Category: Death Education

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Aid in Dying Soon Will be Available to More Americans. Few Will Choose It.

By October, more than one in five U.S. adults will be able to obtain lethal prescriptions if terminally ill. But for those who try, obstacles remain.

By Paula Span

On Aug. 1, New Jersey will become the eighth state to allow doctors to prescribe lethal medication to terminally ill patients who want to end their lives. On Sept. 15, Maine will become the ninth.

So by October, 22 percent of Americans will live in places where residents with six months or less to live can, in theory, exercise some control over the time and manner of their deaths. (The others: Oregon, Washington, Vermont, Montana, California, Colorado and Hawaii, as well as the District of Columbia.)

But while the campaign for aid in dying continues to make gains, supporters are increasingly concerned about what happens after these laws are passed. Many force the dying to navigate an overly complicated process of requests and waiting periods, critics say.

And opt-out provisions — which allow doctors to decline to participate and health care systems to forbid their participation — are restricting access even in some places where aid in dying is legal.

“There are what I call deserts, where it’s difficult to find a facility that allows doctors to participate,” said Samantha Trad, the California state director of Compassion & Choices, the largest national advocacy group for aid in dying.

“We’re nearing a tipping point,” said Peg Sandeen, executive director of the Death With Dignity National Center, which oversaw the Maine campaign. “The issue, while still controversial, is less scary.”

The New Jersey bill had neared passage several times since it was introduced seven years ago, but derailed in 2014 when Chris Christie, the governor at the time, threatened a veto. Finally, legislators passed the Aid in Dying for the Terminally Ill Act this winter, and Gov. Philip D. Murphy signed it in April.

In Maine, the state legislature voted yes this spring, but supporters were unsure what the new governor, Janet Mills, would do. As in New Jersey, a Democratic governor replaced an outgoing Republican who had promised a veto.

Gov. Mills signed the law last month. “I do believe it is a right that should be protected by law — the right to make ultimate decisions,” she said.

What’s changed?

All these laws require states to track usage and publish statistics. Their reports show that whether a state has six months or 20 years of experience, the proportion of deaths involving aid in dying (also known, to supporters’ distaste, as physician-assisted suicide) remains tiny, a fraction of a percentage point.

California, for example, in 2017 received the mandated state documents for just 632 people who’d made the necessary two verbal requests to a physician, after which 241 doctors wrote prescriptions for 577 patients. More than 269,000 California in all died that year.

With such data showing no slippery slope toward widespread use or abuse, “a lot of the hypothetical claims our opponents made no longer carry so much weight with lawmakers,” said Kim Callinan, chief executive of Compassion & Choices.

Ms. Callinan also pointed to changing attitudes within the medical community, once a well funded source of opposition. In recent years, a number of national organizations and a dozen state medical societies have instead adopted neutral stances.

“It levels the playing field a little,” she said.

Opponents, including Catholic organizations and some disability activists, still denounce these laws. In March, an aid-in-dying bill passed the Maryland House of Delegates but failed after a tie vote in the Senate. Opponents are attempting a ballot initiative to repeal Maine’s new law and pursuing a slow-moving court case to invalidate California’s.

Public opinion polls consistently show broad support for aid in dying, however. Compassion & Choices says its upcoming legislative targets include Massachusetts, Maryland again, New Mexico, New York and Nevada.

But the persistently small number of users suggests that most Americans close to death would not personally choose to self-ingest barbiturates, even if they support legalizing that option. The low numbers may also reflect difficulty in actually using these laws.

A recent survey of 270 California hospitals, published in JAMA Internal Medicine, found that 18 months after implementation of the state’s End of Life Option Act, more than 60 percent — many of them religiously affiliated — forbade affiliated physicians to participate.

Compassion & Choices is intensifying efforts to persuade local health care systems, doctors and hospices to agree to consider patients’ requests.

Even aid-in-dying laws long on the books are beginning to draw renewed scrutiny.

