A will doesn’t cover all your bases when it comes to end-of-life decisions.

Here’s what else you need

By Sarah O’Brien

  • A will is just one of several legal documents that help your loved ones know your end-of-life wishes.
  • If a person passes away without a will, a court may decide who gets their assets and who would care for any surviving children.
  • However, some assets pass outside of the will, including retirement accounts and life insurance.

As the coronavirus continues sweeping through U.S. communities and the death toll keeps rising, you might be considering your own mortality.

Regardless of the pandemic, experts say it’s important to plan for when you’re not here — that is, give thought to what would happen to your bank accounts, your home and your belongings, as well as, perhaps, your dependents.

That planning should start with a will. And apparently people know they need to take action, based on Google trends showing a jump in searches for information about creating one. 

“In every jurisdiction, if there isn’t a valid will, assets will pass on to your heirs by law, who may or may not be who you would have provided for in a will,” said Samantha Weyrauch Davis, an estate planning attorney and director with the law firm Hall Estill in Tulsa, Oklahoma. “It also lets you name a guardian for children.”

If you pass away with no will — called dying intestate — a state court decides who gets your assets and, if you have children, who will care for them.

This means that if you have an unmarried partner or a favorite charity but no will, your assets may not end up with them. Typically, the courts will pass on assets to your closest blood relatives, even if that wouldn’t have been your first choice.

However, a will is just one piece of an “estate plan.” An estate just refers to what you own — your financial accounts, possessions and any real estate. Putting a plan in place for those assets helps ensure that upon your death, your wishes are carried out and that family squabbles don’t evolve into destroyed relationships.

In other words, it’s partly about making things easier for your loved ones during an already-difficult time.

Here’s what else you should consider if you want to prepare.

What a will can and can’t do

A will is a document that lets you relay who gets what when you pass away. You can get as specific as you want (you leave a certain family heirloom to a particular person) or keep it more general (you want your surviving spouse to get everything).

However, there are some assets that pass outside of the will, including retirement accounts such as 401(k) plans and individual retirement accounts, as well as life insurance policies.

This means the person named as a beneficiary on those accounts will generally receive the money no matter what your will says. (Be aware that 401[k] plans require your current spouse to be the beneficiary unless they legally agree otherwise).

Those [online] forms or software may not be compliant with your local law, so look at the fine print.

Samantha Weyrauch Davis
Director with Hall Estill

Regular bank accounts, too, can have beneficiaries listed on a payable-on-death form, also known as a POD, which your bank can supply.

If no beneficiary is listed on those non-will items or the beneficiary has already passed away, the assets automatically go into probate. That’s the process by which all of your debt is paid off and then the remaining assets are distributed to heirs. The process can last several months to a year or more, depending on state laws and what’s involved in handling your estate.

If you own a home, be sure to find out how it should be titled to ensure it ends up with the person (or people) you want it to, because the laws can vary from state to state. Moreover, there can be other considerations when it comes to how a house is titled, including protection from potential creditors or for tax reasons later when the home is sold.

Another big decision

As part of the will-making process, you’ll need to pick an executor of your will (sometimes called a personal representative).

This can be a big job, experts say. Things such as liquidating accounts, ensuring your assets go to the proper beneficiaries, paying any debts not discharged (i.e., taxes owed to the IRS), and even selling your home could be among the duties undertaken by the executor.

In other words, just because you’ve known your best friend since elementary school doesn’t mean handling the challenge of being an executor is up their alley.

Where to get a will

To prepare a will, you can turn to an estate planning attorney in your local area — to ensure familiarity with state laws — or use an online option. However, be aware that not all of the web-based alternatives will necessarily reflect the specifics of your state’s law.

“There’s risk in doing it that way,” Davis said. “Those forms or software may not be compliant with your local law, so look at the fine print.”

If an online option ends up being appropriate for your situation, you may be able to find a form to download for free. Software will-making options can run about $60 or more, depending on what else is included. To set up an estate plan with an attorney could run several hundred dollars to more than $1,000, depending on the complexity of your situation.

Also, you’ll need to have a witness and/or notary sign it and make the document official, depending on the state where you live. The American College of Trust and Estate Counsel’s website offers a guide to laws and accommodations in every state if in-person meetings are not permitted due to the pandemic.

Other documents

Typically, estate planning also includes preparing a few other legal documents. This includes an advance health-care directive, also known as a living will.

This document outlines your wishes if you become incapacitated due to illness or injury.

Say you are on life support. Instead of a loved one making the agonizing decision whether to end all life-saving measures, your wishes would be specified in a legal record.

It’s also worth assigning powers of attorney. If you become incapacitated, the people to whom you grant powers of attorney will handle your medical and financial affairs if you cannot.

Often, the person who is given this responsibility when it comes to your health care is different from whom you would name to handle your financial affairs.

As with choosing an executor, make sure whoever you hand the financial reins to is trustworthy and smart.

“I tell my clients it’s really important to carefully consider the individuals you name,” Davis said. “You want to make sure they have the ability, skill set, time and desire to make such decisions and do these sorts of things.”

Make a list of critical documents

While it can be hard to imagine your own death, picture your family having to search through drawers for your original will, documents regarding your bank accounts and other assets, and maybe even your Social Security number.

