Category: Talking about death

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Crematory Is Booked? Japan Offers Corpse Hotels

Part mortuary, part hotel, Japanese corpse hotels allow grieving families to spend the night near the bodies of their loved ones as they make their final farewells. Here’s a look inside of one.

By MOTOKO RICH

[T]he minimalist rooms at the Hotel Relation here in Japan’s third-largest city are furnished with plain twin beds. Flat-screen televisions adorn the walls. Plastic-wrapped cups and toothbrushes are provided in the bathrooms. And just across the hall are the rooms where the corpses rest.

Checkout time, for the living and the dead, is usually no later than 3 p.m.

The Hotel Relation is what Japanese call an “itai hoteru,” or corpse hotel. About half the rooms are fitted with small altars and narrow platforms designed to hold coffins. Some also have climate-controlled coffins with transparent lids so mourners can peer inside.

Part mortuary, part inn, these hotels serve a growing market of Japanese seeking an alternative to a big, traditional funeral in a country where the population is aging rapidly, community bonds are fraying and crematories are struggling to keep up with the sheer number of people dying.

By custom, Japanese families take the bodies of their loved ones home from the hospital and sit for an overnight wake followed by a service the next morning in the company of neighbors, colleagues and friends. Then, in the afternoon, the body is sent to a crematory.
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But as neighborhood ties have weakened, funerals that once involved entire communities are increasingly the province of small, nuclear families. At the same time, Japanese society is getting old so fast and deaths per year are climbing so quickly that families sometimes have to wait several days before a body can be cremated.

The funeral for Hajime Iguchi at Sousou, a so-called corpse hotel in the Tokyo suburb of Kawasaki City, last year.

The corpse hotels offer a practical solution — a place where a body can be stored at low cost until the crematory is ready, and where small, inexpensive wakes and services can be held outside the home.

“We can say the supply doesn’t meet the demand,” mainly in urban areas, said Hiroshi Ota, an official at the Japan Society of Environmental Crematories. While Japan has an estimated 5,100 crematories, Tokyo, with a population of more than 13 million, has just 26.

“The demand for cremation will increase until the baby boomers disappear,” Mr. Ota said.

Japan has funeral parlors, too, an industry that developed as people moved from the countryside to the cities and it became difficult — and often impossible — to take corpses into high-rises. But they cater to larger groups and more elaborate ceremonies, and these days, that can seem a bit much.

In the bubble economy of the 1980s, “Japanese funerals were based on showing off to other people, and people cared how they were viewed by others,” said Midori Kotani, executive researcher at Dai-ichi Life Research Institute, an arm of one of Japan’s largest insurance companies. “But fewer and fewer people talk to their neighbors, so they don’t have to show off or think about how they are viewed by them.”

The corpse hotels are used by families who want a simpler affair, or want to skip a funeral altogether. According to Ms. Kotani, about 30 percent of deaths in the Tokyo area are not marked by a funeral service, up from just 10 percent a decade ago.

After cremation, families usually keep the ashes at home for 49 days before a burial service at a cemetery. On the 49th day, according to Buddhist tradition, the dead are believed to arrive at the next world.

Mr. Iguchi’s body on its way to a crematory.

When Hajime Iguchi died at age 83 last autumn, his sister and brother-in-law held his wake and funeral at Sousou, a corpse hotel in the Tokyo suburb of Kawasaki City. Mr. Iguchi, a lifelong bachelor, had died in a nursing home after a protracted illness, and had few friends left.

“Back in the day, we used to have funerals at home, but times have changed,” said his sister, Kunie Abe, 73. “Neighbors all used to know each other and would help one another out. But today, you don’t even know your next-door neighbor.”

The demand for “itai hoteru” is likely to grow. Last year, 1.3 million people died in Japan, up 35 percent from 15 years earlier, and the annual toll is expected to climb until it peaks at 1.7 million in 2040, according to the Ministry of Labor, Health and Welfare.

About 37 percent of Japanese women who died last year were over 90, with few surviving friends to mourn them. And close to one-fifth of Japanese men never marry or father children, leaving behind few relatives to plan or attend funerals.

The number of people dying alone is also on the rise. In Tokyo, for example, the number of people over 65 who died alone at home more than doubled between 2003 and 2015, the latest year for which government figures are available.

At the Hotel Relation here in Osaka, about a third of the customers forgo a formal funeral. Instead, they sit in the rooms with their dearly departed for a day or two, with only close family in attendance, and then send the bodies for cremation.

Relatives of Mr. Iguchi departing the crematory with his ashes.

“In the past, if you heard someone held a funeral just for family members, people in the neighborhood would say, ‘What kind of people would hold a family-only funeral?’ But now it is accepted,” said Yoshihiro Kurisu, the hotel’s president.

Corpse hotels are more economical than large funeral homes. According to the Japan Consumer Association, the average funeral in Japan runs 1.95 million yen, or about $17,690. The cheapest package at the Hotel Relation costs 185,000 yen, or about $1,768.

The package includes flowers, a room for the family to spend the night in the same room as the corpse, a traditional white gown for the deceased, a simply decorated coffin, transport of the body from the hospital and then to the crematory, and an urn to hold the ashes. Each additional night costs 10,800 yen, just under $100. Families who want separate rooms, wakes or funerals pay extra.

“Itai hoteru” first appeared about five years ago in Japan’s largest cities, and there are only a few across the country. Some have angered residents who do not want to live in such proximity to death and mourning.

Near the Sousou hotel in Kawasaki City, signs on fences protest, “Corpse storage: absolutely opposed!”

