How Does Hospice Care Work?

— Hospice offers crucial end-of-life care with a focus on the patient’s comfort and dignity. Experts explain who is eligible, what it entails and how to understand and navigate the process.

By Dana G. Smith

In February, the Carter Center announced that former President Jimmy Carter had decided to stop receiving medical interventions and had transitioned into hospice care at home. The cause of Mr. Carter’s decline was not revealed, but the 39th president, who is 98, has been public about health issues he has faced in recent years, including melanoma — a skin cancer that spread to his brain and his liver — and numerous falls.

Hospice provides end-of-life palliative care with a focus on the patient’s comfort and dignity. Pain relief is a priority, while treatments intended to prolong life are discontinued. Hospice agencies offer access to physicians, nurses, health aides, social workers and chaplains who assist patients and their families with everything from symptom management to funeral arrangements. The care is typically provided where the patient lives, whether that’s at a private home or in an assisted living facility.

“When people are close to the end of their lives, going to the hospital does not make them feel better anymore, because there’s not necessarily something that we can do to address their underlying illness,” said Dr. Carly Zapata, an assistant professor of medicine at the University of California, San Francisco, who specializes in palliative care. Hospice “is really focused on caring for people — and their caregivers or loved ones — to help them have the best quality of life possible for the time that they have left.”

Here’s what hospice care entails and how to decide if and when it’s right for you or your loved one.

Who is eligible for hospice care

To receive hospice care, a person must have a terminal diagnosis with a prognosis of six months or less to live. In most cases, a physician recommends hospice; patients and their families can also take the initiative and contact hospice agencies, although a doctor must attest that a person meets the qualifications.

“It’s a hard conversation to have,” said Dr. David Casarett, a professor of medicine and section chief of palliative care at the Duke University School of Medicine. “Enrolling in hospice means that you have to confront that person looking back at you in the mirror and realize that you’re going to die.”

Most people receive hospice care for less than one month. In the rare instance that a person lives longer than six months while in hospice, a physician will re-evaluate the person’s health to assess whether the patient still qualifies.

Many people would benefit from enrolling sooner so that they can receive hospice services for months instead of weeks, Dr. Casarett said. But, he acknowledged, “that doesn’t work for everybody — many people really want to continue aggressive treatment up until the very end.”

Hospice is provided regionally, so the first step is to search for agencies that serve your county. Nursing homes and assisted living facilities usually have contracts with one or two local hospice agencies.

Medicare covers the cost of hospice care. (In most cases, the people who require hospice are on Medicare because they are over 65 or have a qualifying disability.) Medicaid and private insurance also typically cover the service, although just like any other health care cost, your insurance may require that you use a specific provider. For people who are uninsured, some hospice agencies operate as nonprofit organizations or provide services free of charge.

If several options are available, “I really strongly recommend that folks talk to more than one hospice” to find an agency that best matches their needs, said Katie Wehri, director of home care and hospice regulatory affairs at the National Association for Home Care and Hospice.

“There are requirements from Medicare that all hospices have to abide by,” Ms. Wehri said. “But then hospices can also choose to deliver additional services, and how they deliver those services is really up to them.”

Ms. Wehri’s organization provides a list of questions for families to ask when talking to potential hospice providers, such as: “What kind of out-of-pocket expenses should be expected for hospice-covered services?”; “How often will a hospice team member visit, and how long will most visits last?”; and “What happens if I need to go to the hospital or the emergency room?”

Dr. Zapata also advised asking about how medical care will change when the patient enters hospice, such as which treatments and medications will be stopped and who will oversee care. Hospice agencies employ their own physicians, but if you have a strong relationship with a primary care provider or a specialist you’ve been seeing, you can request to have that physician continue to supervise care.

“Sometimes people enroll in hospice expecting everything to be the same,” Dr. Zapata said, and when that isn’t the case, it can be “an unwelcome surprise.”

What hospice care entails

Hospice care is most intensive at the beginning, when a person starts the transition, and at the end, as the person is closer to dying. Hospice agencies provide a range of services, support and supplies to help during the end-of-life stage, including medication management, such as for pain, nausea and depression; equipment like hospital beds, wheelchairs or oxygen; help with navigating legal documents and medical bills; and bereavement services for family members.

Nurses are the hospice providers who visit most often. Appointments may be scheduled every day, but more typically they occur one or two times a week. The nurse will check vital signs, ask about symptoms and consult with the supervising doctor about the need for any changes in medication. The nurse also educates caregivers about how to administer medicines or how to assist with a patient’s personal care, like bathing.