The best way to avoid forcing them to deal with that task on top of mourning is to leave an organized list of information that the will’s executor will need to settle your estate, experts say. Be sure this includes passwords so your online accounts can be accessed.

Consider a trust

If you want your kids to receive money but don’t want to give a young adult — or one prone to poor money management — unfettered access to a sudden windfall, you can consider creating a trust to be the beneficiary of a particular asset.

A trust holds assets on behalf of your beneficiary or beneficiaries, and is a legal entity dictated by the documents creating it. If you go that route, the assets go into the trust instead of directly to your heirs. They can only receive money according to how (or when) you’ve stipulated in the trust documents.

The average cost to set up a trust using an attorney ranges from $1,000 to $1,500 for an individual and $1,200 to $1,500 for a couple, according to LegalZoom.com. Doing it yourself with online software could run several hundreds of dollars or more.

Complete Article HERE!

End-of-life planning during the coronavirus pandemic, in 8 steps

How to make crucial financial and health care decisions for you and your loved ones.

By

Surely you’ve heard it’s a good idea to have a will, just in case anything should happen. Yet we tend to put off completing the paperwork — the documents are confusing and it can be distressing to think about our own mortality. A 2017 study found that only about a third of Americans have completed the necessary end-of-life forms.

The Covid-19 pandemic now has many scrambling to figure out how to get wishes into writing. The coronavirus has reminded us that mortality is unpredictable and so it’s a good time to get our medical and financial matters in order.

The benefits to doing so are many: peace of mind knowing that you will get the medical treatment you want; that your possessions and assets, many or few, will be given to those you choose; that you are protecting your family and friends from having to guess what you would want; and preventing the squabbles that could erupt from family disagreements.

But how to complete the necessary paperwork while in social isolation? In some ways, self-isolation provides the perfect opportunity to get your documents together, but finalizing them can be difficult when a notary and witnesses can’t be in the same room with you.

Signing off, online

On March 20, Gov. Andrew Cuomo made New York one of the more than 20 US states to allow remote online notarization of documents — providing a solution to the challenge of self-isolation. It is a temporary law, and no one knows what it will mean once the pandemic has subsided. New York state also requires two witnesses (laws vary by state) to sign some of these documents, a problem that the temporary notarization law does not explicitly address.

Peter Strauss, a senior partner at Pierro, Connor & Strauss and a founding member of the National Academy of Elder Law Attorneys, has instituted a protocol that he and his firm believe will accommodate remote witnesses. Using a video chat program like Zoom, GoToMeeting, or FaceTime, witnesses show their ID and are recorded signing the document by the notary public. Still, Strauss recommends revisiting all documents once your state has safely reopened and completing them in person.

Fern Finkel, a Brooklyn elder care lawyer, said she was concerned that the online notarization process, depending on how the witnesses are involved, could leave documents open to contest. She, too, advised that any documents completed now with online notarization be revisited in the future.

But she and other experts said it is still very important to take steps now to account for medical and financial contingencies should you become ill. “The pandemic is a reason to act, not to delay necessary planning,” Strauss said.

As far as medical contingencies go, “it is really important for doctors to always be guided by the voice and values of the patient,” said Dr. VJ Periyakoil, associate professor of medicine at Stanford and director of the Stanford Palliative Care Education & Training Program. To preserve patients’ voices, Periyakoil and her team have worked with patients to create “The Letter Project,” free and simple forms that help patients communicate their wishes to their family and doctors.

The letters, which are not state-specific and come in eight languages, provide a structured way for each person to think through these important, timely, and emotionally charged issues. They can be printed, filled out, and attached to any state’s forms, also available online. “Our goal is to democratize health care,” Dr. Periyakoil told me, “If people have to choose between groceries or advance directives, groceries are always going to win.”

To get yourself and your loved ones (legally) prepared, here are eight important steps to take.

What you should be doing right now

1. Organize. “The first thing you have to do is understand what you have,” Finkel said. Pull out all your existing documents and organize them in one place. Do you have a health care proxy (designation of a person to make your medical decisions when you can’t), a HIPAA authorization (designation of a person to access your doctor and medical information), a living will (statement of what medical treatments you want in various situations), an intent to return home, a power of attorney, a trust, and/or a last will and testament (statement of how you would like your assets distributed)?

Collect these items in one place in your home — a desk drawer, say, or a file box. (If your documents are somewhere else in a safe deposit box, leave them there — just make sure your family members know where they are.)

Once you’ve done an audit of these documents, you can arrange an online consultation with a knowledgeable attorney to help guide you through what needs to be done. (Justia provides a list of elder law lawyers, for example, or ask your friends for a recommendation.)

To this file, add other essentials that your family members might need should you be incapacitated: checkbooks, insurance policies, safe deposit box keys, Social Security card, passport, birth certificate, and other identification, mortgage, deed or lease for your home, and vehicle titles.

2. Beneficiary designations. During this crisis (or at any time), it is advisable to designate beneficiaries on all of your accounts. Take a look at bank accounts, retirement accounts, and investment accounts to see if they have a beneficiary designation.

“People don’t understand that how accounts are titled is supreme to what’s in a will,” Finkel said. For instance, if your will divides your assets equally among your three children but your oldest daughter is the beneficiary on a bank account, she will receive the accounts’ balance upon your death.

