DEATH
What are your feelings about death? Here are some questions you may not like- but need to address.
1. What are my immediate reactions to the word death?
2. At what age are people most afraid of death
3. At what age would I like to die
4. At what age do I think I will die
5. Here are several consequences of death. Which is the most distasteful
a. I could no longer have any experiences
b. I am uncertain as to what might happen to me if there is life after death
c. I am afraid of what might happen to my body after death
d. I could no longer care for my dependents
e. My death would cause grief to my relatives and friends.
f. All my plans and projects would come to an end
g. The process of dying might be painful.
h. My death could be long and lingering
i. My death would leave my spouse or partner or beneficiaries financially destitute.
There are undoubtedly others. But the point is that you need to objectively discuss these with your spouse, partner, children and/or attorney or planner in order to be sure your wishes and concerns are properly identified in your estate plan.
DEATH: (SF Chronicle) Most of us hope for a nice clean death (we all should be as lucky as Bing Crosby and die while golfing. Actually the "best" one I ever heard of was a man 79 years of age and an avid golfer who hit a hole in one but died suddenly of a massive heart attack teeing off for the next hole). But for most, it won't happen that way. "Death is usually messy, can take a long time and generally involves pain" according to Dr. Sherwin Nuland in his book, "How We Die" . "No matter the degree to which man thinks he has convinced himself that the process of dying is not to be dreaded, he will yet approach his final illness with dread". Dr. Nuland noted that only 20% of the deaths come easily. "And even for those who do achieve a measure of serenity during separation, the period of days or weeks preceding the decline of full awareness is frequently filled with mental suffering and physical distress". Unfortunately, many doctors continue to try all sorts of life sustaining measures even for those that should be allowed to die peacefully. "Treatment decisions are sometimes made near the end of life that propel a dying person willy nilly into a series of worsening miseries from which there is no extrication- surgery of questionable benefit and high complication rate, chemotherapy with severe side effects and uncertain response and prolonged periods of care beyond the point of futility. Better to know what dying is like, and better to make choices that are most likely to avert the worst of it".
DEATH: In 1990 there were 2,148,463 deaths in the U.S. Heart disease accounted for 33.5% and cancer for 23.5%. 96,824 deaths occurred to people between 15 to 34 years of age (4.5%); 202,170 to those between 35 and 54 (9.4%) and 730,645 occurred between 55 and 74 (34.0%). In 1991, heart disease, cancer and strokes accounted for about 2/3 of all deaths in the U.S. Chronic lung diseases rose to fourth place with 90,650 deaths. HIV infection is 6th among blacks and 8th among all men. It has not yet reached in the top 10 for women.
DEATH: Here are the 10 leading causes of death in the U.S. and their 1992 mortality rate per 100,000 people:
1. Heart Disease, 144.3
2. Cancer, 133.1
3. Stroke, 26.2
4. Lung Disease, 19.9
5. Accidents, 29.4
6. Pneumonia, influenza, 12.7
7. Diabetes, 12.9
8. AIDS, 12.6
9. Suicide, 11.1
10. Homicide, 10.5
DEATH: (Kievman) She suggests the following when you know a spouse is dying:
DEATH WITH DIGNITY: From a woman in the Netherlands where euthanasia is legal. "My husband was a man full of dignity. He was so ill. He would have died a terrible death. He wouldn't have been able to breathe and his mind was getting worse. He was someone who always read a lot of books. But he couldn't even read; he just sat in front of the television and watched videos. He wanted to die like a person, not like some kind of plant...... Can you understand this, dying with dignity?" Yes I can.
Patients who use a caregiver should provide instructions such as
1. The general guidelines for my care are/are not to relieve pain and suffering including narcotics to relieve pain
2. If I am no longer eating or drinking well, I want/do not want artificial means to be used to nourish me such as stomach feeding tubes, fluid injection under the skin or intravenous feedings
3. If I get pneumonia or another infection, antibiotics should/ should not be administered.
4. I do/do not want blood transfusions
5. I want/do not want any surgery to assist in my comfort or dignity
6. I want/do not want to be transported by paramedics to the hospital. I want/do not want to die at home
7. I want/do not want to donate body parts
8. I want/do not want any autopsy or I want a specific autopsy.
HIGH COST OF DYING
(WSJ, 1993) One in every seven dollars spent on health care is spent during
the last six months of life. Most Americans say every person deserves life
prolonging care. But is it worth it? Further, can we afford it?
28% OF THE MEDICARE BUDGET IS SPENT IN REIMBURSEMENTS TO PEOPLE OVER
AGE 65 IN THEIR LAST YEAR OF LIFE. THE BULK IS SPENT IN THE LAST 30
DAYS.
That's about $30 billion. That amount could account for about 2/3 of the cost of providing health care for the 37 million uninsured Americans. About 70% of all who die annually are elderly. And as the average age of Americans get older- currently 12.5% are over age 65- the cost for care will rise dramatically. The ever increasing use of new diagnostic and life prolonging technologies adds another 25%. The issue creates a dilemma for all- morally and financially. But it seems logical that the most care should be spent ONLY on those who have a chance to recover. The right to life forms should be mandatory and limit the excess costs and efforts.
A recent survey of 7,600 elderly in 1986 noted that elderly women have a less healthy last year of life as compared to elderly men. It showed that 14% of all who died after 65 were fully functional and 10% were severely restricted. As age progressed, the statistics obviously got worse. 20% between ages of 65 to 74 were fully functional while only 3% were severely restricted. At age 85, only 6% were fully functional while 22% were severely restricted. Of particular note is that women were 40% less likely than men to be fully functional in the last year of life and 70% more likely to be severely restricted. That's why more women should consider long term health care policies and why all should have Durable Powers of Attorney for Health Care.
DEATH: (1997) This comes from a commentary by Michele McCormick titled "We let Dad die with dignity" where she and her mother agreed to let her father die in peace. She said "in America today, death is considered unacceptable. No matter how serious the illness, how profound the injuries, how poor the quality of life will be, we struggle to protect and preserve each life at all costs. And just as strong as our wish that life not end is the desire to separate ourselves from any responsibility for such an event."
"There is no more wrenching decision that to choose death for another. No matter if the dying person has signed a living will or how inevitably death looms, it is indescribably difficult to make such an irreversible decision."
As her father went further and further into unbearable suffering without any hope of recovery, they both hoped that he would die quickly- or that the doctors would let him. Unfortunately not. A nurse said, "your living will has little force here. If your father stops breathing, he will be resuscitated and put on a respirator. If you attempt to interfere, you will be physically restrained."
Did you read that last part? A loved one is dying. The person has always expressed a wish to not live in pain and suffering when the diagnosis is terminal, but the staff would only continue the unending suffering in a vegetable existence. So they immediately contacted the lead doctor and got a DO NOT RESUSCITATE order. They turned off the machines. "Dad died quietly and with great DIGNITY."
Dying- and putting one in a nursing home- are two of the most excruciating issues that we will ever face. Trying to stay unemotionally detached is impossible. But if you prepare yourself for the inevitable, perhaps suffering on both sides can be reduced.