For decades, the model has been the first-in-the-nation Oregon law, which took effect in 1997. It requires a terminally ill patient to see two doctors, make two oral requests for a lethal prescription plus one in writing, and face a 15-day waiting period.

Every state law but one incorporates those elements. (In Montana, a court legalized aid in dying, so there’s no statute.)

“There’s too many roadblocks in the existing legislation,” said Ms. Callinan, whose organization has long promoted that legislation. “They’ve actually made it too difficult for patients to get through the process.”

Indeed, a study from Kaiser Permanente Southern California, a health system that supports patients who request and meet requirements for aid in dying, shows that at least a third of those who inquire about it become too ill to complete the process, or die before they can qualify.

Yet states are enacting even more supposed safeguards. Hawaii, whose law took effect in January, requires a 20-day wait; both its law and a proposed Massachusetts law add a mandated mental health consultation.

By contrast, the Oregon legislature recently approved an amendment waiving the waiting period in cases where the physician believes the patient will likely die within 15 days. Gov. Kate Brown has until Aug. 9 to sign it.

Perhaps, Ms. Callinan proposed, aid-in-dying laws shouldn’t require waiting periods.

“It takes people a long time to find a first doctor, to make an appointment, to find a second doctor, to find a pharmacist,” she said. “The process itself is a waiting period,” one often exceeding 15 days.

Since rural areas face physician shortages, Compassion & Choices has also urged that nurse-practitioners and physician assistants be allowed to provide aid in dying in states where they can legally write prescriptions.

In Oregon, a veteran state legislator has taken an even more audacious step toward expanding access.

State Rep. Mitch Greenlick has introduced several bills that would permit those in the early stages of dementia and other neurodegenerative diseases to use aid in dying, securing prescriptions they could then use later as their illnesses progressed.

“You could make the request when you were cognitively able to do it,” he said.

Every existing state law bars that. Those requesting aid in dying must have mental capacity; dementia patients will have lost it by the time they’re within six months of dying. National groups emphatically oppose Mr. Greenlick’s propositions.

Yet those at heightened risk for Alzheimer’s disease, the most common form of dementia, are already well aware of aid-in-dying laws, and some would opt to use them, researchers at the University of Pennsylvania recently reported.

They interviewed 50 older adults enrolled in a drug study, most with family histories of Alzheimer’s, all found to have elevated levels of the biomarker amyloid. “We describe it as an increased but uncertain risk of developing Alzheimer’s disease,” said Emily Largent, a Penn bioethicist.

The team’s interviews revealed that about two-thirds of the group would reject aid in dying and about 15 percent had ambivalent responses. But one in five said they would pursue it if they became cognitively impaired, were suffering or burdening loved ones.

Overall, “very few understood that they wouldn’t be eligible” for lethal prescriptions under current laws if they developed dementia, Dr. Largent said.

But they were strikingly open to legal aid in dying.

“It was important to have it available,” she said. “Even if they felt they wouldn’t choose aid in dying themselves, they weren’t opposed to it for others.”

Complete Article ↪HERE↩!

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How ‘Death Doulas’ Are Helping People at the End of Their Life

They’re changing how we approach end-of-life care.

by Kristen Fischer

To many people, the word “doula” refers to a childbirth coach. But doulas aren’t only available for when life begins — they can help when life ends too.

An end-of-life doula is a nonmedical professional trained to care for a terminally ill person’s physical, emotional, and spiritual needs during the death process. While you may never have heard of this position in the healthcare field, there’s quite a market for “death doulas.”

The role is also referred to as an “end-of-life coach,” “soul midwife,” “death midwife,” or “transition guide.”

Searching for a way for patients to have a “good death” has become increasingly important in the medical community. Last year the medical journal Behavioral Sciences devoted an entire issue to communication over end-of-life issues to ensure patients’ end-of-life wishes were realized.