Which means that much of your property designation can actually be done remotely by requesting the appropriate form from your bank or financial adviser and returning it by mail. “If these forms need to be notarized, you can do so remotely,” Finkel said.

3. Health care proxy. If you are in isolation with others you may be able to fill out a health care proxy. The document — which varies by state — often requires two witnesses, like your home health aide and your best friend (neither can be your assigned agent). The proxy allows you to appoint an agent who will make your medical decisions should you become incapacitated. You do not need a lawyer or a notary to complete this form. (AARP provides links to these forms for every state.)

4. HIPAA. Everyone should complete a HIPAA form. “If you can’t get two witnesses [for a health care proxy] because you’re self-isolated,” Finkel says, “you can still do a simple authorization [the HIPAA form] to let your close people be able to speak to doctors.”

At a time when visitors are not allowed in hospitals or nursing homes, the HIPAA — an acronym for the law that protects patient privacy, Health Insurance Portability and Accountability Act — will allow your designated loved ones to talk to your doctors about your status. Also, Finkel says, you can name as many designees as you want, just fill out the form with their names and contact information

Once you have completed a health care proxy and/or a HIPAA form, take a photo of them and share it with your designee. “I have HIPAA authorizations for my dad and my husband on my phone,” Finkel told me. They’re at her fingertips should she need them in an emergency. (You can access the HIPAA form here.)

5. Financial institution power of attorney. You can also complete a basic power of attorney form with your bank that designates a person to make financial transactions in those corresponding accounts. You can request the form and, if the institution allows, notarize it remotely. Some banks may have their own procedure, so check with them first.

“Do whatever you can right now to set up a designee for each of the banks you use,” Finkel recommended.

6. Direct deposit and direct pay. Now that you’re at home, it’s the perfect time to put all your bills and monthly payments online. Have your income deposited into one account and your regular bills auto paid from the same account. Heat, electric, gas, cell phone, cable, wireless, water — and your monthly rent or maintenance fee if possible.

“Get everything online, electronically paid, so that all of these things are seamless,” Finkel told me. Should you have to be hospitalized (hospital stays for severe cases of Covid-19 last an average of 10-13 days, with some lasting much longer), when you come home all of your services will be in place.

7. Passwords. While you’re setting up your bills for auto pay, organize all your online passwords. Once you’ve recorded the username and password for all of your utilities, do the same for your online accounts like email, social media, entertainment services, and other online platforms. Share this document with your most trusted person so that they’ll have it in your absence.

8. Have the conversation. This is also the time to talk to your loved ones about your health care and financial decisions. This difficult time might actually make the conversation easier for you and your family. “People around me are dying,” Finkel said. “We’re in a pandemic, and everyone is starting to see their own mortality. Let your loved ones know your wishes.” Tell the people you love where your documents are, and give your health care proxy, power of attorney, and HIPAA to your trusted agents named within them.

And there is one more important thing: “We can take this time to talk to our loved ones,” Periyakoil told me. “If there is one thing even more important than advanced directives, it’s really telling our friends and family how much we love them.”

Complete Article HERE!

Planning For The End Of A Life

Talking about death makes many of us uncomfortable, so we don’t plan for it. NPR’s Life Kit offers tips for starting an advanced directive to prepare for a good death.

By Kavitha Cardoza 

MICHEL MARTIN, HOST:

Thinking about death makes most people uncomfortable, which means many of us end up not planning. But Betsy Simmons Hannibal, a legal editor, says it’s like wearing a seatbelt.

BETSY SIMMONS HANNIBAL: We all wear our seatbelts even though we don’t expect to get in an accident on the way to the store. It’s just, like, something that we know is possible.

MARTIN: So buckle up. NPR’s Life Kit looked into preparing for the end, and reporter Kavitha Cardoza is going to walk us through a simple document called an advance directive.

KAVITHA CARDOZA, BYLINE: You don’t need to have a medical background or a lawyer to fill out an advance directive. You don’t even need a lot of time. And I promise it’s not too morbid. You can easily find an advance directive form online. There are different versions, but basically, it has two sections. The first is the most important – the medical power of attorney. Choose a person who can legally make health care decisions for you if you can’t.

PALLAVI KUMAR: Think about the person in your life who understands you, your goals, your values, your priorities and then is able to set aside their own wishes for you and to be a voice for you.

CARDOZA: That’s Dr. Pallavi Kumar, a medical oncologist and palliative care physician at the University of Pennsylvania. She says your medical proxy should be someone you trust who can handle stress because your loved ones will disagree on what to do, and it can be emotional. So you want to name someone who will carry out your wishes. Kumar says research shows when a caregiver sees a loved one die in the hospital under circumstances they believe that person never would have wanted, they’re in emotional pain for a long time.

KUMAR: And at six months and a year after death, these bereaved caregivers are still suffering from pretty severe depression and anxiety. There’s even some data to show that the survival for those caregivers is shortened.

CARDOZA: So think of an advance directive as a gift you’re giving your loved ones. The second section of the advanced directive document is called a living will. This part walks you through the general approach of how you want to die and what kind of care you want. Do you want to be resuscitated? Are you OK being hooked up to a ventilator? How do you feel about a feeding tube? Dr. Jessica Zitter is an ICU and palliative care physician in California. She says there’s no right or wrong decision. It’s personal.

