Preparing Yourself or a Loved One to Die at Home

by Ray Burow

Death is not a fun topic, but failing to talk about end-of-life plans results in a lack of preparation and exacerbates emotional strain when a loved one passes away at home.

If your loved one opts to live out their final days in their house, or if you care for an elderly spouse or parent who’s in the advanced stages of Alzheimer’s disease, they could die at home. Are you prepared? What are your loved one’s end-of-life wishes? Would they choose to pass away at home? Is hospice care an option, or is a hospital setting a better choice for your circumstances? Medicare often pays for hospice care.

Why some people prefer to die at home

Passing away at home is often preferred by critically ill or older individuals. According to the Stanford School of Medicine, studies indicate that 80% of Americans would choose to pass from this life surrounded by what’s familiar to them, preferably at home. However, many don’t get their wish. Only 20% of Americans die at home, while 60% die in acute care hospitals and 20% die in nursing homes.

People prefer to die at home for various reasons, but perhaps control is a primary contributor. The family can manage who comes and goes, providing an opportunity to gather, reminisce, and properly say goodbye. Caregivers administer palliative care in a comfortable, familiar environment rather than one that is foreign and starkly sterile.

Hospice care will assist with pain management, and no heroic actions are taken to resuscitate the patient, who is allowed to slip away. Depending on the laws in your state, you may be able to keep the body at the house for a period of time, and some families may choose to have the funeral at home, too.

How to prepare for a death at home

Preparing to die at home is a process that must occur before the person’s final days. If you or a loved one has been diagnosed with dementia, it is essential to decide in the early days of the condition, while the decision is still yours to make. Caregivers and loved ones, acting as surrogates, can carry out your wishes, but only when they know what they are.

Advance directive

An advance health directive is crucial to securing end-of-life wishes. It’s a legal document containing the patient’s desires. If the patient is incapacitated, the document expresses their values regarding end-of-life processes. These include whether first responders and healthcare professionals will administer CPR, if the patient will donate organs, and what comfort measures will be in place during the dying process.

When a person dies at home unexpectedly and without an advance directive, first responders typically can’t pronounce them dead, as required by law. Paramedics transport the remains to the nearest hospital emergency room, where a doctor will pronounce them. If hospice is in place, the hospice nurse can pronounce the person’s death at home, and the family arranges for a funeral home to remove the remains.

Without hospice, a living will, or an advance directive, the family must call emergency services when their loved one dies at home. Paramedics, possibly firefighters, and police officers will arrive at your home, but only a doctor or coroner can pronounce death.

Understand that without the proper documents in hand, paramedics have to follow protocol and will often begin administering emergency procedures and transport your loved one to a hospital where a doctor with authority to pronounce can do so. There are exceptions to this rule depending on where you live, and in some cases, paramedics are permitted to pronounce.

Following death

Some states require an autopsy when a person dies at home. If the deceased was advanced in age, an autopsy might not be necessary. In either case, you must make arrangements for transportation to a funeral home or crematorium. Don’t be shy to ask about cost. Funeral homes are required by law to provide that information when requested.

There is much more to preparing for death at home than what we can briefly discuss in this column, including the emotional and spiritual aspects and mourning through the grieving process. Mourning is necessary and healthy, and it’s futile to try and skip it. Grief will rise to meet you in unexpected places and at random times. A grief counselor, pastor, trusted friend, or family member can help you through the mourning process. You don’t need to mourn alone.

Complete Article HERE!

‘I Prepare Wills for a Living, and Here Are 4 Things I Wish Every Family Would Talk About in Times of Health’

By Erica Sloan

As a thing that most people try to avoid, death isn’t a common topic of conversation. After all, discussing it requires confronting its inherent inevitably—but avoiding discussions surrounding it doesn’t just bring blissful ignorance, either. In fact, this tactic can leave your loved ones in the lurch when death does arrive. That’s why estate-planning attorneys suggest considering in advance how you’ll discuss your plans for death with your family, and above all, making a point to do so.