“In the American culture, where the majority of people die in hospitals, death has been routinely denied, sterilized, and/or removed from view,” said Maureen P. KeeleyTrusted Source. Keeley, who is director of graduate studies at the Department of Communication Studies, Texas State University, wrote in the journalTrusted Source. “Talking about dying with the person that is terminally ill can relieve anxiety for both participants in the conversation, and it can help ensure that final wishes regarding treatment at the end of life are honored.”

Currently there a few organizations that administer credentials for death doulas, including the International End of LifeDoula Association (INELDA), International Doulagivers Institute, and Lifespan Doula Association (LDA).

Jeri Glatter, vice president of INELDA, said her organization has trained about 900 end-of-life doulas in the United States since 2015. The organization provides personal certifications as well as training to hospital staff members including hospice workers. In addition to popularity in the United States, there is a significant interest for training in Asia.

Individuals who seek a personal certification often go on to run their own businesses. An INELDA certification involves attending a training session and then applying for the credential. Several requirements, including hands-on work, must be completed to become certified, which takes the average person six to nine months and is quite rigorous, Glatter said.

Life as a death “doula”

For those who embark on the career, it’s quite a personal choice.

​Kelly Sanders, RN, an end-of-life doula from Michigan, worked as a nurse in the long-term care field for many years before becoming a death doula.

“I saw people die without any control over the process,” she recalled. “It seemed as soon as the terminal diagnosis came, the patient became invisible to family and friends. They would talk as if the patient was already gone, even while the patient was in the room.”

She said that hospice cannot provide all of the services a person needs — especially the emotional help — when they have a terminal prognosis.

“Hospice does a great job taking care of the medical aspect of dying, but due to the changing nature of healthcare compensation, little time was left for the other aspects of dying that are just as important for a peaceful passing,” she said. “End-of-life doula services fit that need.”

She said there is a big misconception that hospice provides the same services as a death doula.

“I think it was the overall idea of hospice, but because of Medicare/Medicaid cuts, hospice only has time to deal with the medical needs. They do not have the training to even do the work of a doula.”

Death doulas can fill a gap in care. People can work with a death doula before they reach a point where they qualify for hospice. And an end-of-life doula is able to devote themselves to a single person, going in without an agenda to fulfill that person’s needs.

What a doula does

Sanders said a huge part of the job is to establish trust and build a relationship with patients and their families. It’s important to respect their wishes and not influence their decisions, she said.

As part of her services for Peaceful Journey Home, LLC, Sanders is often asked to take family photos or assist patients in writing letters to ask for forgiveness. Some patients hire her to plan their funerals.

“The more time that you have with a person, the more you learn and it is easier to learn their life story and advocate for their wishes,” she said. Sanders said it’s important to be flexible during the process. When she notes a patient’s wishes and they change, she gently reminds them of their initial preferences but allows them to change their minds.

“It is their death, so they can certainly have the right to change focus,” she said. “Sometimes we don’t always know what we want, and we mold the idea as we go along.”

Some family members rely on the doula to remain present and keep them informed on the patient’s status while they take a much-needed break.

A death doula can also answer questions about the dying process and empower family members to create the kind of environment that the person dying has requested, said Christy Marek, an end-of-life doula from Minnesota who sees patients locally and offers her services via phone and video conference.

“We help family feel competent and central to the process and less afraid of the unknown,” Marek said. “It is a true partnership, and I think that’s the best support we offer for families — assuring them they are not alone.”

Typical services include helping patients create legacy projects or planning a person’s final days and moments. Mostly, Marek said she focuses on creating a safe space for clients to do the emotional and “soul” work needed to help them prepare for their death.

“I help the individual who is dying to stay close to what is most important in the time that remains, to focus on what is possible rather than on limitation, and to support their loved ones in staying as involved as desired as things progress,” Marek said.