RISKS AND DYING: (Parade 1997) Americans die most of
1. Heart Disease- mostly caused by fatty diet, failure to exercise, high cholesterol and high blood pressure
2. Cancer can be caused by toxic chemicals, but also by genetics, viruses and smoking and other preventable activities
3. Stroke- same as heart disease
4. Lung disease- obviously the main problem being smoking
5. Accidents most which are caused by human conduct.
6. Pneumonia/influenza
7. Diabetes
8. HIV/AIDS though will probably be less in the future due to protease inhibitors
9. Suicide
10. Liver disease/cirrhosis which may be caused by excessive alcohol abuse.
A professor noted that " by changing personal behavior, people could reduce their risk of dying early by 70% to 80%." Eight of the ten causes of death (excluding pneumonia and diabetes) are often due to human behavior.
DYING (1997): This commentary was written right at the time the Supreme court denied the right to die and also reading an article by Leah Glasheen on "Humanizing end of life Care". She had some excellent commentary
Expand access to hospice care. Medicare does cover hospice to those with only six months to live, but she suggests that it provide freeer access at an earlier time. In reality however, people don't use a hospice when "they really should" since they want to stay at home as long as possible. It may be viable in some limited cases, but I'm not sure that the dying would use it any faster than they do now.
"Hospice care should be available in all clinical contexts whether it is the cancer center, the general acute care hospital, a nursing home or home health agency" says Ira Byock, president of the American Academy of Hospice and Palliative Medicine. He further states that "it's reasonable for the Health Care Financing Administration to start denying payment to facilities that don't provide state of the art pain management and comfort care." I agree. You should be aware that some doctors will still NOT provide appropriate pain medication even when someone is dying.
Provide continuity of care for dying patients since people get traumatized by "minor" things when they are very ill. She wants to make sure that the funding for care follows a patient from one setting to another "which it rarely does now."
Give more support to those caring for dying members.
Provide more info to dying patients and family members about treatment choices. "A major issue in the care of dying patients in hospitals is the tendency of the physicians to use a lot of high tech interventions, even if there is no reasonable expectation that it will change the life expectancy of the patient".
The report noted that a study concluded that "hospitals have a long way to go in making significant improvements. They found poor pain management, unnecessary end of life interventions, inadequate communication with patients and families."
Did this happen in my father's case when he died in a hospital in June? Only to a limited degree. Since my sister was with him most of the time and since the doctor had known my father for some time, the communication was good and the care was also. Was it perfect? No, but neither is dying.
One notable comment is the issue of dying itself- the denial of Americans to a final destiny. In fact, one of the big problems I see in estate planning is that a lot of final planning- including wills and trusts- are not done because of a man. It's not an issue of WHEN they might die. It becomes an issue of IF they might die. The almost total denial causes undue strife on the survivors
WHERE TO DIE(?): (1997) Here is another quirk in medical treatment for the dying. Dartmouth researchers of 37 million patients in 1994 and 1995 found that many on the East Coast are twice as likely to die in a hospital as people in the West. Older people in Miami, New York City and parts of South Texas are especially likely to spend the dying days in a hospital. They also found a five fold difference across regions in the percentage of patients who spend some of the last six months of their lives hooked up to tubes in an intensive care unit. The variations exist even though there is no evidence "that residents tend to be any sicker or to live any longer in the places where patients receive the most medical treatment." They said that some of the government's spending on dying patients- now about 1/3 of all costs of Medicare- is simply not needed.
Some inequities- about 46% of patients in Miami are treated in the hospital's intensive care unit during their last six months of life.
Medicare patients in Newark NJ and parts of NYC may spend up to 20 days in a hospital during their last 6 months of life. Those in Salt Lake City spend just 5.3 days.
Medicare spends an average of $16,571 for hospitals in Manhattan during a patients last 6 months of life. In Oregon, the cost is about $6,000. The average national cost is $9,000, $12,543 in Chicago, $14,212 in Miami and $15,399 in Harlington, Texas. (Such costs do NOT include doctor bills and patients out of pocket expense which would probably double the cost.)
Nationally, about 35% of all Medicare deaths occur in a hospital.
DYING: 1998 The American Heart Association estimates the economic toll of heart disease and strokes will reach 274 billion in 1998 and may get worse because of the growing older population. While there is recent commentary about healthier citizens, the Association indicated that in 1995 over 570,000 heart patients underwent surgery to bypass block coronary arteries compared to 501,000 patients the year before. The average cost of was almost $45,000. In 1995 heart specialists performed almost 420 thousand angioplasty's. They also performed heart transplants on 2,345 the patients in 1996 at an average cost of $209,000. Cardiovascular diseases claimed over 960,000 lives in 1995- more than 41% of all the nation's death. And still not recognized by women is the fact that heart disease is far more prevalent and dangerous than breast cancer. Data for 1995 show that significantly more women died of cardiovascular diseases- 455,052- than caused by cancer of all forms- 281,611 women (see also other data below) . The Association estimates that more than 58 million Americans have had one or more disorders of cardiovascular disease. Of those, 50 million have high blood pressure; almost 14 million have had one more of the disorders such as angina and other four million others had strokes. Hospital and nursing-home care for heart disease patients cost an estimated $120 billion a year. Doctors bills and other charges amount to almost $26 billion. Drugs cost almost $15 billion. Home care and medical equipment cost are more than $10 billion.
MEN'S AND WOMEN'S HEALTH: (Parade Magazine 1998) Men live about six years less than women. The reasons are as follows
Nine out of 10 on the job fatalities are men.
Five out of seven victims of traffic accidents are men.
At least four out of five suicides are men.
Nine out of 10 HIV positively tested are men.
Statistically, it has been shown that men could prevent as much as 70% of their illness by getting regular checkups and tests and eating more healthfully.
But women don't have it all that easy:
Women see a doctor to four times more often than men, go to the hospital more often and take more prescription medicine. Women spend 35 percent more days confined to bed.
One in two women will develop cancer their lifetime. From men, the rate is one in three
Women have more auto immune disease, strokes and clinical depression.
Causes of death
Women, all ages- heart disease 374,849
Cancer 256,844
Strokes 96,428
Lung disease 48,961
Pneumonia or flu 45,136
Diabetes 33,130
Accidents 31,919
Alzheimers disease 13,607
Kidney disease 12,287
Blood poisoning 11,974
Men all ages
Heart disease 362,714
Cancer 281,611
Strokes 61,563
Accidents 61,401
Lung disease 53,938
Pneumonia or flu 37,787
HIV infection 35,950
Diabetes 26,124
Suicide 25, 369
Homicide 17,740
Racial differences are also noted:
Regarding strokes, blacks die twice as often from strokes' as whites. Tuberculosis- blacks and Hispanics get it twice as often is whites. Diabetes- Hispanics get it twice as much as whites. Stomach cancer- Hispanics get it twice is often as whites. Breast cancer-in any given year it's diagnosed at 112 out of 100,000 white women, 95 black women and 70 Hispanic women. At all stages, black women are more likely than white women to be untreated.
Black men have the highest incident of prostate cancer and the world, three times higher than for white men.