JESSICA ZITTER: Someone once told me her father was – she says, he’s an old, crusty Italian man, and he said if someone else has to wipe my behind, I do not want to live. But there’s many, many others of us – if I was quadriplegic and still have an intellectual and emotional relationship with people, I don’t think I’d want to die.

CARDOZA: Even among patients who are very, very sick with cancer, less than half have had conversations about how they want to die. So it’s critical to share your wishes with your medical proxy and your loved ones as well as your doctor. Share a copy of the form with them.

Dr. Pallavi Kumar says the end of life is about more than just the medical aspect. When she knows a person’s priorities, that helps inform her treatment plan. For some patients, it might mean spending time at home with family. For others, it means trying every treatment possible for as long as possible.

KUMAR: They would say, if you’re telling me that a chemotherapy could give me another month, I want that month because that’s another month I have with my 6-year-old.

CARDOZA: While no one can predict when they’ll die, an advance directive can help you plan for how. It’s not a guarantee but a safety net for having what Doctor Zitter thinks of as a good death.

ZITTER: In order to figure out what a good death is, you have to figure out what a good life is and what living well means to you. That’s the only way to know how to die well because actually, they’re kind of reflections of each other.

Complete Article HERE!

How I Spent My Summer Vacation 2020

Only the most avid readers of this blog may recall a similarly titled posting, How I Spent My Summer Vacation, from August 1, 2016.

St. Joseph Hospital Main Campus

Well, here it is nearly five years later and I have another harrowing experience to tell you about.

Three months ago, I started having some pain in my left shoulder while walking. (Actually, the shoulder pain started three years ago. But after a stress test scheduled by my GP a year ago, to confirm if this was discomfort was heart related, and the test coming back negative, I decided that the pain was structural. I just figured that I had bursitis.) In fact, all symptoms disappeared after the stress test. Go figure!

Anyhow, the shoulder pain reappeared in March. This time around, it began to radiate down my arm. Soon I couldn’t do any kind of walking, let alone hiking, without discomfort. This was a bit of a problem because I’m an avid walker. Two months ago, the shoulder pain began to radiate not only down my arm but into my arm pit and then into my chest and back.

By this time even I knew that this wasn’t no stinkin’ bursitis.

At the behest of my GP, I reached out to my cardiologist again. I had just had a major pain episode that nearly brought me to my knees, and I wanted his input. At the appointment the cardiologist showed only minor concern. He said he wanted me to do another stress test in 30 days and then see him again in six weeks, the end of July. I couldn’t believe it. I was exhibiting all the classic symptoms of angina and I thought I needed more than a promise of a stress test and a follow visit.

At the end of the appointment, as the doctor was leaving the exam room, I said; “What am I supposed to do about all this crippling pain?” “Oh,” he replied, “I’ll write you a prescription for nitro glycerin. When you begin to experience pain, pop a tab under your tongue. This will give you relief.” And so, it did. It was kinda miraculous actually.

Problem was, I needed to pop a tab at least once a day, often twice a day.

When my GP discovered that I was doing so much nitro, he became very proactive. He ordered a chest x-ray, a CT scan, and some blood work. He wanted to rule out lung problems among other things.

When my first nitro glycerin script was nearly exhausted, I call the cardiologist for a refill. His nurse freaked out at the amount of nitro I was taking and said; “Nitro glycerin is supposed to be used sparingly, for emergencies.” I replied; “Well, then I’m having emergencies each and every day, and often twice a day.”

Apparently, this nurse’s concern lit a fire under my cardiologist. She told me that the doctor now wanted me to skip the stress test, still weeks in the future, and come in for an angiogram. He had an opening on July 2nd. Could I last two more weeks? I didn’t think so.

Meanwhile, my GP wanted me to consult with another cariology practice in Bellingham, 45 miles from where I live. Since I had lost all confidence in the local cardiologist, I agreed. In a matter of hours, I was set up with the PeaceHealth cardiology practice. I was to call the next day and set up an appointment with the next available cardiologist. Things were that critical. Last Friday morning I called and set up an appointment for the following Tuesday.

PeaceHealth Logo

My GP also insisted that I call 911 if my pain increased.

That night, Friday night, it did. Despite popping two nitro glycerin tabs in three hours I was still in acute pain and short of breath.

At about 10:30pm I woke up Steve and asked him to drive me to Emergency Receiving at Island Hospital.

Once in the ER, I was immediately strapped to a heart monitor, blood was drawn, and arrangements were made to medivac me to St Joseph Hospital in Bellingham. The first blood test revealed normal levels of the cardiac enzyme which measures the levels of enzymes and proteins that are linked with injury of the heart muscle. I thought that was good news. Four hours later, still in the Island Hospital ER, there was another blood draw. This time the cardiac enzyme reading had spiked. The doctor told me I must have had a heart attack in the interim.

I languished for ten hours in the Island Hospital ER. They were having a problem finding transportation to Bellingham.

At 9:30am Saturday morning I was finally on my way to St. Joe’s.

Once there, I was placed in the Cardiac ICU where I was poked and prodded to within an inch of my life. I also got an echocardiogram. I had had no food or water since the previous evening. I was exhausted and, I’ll admit, frightened.

Being the good little end of life educator that I am, I had the foresight to bring along a copy of my POLST (Physician Orders for Life-Sustaining Treatment) form. The ICU nurses were so surprised that I had this important document with me. They said they never see patients being this proactive.