One of the biggest advantages of having an end-of-life doula is the continuity of care and consistent support. Patients often transition from actively seeking curative treatment to no longer receiving treatment. Some are put in hospice, and some “graduate” from hospice before their death, Marek explained.

“These are all circumstances where care teams change and support systems get disrupted and lost. Having an end-of-life doula throughout the process of end of life ensures that there is a consistent supportive foundation that remains the same,” Marek said.

Family ties can help lead to a ‘good death’

Sanders said it is best when family members are actively involved with the doula to respect the patient’s wishes.

“I try to encourage and engage families to participate in the process, especially if they are not in agreement with the process,” she said. “All input is valuable, but I like to politely remind families that this is not their death. So, the dying person’s wishes and needs come first.”

“Many times, a patient is not able to articulate their wishes, such as cases of dementia, but the patient still deserves a lasting tribute,” Sanders said.

Marek said her goal is to serve the patient even if they forget they hired her, don’t remember what they initially asked for, or have different wishes than family members.

She said her ultimate goal is to get what the patient wants — even if she is hired by family members.

Aside from bedside manner, death doulas have to run their business. Their services might be too costly for some patients, and insurance is unlikely to cover their work.

Sanders said an individual package may cover 20 hours for $700 plus an additional fee if the patient wants more time with the doula.

Marek said that prices typically are flexible and can include a weekly or monthly retainer or individual sessions and packages. An end-of-life vigil, which takes place during the active dying process, can range from $1,500 to $3,500 or so.

Leaning ‘into’ the fear

Anyone who is struggling with their diagnosis or wants to leave something behind for family, may want to seek out a death doula.

Sanders loves her job but admits that it’s hard when a patient passes away. “That part never gets easy,” she said. “I take comfort that I was able to help them transition on their terms.”

“Our culture holds so much fear around death that when we find ourselves face-to-face with it, either our own mortality or that of someone we love, we typically don’t know what to do,” Marek added. “It’s incredibly scary to face into the unknown, so most of us do our best not to.”

But Marek said ignoring real life can be harmful.

“It affects not only the person who is dying, but the entire circle that surrounds them,” Marek said.

The presence of an end-of-life doula helps people “lean into” the pain and fear of the unknown. That frees up space and energy so they can experience the emotions including actual joys that come with death. She said the doula’s experience helping others through death can ease the process for both family and patient.

“The comforting presence of a doula enables opportunities for the dying to connect more deeply with loved ones and to enjoy the time that remains, focusing on possibility rather than only on limitation, on what they can control rather than on what they can’t,” Marek said.

She said she believes that many people would benefit from having an end-of-life doula because they can help foster connections even during an emotionally painful time.

“I believe a death doula — the openhearted presence of someone who won’t turn away in the face of suffering and will offer support to help us work with it rather than fight against it — would benefit everyone at end of life.”

Complete Article ↪HERE↩!

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What Going To A Death Café Taught Me About Being Alive

By Nicola Appleton

“My name is Nicola and I’m here because… I’m frightened of dying,” I say to the group of strangers sat around the table in front of me. But that’s not what I mean, not really. What I meant to say is that I’m here because I’m frightened of not living – there’s a difference. I’m smiling but my heart is pounding and my palms are sweaty. I’m deeply uncomfortable.

It’s a dark and rainy Bank Holiday Sunday and I’m at my first death café meeting, held at the atmospheric Arnos Vale cemetery in Bristol. Until a few years ago, I shut down any thoughts I had about myself and those I loved dying. I was actively disconnected from death, the truth was too painful a prospect to consider.

But then both of my grandmothers passed away. They were 86 and 79 respectively, one had dementia and heart failure while the other had terminal breast cancer, yet their deaths had come as a huge shock to me. I had so fiercely avoided considering that death was even a possibility – let alone a probability – that I didn’t even say goodbye. I still grapple with this, along with the idea that two women that I had loved so much, who had been so vital in life, could one day just… cease to exist.