In 1996 33% of Hispanics, 23%of blacks and 13% of whites had no health insurance.
TOP KILLERS OF YOUNG MEN
15- 24 25- 34 35-44
Accidents Accidents HIV
Homicide HIV Accidents
Suicide Suicide Heart Disease
TOP KILLERS OF WOMEN
15- 24 25- 34 35-44
Accidents Accidents Cancer
Homicide Cancer Heart Disease
Suicide HIV Accidents
MEN AND WOMEN AND DEATH. At every age, more men die than women. Here is a breakdown:
Male Women
At Conception 56% 44%
Under age 5 51 49
30 and below 51 49
50 -54 49 51
Over 65 41 59
Over 85 29 71
Over 100 18 82
All ages 49 51
DEATH: (NCHS 1998) - 56% of death occur in a clinic, medical center, or hospital (try to avoid that at all costs, if possible. The hospital is a lousy place to die). 19% die in a nursing home and 21% died at home. (The other 4% never died and are living in small suburb of New Jersey.)
Medicare was the principal source of payments for the largest number of decedents (46%). Private insurance paid about 20%; about 10% paid for their own medical care and Medicaid paid about 10%. Over half were covered by private insurance or an HMO and 3/4 were covered by Medicare.
DYING: (1999) (NCHS) 56% of deaths occur in a hospital (though that is the last place you really want to die); 19% die in a nursing home and 21% die at home. 10% of decedents never visited a doctor in the last year of life while 10% made about 50 visits.
Medicare was the chief source of payment (46%); private insurance at 20%; 10% paid their won costs and another 10% was paid by Medicaid. Over had the decedents were covered by private insurance or an HMO and 3/4 were covered by Medicare.
About 25% have had a heart attack and about 25% had angina. 40% had hypertension. A third had cancer and another third had arthritis. 15% had some memory impairment.
Illness or injury kept 10% in bed most of the last year of life. About half had a functional limitation due to a physical or mental condition. 58% received care at home from a spouse; daughters provided 46% of the care and 31% received help from nurses. 39% received pain medication during the last year of life.
50% smoked during at least some time in their life. About 25% used alcohol during the last year; 29% used alcohol every day; 2% used marijuana.
For those that died of homicide, suicide or unintentional injuries, 19% had used alcohol during the previous 4 hours of death and 17% had used had taken drugs or medication within 24 hours of death. 33% involved in an auto accident had not used seal belts.
DEATH: (1999) (Christian Tyler) She noted that life expectancy is still going up and that experts expect a lifespan of between 95 and 100 by 2050. And infant mortality is also on the decline. But death still looms over us as some type of unique and mystifying "problem" that is unfaceable. She stated, "....dying is difficult. Not only does it come later than ever, but it is often physically arduous and psychologically disturbing, a mystery hard to comprehend. It can be ugly and messy; and although the fictional death glamorized for film and television seem ever more popular, the real thing has been swept out of public view". "(People)... are worried about what type of death to expect. They want to enjoy a natural death (whatever that means), to die when they are ready and to be present, so to speak, when it happens."
Also notable was the comment that while many want to extend life as long as possible, many times it is NOT the elderly person making the request and attempts but the family that was never around during life. "It us very often the relatives who insist on the full works. They may not have done much for many years, then they swoop in and say, "I'm here to see that everything possible is done".
Well, I can tell you- as if you may have not already guessed- that death is neither simple nor clean (most of it is real messy) nor cheap. In fact, the World Health Organization says that about half of all state money is spent on the care of its citizens during the last six months of life.
But we are all going to die and I suggest that you put in place whatever forms as Physicians Directives, etc. as necessary in your state so it can be accomplished the way you want.
As a 16th century essayist said (he's also dead now), "Let us deprive death of its strangeness; let us frequent it. let us get used to it....Is it reasonable to fear for so long a time something which lasts so short a time?"
DEATH: (Centre for Living with Dying 1999) "Fear is what stops us from reaching for support when we are in grief of any kind and it stops us from giving support to a friend or loved one. We're afraid to say or do the wrong thing so we do nothing."
MORE DEATH: (Dale Borglum) "Until one comes into some kind of intimate contact with death, spiritual practice will be dilettantish. So may people are yearning to find more meaning in life- they are in crisis control mode of existence, and the encounter with death is very different from this rhythm. Death is a mystery; it can't be done in a busy way."
"Many people spend a lot of energy distancing themselves through staying busy, through various forms of intoxication, keeping themselves from slowing down enough to feel the fundamental fear of death that is at the foundation of human experience."
DYING: (2000) Four out of ten dying patients are in severe pain most of the time according to a recent survey. Another study indicated that family members judged pain to have been moderate to severe during the last three days of life. And from the Journal of the American Medical Association- A survey of cancer patients at nursing home indicated a significant undertreatment for pain, particularly for older patients.
| Ages | No treatment for pain | Non opioid analgesics (Tylenol) | Weak opioid (Tylenol with codeine) | strong opioid (Morphine) |
| 65- 74 | 21% | 13 | 267 | 38 |
| 75- 84 | 26 | 16 | 33 | 25 |
| Over 85 | 30 | 21 | 36 | 13 |
End of Life and Quality Care Article: (2000) "we argue that end-of-life care is fundamentally different from other medical care that is measurable by existing quality indicators."
Death and Dying: (Journal of the American Geriatrics Society 2000) The article provides greater detail about patients' experiences at the end of life. It also summarizes the project's previous findings and suggests how they can be used to improve future treatment of patients and influence federal policy to ensure payment for that treatment.Despite added attention to the issue, research suggests that physicians still have much to learn about caring for dying patients. "For patients with heart failure, death was often unpredictable. So even very close to death, they looked like they could live for another six months. Whereas patients with lung cancer really declined dramatically as death approached, so their death, when it did occur, was very much expected." "In our data, by a pretty solid analysis, most patients do not appear to benefit from artificial feeding. It seems to worsen their chances of surviving."
Even in Oregon, where legislation enabling physician-assisted suicide has brought national attention to the issue of end-of-life care, a study published in the June issue of the Western Journal of Medicine shows that pain levels are increasing among dying hospitalized patients. Complaints of high pain levels increased from 33% to 57% in late 1997, and remained at 54% in late 1998.
Advanced Dementia and medical procedures close to death: (Journal of the American Medical Association 2000). You'd think the medical profession would have advanced far enough by now to know that certain measures were- or were not needed- close to death. Patients diagnosed with dementia can live for about 10 years. But patients with advanced Alzheimers or severe dementia were far more likely to die within six months after a major disease or bone breakage. Such individuals who had pneumonia or a hip fracture would far more likely to die within 6 months of treatment (53%- 55%) even though they received the same treatment as those without dementia (only 12%+). "In many cases, the best treatment may to be to maximize pain control (palliative care) and minimize repeated blood tests and the insertion of intravenous lines and urinary catheters which are painful and frightening to demented patients. Some patients with severe dementia may even be better off without surgery to repair a broken hip." "If the patients didn't walk and is not going to walk again, it may be appropriate to just have analgesics and keep comfortable."