At the top of the POLST form, the very first question asked is about Cardiopulmonary Resuscitation Orders. One can either choose: YES CPR: Attempt Resuscitation, including mechanical ventilation, defibrillation and cardioversion (or) NO CPR: Do Not Attempt Resuscitation. I had chosen the second, NO CPR. I hadn’t come to this decision lightly, but it did reflect my deepest held feelings about end of life care for myself.

Later that afternoon I had my first encounter with the cardiac surgeon. He sauntered into my room as brusque as you please and announced that he wouldn’t even consider the life-saving treatment I needed, an angioplasty, if I didn’t change my POLST form to allow a full code should complications arise during the procedure. I was absolutely stunned! I was being held hostage at this most vulnerable point of my life. And for what?

Cardiac surgeons are at the pinnacle of the medical pantheon and most have egos that surpass their bountiful skills. They almost never encounter resistance from anyone, least of all from a lowly patient. But I stood my ground.

“Are you telling me that you won’t save my life if I don’t grant you a full code?”

He responded; “Yes, my hands are tied.”

I couldn’t believe my ears. I tried to explain why I had chosen the DNR (Do Not Resuscitate). He just blew me off. He was so condescending and patronizing. My efforts to defend my choices fell on deaf ears. I could just imagine him thinking; how adorable is this? A layman trying to play doctor with the big boys? The standoff continued.

“Why do we even have POLST forms?” I asked.

“They are for emergencies.” He responded.

“So, and EMT (Emergency Medical Technician) or an ER doc would be constrained by my POLST, but not you, a cardiologist? I see! Actually, I don’t see. This is ridiculous.”

He just stared at me.

You know how this is gonna end, huh?

In the end I sheepshly relented. What could I do? I was so bummed.

The cardiologist walked out of the room without another word and I had no idea where I stood.

Hours later, I asked one of the nurses; “Will I be getting the angiogram, or not?” He didn’t have an answer. Nothing like adding anxiety to an already overburdened heart.

Around 6:00pm two burly nurses stopped outside my room with a gurney. “Let’s get you up here.” One said pointing to the gurney. “What’s going on?” I asked. “Time for your angioplasty.” And just like that I was wheeled off.

I guess it was determined that my case was critical, and no time could be wasted in attending to me, POLST form be damned. My echocardiogram showed a major blockage in my already weakened heart. An hour and a half later I was the recipient of two brand-spankin’ new heart stints, don’t cha know.

Heart Stent

I’ll spare you the gory details of my recovery. I’ve gone on too long already. Suffice to say that with the assistance of a cohort of amazing nurses and other support staff, I am here to relate this story to you. God bless ‘em all!

There are a lot of lessons to be learned here, not least of all is our right to choose the end of life path we desire despite the pressures of conflicting interests. And how we ought to stick to our guns because our wishes are sacred all bullying aside. But the biggest lesson and…

The Moral Of This Story Is
My friends, life is short! Live every day like it’s your last. Be kind to yourself and those around you. Because, in a twinkling of an eye, it can and WILL be over.

The End

End-Of-Life Planning Is A ‘Lifetime Gift’ To Your Loved Ones

By Kavitha Cardoza

Talking about death makes most of us uncomfortable, so we don’t plan for it.

That’s a big mistake, because if you don’t have an end-of-life plan, your state’s laws decide who gets everything you own. A doctor you’ve never met could decide how you spend your last moments, and your loved ones could be saddled with untangling an expensive legal mess after you die.

Betsy Simmons Hannibal, a senior legal editor at legal website Nolo, puts it this way: Planning for the end of life isn’t about you. “You’re never going to really get the benefit of it. So you might as well think about how it’s going to be a lifetime gift that you’re giving now to your parents or your partner or your children. It really is for the people you love.”

Here are some simple, practical steps to planning for the end of life. These tips aren’t meant to be legal or medical advice, but rather a guide to ease you into getting started.

1. Name an executor.

If you’re an adult, you should have a will, says Hannibal. Estate planning is not just for the rich. “It’s not just about the value of what you own. It’s also the feelings that you and your loved ones have about what you own.”

If you own lots of valuable stuff — real estate, trust funds, yachts — you probably need a lawyer. But for most of us, a simple document could do. Your state or county bar associations usually keep a list of lawyers who do this pro bono. Or you could download an online form like Quicken WillMaker & Trust for less than $100. (Full disclosure: Hannibal works for Nolo, which owns Quicken WillMaker & Trust.)

She says the first thing you do is name (in writing) a person whom you trust to take care of everything when you die. In most states that person is called an executor; in some they’re called a personal representative.

Hannibal says it’s a good idea to choose someone from your family. “The most important thing is that you have a good relationship with them — and also that they have a good attention to detail, because it’s a lot of work to be someone’s executor.”

An executor would have to, for example, find all your financial assets and communicate with everyone you’ve named in your will. It’s a big ask, so Hannibal says just be upfront. She suggests asking the person directly, “Would you be comfortable wrapping up my estate when I die?”

2. Take an inventory.

List everything you own, not just things that are financially valuable — such as your bank accounts, retirement savings or car — but also those things that have sentimental value: a music or book collection, jewelry, furniture. Then list whom you want to leave what to.