The death café, a not-for-profit social franchise, is the brainchild of a British man called Jon Underwood. It was Underwood’s belief that Western society doesn’t ‘do’ death particularly well. We have a tendency to avoid and ‘outsource’ it, handing over the handling of our loved ones in their final days to doctors, nurses and undertakers.

Inspired by the Swiss Café Mortel movement that aimed to removed the ‘tyrannical secrecy’ out of topic of death, Underwood wanted to create a place where people could drink tea, eat cake and talk about dying. And so, the first death café event was held in 2011 at his kitchen table in Hackney. His mum, Sue Barsky Reid, a psychotherapist, held the meeting. It was a huge success and, together with his mum, Jon wrote a guide to holding your own death café in 2012. There are now death café events held in 65 countries all over the world.

The objective of the death café is to ‘help people make the most of their (finite) lives’ and regain the control over arguably the most significant aspect of being alive. This message is made all the more poignant when I learn that Jon passed away suddenly two years ago, aged just 44.

In my family and friendship circle, we hardly ever broach the subject of death and if we do, it’s with a certain amount of gallows humour. When my mum asked my dad if he would like to be buried or cremated, he suggested she just put him out with the recycling on big bin day. We laughed, and quickly dropped the subject. I still don’t know what his wishes would be at the end of his life. I don’t know what the wishes are for anyone close to me for that matter, not even my own.

While the organisers of the death café carefully stipulate that this isn’t grief or bereavement counselling, everyone has their own personal reasons for attending. Some have lost someone close to them, others have started to think about the end of their own lives and others are simply curious.

My own reasons are that I had reached the age of thirty having never really acknowledging that people die. I mean, I knew, but until that point it remained a fairly abstract idea. When my grandmothers passed away, with their deaths came the realisation that at any point in the near or distant future, my life – along with those of everyone I love – will one day expire. This knowledge can sometimes feel like a crushing weight. Am I making the most of my life? Am I doing enough living?

The meeting is held by a facilitator, but she doesn’t set an agenda. Instead, the twelve of us sit around a table nursing teas and coffees and she allows the conversation to ebb and flow naturally. The strangers gathered are made up of a broad range of ages, genders and ethnicities, and we all hold varying ideas about what death means. Yet the meeting remains respectful, confronting and moving all at once.

I struggle to articulate my feelings around death without getting overcome with emotion. But I listen to the fears, hopes and beliefs of these strangers who share so honestly and freely, and we all laugh when I tell them I worry that if I die unexpectedly that my sons might one day read the half-finished novel lurking on my desktop before I’ve had chance to properly edit it. What if my legacy is just a few crap chapters of a yet-to-be completed book?

My head is still in the meeting long after I get home. I stand in the kitchen and look out at the tree in the middle of the garden. I recently learnt that the previous owners had planted it many years ago to commemorate the birth of their son, but he had sadly passed away. And so, as my own children play in the shadow of the tree that was planted in celebration of a life that has already ended, my mind wanders as it invariably does to this person, this stranger. How can he be dead if he’s alive in my thoughts? How can he cease to exist if those that loved him in life, love him still in death? My grandmothers might have passed away, but I feel them with me every day. To say that they no longer exist is simply not true.

There is still the fear, there is still the existential dread. But after my first meeting –and I plan on attending more – there’s also a renewed urgency to my life. We’re all here for a finite amount of time. Ignoring that fact doesn’t buy you a few extra years. We’re all born and we all die, but it’s the bit in the middle that really counts.

Complete Article ↪HERE↩!

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Planning Your Own Funeral & Memorial Service

by Anthony Martin

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

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

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

Here’s a good one…

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

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

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

Why You Should Be Planning Your Own Funeral

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

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

Here’s the cold hard truth of it.

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

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

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

Here’s some really good news.

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

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

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

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

You Have To Document Your Plans Or They Do No Good

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

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

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

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

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

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

How To Plan Your Funeral

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

No seriously, it will be.