Death comes along with an emotional and logistical cascade of concerns for those close to the person who passed. While working with a palliative-care professional or death doula once death becomes imminent can certainly help with the emotional side of things, creating an estate plan ahead of time mitigates stress related to the logistics. “This is why we always say every adult should have a will,” says estate-planning attorney Rosalyn Carothers, JD. “For one, that allows you to direct what happens to any of your assets, and two, you’re making it easier and less expensive for your family members to help, as you’d have seen fit.”

“If you indicate clearly [to family members], ‘Here is my plan,’ then everyone can get on the same page, and it’s harder for someone to feel like they’re getting cheated.” —Patrick Hicks, JD, general counsel at Trust & Will

But, because of the inherent sensitivity of a will—deciding who gets what and what goes where—creating one only gets you halfway to solid death preparations. Learning how to discuss your plans for death with loved ones is the other half, both so that they know exactly where to find all the relevant documents in the event of death, and also so that they can help ensure your wishes are carried out effectively, without confusion, disagreement, or unwelcome surprises. “If you indicate clearly, ‘Here is my plan,’ then everyone can get on the same page, and it’s harder for someone to feel like they’re getting cheated, so to speak, when push comes to shove,” says estate planning attorney Patrick Hicks, JD, general counsel at Trust & Will.

Below, estate-planning attorneys share the key elements of end-of-life planning to talk about explicitly with family members, so that everyone knows what to expect should the unexpected occur.

What to discuss with family about end-of-life issues, according to estate planning attorneys

1. End-of-life wishes

A handful of both pre- and post-death desires fit into this category—which covers what you’d like to happen in the event that you’re incapacitated or terminally ill (the details of which can be legalized in a living will) and how you’d like your body to be handled should you pass (like your preferences for burial or cremation, for instance). “You really want to let folks in your life know, ‘Hey, if I’m in this circumstance, do this or don’t do this,’ regarding life support, in particular, so that loved ones feel like they are intimately aware of what you would’ve wanted,” says Carothers.

Even if it’s all legally delineated in your estate plan, talking about these desires openly can spare the people in your life who survive you from some very difficult conversations, says Hicks. It’s also worth mentioning that, in the same conversation, you should tell loved ones exactly where they can find the documents detailing these wishes, so that there’s no need to search for them if and when the time comes.

2. Who will handle what when death nears

Once you start considering your plans for death, you’ll quickly run up against what Carothers calls the “who’s its” and the “what’s its.” This refers to “who” in your life is going to handle “what,” logistically speaking, when you’re about to pass and afterward—which is another big source of potential death-related conflict that can often be avoided with a conversation.

The most contentious roles to consider are who you’ll appoint as your financial and health-care agents under your powers of attorney, or the person (or people) you’re choosing to handle your finances and taxes and your medical decisions, respectively, whenever you become unable to do so. “Sometimes, people don’t want to speak to their kids or siblings about this because they don’t want to hurt anybody’s feelings,” says Carothers. “But, it’s better to let these loved ones know upfront who you’re choosing for what and why.” That way, there’s less chance of a dispute after the fact.

The same goes for clarifying whom you’ll be naming as the executor of your estate (once you have a will in place or while you’re creating one). This is the person who will settle your accounts, manage your personal assets, and disseminate the right assets to the designated beneficiaries of your will after you pass. Talking about this with family members lets everyone know whom they should turn to for any will-related matters post-death.

3. People to call in the event of an accident

Chances are, you may not even know exactly who among a parent or sibling’s friends or acquaintances you should contact directly should they become incapacitated or die. And if you do, it’s even likelier that you don’t have their contact info handy. “Nowadays, everything is just saved in everybody’s cell phones, but what happens if you lose a loved one’s phone in an accident or you just can’t unlock it?” says Carothers.

That’s why she suggests everyone keep a list of the few close friends whom they’d like to be contacted should something happen to them, along with their contact information, and inform loved ones where they can find it in the event of an accident. Also on that list should be the name and contact info of your accountant and homeowner’s insurance agent, if either or both applies, adds Carothers, since these are usually the most important people to reach in any situation where someone is nearing death.