Not surprisingly (and quite unfortunate given the research already done in years past), patients with dementia did NOT receive good pain control. They were given less than half as much pain medication as the patients without dementia." The problem probably is that the demented patients cannot ask for pain medication.
Physician Assisted Suicide (Lawton 2000) "Social attitude toward physician assisted suicide and voluntary active euthanasia are heavily colored by the denial among the younger people that there might come a time when they would be willing to accept a partial life. People in the very later age groups especially have already had some very trying times to deal with and they've developed new frames of reference by which to judge their lives. On the other hand, it's extremely difficult for people in excellent health to imagine incompetency coming upon them."
The Dying Process: Hope for the Terminally Ill: (2000)When a person is diagnosed with a terminal illness, he is confronted with a vulnerability and isolation that belies description. The importance of mundane daily activities fades away in contemplation of one's impending death. Mortality is suddenly confronted, and the concept of hope wanes as the unattainable goal of extended life vanishes. And while denial may temporarily intervene and preclude reality, the fact that life is ending becomes hard to deny as the disease advances. But a seemingly paradoxical question arises: because hope is frequently defined as the expectancy of good in the future, how can a future defined in hours, days, weeks, and months provide hope? To understand the answer to this contradictory question requires an acknowledgment of the dynamic and complex nature of hope and how it changes during the dying process.
Table 1. Interventions that engender hope
Adequate control of symptoms Fostering and developing interpersonal connectedness and relationships Assistance in attaining practical goals Exploring spiritual beliefs Supporting and identifying personal attributes, such as determination, courage, and serenity Encouraging lightheartedness when appropriate Affirming worth by treating the patient as a valued individual Recalling uplifting memories with life review
Dying: (Reuters 2000) At the end of life, many older people who are severely ill from stroke, cancer and other diseases receive PEG, or percutaneous endoscopic gastrostomy--the most widely used form of tube feeding. But researchers at the Indiana University Center for Aging Research in Indianapolis indicate that such tube feeding does not improve the nutrition or overall health of severely ill older people and may be more for the convenience of caregivers and financial decisions. It may be easier for family members to deal with a loved one's death if they know that he or she received adequate nutrition until death, according to the researchers. They note, however, that the flip side of this argument is that tube feeding may only prolong a person's suffering.
They concluded 'We do not have any information that makes us think your loved one will live longer or be more comfortable or functional if we do this procedure. We do know that if the PEG is placed, there is a very high chance that he/she will die soon.''
Cessation of life (2000) -prolonging treatments precedes death in an increasing number of cases, but little attention has been accorded to the quality of dying. In a study of dialysis patients for whom treatment has been withdrawn, researchers found that most deaths following withdrawal of dialysis were good or very good.
Good Death: (Northwestern University bioethicist Linda L. Emanuel, M. D, Journal of Palliative Care Medicine 2000.) Despite the progress made by the hospice and palliative care movement in the care of the terminally ill and helping patients achieve a "good death," a tragic gap exists between the care that dying people want and the care they receive. The reason for this gap is that there is no framework for public policy and clinical interventions relative to end-of-life care that also includes patients' perspectives on what it means to "die well."
Death (2001) Researchers focused on the practices utilized by prominent physicians in the area of bioethics to convey information about advance directives and end-of-life decision making to their patients. Experts spent close to twice as much time (14.7 versus 8.1 minutes,) and were less verbally dominant than other physicians during these discussions. The expert physicians gave less information about treatment procedures and biomedical issues and asked fewer related questions but tended toward more psychosocial and lifestyle discussion and questions. Experts engaged in more partnership building with their patients. Patients of the expert physicians engaged in more psychosocial and lifestyle discussion, and more positive talk than patients of community physicians.
Dying Rich: National Bureau of Economic Research (Mar 2001) Pdf Two researchers in the Office of Tax Policy Research at the University of Michigan, examined data from U.S. federal tax returns to shed light on whether the timing of death is responsive to its tax consequences. The researchers investigated when deaths occurred to discern a pattern of deaths around the time of changes in the estate tax system periods when living longer, or dying sooner, could significantly affect estate tax liability. They found some evidence that there is a small death elasticity, although they admitted they could not rule out that what they uncovered is ex post doctoring of the reported date of death. However, the researchers contend, the fact that they found that postponement, rather than acceleration, of death is more likely to occur suggests that this phenomenon is at least partly a real response to taxation.
FACTS ON DYING LINK: (Brown University Medical School 2001) They found that 14.7% of nursing home residents experience persistent pain after being assessed by the nursing home staff. A study examined the rate of persistent severe pain among all 2.2 million residents of U.S. nursing homes within 60 days of April 1, 1999, finding that of those residents who reported "moderate or excruciating pain" at first assessment, 41.2% reported "severe" pain at a second assessment 60 to 180 days later.
The Edges of Doctoring and "Mercy Killing" (British Medical Journal 2001)Doctors in the Netherlands are allowed to kill patients with "suffering of a medical nature" if they request euthanasia. The law in most other countries declares this illegal. So the Dutch have extended the edges of doctoring. A court in the Netherlands has now decided, however, that doctors cannot accede to requests for euthanasia from patients with "existential suffering" often associated with aging, resulting from loneliness, emptiness, and fear of further decline. The court accepted that the physician’s patient, former senator Edward Brongersma, had endured such suffering. He was obsessed with his physical decline and hopeless existence. He had spoken with his physician on up to nine occasions of his wish to die. But the appellate court accepted that the problems faced were not medical ones and that general practitioners had no expert experience in these questions. It believed that the senator’s physician had promised too soon to fulfill his wish to die, rather than seeking other solutions for his sense of life’s pointlessness. rce: ;323:1384 (15 Dec 2001)
Assisted Suicide: (2002) It is allowed by law in Oregon since 1997. So has there been wholesale slaughter and misuse of the law. In 2001, 44 people had received prescriptions for lethal drugs. But only 21 took their lives. The median age was 68. Thirteen- 62%- were women. About 50% had end stage cancer. I have never seen a problem with this, properly used.
Strategies for Culturally Effective End-of-Life Care (2002) As a result of profound worldwide demographic change, physicians will increasingly care for patients from cultural backgrounds other than their own. Differences in beliefs, values, and traditional health care practices are of particular relevance at the end of life. Health care providers and patients and families may not have shared understandings of the meaning of illness or death and may not agree on the best strategies to plan for the end of life or to alleviate pain and suffering. Good end-of-life care may be complicated by disagreements between physicians and patients, difficult interactions, or decisions the physician does not understand. Challenges may result from cultural differences between the patient's background and traditional medical practice. Values so ingrained in physicians as to be unquestioned may be alien to patients from different backgrounds. Physicians need to be sensitive to cultural differences and to develop the skills necessary to work with patients from diverse backgrounds.
Death with dignity: The Pope does not accept assisted suicide- but neither does he believe that every measure must be taken in a terminal situation. "Telling the doctors that caring for patients must take into account not only the body but the also spirit. And in this perspective, extreme measures at all costs, even with the best of intentions, would be, in the end, not only useless but not fully respectful of the patient who has reached the terminal stage."