Think of it this way.

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

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

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

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

Burial, Cremation, Or Donation

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

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

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

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

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

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

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

In Ground For A Burial

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

In Ground Lawn Crypt For A Burial

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

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

Above Ground Lawn Crypt For A Burial

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

In A Private Mausoleum Above Ground For A Burial Or Cremation

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

In A Community Mausoleum Above Ground For A Burial Or Cremation

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

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

Natural Burial

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

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

Green Burial

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

Spreading Ashes For Cremation

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

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

Memorial Reef For Cremation

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

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

Viewing Or No Viewing

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

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

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

Now Choose The Details To Round Out Your Plans

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

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

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

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

4 Ways You Can Ensure Your Funeral Is Paid For

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

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

Here’s the deal.

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

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

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

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

1) Life Insurance

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

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

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

2) Save Money

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

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

3) Pre-Need Contract

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

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

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

4) Funds From The Deceased’s Estate

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

There’s no question that this is an option.

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

Here’s why we say that.

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

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

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

Put Together A Will Or Living Trust

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

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

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

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

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

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

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

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

The reason is simple.

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

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

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It’s important to think about our own mortality if we want a good death

Australian oncologist Ranjana Srivastava says: In order to die a good death, it helps to have lived a good life. And a good life must involve contemplating one’s own mortality.

By Sally Pryor

It’s a circular philosophy that, as it happens, doesn’t feature nearly enough in the average person’s thinking, at least not in secular Australia. But for oncologist Ranjana Srivastava, living and dying are completely intertwined, and it’s those patients who are able to accept their own death – inevitable, albeit often untimely – who have inspired her to contemplate what it means to die well.

It’s a question, she says, that many doctors don’t manage to properly consider. The medical profession is focused largely on treating illness and making patients better.

“As I have matured as a doctor and became an oncologist, I have been very struck how there seems to be very little place – or no place, sometimes – in our day to talk about dying, let alone dying well, but simply dying,” she says.

And yet her work involves dealing, daily, with dying patients, often caught up in the complexities of the medical system, at sea when it comes to dealing with what happens next. From the young woman, unable to work and far away from her family, to the 80-year-old man, refusing to accept an end point when it comes to treatment that isn’t working, Srivastava can see all the ways that our society – focused primarily in succeeding and moving forward – leaves little room for contemplation.

Srivastava has been writing, compulsively, since childhood, but it was relatively early in her medical career that she realised the power of story-telling, of human narrative, in allowing her to empathise with her patients, and to do her job properly.

“I’m incredibly aware that no matter how ambitious you are as a doctor, you can only do so much, so that’s why a lot of my public writing and thinking has been devoted around how do we empower everyone else, and how do you not just talk to doctors, but how do you go around doctors and talk to people and patients?” she says.

Her latest book, A Better Death, is a meditation on all the different ways in which death, and our awareness, can give meaning to our lives, even without a terminal illness.

“I guess I saw from an early age that what resonated with me, even as a trainee doctor or even going back as medical student, was someone’s story, because you could present a sterile case,” she says.

We’re sitting in a bustling Melbourne cafe, amid a noisy Saturday morning brunch crowd. On the face of it, it’s a jarring setting in which to nut out the concept of death, but Srivastava has a tranquility about her – a calm and blessed kind of reason – that makes you think she’d be the perfect person to have to deliver bad news, and to guide someone through the process of dealing with a terminal diagnosis. Those familiar with her writing – she is a regular columnist in The Guardian – will know that her commentary often starts with the story of an individual. It’s these personal stories that often drive the point home more vividly than any textbook.

“When I began writing, I thought, well how do I convey what I feel without illustrating why?” she says.

“And I continue to think that the way we empower people and the way we educate people is through letting them get a glimpse of themselves in each of those patients.”