4. Sentimental assets

Surprisingly, it’s often the sentimental pieces of property that tend to create the most tension among a decedent’s family members, says Hicks. “With valuable assets, a lot of the time, it gets quickly resolved, either according to the specific plan in place, or in a way where things get divided equally,” he says. “But it’s the things that don’t have a lot of economic value, but that have sentimental value which are typically not accounted for in a will, and then get fought over.”

That could mean a family photo album, an antique, a special piece of artwork, or any other kind of family heirloom that can’t just be cut up into parts and divided equally. “Not having a conversation upfront about who’s going to get which of these items often leads to disputes and disagreements,” Hicks says. Talking explicitly about sentimental pieces in advance can certainly get ahead of these potential arguments, though Carothers also suggests checking to see if your state allows you to file a memorandum along with your will that can include a written file of all these items, listing the person’s name to whom each should go.

Complete Article HERE!

Knowing Someone Has Your Back At The End Of Your Life

By Sara Zeff Geber, PhD

While we were celebrating Passover and Easter with our loved ones and family, National Health Care Decisions Day came and went. It was on Saturday, April 16. It was designated to remind us that no matter our age, planning for the inevitable day when we cannot make our own health care decisions is more than a good idea; it is essential. Not planning for that inevitable event is like flying a plane that you don’t know how to land. The only people who don’t need a plan are those who meet their demise like my father: standing and talking to a friend one minute, and in an instant was lying on the floor – dead. If you are sure that is your fate, then don’t waste your time doing any planning. However, be advised that the ultimate result of not providing end-of-life instructions is that when you find yourself in the hospital toward the end of life (as many people do), the hospital ‘care protocol conveyor belt’ takes over and you will be hooked up to whatever life-support is available to keep your body nourished and your heart pumping.

What Do People Want?

Let’s look at some facts and some history about end-of-life care. Studies on end-of-life preferences demonstrate quite clearly that the vast majority of people want to die at home. However, because of a lack of willingness to talk about preferences for end-of-life care and advance care planning, over one-fifth of patients still die in the hospital. If your wish for the end of your life is an extended stay in an acute care unit of a hospital, hooked up to machines designed to keep you alive, then by all means ignore all of these statistics and opportunities to make other choices. My friend Mitch, a retired ER doc, told me how frequently he watched as family members argued about whether to keep their elder relative alive through extraordinary measures (feeding tube, mechanical ventilation, urinary catheterization, dialysis, etc.) or to let them die a more natural death. Often these well-meaning relatives were confused about what the elder wanted, or remember hearing it differently than another relative. In the end, and in the absence of written instructions, the final decision was almost always “keep her alive.”

End-of-Life Care Will Cost You

For those who still are not convinced that planning is the best way to ensure an end-of-life experience that is under your control and as comfortable as possible, you may also want to consider the cost implications of hospital care versus palliative or hospice care at home.

End-of-life costs for people with chronic diseases can be $57,000/yr. and up. Medicare will generally pick up most of that, depending on medigap coverage, pre-approvals and cooperating providers, and how long you are expected to live, but one study found that out-ot-pocket expenditures for end-of-life treatments and care are still averaging close to $12,000., with a range that goes up to close to $100,000. in the final year of life.

Medicare has covered hospice care since 1983 and usage of this benefit has slowly been increasing. In 2018, for example, 50.7% of those who died had taken advantage of hospice care for their final weeks or months of life. The savings associated with using hospice, rather than in-hospital care or a nursing home is estimated to be $117.-$400. per day.

The best-known way of creating an advance directive (also known as a healthcare proxy or power-of-attorney for health care decisions), is to work with an attorney who specializes in estate planning. They will suggest that you create a full set of end-of-life documents, which usually includes a will, a power-of-attorney for financial decisions, an advance directive, and possibly a trust. They will give you a worksheet and have a series of discussions with you about your preferences for end-of-life care and who you would choose to make decisions for you about your health and finances if you could not make them yourself. In addition to denial about the urgency of creating these documents, the cost of a complete estate plan can range from $1000-$8000., depending on how complex it needs to be.