If you have young children, name a guardian for them. Choose carefully, because that person will be responsible for your child’s schooling, health care decisions and value system.

Hannibal says pets are considered property under the law, so she suggests naming a new owner so that the state doesn’t do it for you.

Digital accounts are also part of your property. This includes social media accounts, online photos, everything in, say, your Google Drive or iCloud, online subscriptions, dating site profiles, credit card rewards, a business on Etsy or Amazon. Hannibal suggests keeping a secure list of all those accounts and the login and password details. Let your executor know where the list is.

Just as you write out specific instructions about your physical belongings, be clear about what you’d like to happen with your online information.

She says it’s better not to have a handwritten will, because proving you wrote it will require a handwriting expert. So keep it simple. Just type out your wishes and have two witnesses watch you sign and date it. Then have them do the same. Hannibal says by signing it, “they believe that the person who made the will is of sound mind, and that’s a pretty low bar.”

You don’t need to file your will anywhere; neither do you need to get it notarized for it to be legally binding. And don’t hide it. Hannibal says just tell your executor where you’ve kept a copy.

Remember that your decisions will change over time. So if you have a child, buy a house or fall out with a family member, update your will.

3. Think about health care decisions.

Your will takes care of what happens after you die. An advance directive is a legal document that covers health care and protects your wishes at the end of your life.

There are two parts to an advance directive. The first is giving someone your medical power of attorney so the person can make decisions for you if you can’t. The other part is called a living will. That’s a document where you can put in writing how you should be cared for by health professionals.

Jessica Zitter is an ICU and palliative care physician in Oakland, California. She says that we’ve become experts at keeping people alive but that quality of life can be forgotten.

She has seen thousands of situations of loved ones making difficult and emotional decisions around a hospital bed. It’s worse when family members disagree about a course of action.

You know the saying “The best time to plant a tree was 20 years ago. The second best time is now”? Zitter says with the coronavirus in the news every day, more people are realizing that these end-of-life conversations are important. “That tree was always important to plant. But now we really have a reason to really, really plant it. … That time is now.”

You may have heard of Five Wishes, which costs $5 and will walk you through choices, or Our Care Wishes, which is free.

4. Name a medical proxy.

Pallavi Kumar is a medical oncologist and palliative care physician at the University of Pennsylvania. Kumar says the most important medical decision you can make is to choose a person who can legally make health care decisions for you if you can’t. This person is sometimes called a medical proxy or a health care agent. Naming the person is the first part of the advance directive.

“Think about the person in your life who understands you, your goals, your values, your priorities and then is able to set aside their own wishes and be a voice for you,” she says. You want someone you trust who can handle stress, in case your loved ones disagree on what to do.

5. Fill out a living will.

After you’ve chosen your medical proxy (and named a backup), you need to think about what kind of care you want to receive. There’s no right or wrong; it’s very personal. The document that helps you do that is called a living will. It’s part two of the advance directive.

A living will addresses questions such as “Would you want pain medication?”; “Do you want to be resuscitated?”; and “Would you be OK being hooked up to a ventilator?”

Kumar says she asks her patients what’s important to them and what their goals are. For some with young children, it means trying every treatment possible for as long as possible, no matter how grueling.

“They would say, ‘If you’re telling me that a chemotherapy could give me another month, I want that month. Because that’s another month I have with my 6-year-old.’ ”

Other patients might want the exact opposite. “They would say, ‘I’ve gone through a lot of treatments and I … feel I’m not having as many good days with my kids. So if the disease gets worse, I want to spend that time at home.’ ”

Kumar says even among patients who are very sick with cancer, fewer than half have had conversations about how they want to die. So talk about your wishes. Once you’ve filled out the advance directive forms, share your decisions with your medical proxy, your loved ones and your doctor.

6. Don’t forget the emotional and spiritual aspects of death.

How you want to die is personal and about much more than just the medical aspect. For some, it’s about being at peace with God; for others, it’s being kept clean. Still others don’t want to be left alone, or they want their pets close by.

Angel Grant and Michael Hebb founded the project Death Over Dinner to make it easier for people to talk about different aspects of death as they eat. “The dinner table is a very forgiving place for conversation. You’re breaking bread together. And there’s this warmth and connection,” says Grant.

Some of the emotional and spiritual questions people talk about are “You were just in a big quake and death is imminent. What are you concerned about not having done?”; “What do you want to be remembered for?”; and “If you could have any musician play at your funeral, who would it be?”

Grant says reflecting on death automatically forces you to think about your life. “That’s the magic of it,” she says.

“We think it’s going to be morbid and heavy. But what these conversations do is they narrow down our understanding of what matters most to us in this life, which then gives us actionable steps to go forward living.”

Grant doesn’t believe a “good death” is an oxymoron. “A good death is subjective, but there are some things that I have heard over and over again for many years at death dinners. … A good death is being surrounded by love, knowing you have no emotional or spiritual unfinished business.”

Complete Article HERE!

Last wishes and clear choices

– Learning how to talk about end-of-life care

Before patients can state their preferences about dying, they need to talk about them first.

By

Conversations around end-of-life medical care can be challenging. Consider someone I’ll call Mrs. Jones, an elderly patient with advanced heart disease. When her doctor asked her to discuss the kind of care she wanted to receive at the end of her life, Mrs. Jones said that she had devoted a lot of thought to the matter and had clear instructions she wanted her family to follow.