One of the most important lessons she has learned is that everyone has the ability to control the way they die, through the way they choose to live out their last days. The many stories in A Better Death bear this out in different ways, but all with the same ultimate conclusion: if we could all live knowing that we will one day die, our lives will have more meaning, and we will be more motivated to leave some kind of legacy. Insisting on further treatment, even when it has become futile, or refusing to make arrangements for family and help them plan for the future, can make dying well impossible. But how individuals respond to dying has as much to do with society’s fear of morbidity, of talking about death, as with the individual.

“I absolutely think we have control over it, but the more I work, I think that it needs to be almost a societally determined thing,” she says.

“I think it’s very difficult for an individual to do this on their own, because there are so many forces. I will see this, where one of my patients will say, ‘I think I’m ready to just go peacefully, to stop treatment, to focus on being outside on a day like this and enjoying the gardens’, and someone else, who has not come to terms with their mortality but someone close to that patient, will have a different view. And I think it’s always easy to get taken in by that, and I think our medical system makes it very difficult to call it a day.”

Ultimately, she says, dying without a sense of peace is costly, both to the individual, and to society at large.

“There is an enormous cost to the family and to survivors, and this borne out by research and evidence, and then there is the cost to the taxpayer and society, so at every level there are serious costs,” she says.

“I think it’s driven both by patients and doctors, I would say, I don’t think every doctor is pushing patients to have more treatment, to not adopt palliative care, to not think about quality of life, I don’t think it’s as binary as that, and I think it goes back to the kind of society we are. There’s a lot of instant gratification in life – you want something, you get it. You see something, you can buy it, and health literacy is low in general. So I think people genuinely have trouble believing that many chronic illnesses and terminal illnesses cannot be reversed, and are not curable.

“We all have to ask this question of ourselves as to how we are going to contemplate our mortality and not just leave it to our doctors.”

And yet, she says, her work – and the world in general – is filled with examples of hope. While she is “continually astonished” by the number of elderly patients who, when asked, say they have never thought about dying, she is often consoled by examples of people who have thought the whole thing through.

“Just in the news I was listening to Bob Hawke’s widow speak about his death, and one of the things she said that quite struck me was Bob felt he had nothing else that he wanted to do – he was ready,” she says.

“And I thought, here is a man who has soared to the heights of accomplishment, and somehow he has managed to step back and back every year and every decade, until he has reached a point where he says, I have done what I need to do… I found that remarkable, and that’s why there is so much peace associated with him – he lived to a good age, he was able to live well, but he was able to articulate to the family left behind that he was ready to go, and I think it’s very consoling.”

How does she think she will come to deal with her own mortality?

“That’s a really good question. I would like to think that a career in oncology will not have been wasted when it comes to my contemplating my own mortality,” she says. “The reason I could never be sure about this is that I see how people can change when they are ill. It’s very difficult to be over-confident about how you would be when you are sick, when you are speaking about it when you are well. It’s something that each of us has to experience for ourselves. But I do feel that I am more blessed than most in having a lot of good teachers.”

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What is a good death?

How my mother planned hers is a good road map for me.

By Cynthia Miller-Idriss

Years ago, I called my brother to ask whether he would serve as my health proxy, charged with making decisions about my care in the event of some unforeseeable disaster.

“Sure,” he said affably, and then added: “You should be mine, too. I mean, if I lost a leg or something, I wouldn’t want to live. You’d pull the plug, right?”

Unsettled by our widely disparate visions of a good life — and a good death — I quickly hung up and called my sister instead.

But more than a decade later, as we saw our mother succumb to the final stages of an indignant, drawn-out death from Alzheimer’s disease, I find myself returning to my brother’s words. I still find his view of a good life terribly narrow: If I lost a leg, I would certainly want to live. But I have also come to appreciate his utter certainty about what a good life — and a good death — looks like for him.

Most of us avoid thinking about death, which makes a good one harder to come by. Two-thirds of citizens in the United States do not have a living will. Although most Americans say they want to die at home, few make plans to do so, and half will die in hospitals or nursing homes instead — a situation Katy Butler, author of “The Art of Dying Well,” attributes in part to our “culture-wide denial of death.”