Quick and Easy Advance Directive Online

If you are now convinced that advance care planning is important and necessary but you aren’t ready to do the full estate plan, there is a way to produce and file just the advance directive document, online – and it’s free! Since 2009, Vital Decisions has worked with individuals through health insurers to set up their wishes, should they be unable to communicate their wants at the end of life. Today, in addition to their insurance partners’ clients, they also offer a free program for the general public. It’s called My Living Voice and it guides you through three stages of preparing an advance directive: 1) setting a healthcare proxy 2) Talking through values 3) Goals of Care and Treatment wishes. So check it out, in honor of National Health Care Decisions Day, and give your loved ones the peace of mind of knowing what you want at the end of your life. Plus, it will give you peace of mind that you have communicated your final wishes to those who will be making decisions for you when you cannot.

Complete Article HERE!

Don’t leave your health decisions to chance

It’s easy to put off making important decisions in life, especially health care decisions. They can be uncomfortable and complex. Yet taking time to discuss and document your health care wishes can bring peace of mind and lead to better health outcomes in the future.

By William Creech

It’s easy to procrastinate

There are so many things to do every day, an almost-limitless amount of “low hanging fruit” items to cross off the list. It’s easy to put off thinking about your health care wishes.

There are many more enjoyable things to plan and ponder, while considering your health care wishes can feel like a chore. When given a choice between planning a vacation or outlining your end-of-life wishes, it’s easy to pick the more fun, less distressing task.

You also may procrastinate because you believe these decisions can wait for a more appropriate time in the future. Unfortunately, the right time and circumstances never seem to line up.

Documentation of your wishes

Thinking through and documenting your health care wishes tells your family and health care team what kind of care you want if you are too ill to express your wishes yourself. This could occur if you’re terminally ill, seriously injured, in a coma, in the late stages of dementia or near the end of life.

Some decisions that you should document include when you want to be resuscitated by CPR, when and for how long you want to be placed on a mechanical ventilator, or if you want to be fed through a feeding tube.

Record your wishes in a legal form called an advance directive. This document isn’t just for older adults. Anyone over 18, regardless of state of health, can complete an advance directive. It’s only activated if or when you are incapacitated and cannot make health care decisions.

One type of advance directive, a power of attorney for health care, is preferred because it makes your care wishes known and designates a person to make decisions for you if you cannot speak for yourself. This person is called a “health care agent.”

When selecting your health care agent, remember this story:

Two leaders pondered a difficult decision and were united in their approach. But soon, the second leader started to second guess the decision. The first leader said to the second, “Now is not the time to be a fence straddler.”

As you select your health care agent, pick a person you trust to follow your wishes and hold firm to the decisions.

You can update an advance health care directive or power of attorney for health care at any time, such as after a new diagnosis, a change in marital status or if your thoughts about end-of-life care evolve.

Get better outcomes

Procrastinating health care decision-making is a serious matter, so the sooner you begin, the better the potential outcome.

In some cases, life can be prolonged using advanced technology like ventilators, vasopressors and surgery. It’s great to be an educated health care consumer and understand the available treatment options, but it’s also important to remain objective, and listen to and heed the advice of your health care team.

If your health care team is unsure of your wishes, they may insist on prolonging care or performing invasive treatments on your behalf. These actions can have serious negative side effects and result in low quality of life.

Documenting your wishes early ensures that you will get the medical care you want and need while avoiding unwanted heroic measures that may be harmful. It also relieves unnecessary suffering, and eases your family and friends of decision-making burdens during moments of crisis or grief. What a gift this is for them.

Tips for difficult decisions

These conversations and decisions are not easy, but they are important.

Here’s my advice on tackling difficult decisions with your family and friends:

Don’t kick the can down the road.

Sometimes getting started is the hardest part. Years ago, I drove a vehicle with a manual three-speed transmission on the column. Unlike the automatic engines found in cars today, you could give this car a small push downhill to start the engine. In the same way, some people just need a little push to get started.

