood circulation or brain function irreversibly cease in a person. Both will eventually happen when someone dies, it’s just a matter of what happens first.

Brain death is less common, and occurs after the brain has been so badly damaged that it swells, cutting off blood flow, and permanently stops, for example following a head injury or a stroke.

The more widespread type of death is circulatory death, where the heart comes to a standstill.

After circulation ceases, the brain then becomes deprived of oxygenated blood and stops functioning.

The precise time it takes for this to happen depends on an individual’s prior condition, says intensive care specialist Dr Matthew Anstey, a clinical senior lecturer at University of Western Australia.

“Let’s say you start slowly getting worse and worse, where your blood pressure is gradually falling before it stops, in that situation your brain is vulnerable already [from reduced blood flow], so it won’t take much to stop the brain,” Dr Anstey says.

“But if it’s a sudden cardiac arrest, the brain could go on a bit longer. It can take a minute or two minutes for brain cells to die when they have no blood flow.”

This means, on some level, the brain remains momentarily active after a circulatory death. And while research in this space is ongoing, Dr Anstey does not believe people would be conscious at this point.

“There is a difference between consciousness and some degree of cellular function,” he says. “I think consciousness is a very complicated higher-order function.”

Cells in other organs – such as the liver and kidneys – are comparatively more resilient and can survive longer without oxygen, Dr Anstey says. This is essential for organ donation, as the organs can remain viable hours after death.

In a palliative care setting, Professor Boughey says the brain usually becomes inactive around the same time as the heart.

But he says that, ultimately, it is the brain’s gradual switching off of various processes – including breathing and circulation – that leads to most deaths.

“Your whole metabolic system is run out of the brain… [It is] directing everything.”

He says it’s why sometimes, just before death, a person can snap into a moment of clarity where they say something to their family. “It can be very profound … it’s like the brain trying one more time.”

What does a dead person look like?

“There is a perceptible change between the living and dying,” Professor Boughey says.

“Often people are watching the breathing and don’t see it. But there is this change where the body no longer is in the presence of the living. It’s still, its colour changes. Things just stop. And it’s usually very, very gentle. It’s not dramatic. I reassure families of that beforehand.”

A typical sign that death has just happened, apart from an absence of breathing and heartbeat, is fixed pupils, which indicate no brain activity. A person’s eyelids may also be half-open, their skin may be pale and waxy-looking, and their mouth may fall open as the jaw relaxes.

Professor Boughey says that only very occasionally will there be an unpleasant occurrence, such as a person vomiting or releasing their bowels but, in most cases, death is peaceful.

And while most loved ones want to be present when death occurs, Professor Boughey says it’s important not to feel guilty if you’re not because it can sometimes happen very suddenly. What’s more important is being present during the lead-up.

What happens next?

Once a person dies, a medical professional must verify the death and sign a certificate confirming it.

“It’s absolutely critical for the family to see … because it signals very clearly the person has died,” says Professor Boughey. “The family may not have started grieving until that point.”

In some cases, organ and tissue donation occurs, but only if the person is eligible and wished to do so. The complexity of the process means it usually only happens out of an intensive care ward.

Professor Boughey stresses that an expected death is not an emergency – police and paramedics don’t need to be called.

After the doctor’s certificate is issued, a funeral company takes the dead person into their care and collects the information needed to register the death. They can also help with newspaper notices or flowers.

But all of this does not need to happen right away, Professor Boughey says. Do what feels right. The moments after death can be tranquil, and you may just want to sit with the person. Or you might want to call others to come, or fulfil cultural wishes.

“There is no reason to take the body away suddenly,” Professor Boughey says.

You might feel despair, you might feel numb, you might feel relief. There is no right or wrong way to feel. As loved ones move through the grieving process, they are reminded support is available – be it from friends, family or health professionals.

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