Specifying what a good death means is especially important for dementia patients, who will lose the ability to express their own wishes as the disease progresses. In the early stages, patients have time to reflect and clarify what they do and do not want to happen at the end of their lives. But these options dry up quickly in later stages.

This means that most families are left with a terrible series of guesses about both medical interventions and everyday care. Are patients still enjoying eating, or do they just open their mouths as a primitive reflex, as one expert put it, unconnected to the ability to know what to do with food? What kinds of extraordinary resuscitation measures would they want medical staff to undertake?

In the absence of prior directives, such considerations are estimates at best. As I sat beside her one recent morning, my mother repeatedly reached a shaky hand to her head, patting the side of her face. Puzzled, I leaned in.

“Does your head hurt?” I wondered. She moved her palm with painstaking slowness from her head to mine, cradling my cheek. “Are you in pain?” I asked. Her mouth parted, but no words came. My eyes welled. Is this the path to the good death she wanted?

I may never know the answer. But over time, I did learn how to help her have a better one. One afternoon, after she was frightened by the efforts of two nurses in her residential dementia care facility to lift her from a wheelchair, a quiet phrase slipped out of her mouth. “There you go,” she murmured calmly, just as she had for a thousand childhood skinned knees and bee stings. She was consoling herself, I realized, and teaching me how to do it at the same time.

I learned to read micro-expressions, interpreting small facial shifts for fear, anxiety or contentment. I discovered I could calm her breathing with touch: holding her hand or settling my hand on her leg. She would visibly relax if I made the shushing sounds so second-nature from the sleepless nights I’d rocked my own babies.

“It’s okay, love, you’re okay, I’m here, I love you,” I would murmur, patting her shoulder. She would sigh, and close her eyes.

Some of the path to her good death was luck. Michelle, another dementia resident, decided she was my mother’s nurse. She sat beside her constantly, holding her hand and tucking small morsels of coffeecake between her lips. Whenever I arrived, Michelle would spring up, give me a surprisingly fierce hug and offer her informed assessment of how my mother was doing. “I take care of her,” she told me repeatedly, stroking my mother’s cheek.

Other parts of her good death came through privilege. She was the last of a generation of teachers to retire with a significant pension, easing the substantial financial burden of 24-hour care. My father’s own secure retirement enabled him to care for her at home for years, and to spend hours with her every day after she moved into a residential care facility.

But her good death is also a result of planning. Having laid out her wishes with some precision, my mother was part of the minority of Americans with an advanced directive specific to dementia. This means that we knew she wanted comfort feeding, but no feeding tube. A DNR (do not resuscitate) order helped guard against unnecessary pain and suffering — the broken ribs common in elderly resuscitation attempts, for example — in case of a catastrophic event. In the end, her wishes were followed: there were no tubes and no machines.

Some indications suggest more Americans are starting to think about what a good death will look like.

There are initiatives to encourage people to talk about end-of-life care. The Death over Dinner movement suggests groups of friends host dinner parties to process how they feel about death. “How we want to die,” the movement’s website prompts, “represents the most important and costly conversation America isn’t having.” Indeed, advising people on how to die well may be the logical next step for a burgeoning wellness industry that has captivated the attention of a generation trying to live a better, more balanced life.

There is no way to know for certain whether my mother’s death was the good death she wanted. But her willingness to think it through left us with less guesswork than most — and provided a good map for me as I tried to figure it out.

I am not sure I could ask for anything more.

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A Graceful Exit: Taking Charge at the End of Life

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

By Claudia Rowe

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

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

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

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

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

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

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

In denial

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

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

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

Talking about death

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

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

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

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

Slow medicine

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

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

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

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

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

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

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

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

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

Death with dignity

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

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

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

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

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

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

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

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

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

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