Hisao Takegishi, the hotel’s owner, said he understood why neighbors were uncomfortable. But he said his staff tried to be as discreet as possible when bringing in bodies.

A cemetery outside Tokyo. Nearly all people who die in Japan are cremated.

Inside, Mr. Takegishi painted the walls in pastel colors and equipped the rooms with green sofas and stools. They look more like start-up break areas than a setting for wakes or funerals. The entryway, with shelves of plants and a few books, evokes a spa.

“I did not want it to look too sad or lonely,” he said. Sousou has relationships with funeral directors and monks, and can help clients plan modest services.

Yuki Matsumoto, the executive director of the All Japan Funeral Directors Co-operation, which represents about 1,340 long-established funeral homes, said some owners of the new businesses paid little regard to standards or the dignity of the dead.

Japan does not require a license to open a funeral business, and there are few regulations for how they operate. “So in this situation, it is possible that bad-intentioned businesses can enter the industry,” Mr. Matsumoto said.

But Mr. Kurisu at the Hotel Relation said traditional funeral homes just resented the new competition. “I am hated by people in the business because I am driving down the prices of funeral services,” he said.

At Mr. Iguchi’s tiny funeral ceremony last fall, a monk chanted last rites as his body rested in a coffin lined with white satin. Five guests, all relatives, sat in folding chairs nearby.

After the chanting, they rose to lay flowers and origami cranes on Mr. Iguchi’s body, making a bright garland around his head and on his chest.

His sister, Mrs. Abe, leaned close to her brother’s ear. “So long,” she whispered.

Complete Article HERE!

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Pall bearing traditions have deep roots

By KARRIS GOLDEN

[I] recently read two books in which the notion of female pallbearers was portrayed as a novelty.

One was set in a village in southwest England at the outset of World War II. Most of the “able-bodied” have left the community to serve in the military. When a bomb results in the deaths of two women from the local choir, pallbearer duties fall to female peers — by default.

The second book was set in western Minnesota during the 1980s. A high school student committed suicide, and two female classmates volunteer as pallbearers. Despite the girls’ earnestness, several adults strongly discourage the notion.

The topic of women bearing a loved one’s pall is not a significant plot point in either book. However, both highlight the significance of pallbearers and some gender biases that continue to persist.

In our modern society, “pallbearer” is a general term. If you accept or volunteer to be a pallbearer, you will help convey the casket during various parts of the funeral and burial. It usually involves helping to carry the casket at least a short distance.

Men and women who fill pallbearer roles don’t necessarily attach religious convictions to it. However, the role tends to hold spiritual meaning for those who accept and/or volunteer for the duties. That is, pallbearers essentially understand the duty includes conveying a loved one to his or her final resting place.

That is why “honorary” pallbearers are sometimes listed. Honorary pallbearers are almost always volunteers. The causes vary, such as having more than enough pallbearers or listing those who can’t physically fulfill the physical requirements.

In all cases, the role indicates the desire to fulfill a personal duty to the deceased.

The word “pall” originally comes from Christian traditions and refers to a cloth used to cover the dead.

Thus the practice of bearing a standard of mourning — generally, the “pall” — for the dead comes from various religious practices. These exist in some version across several belief systems.

Many religious scholars believe practices created around such funereal rites have ancient roots and form the foundation of humans’ first religious practices.

The liturgical significance of the pall essentially serves as a universal symbol of death.

For early Christians in north and west Europe, the pall was often black, in keeping with the color of mourning. For example, a poor Scot was buried in the simple black pall when he or she couldn’t afford a casket. Danes draped a black pall over the casket, wagons, carriages and horses.

Over the years, many belief systems have included messages of hope in funeral services, such as the Christian belief in the resurrection. For this reason, white is now a common symbolic or liturgical funereal color.

Considering the significance of the role, why are female pallbearers still relatively uncommon?

I combed through online discussion boards in search of candid conversations about perceptions of female pallbearers. I found sites where men and women alike offered their take.

Many believe it likely women aren’t as able to bear their portion of the weight. Meanwhile, women who insisted they could carry their fair share wondered if popular styles of women’s dress shoes knock them out of the running.

While I understand these opinions, I also believe they shouldn’t preclude women from taking up this role. When viewed as the symbolic and sacred responsibility of a child, grandchild, sibling or special friend, both men and women should rise to the occasion.

Complete Article HERE!

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Should I Help My Patients Die?

By JESSICA NUTIK ZITTER

[I] WAS leafing through a patient’s chart last year when a colleague tapped me on the shoulder. “I have a patient who is asking about the End of Life Option Act,” he said in a low voice. “Can we even do that here?”

I practice both critical and palliative care medicine at a public hospital in Oakland. In June 2016, our state became the fourth in the nation to allow medical aid in dying for patients suffering from terminal illness. Oregon was the pioneer 20 years ago. Washington and Vermont followed suit more recently. (Colorado voters passed a similar law in November.) Now, five months after the law took effect here in California, I was facing my first request for assistance to shorten the life of a patient.

That week, I was the attending physician on the palliative care service. Since palliative care medicine focuses on the treatment of all forms of suffering in serious illness, my colleague assumed that I would know what to do with this request. I didn’t.

I could see my own discomfort mirrored in his face. “Can you help us with it?” he asked me. “Of course,” I said. Then I felt my stomach lurch.

California’s law permits physicians to prescribe a lethal cocktail to patients who request it and meet certain criteria: They must be adults expected to die within six months who are able to self-administer the drug and retain the mental capacity to make a decision like this.
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But that is where the law leaves off. The details of patient selection and protocol, even the composition of the lethal compound, are left to the individual doctor or hospital policy. Our hospital, like many others at that time, was still in the early stages of creating a policy and procedure. To me and many of my colleagues in California, it felt as if the law had passed so quickly that we weren’t fully prepared to deal with it.