Hospice teams provide crucial emotional and logistical support, as well. Social workers might assist in setting up a will, power of attorney or funeral arrangements. Spiritual care providers — religious or nondenominational — can help a person come to terms with the end of life through prayer or facilitating conversations with loved ones.

For all the benefits and services offered through hospice, though, it does not provide round-the-clock, in-person assistance. If a person is undergoing hospice at home, “It is the patient’s family or friends who are often providing care to them,” Ms. Wehri said. (In assisted living facilities, staff members will administer care.)

Because of this reality, “hospice almost never provides the level of support that families expect,” Dr. Casarett said. “That’s nothing against hospice; it’s just when you’re trying to take care of somebody who’s dying at home, you need all the help you can get.”

If someone’s needs are beyond what can be managed at home, many hospice agencies have inpatient facilities, or they work with a hospital or a nursing home. But those inpatient stays are intended to be used for temporary, acute concerns, such as if medication needs to be administered intravenously, and insurance will often cover them for no longer than a week.

For people who live alone, or if receiving care from family is not an option, it may be necessary to hire a home caregiver or to move to a nursing home. Unfortunately, these options can be expensive and are not typically covered by insurance. Experts say this is the biggest challenge when it comes to hospice care.

When a loved one is being cared for at home, a “beautiful part” of hospice is that, logistically, it doesn’t really require any preparation, Dr. Zapata said. The people who deliver the medical supplies will rearrange your furniture to fit a hospital bed. The social worker will help make sure advance directives are taken care of.

Instead, she said, the preparation that’s needed “is the acknowledgment that someone is getting close to the end of their lives” and deciding how to make the most of that time.

Complete Article HERE!

What I learned about grief from working at a funeral home

— Talking about death, grieving and deathcare options can be positive

By Heather Taylor

When I tell people I worked at a funeral home, I expect one of several responses: they are surprised, change the subject or express how depressing they think the job is. There were some sad days during my two years of work as a funeral arranger in the deathcare industry, but I felt great satisfaction in helping and supporting people during a hard and stressful time. The lessons I learned from having a front-row seat to hundreds of families’ grief have remained with me, and there is a benefit to sharing those lessons with others.

The importance of talking about death, dying and grieving is not always fully understood in our culture and it is often treated as taboo. A 2022 study by a life insurance company, Ethos, found while Americans think about death frequently, they do not talk about it. Among other topics considered to be inappropriate or uncomfortable in polite society including money, sex, politics and religion, the study stated people would prefer to talk about anything other than death.

Despite this unwillingness or inability to talk about dying, it is a universal experience. Everyone will die, and will experience the death of people they love, whether they discuss it or not.
There have been increased efforts to start discussions around death and grief recently, as people question established funeral practices and challenge cultural norms. Organizations like The Order of the Good Death and Death Cafe began to give an appropriate forum to talk about more morbid topics.

Caitlin Doughty is a funeral professional and the creator behind the YouTube channel “Ask a Mortician.” In her book, “Smoke Gets in Your Eyes,” she writes about why it matters to talk about these issues and how speaking about death can positively impact grief.

“It is never too early to start thinking about your own death and the deaths of those you love,” Doughty said. “Accepting death doesn’t mean that you won’t be devastated when someone you love dies. It means you will be able to focus on your grief, unburdened by bigger existential questions like ‘Why do people die?’ and ‘Why is this happening to me?’ Death isn’t happening to you. Death is happening to us all.”

I saw firsthand how families were able to address their grief around the death of a loved one when they were better prepared for it. Of course, there are instances of tragedies that catch people off guard, but generally being at least a little prepared for death and funeral proceedings provides more time and mental capacity to grieve the loss.

“It is never too early to start thinking about your own death and the deaths of those you love.”
— Caitlin Doughty

Another important lesson I learned about grief while assisting families is there is no singular way to grieve death.

As I worked answering phones, greeting people and taking information for death certificates, I had the privilege of talking to people of all ages, races and religious affiliations. All had experienced the death of someone they knew, but beyond that, they did not share much in common.

Some people were relieved that an elderly family member was no longer experiencing pain or chronic illness. Some were hysterical over the death of someone lost at a tragically young age. Others came in a numb state or were ready to get down to business.

I spoke to people who wanted to tell me their whole family history or love story. Others hadn’t heard from the deceased in years and had little to share.

One young woman around my age conducted herself with an almost preternatural composure for the entirety of her father’s funeral, only to break down in sobs when it was done. She told me she felt selfish because she didn’t want to take away attention from her dad, but over the course of the previous week, the rest of the family forgot her birthday had come and gone.