Reforming Care at End of Life: A Case Study (Annals of Internal Medicine 2002;137:117-122 (16 Jul 2002) Most people in developed countries will live with a serious, eventually fatal, chronic condition for months or years before dying; yet, the delivery of health care services has only just recently begun adapting to this reality. Quality improvement methods have been effective in helping clinical services to make substantial changes quickly. This paper discusses a composite case study in a nursing home setting, which builds on experience with multi-site collaborative efforts and introduces quality improvement methods in the context of end-of-life care.
Dying: (2002) 10 tips from David Woods, president of the Life and Health Insurance Foundation for Education (LIFE) to make your dying a little less trying for your loved ones.
1. Have a will and update it periodically. The will designates executors, guardians and trustees, which are all important to review periodically. Your executor's first task is to locate your will, and you can help by keeping the original in a fairly obvious place. A good start is to put your will in an envelope on which you have typed your name and the word "Will." You should then place the envelope in a fireproof metal box, file cabinet or home safe. An alternative is to put it in a safe deposit box.
2. Have health care directive (living will). A living will is a medical directive written in advance that sets forth your preference for treatment in the event of your inability to direct care. The document may be drafted to include when the directive should be initiated and who has the decision-making responsibility to withdraw or withhold treatment.
3. Have a power of attorney. You should name your spouse or a close friend or relative to have power of attorney for you. Whoever you designate will be authorized to manage your affairs, typically financial ones, if you're not able to handle them yourself.
4. Have life insurance. Purchase adequate life insurance for yourself now to help your family avoid financial pitfalls later. Having the right amount of coverage will help ensure that the dreams you have for your family will be realized even if you're not there to witness them. Determining how much life insurance to buy can be complicated, so it often helps to seek assistance from an insurance agent or other financial advisor.
5. Review beneficiary designations for your various financial accounts (retirement, life insurance - both personal and through work). Check annually to ensure those named in your insurance policies, 401Ks and the like are still relevant to your needs and wishes. Many people are under the misconception that if they have a will, they are covered. This is not true - beneficiaries designated in documents generally fall outside the scope of a will so it is critical that you keep your records updated.
6. Specify where important financial account information is located (savings, retirement, college funding, mortgage, insurance). It may sound like an obvious thing to do, but few people keep a list of their important records, and fewer still could name them all quickly in an impromptu quiz. Keep a master list and review it annually. Include bank accounts, mortgages, retirement plans, health care plans, investments, creditors etc.
7. Specify where important non-financial information and valuables are located (marriage certificates, birth certificate, titles/deeds for the house/cars, passports, jewelry, safe deposit box key, items in storage facilities)
8. Specify your final arrangements (burial or cremation, where you want to be buried, whether you want to be an organ donor)
9. Have a list of professionals who assist you with your family's legal and financial affairs (insurance agent, attorney, accountant, etc)
10. Explain to heirs how your trust works. Trusts are often a useful legal and estate-planning device for protecting assets from estate taxes and providing a vehicle to be sure survivors gets proper administrative and investment advice and counsel. An attorney is the best source of information about the proper use of trusts and whether one would be appropriate for you.
End-of-Life Care: (2003) Questions and Answers National Cancer Institute
Dying (USA Today 2003) Half of the 1.6 million people living in nursing homes suffer from untreated pain. A report on each states ability to provide eight end of life services generally got a rating of c, d or f.
Just 25% of Americans die at home surrounded by friends and family- though 70% would prefer to do so. That said, it is impossible to treat many of them at home with certain diseases though it still should be greater than 25%.
35 states have laws making it hard for doctors to prescribe medication to dying patients.
Mst Americans get aggressive end of life care in a hospital and not at home.
Most U.S. hospitals still do not have end of life programs that automatically deliver services to the dying patient.
Just 39% of doctors caring for dying patients had been trained in issues that some up as death approaches.
Dying: Daily Review (Leonard Laster 2003)- The article noted this comment from a child whose dying elderly mother was being taken care of by a young physician, "From our vantage pint, he could have done better job of managing her decline. To us, his care verged on being insensitive and of a quality that one would not wish for anyone's parents when their time comes."
Also, during her final days, she was often in pain. "To relieve her, the doctor ordered a medication. But the dose was very low..... As the situation progressed, it became clear that my mother in law was not receiving enough pain medication." It took two weeks and a meeting before an ethics committe before the hospice suggestions were ordered and she was put on intravenous morphine." She died three weeks later.
This attitude by a physician is "hard to believe" but exists in too many situations with the elderly.
Dying: Excellent Insight (2003) - Anxiety, depression, hopelessness, and confusion are commonly experienced by patients at the end of life. The prevalence of depressive disorders among the terminally ill has been reported to be as high as 77 percent while delirium or confusion affects an estimated 85 percent of persons near life's end.
Nonphysical concerns such as hopelessness, loss of dignity, and the sense of being a burden to one's family are the source of much suffering and most often cited by patients who request assistance in death.
physicians often pay less attention to the psychiatric aspects of a patient's care because of time pressure, preoccupation with physical symptoms, and lack of training in or comfort with making psychiatric diagnoses.
Yet, those doctors who are least comfortable with making and treating psychiatric diagnoses are the ones most likely to care for dying patients.
Project on Death in America: Newsletters
Promoting Excellence : Critical Care Workgroup : Seven End-of-Life Care Domains. (2003) Exceptional material by exceptional people.
Domain 1 - Patient and Family Centered Decision Making
Domain 2 - Communication within the Team & Patients/Families
Domain 3 - Continuity of Care
Domain 4 – Emotional & Practical Support for Patients/Families
Domain 5 – Symptom Management & Comfort Care
Domain 6 – Spiritual Support for Patients/Families
Domain 7 – Emotional & Organizational Support for ICU Clinicians
Assisted suicide: Oregon said Attorney General John Ashcroft has no right to interfere with doctor-assisted suicide in Oregon because states have historically regulated the practice of medicine. The law, approved by voters in 1994, lets doctors prescribe a lethal dose of narcotics to terminally ill patients who request assistance.
In 1997, the U.S. Supreme Court ruled that states could decide whether to allow assisted suicide
"Patterns of Functional Decline at the End of Life,” (2003) Health care workers need to move away from a “one size fits all” approach to palliative care, researchers conclude.
New scientific evidence reported by the National Institute of Nursing Research (NINR) shows consistent patterns of decline of functioning for four different types of dying. This suggests that different pathways to death require more flexibility of healthcare and hospice services to meet the needs of critically ill patients whose time until death is unpredictable.
While 23% of Americans die of cancer — a disease with a distinct terminal stage associated with palliative care — those who are chronically ill are not diagnosed as terminal, "yet they may also need palliative care,"
Palliative care offered mainly by hospice emphasizes compassionate therapies focused on physical, psychological, social and spiritual needs of the patient, family and caregiver. Currently, those services may not be available, because reimbursement for hospice requires a diagnosis that predicts a life expectancy of six months or less if the terminal illness runs its normal course.
The four pathways to death are:
1) Sudden Death. There was no functional decline for this group.
2) Expected Death in the short term from cancer. The cancer patients had good functional status early in their final year that degenerated markedly three months prior to death.