That aside, the idea of hastening death is uncomfortable for many doctors. In its original version, the Hippocratic oath states, “I will not administer poison to anyone when asked to do so, nor suggest such a course.” The American Medical Association, the nation’s largest association of doctors, has been formally opposed to the practice for 23 years. Its ethical and judicial council has recently begun to study the issue further.

At a dinner shortly after the law went into effect, I polled 10 palliative care colleagues on their impressions of it. There was a chorus of groans. Like me, they were being asked about it with increasing frequency, yet hadn’t found an answer that felt right. It wasn’t necessarily that we disapproved, but we didn’t want to automatically become the go-to people on this very complex issue, either.

This first patient of mine was not a simple case. When I walked into his room, he glared at me. “Are you here to help me with this aid-in-dying thing?” he asked. He was in his early 60s, thin and tired, but in no obvious distress. From my read of his chart, he met all criteria to qualify. Terminal illness, decision-making capacity, ability to self-administer the medications. And he had made the requisite first request for the drugs two weeks earlier, as procedure dictates.

When I asked why he wanted to end his life early, he shrugged. “I’m just sick of living.” I asked about any symptoms that might lie behind his request: unrelenting pain, nausea, shortness of breath. He denied them all. In palliative care, we are taught that suffering can take many forms besides the physical. I probed further and the floodgates opened.

He felt abandoned by his sister. She cared only about his Social Security payments, he said, and had gone AWOL now that the checks were being mailed to her house. Their love-hate relationship spanned decades, and they were now on the outs. His despair had given way to rage.

“Let’s just end this,” he said. “I’m fed up with my lousy life.” He really didn’t care, he added, that his sister opposed his decision.

His request appeared to stem from a deep family wound, not his terminal illness. I felt he wanted to punish his sister, and he had found a way to do it.

At our second meeting, with more trust established, he issued a sob, almost a keening. He felt terrified and powerless, he said. He didn’t want to live this way anymore.

I understood. I could imagine my own distress in his condition — being shuttled like a bag of bones between the nursing home and the hospital. It was his legal right to request this intervention from me. But given how uncomfortable I was feeling, was it my right to say no?

In the end, he gave me an out. He agreed to a trial of antidepressants. “I’ll give you four weeks,” he said. He would follow up with his primary care doctor. I couldn’t help feeling relieved.

The patient died in a nursing home, of natural causes, three months later. And I haven’t had another request since. But the case left me worried. What if he had insisted on going through with it?

I’ll admit it: I want this option available to me and my family. I have seen much suffering around death. In my experience, most of the pain can be managed by expert care teams focusing on symptom management and family support. But not all. My mother is profoundly claustrophobic. I can imagine her terror if she were to develop Lou Gehrig’s disease, which progressively immobilizes patients while their cognitive faculties remain largely intact. For my mother, this would be a fate worse than death.

But still. I didn’t feel comfortable with the idea of helping to shorten the life of a patient because of depression and resentment. In truth, I’m not sure I am comfortable with helping to intentionally hasten anyone’s death for any reason. Does that make me a hypocrite?

I realized it was past time to sort out my thinking and turned to the de facto specialist in our area on this issue for counsel. Dr. Lonny Shavelson, an emergency medicine and primary care physician in Northern California, has been grappling with the subject for many years.

Given his interest in the topic, Dr. Shavelson felt a personal obligation to ensure that this new practice would be carried out responsibly after the law was passed. He founded Bay Area End of Life Options, a consulting group that educates physicians, advocates on patients’ behalf and prescribes the lethal concoction for some patients who meet the criteria for participation.

He has devised a process for his patients that not only adheres to the letter of the law, but goes far beyond it. His patient intake procedures are time-consuming and include a thorough history and physical, extensive home visits, a review of medical records and discussions with the patients’ doctors. He assesses the medical illness, the patient’s mental and emotional state and family dynamics.

He does not offer the medications to most of the patients who request them, sometimes because he deems them more than six months away from death or because he is worried that they have been coerced or because he believes that severe depression is interfering with their judgment. Since starting his practice, he has been approached by 398 patients. He has accepted 79 of those into his program and overseen ingestion and death for 48.

Dr. Shavelson’s careful observations have made him something of a bedside pharmacologist. In his experience, both the medications used and their dosages should be tailored to individual patients. While all patients enter a coma within minutes of ingesting the lethal cocktail, some deaths take longer, which can be distressing for the family and everyone else involved. One of his patients, a serious athlete, experienced a protracted death that Dr. Shavelson attributes to the patient’s high cardiac function. After that experience, Dr. Shavelson began to obtain an athletic history on every patient, and to add stronger medications if indicated.

In another patient, a mesh stent had been deployed to keep his intestines from collapsing. This stent prevented absorption in key areas, slowing the effect of the drugs and prolonging his death. Dr. Shavelson now routinely asks about such stents, something that a doctor less experienced in this process might miss.

Dr. Shavelson strives to mitigate all symptoms and suffering before agreeing to assist any patient in dying. He recounted many cases where patients no longer requested the medications once their quality of life improved. He counts these cases among his greatest successes. This demonstrates that his commitment is to the patient, not the principle.

When I asked Dr. Shavelson how he might have proceeded with my patient, he said he would have tried everything to relieve his distress without using the lethal medication. But if in the end the patient still wanted to proceed, he would have obliged, presuming his depression was not so severe as to impair his judgment. “I don’t have to agree with a patient’s reasoning or conclusions,” he said. “Those are hers to make, just as much as turning down chemotherapy or opting not to be intubated would be.”