One of the questions I heard repeatedly was a variation of “What am I supposed to do? Is this normal?”

But there is no single way to grieve, and no way that is inherently right. Grief has as much to do with the person who died and all they represented as it does with the people who are living.

Over the years, there have been different theories and models created to explain the process of grieving. Perhaps the most well-known is the concept of the five stages of grief.

This model of grieving was originally introduced in the late 1960s by psychiatrist Elisabeth Kubler-Ross. The main takeaway from this framework was people may feel or work through emotions of denial, anger, bargaining, depression and acceptance when facing a loss.

Kubler-Ross updated the concept of the stages of grief over time, writing with David Kessler in “On Grief and Grieving”:

“They were never meant to help tuck messy emotions into neat packages. They are responses to loss that many people have, but there is not a typical response to loss as there is no typical loss. Our grief is as individual as our lives.”

Kubler-Ross acknowledged that people who reach the acceptance stage have not necessarily conquered grief. A misquoting or misunderstanding of the stages has contributed to the idea that a person can work through the stages and then move on.

This framework can still be helpful in letting people know the emotions they feel are valid and acceptable.

“Our grief is as individual as our lives.”
— Elisabeth Kubler-Ross & David Kessler

However, there is another theory around grief that was introduced to me while I was working in the funeral industry which I have found more helpful and accurate to people’s experiences.

The concept of “growing around grief” was introduced by a grief counselor, Lois Tonkin, in 1996. Tonkin had spoken to a mother who lost a child and participated in an Elisabeth Kubler-Ross workshop to address her grief.

Rather than finding that her grief had disappeared as she worked through her emotions, the mother reported it instead stayed the same size, but with time “her life grew around it.”

Tonkin illustrated the model with a simple graph showing a large, white circle representing life, with a smaller, shaded circle within meant to represent grief.

“There were times, anniversaries, or moments which reminded her of her child, when she operated entirely from out of the shaded circle in her life and her grief felt just as intense as it ever had,” Tonkin wrote. “But, increasingly she was able to experience life in the larger circle.”

In the immediate aftermath of a death, it can be hard to imagine life will go on. While I was working, I often saw families over the course of several weeks or months after a death had occurred. With time and further life experiences, their grief did not disappear, but they were able to function and forge on.

Tonkin’s concept of grief is encouraging in these instances because it does not imply a person will forget their loved one or shrink their grief, but rather add to their own life after loss.

“In this way, they continue the process of integrating the loss with their lives and moving forwards,” Tonkin wrote.

Table with a photo of an elderly woman, a cremation urn, and a hand placing flowers.
Cremation is a popular method of disposition, but should it be one of the only options?

It may also become easier to grieve as Americans work toward offering increased options for deathcare and the disposition of remains.

In the past, funeral activities were primarily managed at home, allowing the family to take part in meaningful rituals. Around the time of the American Civil War, the practice of embalming was popularized, and in the years following, deathcare became industrialized and commercialized, moving from inside homes to behind closed doors.

In the 1960s, around the time of Jessica Mitford’s book “The American Way of Death” which criticized the funeral industry, cremation began to rise in popularity. It was seen as a more cost-efficient form of disposition.

Today, burial and cremation are the primary options available to Americans. For those who have not made plans ahead of time, the process falls upon family members who can feel overwhelmed and left without sufficient options.

“Choice doesn’t enter the picture for the average individual faced, generally for the first time, with the necessity of buying a product of which he is totally ignorant, in a moment when he is least in a position to quibble,” Mitford wrote.

The high cost of funerals, along with the limited choice and opportunities for personalization add stress to families and leave them wondering if they made the right decisions.

While I was working, I saw people seek out ways to incorporate creativity into arrangements for their deceased friend or family member, and I saw how satisfying this could be.

There were instances of people bringing in nontraditional items to use instead of cremation urns, including canning jars or teapots belonging to the deceased. The local Indigenous community built their own caskets for tribal members on several occasions, creating something personal through community effort, often emblazoned with farewell messages and signatures.

These were ways to work around the impersonal and often more expensive options available, and they were a truer representation of the person who had died.

Thankfully, though I was only able to offer burial and cremation options while I was working, increased choices should be available to some states soon.

California recently decided to allow alternative disposition options including alkaline hydrolysis, commonly known as “aquamation” and terramation or “human composting.” Human composting will not be available until 2027, as requirements and standards are currently being put in place.

Both options are more environmentally friendly than traditional cremation, and existing terramation companies have shown an interest in involving families in the process and offering personalized service.