Perhaps you feel the day will never come that you face a serious injury or illness or that you will die in your sleep. But nearly every family is affected by a serious illness or injury at some point. If decisions are put off and not documented, a well-intentioned but uninformed family member could make decisions that don’t align with your wishes. I have found this to be the case on many occasions. A rolling snowball in the form of unmet health care decision-making can lead to a big mess that can become a proverbial avalanche if left unheeded.

Don’t decide to do nothing.

Inaction is still an action. If you refuse to make difficult decisions in health care, you are still deciding, but it’s much riskier. It’s like gambling on a roulette wheel. You don’t know where the ball is going to stop. Instead of taking action to improve your odds, you are just hoping for a good outcome.

You take control by expressing your wishes and choosing a responsible health care agent in an advance directive. These actions guide your roulette ball by adding flappers on the wheel that align with your desires. Doing so can make the difference between comfort or chaos for you, your health care team and your family.

Keep points simple yet specific.

As you complete your advance directive, you will be advised to consider all options. This can feel overwhelming. The key is to keep it simple because there is no way you can cover every possible scenario.

Too often, advance directives are too generic or too detailed. I recommend a happy medium where some key themes are outlined and cover a myriad of scenarios. Keep it simple when you can.

Let professionals guide you.

When you are ready, find a health care professional to guide you through completing an Advance Directive booklet. Social workers and chaplains in health care organizations, along with faith leaders, community service workers in local communities and volunteers, are trained to assist you. Your primary care provider also can assist. These professionals will help you work through the decisions, but they won’t tell you what to do.

Advanced planning and outlining your wishes before you need the care gives you the opportunity to communicate your wishes with your family. Talk with them about your advance directive and health care wishes, along with your rationale behind the decisions. Give a copy to your health care agent and health care team.

It’s prudent to be a well-informed patient as you outline your health care wishes. They are not only life decisions, but also they’re life-altering.

Helpful links:

Complete Article HERE!

After Widowhood Comes a Second Act with Purpose

What I learned after my husband’s death helped me build a business to help others handle their own myriad of tasks

Ronnie Genser and Sandy Weinberg on the final cruise they took together before his unexpected death

By Ronnie Genser

My unexpected journey to my “second act” began on September 20, 2011, the second day of Rosh Hashanah (Jewish New Year 2011) when my beloved husband Sandy (Sanford) Weinberg, age 61, had an unexpected massive heart attack around 11 pm.

Sandy was a health care management professor at the graduate level and a worldwide FDA Regulatory Affairs consultant, who also lectured and trained pharmaceutical companies around the world on how to get their new drugs through the U.S. regulatory process. He had just returned a few hours earlier from a speaking engagement to European pharmaceutical executives at one of his client companies in Cork, Ireland.

A week later after two operations when his doctors told me there was no more they could do, they asked me what I wanted to do. Fortunately, I knew what Sandy would have wanted because ten years previously we not only completed our Advance Directives for Health Care in our home state of Georgia, but we also discussed our end-of-life values and wishes.

Doing What Needed to Be Done

Based on these discussions, I asked his doctors if I could have 36 hours for the immediate family to arrive, then say their goodbyes, and recite the Vidui (Jewish confessional) prayer at his bedside. I also told the medical personal attending him that afterwards it would be time to turn off the life support machines keeping him alive. He died on October 8, 2011 – Yom Kippur (the Jewish Day of Atonement), just as Neilah (the Yom Kippur closing prayer) was beginning in the Eastern time zone.

My long-time financial advisor and friend told me, if what had happened to me should ever happen to her, she’d have me on ‘speed dial.’

About three months after my husband’s death, while speaking with my long-time financial advisor and friend, she told me if what had happened to me should ever happen to her, she’d have me ‘on speed dial.’ This was because not only was her husband one of her employees, but also because I had shared with her many of the challenges and tasks I initially faced after my husband’s unexpected death. She also said she could not both run her business and do all the things that needed to be done.