I recently called colleagues at other hospitals to learn how they were handling this law. Like me, most of them hadn’t yet had much experience with it, but their involvement has mostly been positive. They described the few cases they had handled as “straightforward” — patients had carefully thought through the decision and had full family support. Most patients were enrolled in hospice care and supported throughout the ingestion process by trained personnel, almost always in their homes. My colleagues reported that they were free to opt out of the program if they were uncomfortable prescribing the medications. (Catholic health systems do not participate.)

Dr. Meredith Heller, director of inpatient palliative services at Kaiser Permanente San Francisco, said that while she understood my ambivalence, she herself felt significantly better about it than she had expected to. “Surprisingly, the vast majority of cases here have gone smoothly,” she told me.

A little over a year after the law went into effect, I am heartened by the positive responses I am hearing from my colleagues around the state. I am relieved that most cases seem straightforward. I am grateful that there are dedicated physicians like Dr. Shavelson willing to do this work. And I am reassured by the knowledge that patients in California now have the legal right to exercise this power when they feel there is no other path.

But I am also concerned. As our population continues to grow older and sicker and more people learn that this law exists, we will need a highly trained work force to steward patients through this process.

My patient deserved an evaluation by a physician like Dr. Shavelson, not someone like me, with no training in this area and ambivalence to boot. We need formal protocols, official procedures, outcome measurements, even a certificate of expertise issued by an oversight board. None of these are in place in any participating state, according to Dr. Shavelson. Yet all medical procedures require training. Why should one this weighty be an exception?

What about payment? Providers can bill for an office visit and the cost of the medication. But because there are no specific codes established for this procedure, reimbursement doesn’t come close to covering any effort to do this well. On top of that, many insurers won’t cover it, including federal programs like Medicare and the Veterans Health Administration.

And will this new “right” be available to everyone? Most communities won’t have a Dr. Shavelson, who offers steep discounts to low-income patients. I worry that public hospital patients like mine will not be able to afford this degree of care. These are inequities we must address.

THERE is another question I feel compelled to raise. Is medical aid in dying a reductive response to a highly complex problem? The over-mechanization of dying in America has created a public health crisis. People feel out of control around death. A life-ending concoction at the bedside can lend a sense of autonomy at a tremendously vulnerable time.

Yet medical aid in dying will help only a tiny fraction of the population. In 2016, just under four-tenths of 1 percent of everyone who died in Oregon used this option. Other approaches such as hospice and palliative care, proven to help a broad population of patients with life-limiting illness, are still underused, even stigmatized. The American Society of Clinical Oncology recommends that patients with advanced cancer receive concurrent palliative care beginning early in the course of disease. In my experience, far too few of these patients actually get it.

Unlike medical aid in dying, which will be used by a small proportion of the population, palliative interventions can improve the lives of many. My patient hadn’t been seen by a palliative care physician before he made his request. Although recommended, it isn’t required by law. And yet this input gave him another option.

Medical aid in dying is now the law in my home state, and I am glad for that. But our work is just beginning. We must continue to shape our policies and protocols to account for the nuanced social, legal and ethical questions that will continue to arise. We must identify the clinicians who are best qualified and most willing to do this work and then train them appropriately, not ad hoc. And we must remember that this is just one tool in the toolbox of caring for the dying — a tool of last resort.

Complete Article HERE!

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Learning how to handle grief in college harder than expected

Grieving for my brother was much harder away from home, but getting help and hearing other students with similar experiences helped me to become a more independent person.

By Laura Townsend

[B]y the time I got to college freshman year, I thought I had learned how to handle my grief. It had been three years since a car accident took the life of my adored big brother. For three years, I had been learning how to navigate a world in which he no longer existed. I was in constant pain, but I thought I had my grief under control.

A few months into my freshman year, I suffered a breakdown. Grieving for my brother in college was nothing like it was in high school. For the first time, I was forced to miss my brother entirely by myself. At home, my friends and family were grieving alongside me. I had been leaning on them so heavily that when they were no longer there to hold me up, I collapsed.

College is a difficult transition for everyone. We are forced to adjust to a new way of living while balancing coursework and a social life. In college, we learn who we are separately from those who raised us. Everything around us feels new, and yet our old problems still remain. They linger until we are forced to confront them.

As college stresses continued to build, I suppressed my feelings of grief and homesickness. A breakdown was inevitable.

The beginning of the breakdown occurred in the middle of one of my classes, when the professor played a disturbing video of a car accident. The video triggered memories I had been suppressing for months. I ran out of class crying.

After the incident in the classroom, I could no longer contain my grief. I began having panic attacks on a nearly daily basis. I missed classes and fought with friends.

After a particularly severe panic attack, I decided I needed help; I scheduled an appointment with University Counseling Service. At my first appointment, my therapist (a peppy graduate student) informed me that significant portions of the service’s clientele are grieving students. She hit me with a cliché: “You are not alone,” which I actually really needed to hear.

Grieving in college can feel isolating. At home, there were pictures of my brother on every wall of the house. My parents were always talking about him. Even my friends would recall stories from time to time. At college, nobody knew who he was. New friends did not want to discuss deeply personal matters right away. I did not want to be a burden to them.

What I failed to realize freshman year, however, was that many of my friends were dealing with their own grief at the same time. Many of them were struggling as much as I was.

Grief is an all-consuming feeling that never goes away. As long as my heart is beating, I will mourn the loss of my brother. He is always on my mind. Grieving in college has been an entirely different process than grieving at home. It is never easy, but once I learned to open up and let myself feel sad when I needed to, it became manageable. Learning how to grieve in college was an essential step to learning how to be an independent person.