Green burials, where a body is not embalmed or buried in a traditional casket are legal, but often cemeteries will require specific items which make green burial impossible. Cemeteries dedicated to green burials or conservation burials are gaining interest, but are still less available than traditional options.

Further education and discussion about these topics can only open the door to providing more options for grieving families to feel they are honoring their loved ones in ways that bring them satisfaction. Through researching and spreading the word about alternative burial and cremation options, we can assist in opening the door for legislation to allow them. This can also lead to pressuring existing businesses to offer a broader range of services.

A skull vase full of blue, white and purple flowers sits next to a sign that reads "people are dying to work with me."
Humor can help too! This was my desk decor at my funeral home job.

I can’t claim that I have attained a level of enlightenment from my experiences in the funeral industry that will keep me from feeling grief when those close to me die. In fact, I know the opposite will be true and their losses will hurt deeply. However, I’ve seen from the example of others that life can and will go on.

I also hope through supporting legislation and education about increased options for deathcare, I may be able to provide my loved ones and eventually myself with an appropriate, fitting end. Personally, I want to be buried in a green burial cemetery or composted!

From what I have learned, I hope I have a better grasp on the concept of my own mortality, and I am able to offer more grace and empathy to others in grief — and to myself. Those are the values I find most important from the lessons I’ve been fortunate enough to learn from both the living and the dead.

Complete Article HERE!

Psychedelics in ancient Greece

— Death and rebirth during a renowned religious ceremony

The

Going back as far as 3,500 years ago in ancient Greece, followers of a cult to the goddess Demeter participated in a secretive and profound religious ceremony during which they consumed a hallucinogenic drink. The rituals were meant to reenact the story of the goddess’ loss of her daughter to the god of the underworld, and their subsequent reunion. 

Symbolizing death and rebirth, the ceremony, called the Eleusinian Mysteries, was meant to elicit feelings of awe, joy, and spiritual enlightenment, and to give followers a deeper understanding of life and death. Amplified by the consumption of a psychedelic potion, the ritual is thought to have brought on a mystical out-of-body experience, similar to how many people today describe a psilocybin or LSD trip. Psychedelics are having a resurgence today, and research shows the many benefits of the substances, including, simply, leading a fuller life and feeling more connected to the world. The Mysteries were an essential rite of passage to many ancient Greeks, and their importance is hard to understate. These ancient perceptions of psychedelics and the Mysteries can help us understand the power of these substances and the benefits they offer today.

What were the Eleusinian Mysteries?

Eleusis is a town just northwest of Athens, Greece, an agricultural society out in the countryside, and a setting ripe for a cult to Demeter, the goddess of the harvest and the bringer of a bountiful crop. More importantly, it’s a place where wheat or barley likely grew, which are the probable sources of the psychedelic substance in the kykeon, the psychedelic drink consumed during the Mysteries.

Meaning “to stir, or mix” in Greek, the kykeon was thought to have contained an ergot fungus from the barley plant, a substance similar in structure to today’s LSD. There is some debate as to whether the kykeon was psychedelic or not, but famed chemist Albert Hofmann, most known for discovering LSD, makes a strong case for the ancient Greeks having access to this psychedelic fungus.

The origin of the Eleusinian (usually pronounced el-oo-SIN-i-an) Mysteries is somewhat hazy, but it stretches back to at least 1500 BCE, if not before. People from all walks of life took part: rich, poor, men, women, slaves, foreigners; as long as you could speak Greek, you could participate. Even some Roman emperors participated.

For six months before the ceremony, participants learned rites and rituals for the ceremony—called the “lesser Mysteries”—and then in the fall, it began: Participants walked in a procession from Athens to the temple of Demeter at Eleusis, spent nine days there, and then walked in a procession back to Athens, renewed by the experience.

The treks to and from the temple likely symbolize Persephone’s descent to the underworld, and then her ascent back to the land of the living to be with her mother (more below). At the temple, not much is known—hence, why it was called the “Mysteries”—because speaking of the rituals was punishable by death. There is some evidence of animal sacrifice, and the psychedelic kykeon was consumed during the time at the temple. 

Persephone is a fascinating figure in Greek mythology, straddling the line between life and death: She is both daughter of the harvest and queen of the underworld. Every year, she dies and is reborn—in revering her, the ancient Greeks sought to find out what secrets she held of life and death.