3) Entry-Reentry Deaths, where people slowly get worse but go home between hospital stays. These patients have a serious chronic illness that presents an ongoing threat of sudden exacerbation and death caused by organ failure.
4) Lingering, Expected Deaths, associated with frailty in old age. Patients have no reserve defenses, and either die when an unpredicted medical challenge occurs or decline so gradually that signs of the end cannot be clearly identified. Twenty percent were classified as frail in the study, and they were relatively disabled throughout the year before death. These patients typically resided in nursing homes.
Has Anyone Ever Died of Old Age? (PDF) LONGEVITY CENTER–USA, Leonard Hayflick, Ph.D., Harry R. Moody, Ph.D.
Means to a Better End: A Report on Dying in America Today
Notifiable Diseases/Deaths in Selected Cities Weekly Information
Cigarette Smoking-Attributable Morbidity --- United States, 2000
LTC- (2003) MetLife’s research study entitled “Financial Impact of Premature Death” notes a disturbing financial picture from the point of view of the surviving spouses:
Two-thirds of spouses (65%) reported that the death had a “devastating” or “major” financial impact on the families’ financial security.
More than one third (39%) of surviving spouses received no life insurance proceeds at all.
Two-thirds of spouses who did receive life insurance benefits, received proceeds that were less than three times the annual income of the deceased. One in four beneficiaries received benefits that replaced less than one year of the deceased’s income.
Less than half (46%) of the spouses who received life insurance proceeds described the amount of coverage as “adequate.”
Nearly half (46%) of deceased spouses did not have a will.
In addition, many families were required to make significant financial adjustments, including working additional jobs, longer hours; withdrawing money from savings accounts, retirement accounts and investments; moving to smaller, less expensive housing, reducing spending on their children’s education; and borrowing money.
Dying: MetLife's "Financial Impact of Premature Death" 2003 study of widows and widowers reveals the necessity of adequately assessing personal life insurance needs. Participants indicated an average recovery period of four to five years before their financial circumstances returned to what they were at the time of their spouses' deaths. Disturbingly, two-thirds of spouses reported that the death had a "devastating" or "major" financial impact on the families; more than one third of surviving spouses received no life insurance proceeds at all; and two-thirds of those who did receive proceeds received less than three times the annual income of the deceased. Also, nearly half of deceased spouses did not have a will.
A good death: (NY Times 2004) All too often, life is prolonged in pain or discomfort, with medical interventions and instruments precluding an opportunity for loved ones to say goodbye. "Poor communication is not the only obstacle to a peaceful death. "Some patients are overtreated, receiving aggressive care until their last breath. Others are undertreated, so much so that their final moments are steeped in physical pain. Still others receive conflicting advice from doctors and nurses on the best course of action, leaving them confused and unprepared for death."
In a 1996 report endorsed by more than 30 health care groups, the American Geriatrics Society listed nine important factors for quality care at the end of life: alleviating physical and emotional symptoms; helping the patient maintain dignity; using treatments that reflect the patient's wishes; avoiding "inappropriate aggressive care"; giving the patient and family quality time together; giving the patient the best possible quality of life; minimizing the family's financial burdens; informing patients about insurance coverage; and helping the family with bereavement.
But six years later, a review of care near the end of life published by the geriatrics society revealed "overwhelmingly disappointing results. Far too many deaths were still marred by unwanted treatment and hospitalization, inadequate relief of pain and other debilitating symptoms, and inept communications.
End of Life Decisions- collections from other journals (2004)
The Uniform Simultaneous Death Act was adopted in most states. (2004) The act states that when an insured and beneficiary have died and there is not sufficient evidence to determine who may have died first, the insurance policy benefits will be distributed as if the insured had died after the beneficiary. If, however, there were evidence that the beneficiary died after the insured, that there was short-term survivorship, the insurance policy benefits would go to the beneficiary’s estate.
Dying: An average of 195,000 people in the U.S. died due to potentially preventable, in-hospital medical errors in each of the years 2000, 2001 and 2002.
"If we could focus our efforts on just four key areas -- failure to rescue, bed sores, postoperative sepsis, and postoperative pulmonary embolism -- and reduce these incidents by just 20 percent, we could save 39,000 people from dying every year."
Dying: (NY Times 2005) For the last few decades, the share of Medicare costs incurred by patients in their last year of life has stayed at about 28 percent.
End-of-life care does prolong life but may end up only prolonging suffering. In such cases, reducing pain may be a better use of resources than heroic attempts to save lives.
One doctor noted, "Sometimes, you know that death is inevitable over the next few weeks or few months," he said. "And then there are some doctors, and some families, who just don't want to confront that, and feel that they want to and should invest everything possible - the maximum amount of resources - in fighting the inevitable. That often results in prolonging the pain and discomfort of dying."
An alternative to saying no would be to encourage severely ill patients to choose hospice care, where the emphasis in treatment shifts from cure to quality of life. Patients are made to feel as comfortable as possible, and reducing pain takes precedence over radical procedures. At present, only about 1.6 percent of Medicare benefits pay for hospice care.
Despite the less-intensive brand of treatment, hospice care may not be cheaper than hospital care.
Dying: (WSJ 2005) doctors and hospitals are working to give patients more autonomy at the end of life, offering them more options to decide how, where and sometimes even when they die.
While in the past doctors assumed that being depressed was normal for the terminally ill, some are now prescribing antidepressants and antianxiety medications even to those with only a few weeks left to live.
Doctors are also increasingly willing and able to help patients come closer to timing their deaths, sometimes helping patients who want to remain alive to see a particular event.
In a 2004 study published in the Journal of the American Medical Association, researchers surveyed the families of 1,578 people who had recently died and found that about one-quarter of patients didn't receive adequate treatment for pain and shortness of breath.
Below are some of the new options that patients can discuss with their doctors.
Relieving Symptoms
The workhorse of pain medication is still morphine, a 200-year-old drug that is effective -- and controversial. That is because very high amounts can depress respiration and even cause someone to stop breathing.
But a number of more advanced pain treatments have been developed in recent years. And perhaps more significantly, palliative-care centers are finding success treating the dying with medications not necessarily meant for terminal illnesses.
Keeping patients symptom-free often requires doctors to juggle multiple medications. If every symptom can't be alleviated, some doctors at hospices and palliative-care programs are now allowing patients to choose which symptoms they want addressed. For example, sometimes shortness of breath -- which can be caused by congestive heart failure, lung cancer and other conditions -- can only be relieved if a patient is in a sleep state. "I've had patients who have said they would rather be breathless and awake," says Dr. Morrison of Mount Sinai.
There is also some new thinking on morphine itself. Recent studies suggest that morphine, though it can depress respiration, doesn't actually hasten death. A study published last year in the journal Chest showed that among 75 patients withdrawn from ventilators that help them breathe, those treated with morphine and antianxiety medications died in about the same time as those who weren't treated. The new data have made some doctors more comfortable about using morphine in big enough doses to control pain.
When to Die
The decision about when to say "enough" is now much more complicated than just whether or not to turn off the machines. Doctors at palliative-care centers and elsewhere are increasingly amenable to pursuing aggressive treatment for patients who are willing to endure it in order to gain even a little more time.