First Mrs. Jones wanted to be buried near her family – above ground – and she wanted her grave to be covered with yellow and white flowers. Second, she wanted to be laid out not in a dress but in her nightgown and robe. And finally, she wanted to be buried with a treasured photograph of her boyfriend, which showed a handsome young man in military uniform.

But her doctor was asking a different question. Specifically, she needed to know how Mrs. Jones wanted the medical team to care for her as she was dying. Mrs. Jones said that she hadn’t thought about end-of-life care, but she would like to learn more about her options.

After discussing the choices, Mrs. Jones expressed some clear preferences. “I know for a fact that I not want to undergo chest compressions, and I don’t want anyone using tubes to breathe for me or feed me.” Her doctor arranged for Mrs. Jones’ daughter to join the conversation. The conversation wasn’t easy – Mrs Jones and her daughter cried as they talked – but afterward they were grateful that they had shared everything so openly.

Shilpee Sinha, MD, Mrs. Jones’ doctor, has these conversations every day. She is the lead physician for palliative care at Methodist Hospital in Indianapolis, where she specializes in the care of dying patients. She also teaches medical students and residents how to provide better care for patients at the end of life.

Sinha is part of a relatively small cadre of such doctors nationwide. It is estimated that only about 4,400 doctors specialize in the care of terminally ill and dying patients. The US is currently facing a shortage of as many as 18,000 of these specialists. There is only one palliative care specialist for 20,000 older adults living with severe chronic illness.

On average, 6,800 Americans die every day. The majority of deaths are anticipated. Consider that about 1.5 million people enter hospice care each year. This means there is ample opportunity for many patients to talk with their doctors and family members about end-of-life care.

Before patients can explore and express their preferences about dying they first need to have a conversation like the one between Sinha and Mrs. Jones. In too many cases, no such conversation ever takes place. Patients often don’t know what to ask, or they may feel uncomfortable discussing the matter. And doctors may never broach the subject.

At one end of the spectrum, doctors can do everything possible to forestall death, including the use of chest compressions, breathing tubes, and electrical shocks to get the heart beating normally again. Of course, such actions can be traumatic for frail and dying patients. At the opposite end, doctors can focus on keeping the patient comfortable, while allowing death to proceed naturally.

And of course, end-of-life care can involve more than just making patients comfortable. Some patients lose the ability to eat and drink, raising the question of whether to use tubes to provide artificial hydration and feedings. Another issue is how aggressively to promote the patient’s comfort. For example, when patients are in pain or having trouble breathing, doctors can provide medications that ease the distress.

Another issue is ensuring that the patient’s wishes are followed. This does not always happen, as orders can be lost when patients are transferred between facilities such as hospitals and nursing homes.

Fortunately, most states across the country are beginning to make available a new tool that helps doctors and patients avoid such unfortunate outcomes. It is called POLST, for Physician Orders for Limiting Scope of Treatment. First envisioned in Oregon in the early 1990s, it grew out of a recognition that patient preferences for end-of-life care were too frequently not being honored. Typically, the doctor is the one to introduce POLST into the conversation, but there is no reason patients and family members cannot do so.

The cornerstone of the program is a one-page form known in Indiana as POST. It consists of six sections, including cardiopulmonary resuscitation (CPR); a range of other medical interventions, from admission to the intensive care unit to allowing natural death; antibiotics; artificial nutrition; documentation of the person with whom the doctor discussed the options; and the doctor’s signature.

The POST form helps to initiate and focus conversations between patients, families, and doctors around end-of-life care. It also fosters shared decision making, helping to ensure that all perspectives are taken into account, and ensuring that patient wishes are honored.

POST can be applied across all settings, from the hospital to the nursing home to the patient’s home. It can be scanned into the patient’s electronic medical record, ensuring that it is available to every health professional caring for the patient. And it does not require a notary or an attorney (or the associated fees), because it is a doctor’s order.

Of course, merely filling out the form is not enough. The patient’s wishes can be truly honored only if the patient and family understand the options, have the opportunity to pose questions, and trust that their wishes will be followed. In other words, POST achieves its purpose only if it is based on the kind of open and trusting relationship Dr. Sinha had developed with Mrs. Jones.

Providing such care isn’t easy. “Our health care system pays handsomely for curative care,” Sinha says, “but care at the end of life is probably the most poorly compensated kind that doctors provide. This can make it difficult to get hospitals and future doctors interested in it.” Thanks to initiatives such as POLST and doctors such as Sinha, however, such care is finally getting more of the attention it deserves.

Complete Article HERE!

How COVID-19 May Reframe End-of-Life Care Planning Engagement

The COVID-19 pandemic has renewed patient appreciation for end-of-life care planning, pushing providers to explore best practices for engaging these conversations.

By Sara Heath

For years, the concept of end-of-life care planning has been elusive to intensive care unit (ICU) providers. Not a lot of patients have engaged in these types of communications, and it hasn’t been hard to see why: end-of-life care planning is by nature a grim topic and can make a lot of people — including clinicians — feel uncomfortable.

But that’s started to change now that the COVID-19 pandemic has gripped the nation. At this point, over 100,000 people have died from the novel coronavirus, and it’s pushed end-of-life care planning as a key topic of conversation.