In polytheist ancient Greece, Demeter was the goddess of the harvest, responsible for a bountiful crop, which fed humankind, whom the gods created in their image. She had a beautiful daughter named Persephone (usually pronounced per-SEH-fuh-nee), who caught the eye of Hades, god of the underworld. One day, Hades abducted Persephone, taking her to the underworld to be his wife. While there, she ate the seeds of a pomegranate, imprisoning her there, according to divine law.

Demeter was inconsolable at the loss of her daughter and so the crops withered and died, and humankind began to starve. The goddess searched for her daughter for nine days and ended up in the town of Eleusis, where the town took her in. Eventually, she commanded them to build her a temple, where the Mysteries eventually took place.

The other gods were distraught at the humans dying, so Zeus, king of the gods, went down to the underworld and struck a deal with Hades: For half of the year, Persephone would reside in the land of the living with her mother, Demeter, and for the other half, she would live in the underworld with Hades as his wife.

When Persephone came back to the land of the living, Demeter was overjoyed and the crops flourished; but six months later, Persephone had to return to the underworld, Demeter became sad, and the crops began to wither and die again. The cycle repeated year after year.

Persephone’s story explains the changing of the seasons in ancient Greece: fall begins with her descent, Demeter’s sorrow, and the crops dying, and spring occurs with her ascent back to the land of the living, Demeter’s joy at their reunion, and the crops flourishing.

What purpose did the Mysteries serve?

There’s no doubt that the Mysteries were a rite of passage to many in ancient Greece. The intense, six-month preparation for the ceremony and the diversity of people who participated in them point to the importance of the experience across ancient Greek culture. The ceremonies also existed for more than 2,000 years, and it took the spread of Christianity to wipe out the practice.

The spiritual aspects of the ceremony relating to the goddesses Demeter and Persephone are obvious, but when the practice of drinking the psychedelic kykeon is added to the experience, the Mysteries gain a deeper, more profound meaning.

The way that ancient Greeks described these ritualistic experiences are similar to modern descriptions of tripping on psychedelics. Even the benefits that Greeks received from participating in the Mysteries mirror the benefits of psychedelics consumed in scientific studies today, including opening the doors to a more fulfilling and satisfying life, better coping with loss and death, and gaining a deeper understanding and appreciation of the world, among others.

We have the advantage of scientific study today, and current research shows the benefits of “mystical experiences” brought on by psilocybin, as well as “experiencing God” or an “ultimate reality,”  resulting in greater life satisfaction, purpose, and meaning, even decades after the initial psychedelic experience.

Some descriptions of what participants underwent during the Mysteries are similar to the experience of ego death today, or the loss of self, often experienced during a psychedelic trip. Disassociation, hallucinations, fear, joy, a mix of other emotions, and a deeper understanding of the world are all experiences described during both the Mysteries and a psychedelic trip. The dissolution of the ego can lead to the feeling of oneness with the world, helping to break unhealthy thoughts and behavior patterns.

Participants were also said to have returned from the ceremony full of joy and happiness, with the fear of death diminished. Philosopher Plato reportedly participated, and said that the Mysteries were a purifying experience, and those who participated “shall dwell with the gods.” Ancient texts talk of the intense sensory experience of the Mysteries, speaking of a “marvelous light” and a “huge fire,” perhaps similar to hallucinations seen while on psilocybin or LSD.

Today, psilocybin and other psychedelics are also being used to treat end-of-life anxiety and help people with terminal illnesses cope with death. In another study, 67% of participants rated a psilocybin experience to be the single most meaningful experience of their life, or in the top five most meaningful experiences.

The Greeks knew the power of the Mysteries and the kykeon, and closely guarded their secrets. Psychedelics, and the story of Persephone’s continual death and rebirth, can help us all come to terms with death and appreciate life for what it is.

Complete Article HERE!

Ushering Pets Gently to the End

— A caring and dignified death by in-home euthanasia can help bring solace to grieving pet owners

Kerri Miller’s dog, Cookie

By Kerri Miller

The first message I left on the veterinarian’s phone last winter was so distorted by tears and grief that I had to call back twice to repeat the details.

It had been 26 hours of sleeplessness and stress since our older shepherd’s legs had given way beneath her and I realized she wouldn’t be able to stand again on her own.

We were fast approaching a moment where her diminished quality of life — she wasn’t eating much and had given up on our daily walks — was edging into suffering. My husband and I anguished over what we knew was inevitable. We’d used in-home euthanasia services when our previous dog had developed cancer, but I think I would’ve been comforted if I’d known about the advice that veterinarians like Dr. Kenzie Quick gives to clients in times like these: “Better a moment too soon than a day too late.”