Complete Article HERE!

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A good death

It would be foolish to think that we can control when our time is up. But neither should we face that moment unprepared. Not only for our sake, but for the people we leave behind.
 

By Vivien Shiao

[T]HE only certainty in life is death. But this is not something we like to think about – not when we are at our prime, our careers powering ahead, and the future bright. In fact, as you flip through the papers, about to tuck into a nice brunch with loved ones, you may even question why we want to mention it at all, potentially casting a pall on a perfectly good weekend. The reality is, there are just as many ways to die as there are ways to live. It can come like a thief in the night, sudden and without warning. For others, death comes as an impending train – relentless and closing in. Or sometimes, long after the body and mind have withered, death still does not come. As the ultimate human experience we all cannot run away from, it matters how we approach death. How we live the rest of our days depends on it.

What a good death means

A good death is hard to define. In many instances, the process of dying is described as a battle to be won, a fight between life and death. Rage, rage against the dying of the light, wrote poet Dylan Thomas.

But doctors intimate with death tell The Business Times that this struggle to extend life without thought to its quality is not necessarily what people want.

Dr Ng Wai Chong, chief of clinical affairs, Tsao Foundation, is a physician who is well acquainted with death. To him, a good death is the ultimate challenge. “It is one with a good mind, one that is peaceful, one that has closure. All the big questions in life have been answered… To prepare for a good death, you need to live a life that is responsible and with a clear conscience.”

Those who are prepared are typically contented, accepting and also grateful, says Dr Ng. For Dr Neo Han Yee, a palliative care consultant at Tan Tock Seng Hospital, a good death means a life of little regret or guilt, and being at peace knowing that loved ones will be taken care of. “It is difficult to achieve zero suffering, but on a spiritual aspect, these people feel that their lives have been worthwhile and they are ready to move on.”

A good death also has a social dimension, he explains: People with the “foresight” to invest their time and effort in relationships, in turn, receive support in their last days from family and loved ones. They are the ones with the wisdom to prepare early and help family members cope with their impending passing, he says.

Planning for the end

A good death doesn’t come by accident. It takes planning and preparation in many aspects – financial, legal, psychological, social, medical, and even spiritual – to make it happen. This is not just to ease one’s passage, but also to ease the burden on loved ones.

If the end-of-life process is a long drawn out one, the stakes are even higher. For example, if you become mentally incapacitated due to your illness and your children have no idea what your last wishes are, they could end up spending tens of thousands trying to treat you, in the hopes of extending life.

Not only could this increase your distress in your last days (though with no ill intention), the lack of clarity is likely to result in conflict among family members, and financial issues. Such a scenario may seem like the stuff of TV dramas, but it is a lot more common than you think, according to experts that BT spoke to. So, rather than wait for a crisis to strike, it may be prudent to plan ahead when things are hunky dory and you still have sound presence of mind. This could prevent unnecessary expenditure, heartache and headache for others further down the road.

Alfred Chia, CEO of financial advisory firm SingCapital, says that procrastination is one of the biggest mistakes that people tend to make regarding their finances. He is also the co-author of Last Wishes: Financial Planning, Will Planning and Funeral Planning in Singapore. “Planning for death should not be viewed as taboo or negative. In fact, it is a celebration of our life in this world,” Mr Chia says. He advises people to plan for retirement early to avoid “huge financial stress” later. Work out the amount needed each month for the ideal lifestyle post-retirement and the number of years you expect to provide for, he says. The right insurance policy can also help achieve your goals in a more cost-effective way, he adds.

Other mistakes he has observed others make is to fall prey to financial scams, and to invest in instruments that don’t suit their risk profile. He says: “There is a saying that when I pass on, I have not spent all my money. While that is a regret, it will be even more regretful if I have spent all my money, and yet am still alive with no capacity to earn an income.”

On the flipside of the coin, those who are extremely wealthy have even more compelling reasons to plan. To manage their wealth, they often turn to family offices – private wealth management advisory firms.

Mr Chia says that planning ahead for the wealthy can help keep family unity and prevent squabbles over inheritance. Family offices can also spread the distribution of wealth over an extended period so that the children won’t be “spoilt” with the sudden wealth, he adds.

Working with the law

When life ends, a host of issues crop up for loved ones, that can only be properly resolved within the confines of the law.

Most people know the significance of wills, but there are other considerations such as trusts and Lasting Power of Attorney, or the LPA.

A will is for the distribution of assets after one’s death, while an LPA is for the appointment of a person or persons (known as the donee) to make decisions for you on “health and wealth” before your death.

Doris Chia, litigation partner of David Lim & Partners, saysthat most people with elderly parents would want to do an LPA, so that they are able to access their parents’ bank accounts or assets to pay for their parents’ medical bills when their parents are unable to do so.

One thing to bear in mind is that the LPA only kicks in in the event of loss of mental capacity. So although you may do an LPA now, it may only be valid decades later, says Ms Chia. Or, it may never come into effect at all if the person who appointed the LPA remains mentally healthy.

Ms Chia also warns that the LPA comes under the Mental Capacity Act, which means it can only be made by a person of sound mind. Once there is an onset of a mental issue such as Alzheimer’s or senile dementia, it will be too late to make one.

The consequences can be serious. She cites an example where the mother of one client became mentally incapacitated and then fell ill, and the client was unable to sell a private property that she owned jointly with her mother.

Without an LPA, she had to apply to the court for deputyship to sell the property, to fund her mother’s medical needs. This process cost “tens of thousands of dollars”, according to Ms Chia.