I thanked her for the vote of confidence, but politely told her I did not have the time or personal bandwidth to start a new business. Not only was I attending to all the ‘after a death’ tasks (i.e., ‘the stuff’) I needed to do, but I was also running my 20-year-old business, Genser International Consulting, a sole proprietor international sales and marketing consulting company, focused on helping U.S. companies find export markets for their products, and overseas firms find new or additional U.S. markets.

Preparing to Start My New Business

Five months later, I had dinner with another long-time friend who had been in international finance for many years and had left that career to become a financial advisor. She immediately said I needed to speak to the Financial Planning Association of Georgia (FPA of GA) of which she was a member. Ten days after we spoke, she called to tell me I would be their monthly speaker in two months.

A man wearing a button up shirt and tie smiling. Next Avenue, bereavement, grief, widow
Sandy Weinberg

Great reviews after my speech led me to really think about starting a new business, which I did. However, it took me a couple of years to figure out what services I would offer, and more importantly how to verbalize them in a way potential clients could easily understand.

Because I didn’t know anyone who was doing what I wanted to do, there appeared to be a market opportunity for this type of service, especially as the boomers began to age.

I named my business “Bereavement Navigators”, not a great name for what I do, but after (1) my two friends and I spent a lot of time searching for words to name my business, (2) my FPA of Georgia speech date was looming on the horizon, and (3) I wanted to at least have business cards and a business license prior to my speech, even if I didn’t yet have clients, we settled on this name.

Complete Article HERE!

How to choose and prepare your DPOA, the person who may control the way you die

Man at the Helm, Portrait of Signac, 1892 by Theo van Rysselberghe

By Richard B. Stuart DSW, ABPP
Co-chair Ethics Committee, Swedish/Edmonds Hospital

Getting the end-of-life treatment you want requires cooperation by three people who care. It begins with you creating a living will that describes treatments you do and do not want. Remember that if you lose capacity to speak for yourself before you declare your preferences, you are at risk of undergoing the treatments that may better serve the interests of others than respect your interests. You also need a provider who understands what you want and who will translate your preferences into a Conditional Medical Order (CMO) or Medical Orders for End-of-Life Intervention (MOELI) that can be entered into your medical record to increase the likelihood that the treatment you undergo is the treatment you want to receive. To complete your team, you need a healthcare surrogate (also known as an advocate or proxy) who will request the service you want when you are incapacitated. Your surrogate is like the helmsman who has the vital job of steering the craft over troubled waters by carefully following instructions from the captain. Without a firm hand, the ship will be at the mercy of the sea: it might reach port, but could also crash on a rock. Without a strong surrogate, you could get the care you want, or much more or much less treatment than you desire.

Similar to other states, Washington provides the following guidelines for a Durable Power of Attorney (DPOA) (“durable” because it remains in force after you lose decision-making capacity):

If the decision that the patient would have made if competent cannot be determined, then the authorized person(s) must determine that the proposed health care is in the patient’s best interests. What choice would this particular individual make if he/she were competent?

Based on the patient’s preferences and eccentricities the decision may not be what most people would choose. (RCW 7.70.065(1)(c))

This statute also stipulates that when no DPOA has been authorized, the statutory hierarchy of possible decision makers includes, in order: court-appointed guardian, attorney in fact, spouse or domestic partner, adult children, parents, or adult siblings. The following may not be substitute decision-makers: any of the patient’s physicians or owners, administrators, or employees of treating facilities unless also a spouse, domestic partner, adult child, or sibling.

The attached Step 4 of 6 Steps Living Will (www.6stepslivingwill.org) provides a form for creating a DPOA that includes contact information for principal and backup surrogates. To avoid potential conflict during crises, you should have only one surrogate, with a designated second person who can step in if the first is indisposed. It also allows for designation of those people you do not want to allow to participate in critical care discussions despite their being legally authoried to do so. Notarization of the document is recommended, but verification by the signature of a witness who is not your doctor, an employee of the facility in which you receive care, or an heir can suffice. It is important to check the requirements in any state in which you expect your DPOA to be used.