“This little buddy of mine has seen me through so many things that no one else has.”

Quick, a Tucson, Arizona, staff veterinarian with Lap of Love, a company that provides in-home hospice and euthanasia service for pets, acknowledges that knowing exactly when to make the decision to put a companion animal out of their pain is a delicate one. “There is no perfect time,” she says. “Any time between when their quality of life is no longer good but they’re not suffering. Any time in that zone is the time to say goodbye.”

Saying goodbye to Rex, Heather Boschke’s Yorkie/Pomeranian mix, was something she dreaded. “He’s seen me through job transitions, two boyfriends and one fiancé. This little buddy of mine has seen me through so many things that no one else has.”

But at sixteen years old, Rex had advanced kidney disease, wore diapers and was struggling to walk. Boschke and her husband reached out to friends who recommended MN Pets, Minnesota-based in-home euthanasia care.

What she found, Boschke says, was empathy and, most important, confirmation that she was making the best decision for Rex. “The memory we have of his passing was caring and dignified.”

Paradox of Difficult Yet Fulfilling Work

Quick believes that’s an essential part of her interaction with the pet owner, from the first call to the moment when the animal is gone. “My role is to come in, be calm, validate their decision and then to take really good care of their pet. To let them know that I have this under control and to provide that peaceful transition,” she explains.

A woman holding a small dog. Next Avenue, in-home euthanasia for pet, putting pet down at home
Heather Boschke and Rex

Dr. Karen Fine, a veterinarian and author of “The Other Family Doctor,” writes that when she began making house calls and offering in-home euthanasia services, she had to learn to be comfortable “around grief and intense emotions.” She adds, “I often felt like I didn’t belong in the sacred space between human and animal at such a pivotal moment.”

The number of vets who specialize in in-home euthanasia has grown over the last several decades, but overall, there is a shortage of practicing veterinarians. That means that the demand for in-home services like hospice and euthanasia has skyrocketed.

Kristi Lehman, a veterinary social worker for MN Pets, worries about the demands on the doctors and staff. “Our team is being pushed to their physical limits with how many families they can see and how many appointments they can drive to. So, there is a lot of discussion about our doctors’ quality of life.”

Complete Article HERE!

The ‘death checklist’

— Choosing your agents

OK, maybe the ‘life checklist’ sounds better. Either way, this starts a whole series of reports to get us ready for the end.

By Jason Wheeler

Show of hands: Who is ready to die? OK, that certainly doesn’t sound appealing.

So, as we do a whole series of reports about preparing for future eventualities, we’ll change the original idea from ‘The Death Checklist’ to ‘The Life Checklist’.

That makes sense anyway because preparing your finances for after you die is a part of life. And it’s a critical part for the people you leave behind.

Let’s start with the care you get that may keep you from dying right now.

Texas has long led the nation in the number of people who are uninsured. It’s a good idea to have health insurance in some form. Because if things go really wrong for you health-wise, it gets costly fast. The average hospital bill in Texas went up 38% from 2016 to 2020. The costs can be an onerous burden even if you are covered. But especially if you are not, those bills can quickly diminish the assets you might have been planning to leave behind to loved ones.

Choosing someone to make your health care decisions if you cannot

Regardless of your insurance situation, if you end up needing treatment, it may help you and those who care about you to designate someone now to be your agent with a medical power of attorney.

Some recommendations say if you are married you should fill out one of these forms too, even if the agent you name is your spouse.

In addition to filling out the form, you discuss your medical wishes with your designated medical power of attorney in case something happens to you, and you are unable or incompetent anymore to make your medical wishes known to healthcare providers.

Make sure the person you designate is someone you trust…and that it is someone who makes good decisions under pressure (and may be able to withstand pressure from other family members who might want something for you that goes against your wishes).

In this document you can limit the decisions your agent can make, you can allow it to go on indefinitely or put an expiration date on it, and you can choose alternate agents in case your agent dies or is incapacitated with you. You can also subsequently revoke this document and make a new one if you choose.

Choosing someone to handle your financial affairs if you cannot

If you want to designate the same person or another person to also handle your financial affairs, and make those decisions when you cannot, that’s going to require another document.

Whoever you select to handle your financial affairs if you are unable to, you want to make sure you really trust the person.

If you select this person to have what is called a durable power of attorney, they can make decisions about a lot of different things involving your money. On the form, you can initial the things they can do regarding your money, your possessions, your real estate, investments, social security, retirement, and other things…even your digital assets and content of electronic communications.

You can also limit or extend their powers. And you get to decide when the durable power of attorney begins.