“A person applying to be a deputy has to file several affidavits in court. This also costs money. You can save all this heartache now by doing an LPA. What’s the harm?”

According to the Office of the Public Guardian, the fee for LPA certificate issuers ranges from S$25 for a general practitioner to S$500 for a psychiatrist – still much more affordable than applying for deputyship.

Another group of people that Ms Chia urged to apply for LPAs are singles, and people who identify as LGBT (lesbian, gay, bisexual, transgender).

“For LGBT people, it is essential to do an LPA as it allows the partner – and not family members, if that is your choice – to make decisions on your personal welfare and property and affairs. Otherwise, legally, your partner has no say over such matters in such circumstances.”

Where there’s a will

Aside from the LPA, the will is another matter to be considered seriously. For non-Muslims who die without making a will, distribution of assets will be according to the Intestate Succession Act. For example, the surviving spouse will get 50 per cent of assets, with the rest divided among their children. For singles, the assets will go to their living parents. Otherwise, it will go to their siblings.

Muslims follow the Muslim intestacy law, the faraid. Only one-third of their assets can be willed away, with the rest distributed according to the faraid.

For those who don’t want to follow the standard distribution rules, making a will is vital. Some people, Ms Chia has observed, don’t trust their spouses too much and prefer to give everything to their children.

The existence of a will gives much quicker access to assets. For people who die with a will in place, a Grant of Probate allows the process to move much faster compared to the Letter of Administration for those who die without a will, says Ms Chia.

Even so, the existence of a will is no guarantee that it will be carried out. It may be hidden, or lost, or challenged. It’s important that the executors of the will – those who will administer and distribute your estate upon death – know where the will is, together with proper instructions on bank accounts, assets and insurance policies.

Details make all the difference. “I always say to my clients, do a will that can last many years,” says Ms Chia. “Don’t say Property A goes to one son, and Property B goes to another son. If you sell Property B and you forget to amend your will, one son will end up with nothing.”

Instead, she recommends that the executor be instructed to sell all assets and for the proceeds to be distributed according to percentages.

State of mind and health also matter. It’s better to make a will when you are healthy and of sound mind so that there will be no dispute later, Ms Chia advises. She observes that most people do not think about end-of-life decisions until they are forced upon them. But wills are sometimes contested if the person had made it when they were very old or very sick.

Giving the assets in a trust, as opposed to in a will, prevents challenges by family members, says Ms Chia. Often used for succession planning, a trust protects family assets for the good of beneficiaries who are either too young, financially immature or vulnerable until they either come of age or reach a certain maturity.

The assets put into a trust are a gift made in a person’s lifetime, and not upon his death. Once the assets vest in the trust, they no longer belong to him. The assets will not form part of his assets at the point of his death and hence, a trust cannot be contested, explains Ms Chia.

Having a trust could also mitigate the heavy taxes applicable to estate duty in certain overseas jurisdictions, or safeguard assets from the possibility of lawsuits by creditors.

One particular group that can benefit are family members with special needs, she adds. Setting up a trust with that particular person as the beneficiary is a way to plan for a day when one can no longer care for him or her in person, says Ms Chia.

A conversation about care

Perhaps, due to cultural mores, or perhaps the need to “protect” their parents, some children refuse to even talk about death with their elderly parents, even as it is looming.

Sometimes, the severity of their condition – or even the amount of time they have left – is deliberately kept from them by well-meaning family members, thinking that mentioning it will result in emotional instability.

TTSH’s Dr Neo observes: “Quite often, when a person is so sick, family members are pushed into a corner. They don’t know how to broach the topic.”

But doctors and healthcare professionals are actively trying to change this mindset with the introduction of the Advanced Care Plan (ACP). It is a voluntary discussion on future care preferences between an individual, his or her family and healthcare providers.

While not legally binding, it describes the type of care the person would prefer, if he or she is to become very sick and unable to make healthcare decisions in the future. Compared to the Advanced Medical Directive (AMD) which has a very narrow scope of criteria, the beauty of the ACP is in the conversation, says Dr Ng from the Tsao Foundation.

“The goal is to respect a person’s rights to self-determination. It encourages people to think about existential issues and helps the people conducting it to get into the value system of the person. Scenarios might change, but the general drift is there, so it will bring some clarity.”

Otherwise, caregivers who don’t know what patients want will end up going on the “path of least resistance”, which often means over-investigation of treatment, says Dr Ng.

An AMD allows you to register in advance your wishes not to have any extraordinary life-sustaining treatment to prolong life in the event that you become terminally ill and unconscious and where death is imminent. However, the definition of a “terminal illness” is extremely specific.

Among the wealthier and more educated patients or caregivers, Dr Ng has also observed a sub-group of people who approach medical conditions with a consumer attitude. Instead, he advocates having a doctor as a lohealth partner that you can trust, with a relationship built over a long time.

“I see people over-treat, over-investigate, but a primary care doctor is a better way of managing health. The person can help you clarify your purpose, your goals and the best strategy to proceed. Along the way, he can even do your ACP with you and be a facilitator when it comes to complex family dynamics.”

Beginning with the end

It is not just the medical aspect of health that people should take into account in their last days. There’s also the need to think about the social, emotional and psychological state of the person.

TTSH’s Dr Neo explains that the intensity of pain is often heavily coloured by one’s emotions. To cope with the end of life, people must build up psychological preparedness and fortitude, he says.

To him, thinking about death is constructive for thinking of life.

He observes: “Life is impermanent. You treasure people around you a lot more, you don’t waste time on things not worth it. You invest your time and effort in things worthwhile. You know how to value relationships much more, so when the time comes, you will be wiser as you have thought about it for a longer period of time.”