Since your life is in your surrogate’s hands, it is essential to choose your advocate wisely. Many people unthinkingly pick a partner or other relative, but the person closest to you may not be the one who can do the best job for you. I have witnessed situations in which the wheels fall off the tracks when surrogates were too emotional to speak during critical discussions, clearly did not understand the issues, were unreachable, or were either so argumentative that they alienated providers or so acquiescent that they let providers do as they wish.

A good surrogate has at least the following 7 characteristics: (1) knows you well and understands your core values, (2) has sufficient health literacy to understand the meaning of treatment alternatives and their effects, (3) is willing to put time into learning the details about each option, (4) is reachable so you can communicate any changes in your plans and so your surrogate can be contacted to participate in critical care decision-making, (5) has enough emotional control in pressured situations to be able to think clearly and collaborate, (6) is willing to control personal bias and allow your values to guide decisions, and (7) meets the standard of mental capacity. In the state of Washington, surrogates cannot be your physician or employees of the facilities in which you receive care. Other states may have additional restrictions.

Before creating a DPO, it is important to raise the following questions with the person you would like to name as your surrogate to make sure your preferences will be presented effectively. (1) “What did you hear me request?” This question is important because people often hear what they want to hear rather than what the other person says. Inviting your surrogate to participate in discussions that create the orders is an excellent first step toward this understanding. Doing so also allows your surrogate to get answers to any questions that may augment understanding during decision-making crises. It also allows your provider and surrogate to meet, which can facilitate challenging discussions. It is also important to continue the discussion with your surrogate over time to offer a reminder of what you want and alert your surrogate to any changes. (2 and 3) “If you were in my condition, which treatment(s) would you choose for yourself?” And “How do the choices you would make for yourself differ from those I made?” These questions are essential as a way to differentiate your preferences from what your surrogate would choose so yours prevail. (4) “Did I direct you to limit choices strictly to terms in my CMO or MOELI or did I give you the authority to add your own perspective or that of others you may consult?” Since critical care options are rarely black or white and the trajectories toward death are variable, there is often room for discussion. Make clear whether you grant some latitude, and if you do, stress that the final decision must accord with your values. (5) “How would you respond if a provider or significant other urged you to override my choices?” You want to be sure that your surrogate will choose the course you want and will resist pressure to do otherwise. I have seen providers say things like, “when my mother was critically ill, this is what I decided….” Statements like this are coercive and totally inappropriate because they put surrogates on the spot, with the implication that doing anything else is uncaring. These “what…if” discussions can be great training.

End-of-life treatment decisions are emotional for all concerned, and passionate objections can be raised that threaten family ties. For example, one son might argue that “Dad is a fighter and wants everything possible done” while his brother believes that “Dad has put up a good fight and now wants to end his life with dignity before pain and incoherence destroy his identity”. In another family, while discussing their sibling’s critical care, one sister who considers pain “interesting and endurable” might want treatment prolonged while the other believes one should “meet death standing up” and be allowed to die without having become disoriented when immobilized and attached to multiple irritating tubes. It is important to accept the fact that everyone is entitled to an opinion. But when one insists that others must agree, families can irreparably fall apart due to the impact of intense battles that could have been avoided by the clearly written statement of the patient’s wishes. If possible, a high level of understanding and agreement can result from inviting all interested parties to join a meeting in which the patient and provider lay out the logic of the patient’s choice.

Living wills, CMOs, and MOELIs are wonderful documents. But they may not have any impact on the treatment you undergo if you did not choose a surrogate wisely and helped that person prepare to act in your interests when decisions must be made quickly during medical crises.