“The virus and the pandemic shined an important light on end-of-life care planning and the need for people who don’t have medical problems to still consider what their wishes would be. That’s because this virus can unfortunately strike folks who are healthy,” said Lauren Van Scoy, MD, a pulmonary and critical care physician at Penn State.

The number of patients coming into the ICU with an advance directive or having discussed some kind of end-of-life wishes with their family members of providers was scant prior to the pandemic. Patients and providers alike have long been uncomfortable with these types of conversations, largely because talking about death can be difficult and scary.

Per 2016 data, many hospitals don’t have much of a protocol for engaging patients in advance care planning or recording end-of-life wishes. Meanwhile, just under half of providers are uncomfortable with addressing the topic with their patients because they are unsure of what to say, the survey out of the John A. Hartford Foundation, the California Health Care Foundation, and Cambria Health Foundation revealed.

Several providers said that they struggle with identifying the proper time to broach care planning with their patients. Forty-eight percent of providers didn’t want their patients to think that they were giving up on them, and 46 percent didn’t want their patients to give up hope.

But this lack of advance care planning between patient and provider or patient and family member can have negative consequences down the line. For the patient, it decreases the likelihood she will receive hospice care at the end of her life and increases the odds she will receive intensive therapies, which can be both costly and unwelcomed by the patient.

And for the family, limited understanding of a loved one’s end-of-life care wishes can lead to serious distress.

“Care planning is so important because not only does it help the patient to receive care that’s consistent with their wishes, but it also helps the family members to have a lower-stress experience,” Van Scoy explained. “They have less psychological morbidities afterwards, and less stress related disorder.”

The data show that up to 30 percent of families who have to make end-of-life decisions experience post-traumatic stress disorder symptoms, Van Scoy pointed out, referencing a seminal study published in American Journal of Respiratory and Critical Care Medicine.

“That’s one of the things that advanced care planning can help to reduce the likelihood of, the stress related symptoms, so that’s why it’s really important for both the patient and the family,” she added.

Of course, advance care planning hasn’t totally been unheard of. In 2015, CMS said it would start paying Medicare providers for holding advance care planning talks with patients, with the goal of improving the quality and experience of end-of-life care and potentially decreasing the use of costly and intensive therapies. Increasing reimbursement for these activities potentially served as an incentive to increase engagement.

And older adults, knowing they may be nearing the end of their lives, have also been at least somewhat receptive to these conversations.

“As people get older, they’re more likely to do advanced care planning,” Van Scoy said, suggesting that this is not enough.

“As we know, medical catastrophe can happen for anyone of any age. We’re often faced with patients, particularly in the ICU, who have not had conversations about what their goals are, what their wishes are, what their preferences are. Families are often quite distressed when having to make decisions.”

But again, that trend has started to change, as more Americans face the reality that they could contract the novel coronavirus. And although COVID-19 has a pronounced impact on individuals with comorbidities, the fact of the matter is anyone could succumb to it.

“The virus has given us an opportunity to have that teachable moment to show that, whether you were diagnosed with coronavirus, or have cancer or a car accident, or some other sort of acute and unexpected illness, it’s always good to have good care planning done in advance,” Van Scoy stated.

“The coronavirus pandemic has allowed people to think about it in a new context as opposed to, ‘advanced care planning is just for old and sick people, not for me,’” she continued. “Now we’re having a conversation nationally about ventilators and ICU use and people needing emergency critical care. People are thinking, ‘gosh, I very well could end up on a ventilator.’ The coronavirus has changed the conversation to be more relevant, more pertinent, and brought it to a broader scope of Americans, not just elderly or those with illness.”

And while patients and providers alike are facing a renewed appreciation for advance care planning, Van Scoy has uncovered new strategies to make these conversations more palatable. After all, just because more patients recognize the need for advance care planning doesn’t make these conversations any less uncomfortable.

As part of her research on patient experience and communications in the ICU, Van Scoy has developed a game that brings advance care planning into the community in an agreeable way. The game, titled Hello, can be delivered in both the healthcare facility or in a community-based setting as it pushes patients to consider what is important to them at the end of their lives.

“The Hello tool is a game that allows patients and their families and friends to come together and talk in a way that’s sort of less serious and less intrusive,” Van Scoy explained. “The game features questions that are asked in a way that are easy to answer. Questions are things like ‘what music would you want to be listening to on your last day of life’ or ‘what are three non-medical facts that your doctors should know about you.’ It approaches this topic in a very soft way, but yet it’s still getting into the meat of the problem.”

And the qualitative data shows this approach has been effective, especially in traditionally marginalized populations for whom end-of-life care planning is even less prevalent. Van Scoy largely credits this to the community-based setting in which she has deployed Hello.

“We leverage those networks to get individuals set up to have these conversations in places outside the healthcare system,” Van Scoy noted. “Users are comfortable and they can lean on each other as opposed to leaning on the healthcare system, which in underserved populations have had some historic problems with trust.”

This new information about carrying out advance care planning will be essential going forward, as the COVID-19 crisis ideally renews patient and provider appreciation for these conversations. As the healthcare industry works to adapt to the novel coronavirus, understanding the best ways to address end-of-life wishes will help providers treat their ailing patients with dignity.

Complete Article HERE!