To build psychological maturity, he advises people to find a higher meaning in life, or a certain “calling”. Singaporeans tend to forget this, he notes, as we trudge along in our work and family life. Happiness is always projected in the future, instead of finding meaning in one’s current existence.

At the crux of it, people are too busy trying to beat each other or accrue financial gain to think about their own vulnerability, says Dr Neo.

“We live in a very illusory world. Only when a crisis hits then will the person be shaken and realise that life is fragile. If we don’t make mental, emotional and financial preparations before, you will find it hard to cope with the situation. We often underestimate how much we can prepare for death.”

No one can predict how much time we have left on this Earth. But if we put in as much thought about how we want to die as much as we think about how we want to live, surely our days here – limited though they may be – will be all the more precious and meaningful.

What you need to know

Will

  • Make sure your executors can find it. Ms Chia from David Lim & Partners cites an incident when a client made a will and was so secretive about it that his family couldn’t find it after his death. Be aware also that:
  • The will is sometimes contested if it was made at a time when the person was very old or ill.
  • CPF nominations and insurance policies with a named beneficiary are not part of the will.
  • Property – private or HDB – held in joint tenancy will automatically go to the survivor and hence cannot be part of the will for distribution.

Lasting Power of Attorney

  • Can only be used when the person who makes it (the donor) loses mental capacity and is only valid when the donor signs it when he is of sound mind.
  • One fear that people have about LPAs is that their children or donees can “help themselves” to the donor’s money when he or she is mentally incapacitated. Ms Chia debunks this: The money can only be used for the person’s welfare and medical expenses, and they will need to submit accounts to the Office of the Public Guardian, which serves to safeguard the interests of individuals who lack mental capacity and are vulnerable. In addition, more than one donee can be appointed to guard against dishonesty.

Trust

  • Anyone can set up a trust, says Ms Chia, but the costs are higher compared to arranging a will, or even setting up a private interest foundation, an entity which has the characteristics of both a company and a trust. “If the trust requires professional trust managers to make investment decisions or payments over several generations, this will cost money to administer. One needs to weigh the asset value against the cost of administering the trust,” she says.

Advance Medical Directive

  • Legally binding, but very narrow definition of “terminal illness”.
  • The AMD registry is only accessible during office hours. A doctor facing an emergency situation in the night will be unable to retrieve and verify an AMD. In fact, the AMD Act Section 15 has also been frequently interpreted as an offence for a doctor to query his patient about his AMD, according to Dr Neo of TTSH.

Advance Care Plan

  • Puts everyone on the same page, as it describes the type of care you would prefer, if you become unable to make healthcare decisions in the future. U For people with an ACP, the palliative care is much smoother for everyone involved as they don’t feel burdened with tough decisions, says Dr Ng of Tsao Foundation.
  • Not legally binding, and can be changed and reviewed, preferably with your primary care doctor or the main doctor tending to your advanced illness.

Complete Article HERE!

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We fear death, but what if dying isn’t as bad as we think?

Research comparing perceptions of death with accounts of those imminently facing it suggest that maybe we shouldn’t worry so much about our own end

Death terrifies many of us, but is, of course, central to the human condition. What if it’s not as bad as we fear?

By

“The idea of death, the fear of it, haunts the human animal like nothing else,” wrote Earnest Becker in his book, The Denial of Death. It’s a fear strong enough to compel us to force kale down our throats, run sweatily on a treadmill at 7am on a Monday morning, and show our genitals to a stranger with cold hands and a white coat if we feel something’s a little off.

But our impending end isn’t just a benevolent supplier of healthy behaviours. Researchers have found death can determine our prejudices, whether we give to charity or wear sun cream, our desire to be famous, what type of leader we vote for, how we name our children and even how we feel about breastfeeding.

And, of course, it terrifies us. Death anxiety appears to be at the core of several mental health disorders, including health anxiety, panic disorder and depressive disorders. And we’re too scared to talk about it. A ComRes survey from 2014 found that eight in ten Brits are uncomfortable talking about death, and only a third have written a will.

But we don’t need to worry so much, according to new research comparing our perception of what it’s like to die with the accounts people facing imminent death. Researchers analysed the writing of regular bloggers with either terminal cancer or amyotrophic lateral sclerosis (ALS) who all died over the course of the study, and compared it to blog posts written by a group of participants who were told to imagine they had been diagnosed with terminal cancer and only had only a few months to live. They looked for general feelings of positivity and negativity, and words describing positive and negative emotions including happiness, fear and terror.

Blog posts from the terminally ill were found to have considerably more positive words and fewer negative ones than those imagining they were dying – and their use of positive language increased as they got close to death.

Kurt Gray, one of the study’s researchers, said, “I imagine this is because they know things are getting more serious, and there’s some kind of acceptance and focusing on the positive because they know they don’t have a lot of time left.”

The researchers also compared the last words and poetry of inmates on death row with a group of people tasked with imagining they were about to face execution. Again, there were fewer negative words from the prisoners. Overall, those facing death focused more on what makes life meaningful, including family and religion.

“We talk all the time about how physically adaptable we are, but we’re also mentally adaptable. We can be happy in prison, in hospital, and we can be happy at the edge of death as well,” Gray said.

“Dying isn’t just part of the human condition, but central to it. Everyone dies, and most of us are afraid of it. Our study is important because it’s saying this isn’t as universally bad as we think it is”.

But before we get too ahead of ourselves, the research prompts a few questions. Lisa Iverach, a research fellow at the University of Sydney, explained that the study highlights how the participants may have been less negative because the mystery around death was removed.