You can also opt for co-agents and decide if they work together or work independently on your behalf. This would be in effect until your death. But you can revoke it, too.

If that seems like too much there are also limited powers of attorney for things like selling an automobile or dealing with your taxes.

You can also read more about powers of attorney here and here.

Complete Article HERE!

5 key things to know when you create a will and make other end-of-life plans

By Sarah O’Brien

  • Planning for who makes decisions and who gets what when you die is “a gift” for your family, says a financial advisor.
  • While many people think estate planning is only for the wealthy, experts say that’s not the case.
  • Here are some key things to think about when you give thought to your own end-of-life plans.

Contemplating your own death may not be on the list of things you’re eager to do.

Yet for your family or other loved ones who would find themselves trying to sort out your affairs while also dealing with the emotional fallout from losing you, your having a so-called estate plan is important, experts say. And this is the case whether you are wealthy or not.

“When you get your things in order, it’s a gift you’re giving your family,” said certified financial planner Lisa Kirchenbauer, founder and president of Omega Wealth Management in Arlington, Virginia.

In simple terms, your estate plan spells out who you want making decisions and who will inherit what you own. “Estate” simply refers to possessions and other assets.

Experts say most estate plans don’t need to be complicated. But to make sure your wishes are carried out, they do need to be done correctly — which may make it worth consulting with a local attorney who specializes in estate planning.

Here are five key things to know if you start thinking about how you’d craft an estate plan.

1. A will may not cover all your bases

A will is a basic part of an estate plan. It lets you identify who you want to receive certain property and allows you to name a guardian for dependent children. If you don’t have a will in place when you die, the courts may decide who gets what or who is appointed guardian.

However, some assets pass outside of the will, including retirement accounts such as 401(k) plans and individual retirement accounts, as well as life insurance policies and annuities. This means the beneficiaries listed on those accounts supersede any instructions in your will.

“If your ex-spouse is listed on the beneficiary designation, your ex-spouse will get the money regardless of what your will says,” said CFP Stephen Maggard, an advisor with Abacus Planning Group in Columbia, South Carolina.

Be aware that many 401(k) plans require your current spouse to be the beneficiary unless they legally agree otherwise.

Regular bank accounts, too, can have beneficiaries listed on a payable-on-death form, which your bank can supply. Same goes for brokerage accounts.

If no beneficiary is listed on these various accounts or the named person has already died (and there is no contingent beneficiary listed), the assets automatically go into probate.

That’s the process by which all of your debt is paid off and the remaining assets that are subject to probate — which includes those that pass through the will — are distributed to heirs. This can last several months to a year or more, depending on state laws and the complexity of your estate.

2. You’ll need to carefully pick your will’s executor, other key roles

When you create a will, you name an executor to carry out your wishes and handle your estate. It can be a big job.

Things such as liquidating or closing accounts, ensuring your assets go to the proper beneficiaries, paying any debts not discharged (i.e., taxes owed) and even selling your home could be among the duties overseen by the executor.

This means that you need to make sure whoever you name is up for the job — and that they are amenable to taking it on.

Additionally, an estate plan should include other end-of-life documents, including a living will. This outlines the health care you want and don’t want if you become unable to communicate those desires yourself.

You also can assign powers of attorney to trusted individuals so they can make decisions on your behalf if you become incapacitated at some point. Often, the person who is given this responsibility for decisions related to your health care is different from whom you would name to handle your financial affairs.

Just be sure to name alternatives.

“It’s super important to have backup people in all roles in the estate plan … in case someone cannot serve,” said CFP Jennifer Bush, a financial planner with MainStreet Financial Planning in San Jose, California.

3. Some assets get a ‘step-up in basis’

If you have assets such as stocks, bonds or real estate (i.e., a house) and are considering gifting them to children or other heirs while you’re alive, it might make more sense to wait.

When these assets are sold, any increase from the so-called cost basis (the value when the asset was acquired) and the sale price is subject to capital gains taxes.

However, upon your death, your heirs who inherit those assets get a “step-up in basis.” In other words, the market value of the asset at your death becomes the cost basis for the heir — which generally means any appreciation prior to that is untaxed. And when the heir sells the asset, any gains (or losses) are based on the new cost basis.

On the other hand, if you were to gift such appreciated assets to heirs before your death, they’d assume your original cost basis — which could translate into an outsized tax bill when the assets are sold.

“We find ourselves often recommending that clients give adult children cash instead,” Maggard said.

4. You may want to consider setting up 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 or other concerning behaviors — 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 are left to 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.