Additional resources

Standardizing Protection of Patients’ Rights From POLST to MOELI (Medical Orders for End-of-Life Intervention).
Stuart RB, Thielke S.J Am Med Dir Assoc. 2017 Sep 1;18(9):741-745. doi: 10.1016/j.jamda.2017.04.022. Epub 2017 Jun 13.PMID: 28623154

Use of conditional medical orders to minimize moral, ethical, and legal risk in critical care.
Stuart RB, Birchfield G, Little TE, Wetstone S, McDermott J.J Healthc Risk Manag. 2022 Jan;41(3):14-23. doi: 10.1002/jhrm.21487. Epub 2021 Nov 17.PMID: 34791745

Here is a sample:

DURABLE POWER OF ATTORNEY FOR HEALTHCARE

Preparing your loved ones for when you are no longer there

It is essential to ensure that all your affairs are in order to avoid your family having to scurry around when you die.

By Tian Ebersohn

Since the outbreak of the Covid-19 pandemic, the virus has spread worldwide like wildfire, and millions of people have been affected by the unexpected death of a loved one. Nobody wants to think about death, but ask yourself this question right now – what if I were to die today? Would your loved ones be plunged into chaos and uncertainty and have to deal with this on top of the trauma of your passing?

In order to protect your loved ones from this harsh reality, you might want to apply the following practical guidelines while you’re still alive.

It is essential to ensure that all your affairs are in order, to avoid your spouse and family or your next of kin having to scurry around in the event of your death.

  • Put together a “life file” that contains all your important documents and information, along with a full list of, for example, your assets and liabilities, credit insurance, policies, usernames and passwords, as well as your executor and financial advisor’s contact details.
  • Ensure that you have a valid will in place.
  • Should you not wish to be kept alive artificially you might consider having a living will drawn up. A living will is an instruction to medical practitioners and your next of kin regarding your wishes if the difficult decision to turn off the machines that are keeping you alive must be taken. If you are a registered organ donor, you can also put this fact on record in your living will.
  • Your loved ones need to be aware of your wishes regarding cremation or burial, the details of any funeral cover you may have, and whom to contact when the inevitable happens.

The suggestions that follow might sound trivial, but make sure your spouse and family know how everything works in and around the house.

  • Be certain that your spouse has access to sufficient funds to cover all expenses for at least six to eight months. Most of us are aware of the challenges facing the Master’s offices nationwide, and estates are taking longer to be wound up.
  • Your spouse needs to start building up their own credit record in your lifetime to be able to qualify for services and utilities, a cell phone contract, a mortgage or a hire purchase agreement after your death, if not already.
  • Check that beneficiaries have been nominated for all your life policies, where necessary, and that nomination forms have been completed in respect of any annuities and group insurance you may have.
  • It is a good idea for your spouse to meet with your financial advisor and start building a relationship of trust between them so that the advisor can provide professional advice on your spouse’s future once you are longer there.
  • Have business continuity discussions with partners / next of kin to manage continuity and risks.
  • Ensure liquidity in the estate to pay administration costs, liabilities and taxes that will become due.

Using the above basic guidelines will have a positive effect and make the transition easier for all concerned.

Some guidelines for the surviving spouse to manage financial expectations:

  • Adequate funds are unlikely to be a major problem for your surviving spouse if you have managed your affairs well during your lifetime. This includes having made provision for life insurance so that there will be sufficient income to cover the expenses, as well as having set up a network of competent and reliable people to provide your spouse with professional advice.
  • If the surviving spouse is in the unfortunate position of having insufficient funds, careful planning must be done to provide for the basic expenses such as rent or a mortgage, as well as utility bills, food and insurance premiums.

It is important for your spouse to receive advice from a financial advisor – one with whom a good relationship has already been established – on investments, cash flow and how a basic budget (income and expenses) work. The financial advisor will assist here with a new plan to secure your spouse’s future.

  • Don’t be in a rush to make major financial decisions straight away. Something that sounds like a good idea right now will not necessarily seem so wise in six months or a year.
  • People are living longer and provisions must be made for the available funds to generate an adequate income. Ensure that the quantum of life insurance is determined in line with a properly prepared cash flow projection.
  • A surviving spouse should update their will in order to make provision for guardians, trusts and the like.

People often make poor financial decisions during the mourning process and therefore it is important to obtain reliable professional advice ahead of time in order to help you make well-informed choices, both for your benefit and for your family’s future.

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