“Individuals facing imminent death have had more time to process the idea of death and dying, and therefore, may be more accepting of the inevitability of death. They also have a very good idea about how they are going to die, which may bring some sense of peace or acceptance.”

But not all of us will know how, or when, we’re going to die in advance of it happening, and therefore will miss out on any benefits to be had by uncovering its uncertainty.

Havi Carel, Professor of Philosophy at the University of Bristol, agrees with the study’s findings on how adaptable we are. “I think you get used to the idea of dying, like we get accustomed to many things. The initial shock after receiving a poor prognosis is horrific, but after months or years of living with this knowledge, the dread subsides,” she said.

However, Carel also pointed out that there’s an important distinction between positive responses and pleasantness, and that there are some unpleasant and painful events we’d still be positive about, such as childbirth.

“Blogs are written for public consumption and they remain there after people’s death. Using blogs and poetry may reveal only the outward-facing emotions people are willing to share, or even simply created to fashion how they want to be remembered. Do people really tell the truth in their blogs? Perhaps, to an extent, but these are very public media,” Carel said.

“Perhaps they are ‘putting on a brave face’. It is impossible to tell, but blogs are clearly not the most intimate mode of communication. It may have better to use diaries, recorded conversations with loved ones, or even personal letters.”

Nathan Heflick, researcher and lecturer at the University of Lincoln, also warns against interpreting the results to mean that dying people view death as a wholly positive experience. “I think that is a dangerous message, and it isn’t a conclusion reflected in the study’s data. Being less negative is different from welcoming it or wanting death,” he said.

“People will fear death. These people dying feared death. They just didn’t fear it as much as people think they would.”

If fear of death is, in fact, as inevitable as the event itself – there’s one change we can make to help. In Western culture, we tend to pretend death doesn’t exist, whereas research has indicated that the East Asian yin and yang philosophy of death – where life can’t exist without death – allows individuals to use death as a reminder to enjoy life.

“I think the UK and the US are death-denying cultures, in that death is mostly avoided as a topic,” Heflick said.

“The less something is openly discussed, the scarier it becomes. While avoiding talking about death can reduce a little discomfort in the short term, it probably makes most of us much more anxious to die in the long term.”

Complete Article HERE!

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Zen Hospice co-founder works to create mindful, compassionate care

If someone is going to be a compassionate presence to the dying, “they have to look at their own relationships to these issues — to sickness, to aging, to dying and to suffering,” says Frank Ostaseski, with his cat Bodhi on his Sausalito houseboat.

By Colleen Bidwill

After losing both of his parents at a young age, Frank Ostaseski channeled his pain into a life of service.

Frank Ostaseski’s “The Five Invitations” shows what dying can teach about living.

Ostaseski, 65, of Sausalito, has been an advocate for contemplative end-of-life care, and was honored by the Dalai Lama for his years of service to the dying. In 1987, he co-founded the Zen Hospice Project, the first Buddhist hospice in America, and in 2004 created the Metta Institute, which teaches physicians, nurses and family members how to practice “mindful and compassionate care.”

His recent book, “The Five Invitations,” shows what dying can teach us about living.

Q What made you be a champion for mindful and compassionate care?

A Death and I became friends very early on, or at least we got acquainted very early on. My parents died when I was quite young. My mother when I was 16 and my dad a few years later, and then, I worked for a long time with kids who were severely disabled. That kind of introduced me to my life of service, and later, I worked in refugee camps in Mexico and Central America. Then, I came back and the AIDS epidemic was hitting and so, one thing was stumbling into another, in a way. And one of the things that I saw was what mattered most: not necessarily the treatment plan that the person was involved in, although that is important, but what mattered was the quality of the presence of people around him or her.

Q What are you teaching end-of-life caregivers?

A The first thing if someone is going to be a compassionate presence, is that they have to look at their own relationships to these issues — to sickness, to aging, to dying and to suffering. … We teach our physicians and nurses and others to learn to listen very precisely and not in the context of what is happening, but also to the emotional and to the somatic cues that person is giving. And then you give information in a way that is accessible to the other person.

Q You’ve sat by more than 1,000 bedsides of those who were dying; was that difficult?

A Oh, absolutely. It’s a lot. I try to be real with people, in other words, if I feel grief, I will share it. I’ll say, “I’m going to miss you.” “I’m really learning a lot from you.” “Wow, this is so sad to hear you say this.” So, it can be difficult but difficulty doesn’t stop me. During the AIDS epidemic I was working with 20 to 40 people a week who were dying, so I had to do things that really balanced me. I went to a hospital in San Francisco where my friends were nurses and they were taking care of babies that had been born to addicted mothers, and I would hold these babies in a rocking chair. There was something about that, that gave me the wherewithal, the strength, to continue and to do the work that I was called to do. I also did life-affirming things; I swam in the bay because it’s cold and it’s refreshing. I still do that.

Q What is a typical day for you?

A When I was running the Zen Hospice, I was on call 24 hours a day, seven days a week, that was my life. And I was raising four children at the same time. I retired from that, in about 2005, to focus my attention more on teaching and mentoring others. That happened partially because, after 20 years, it was time to let other people take that role, and also my children were growing up and my caregiver energy started to shift and my teaching energy came forward. I travel, quite a lot. My day often includes getting to and from airports, and then finding myself in front of a group of people, and my primary job is to keep them human. The expectations on [doctors] are really just unbelievable — they’re being driven mercilessly by a system that’s making unreasonable demands on them, so it’s natural that they start to shut down because that’s a strategy. So if we can help them stay engaged without burning out, that’s a huge gift to the world.

Complete Article HERE!