For example, stopping dialysis in someone with kidney failure usually leads to a peaceful death -- the person gets sleepier and sleepier until he or she falls into a coma and slips away. Alternatively, the patient would ultimately die of something else, such as a severe infection or a gastro-intestinal hemorrhage that could make for a more painful death. Some doctors are reluctant to push aggressive treatment that will buy only a little time and perhaps cause more suffering.
Where to Die
The movement in recent years to allow more people to die in their own homes is getting a further push from hospices and palliative-care programs. House calls from doctors and nurses and portable medical equipment, such as morphine pumps, are making it easier for people to die in familiar surroundings.
Mental Health
While deep sadness is normal and expected in dying patients, some doctors say that more-severe symptoms of depression can and should be treated -- even in patients with only a few weeks to live.
Traditional antidepressants, however, such as Prozac and Paxil can take weeks to work, time that some dying patients don't have. Now, doctors in palliative-care programs have found that using Ritalin can lift depression in just days.
Coping with Grief By Dorothy Womack
Today I am talking to those of you who are the remaining spouse, having placed your loved one into a care facility.
Perhaps you are the type of person who needs to stay busy rather than just sit at home when coping with this condition known as Alzheimer’s. I would suspect that this is the case: God is making a way of escape for you by leading you to influential people in order to make a significant difference in the lives of other Alzheimer patients and caregivers. As far as your personal life goes, you are in the midst of living your grief out already. Even though your mate is still alive, you are daily suffering from the loss of the intangibles that make up their unique persona. Their personality is deteriorating along with their body; you are completely separated from your companion of a lifetime. You know that nothing is ever going to be like it was before. Your shared home is just an empty reminder of better days.You live daily with the memories of the trauma endured when you two lived there together.
Grief started for you long before your loved one entered the care facility. These feelings will continue on after their physical death. The thoughts you have are normal. Remember that you are suffering losses every single day, in some form or another. You probably never intended to be apart from each other until one of you died. Instead, every day, they are dying in front of you on many levels. Although you know that their spirit remains unchanged and lives on forever, seldom will you see that side of them when you are together. Right now, it is hard for you to grasp that you are never alone, even though they are leaving your life a little at a time. You know the grief of caregivers around the world; the grief that is caused by separation from a lifetime partner who has not left this world yet. You will one day face and accept that they have gone on to Heaven and left you behind in this world. Please remember that none of this was by their choice. We may never understand why this disease took them away but we do know they cannot come back as the strong, dependable, communicative and protective partner that they once were. Those days are gone for good.
Part of the process of grieving is to face these undeniable painful losses as they occur and then find the strength to overcome their staggering impact. I believe this is what you are attempting to do by continuing to be a part of the world around you. The longer you have loved someone, the longer and more pronounced your grief. You grieve now while they still remain in their body. You will grieve more when they leave. Eventually that grief will turn to a form of peaceful acceptance. You will know they have gone on ahead of you. Then it will no longer bring you pain and devastation. You will come to a place of acceptance over all of this, every single bit of it. Grief does not end overnight and the more sensitive you are, the longer it takes. You can expect grief to last as little as 6 months or as long as 5 years, depending on the person. It is because you are so sensitive and love so deeply, that you grieve so much. Never lose sight of the truth; you and your loved one are one for eternity. Remember that love is the most important commodity we have on this earth. Walk in it always, and you will be okay in the outcome.
Life and Death": A survey of American attitudes toward Life and Death shows a nation of citizens who are worried about illness, accidents, old age, and death, yet who are unwilling or unable to spare the money or attention required to prepare for what they fear. A substantial majority of 79% agree that Americans have become generally more anxious, yet only 16% feel up to contemplating the costs of old age and illness, 48% prefer not to think about the costs associated with illness and death, and 41% percent say that, at this point in their lives, they don't have money to spare for insurance.
Overall, 55% of respondents have become more concerned about dying unexpectedly, 52% have become more concerned about a friend dying, 76% have become more concerned about an elderly relative dying, and 81% have become more concerned about a close family member dying.
Only 53% of the sample have homeowners insurance, for instance, and only 12% have renters insurance; fully a third of respondents (33%) are without any form of housing insurance, leaving them open to potentially enormous costs in the event of fire or another such event. The dwellings of the youngest cohort, those aged 18-29, are predictably the least insured-just 42% have home or renters insurance. But even the older cohorts aren't properly covered: 73% of 40-49s, 83% of 50-59s, and 81% of over-60s.
Asked whether they and their families have adequate insurance for a range of circumstances, 27% indicated they are not covered for general medical costs, 33% have no critical-illness coverage, 46% are short on income protection in case of disability, 32% are vulnerable on personal liability, 35% have no life- insurance coverage, 37% have inadequate coverage for funeral costs, and a very high 55% are short on coverage for their "twilight years" care in a residential home with medical facilities.
Dying (HealthGrades, Inc 2006) "a typical patient may be 65% less likely to die at a hospital with high quality ratings than at a hospital with low quality ratings."
Describing the road to death- (2006) A hundred years ago, more than 80% of Americans died of acute illnesses, mainly pneumonia, tuberculosis, and complications of infectious diarrhea and childbirth. Rapid death was common, and much of it occurred in the young.
By 2000, more than 80% of Americans died of illnesses that were chronic and progressive, mainly heart failure, cancers, progressive lung diseases, and complications of stroke and dementia. Today, rapid death among the young is rare, while predictable death among the aged is the norm.
Symptoms of Major Health Conditions Affecting the Elderly
Let's Not Talk About That Now... By Jennifer Kay (2006)
Too often families do not like to talk about issues surrounding death, dying and funerals. Why should they ask? Soon enough we all will have to deal with these issues. So what’s wrong with waiting till the need arises?
Just like you need to know about health insurance, life insurance, social security benefits and living wills, knowing about funeral arrangements and cemetery property helps you make the financial and emotional decisions you will be comfortable with in years to come.
Over the years, the funeral and cemetery industry has changed. It makes sense for the consumer to pre-plan their arrangements, not only because there is incentive to do so, but even more, because there are also many emotional benefits to pre-arrangements.
ASK YOURSELF AND YOUR FAMILY TO CONSIDER THE FOLLOWING QUESTIONS:
What’s really involved in a funeral arrangement? Most families, if asked this question will answer “They pick up the body and take it to the cemetery.” Nothing could be further from the truth! A good funeral director will sit with your family and hear what your family members are saying. Do you all want the same kind of funeral? Do you all agree on the same casket? Are there “Feuding Members of the family” who will all want to be heard at the funeral? Who will speak? What type of clergy will be appropriate for your family? How will your loved one’s memory be reflected at the service? Will you have a service at all? And if not, will you regret that afterwards.
In addition to preparing many documents and obtaining appropriate signatures, arranging for the death certificate to be signed and notifying Social Security of the death, the funeral director is also a liaison between the family, clergy and the cemetery staff. If selected wisely, your funeral director will be your family’s advisor, helping them to feel comfortable and making sure your wishes are being honored. Funeral directors “work behind the scenes” from the moment they are contacted, insuring things are being done correctly and in a timely manner.