5. You’ll need to revisit your estate plan

Anytime you have a major life change — such as birth of a child or divorce — it’s important to review your estate plan.

You’ll want to confirm that your named executor (or trustee, if you set up a trust) is still an appropriate choice. Additionally, check all listed beneficiaries on your financial accounts to make sure no updates are needed.

Additionally, If you move to a new state, be sure to check whether you need to update any part of your plan so it follows that state’s laws.

Complete Article HERE!

Dance Me to the End of Time

— South African film on death is a powerful celebration of life

Activist and theatre director Nancy Diuguid, left, with partner and film-maker Melanie Chait.

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In her 2021 documentary Dance Me to the End of Time, South African film-maker and educator Melanie Chait has produced a truly great film. Not only for the breadth of themes it broaches – from cancer to green activism, from lesbian love to arts therapy – but also for the intensity with which she deals with these themes.

One of the hallmarks of a great film is its ability to transport audiences; to hold their undivided attention and evoke deep emotions in them. The documentary does this, as it pieces together four years of home movie footage filmed by Chait.

This very personal, award-winning film chronicles the final years and death of Chait’s life partner, London theatre director Nancy Diuguid. Diuguid died from breast cancer. The film is, of course, more than just about the death of Diuguid. It is also about the triumph of lesbian love in the face of death as well as the ecological and feminist politics of Chait and Diuguid.

In the process it elevates itself above death and disease to become a veritable celebration of life and love. Powerfully original, it is also likely to change the way people think about the food they eat and how it is produced. This is particularly important given the ever increasing prevalence of cancers.

The art of death

Dance Me to the End of Time has been enjoying a successful festival run after premiering at the Encounters documentary festival in South Africa and has won several international awards.

The documentary fits into a genre of film-making which focuses on disease, dying and death. This genre was popularised in the early 1990s by films which documented the death of people living with AIDS. These are films such as Silverlake Life by US director Tom Joslin and Modesty and Shame by French writer and photographer Hervé Guibert. I argue in an article on this genre that there is something more to such films than just the representation of diseased bodies and slow deaths.

Dance Me to the End of Time shows how two women face the presence and reality of death. Diuguid thinks through how, although she was losing control of her body, she still wanted to be “present in the process of dying”. Chait contends with the idea of losing her loved one. She expresses her helplessness in offering the comfort that her dying lover required:

It felt like I was playing God: deciding what to do, when. Nancy was so unlike the Nancy I had known. I only wished I could do better with the process of knowing how to comfort and help ease her anguish.

Despite the difficult conversations they have about death and the meaning of loneliness, it’s fascinating how the film eloquently demonstrates that even in the face of death, the couple was able to experience happiness. In many instances, Diuguid is filmed swimming in the ocean or dancing with their adopted son, Desmond. This film is a beautiful ode to lesbian love, an elegy of two women loving one another through sickness and health.

Ecological and feminist politics

Chait also weaves into this personal story the important feminist and ecological work that the couple did to expose the health dangers of pesticides. When diagnosed with cancer, Diuguid decided to adopt a holistic, integrated medical approach combining traditional medicine and natural methods.

The story of US scientist and ecologist Rachel Carson is woven into that of Chait and Diuguid. From as far back as the early 1960s, Carson had exposed the health hazards of pesticides, especially DDT, used to spray farm crops. Diuguid grew up on a farm in Kentucky and experienced how small wildlife would be killed days after the spraying of their farm.

A black and white photo of a woman in a collared shirt, smiling.
Rachel Carson.

Diuguid and Carson both died of cancer. By drawing parallels between their lives, the film highlights the politics of what and who is responsible for causing cancer. In its focus on the gruesomeness of the effects on cancer, Dance Me to the End of Time is itself political in dealing with ecological questions and the impact of pesticides.

The film also shows how, when Diuguid was diagnosed, she was able to use the creative arts and her lesbian identity as tools to campaign for justice and to heal others. Through an initiative called VOICES, she used expressive arts to help women and children deal with trauma in the townships of Johannesburg. In addition to the historical trauma of apartheid, townships in South Africa have had to do contend with high levels of intimate forms of violence.

Vulnerability and dignity

A film poster featuring two women, one lying in bed.

Even in chronicling Diuguid’s dying, the film does not rob her of her dignity and humanity.

In fact, the film celebrates her life and her important work in expressive arts therapy.

In its personal and deeply emotional texture, Dance Me to The End of Time offers a sincere depiction of how to face death and more importantly how to live life to its fullest.

Complete Article HERE!