What is involved in purchasing cemetery property? Most cemeteries have many different properties that you may purchase. You may choose a niche (A space in a mausoleum to place the cremated remains), a grave in a section with a headstone or a grave in a section which only has flat markers, a crypt in a community mausoleum or a separate, private family mausoleum. There may be a requirement for an outer enclosure (sometimes called a vault) as well as labor fees for burial.
How important is the location? Is convenience for visiting, beauty of the cemetery or being in or near the family plot the greatest priority? If a cemetery is located in a residential neighborhood, how will you feel as the neighborhood changes? Is this your second marriage and which spouse would you like to be buried with? Do you want to purchase extra plots for unmarried siblings or children and their families? These re just a few of the questions you need to consider.
What are my family’s values about funerals and cemeteries?
Often, I hear people saying things like “Just give me the cheapest funeral possible: I wont be here to know the difference.” While this may make economic sense to you, it frequently leaves those behind without a sense of closure. Funerals are a time for people (whether it is 2 or 200) to come together too say good-bye and honor the deceased. It is important for your family to have a dialogue and have everyone’s feelings considered. In addition, not everyone in a family has the same religious beliefs. These feelings need to be considered also. Usually most everyone’s needs can be respected if discussed in advance.
Remember that pre-arrangements are a blueprint for your wishes. While funeral or cemetery pre-need counselors can help you with these decisions they cannot anticipate all your family’s needs. Therefore these arrangements are flexible and can be changed. At the time of death, your funeral director will meet with a spokesperson for the family and review all the arrangements to make sure the family information is correct and current. At that time, adjustments will be made if needed. Before you choose a funeral director and cemetery, you might want to take the time to visit the facility and meet the staff who will be working with you.
Consider whether or not you have talked with your family about this important topic. While many people feel that their family can take care of this at the time of their death, they do their surviving family no service by leaving it till then! Like any other major purchase you would make, you should be an informed consumer and get the information in advance.
Home Hospital: (2006) it offers sophisticated medical oversight -- including nurse and doctor visits, X-rays and other tests -- to patients willing and able to receive such care in their own beds. The average length of "stay" for the at-home patients is a little more than three days, compared with an average of about four days for patients choosing to stay at the hospital.
the price tag for treating similarly ill patients at home was $5,081, or a third less than the $7,480 cost of treating a patient in a hospital bed.
Hopkins' two-year pilot study starting in 1996 suggested that home treatment was as safe and satisfactory as hospital care. With lower overhead -- such as room costs, electricity and meals -- and fewer costly tests to administer, the program, which tracked 17 patients, was also found to be about 60% cheaper.
Dying: (2006) Six months after the deaths of spouses, almost half of those studied showed few symptoms of grief.
In the past, mental-health professionals often suspected people who show little grief are "either in denial, emotionally distant, or lacked a close attachment to their spouses. But the study found that older widows and widowers tend to view death as fair, and a natural part of life.
Losing someone later rather than earlier in life tends to lead to a far-shorter period of mourning. "Many older couples have achieved all they hoped to do together. They've seen children and grandchildren thrive in adulthood. They think, 'OK, now I can die.' " Each year, about 650,000 Americans over 65 lose spouses. Just 16% of surviving spouses in the study showed signs of "chronic grief" -- including high levels of depression -- 18 months after their loss.
Dying- (USA 2007) If you are dying in Miami, the last six months of your life might well look like this: You'll see doctors, mostly specialists, 46 times; spend more than six days in an intensive care unit and stand a 27% chance of dying in a hospital ICU. The tab for your doctor and hospital care will run just over $23,000.
But spend those last six months in Portland, Ore., and you'll go to the doctor 18 times, half of those visits with your primary care doctor, spend one day in intensive care and stand a 13% chance of dying in an ICU. You'll likely die at home, with the support of a hospice program. Total tab: slightly more than $14,000.
Portland and Miami reflect that tremendous variation among regions. The most expensive city out of 309 hospital referral regions is Manhattan, at a cost of $35,838 for the last six months; the least expensive is Wichita Falls, Texas, at $10,913.
Estimates show that about 27% of Medicare's annual $327 billion budget goes to care for patients in their final year of life.
experts on the end-of-life care say one main reason for the vast difference between the two cities may be that in Oregon, doctors, or staff at hospitals and hospices, encourage patients with life-threatening illnesses to talk about the end of life, what kind of medical care they want and where they want to die. The state has a history of such debate: Oregon residents have long supported palliative care, a term usually used to describe medical care for the terminally ill that focuses more on comfort treatments than cures. And, in 1994, voters there became the first in the nation to approve doctor-assisted suicide, a referendum signed into law in 1998.
TALK IT OVER WITH DOCTORS, FAMILY by Laura Parker (2007)
Is a living will enough? When planning end-of-life decisions, not always.
Legal and medical analysts encourage people preparing advance directives to talk over their wishes with their doctors, their family and their health care surrogate.
"The idea that we could somehow control all of this complicated communication through a piece of paper is asking way too much of the law," says Bill Colby, an attorney who represented Nancy Cruzan in a 1990 landmark Supreme Court right-to-die case. The high court allowed a feeding tube to be removed from Cruzan, who had been left in a persistent vegetative state after a car accident seven years earlier.
Several states, including Oregon, Washington, New York and West Virginia, have begun programs that use forms known as POLST, or Physicians Order for Life Sustaining Treatment. These forms travel with the patient from one health care facility to another.
More important, they also translate the patient's wishes into doctors' orders, written onto medical charts. The forms are recognized by medical personnel from emergency medics to nursing staff and physicians at hospitals and nursing homes.
"Millions of people in this country have completed advance directives and think they have taken care of everything," says Susan Tolle, a physician and director of the Center for Ethics in Health Care at Oregon Health & Science University in Portland, who pioneered Oregon's POLST program. "But unless they have written orders to put wishes into action, you can't be sure."
Death- (2007) National Geographic magazine recently listed the lifetime probabilities of a U.S. resident dying in relatively common ways. Given that there are now about 300,000,000 U.S. residents, here's a listing of how many of us are likely to die in each of the listed ways:
heart disease 60,000,000
cancer 42,857,000
stroke 12,500,000
motor vehicle accident 3,571,000
suicide 2,521,000
falling 1,376,000
firearm assault 955,000
pedestrian accident 479,000
drowning 298,000
motorcycle accident 294,000
fire or smoke 270,000
bicycling accident 61,000
air/space accident 59,000
accidental firearm discharge 58,000
accidental electrocution 30,000
alcohol poisoning 30,000
hot weather 22,000
hornet, wasp, or bee string 5,300
legal execution 4,800
lightning 3,800
earthquake 2,600
flood 2,100
fireworks discharge 900
Dying: (USA 2007) For patients who are dying of cancer, few things are as profound as their relationship with God. Among the terminally ill being at peace with God is more important than just about anything else, ranking only marginally lower than the desire to ease physical pain.
Patients who felt "completely supported" spiritually reported better quality of life, Balboni says. On a 50-point scale, those who felt totally supported rated their quality of life 14 points higher than those who had no support.