Successful Elderhood and A Good Death

littleton elder law

Mercury and his Caduceus

This is my second installment on the theme of successful elderhood and its obstacles.

In this post, I am revisiting the theme of “a good death.”  I first wrote about this in 2013 and recounted my experience with my father’s death at his home in 2010.  As I write this post, I am reminded that this theme is picking up more attention.

Perhaps I will start with the practical first – how does one, with her or his own planning or good fortune, as well as with the assistance (and sometimes this is a difficult term to use in this context) of loved ones or others – pull off a good death?

Let’s start with some numbers here.

Here are some recent (released 4/16) figures from the U.S. Centers for Disease Control and Prevention which shed light on older persons’ health and mortality.  Looking at the data in NCHS data brief No. 182, from January 2015 – it states:

From 2000 through 2010, the number of adults aged 85 and over in the United States rose 31%, from 4.2 million to 5.5 million, and in 2010, this age group represented almost 14% of the population aged 65 and over (1). It is estimated that by 2050, more than 21% of adults over age 65 will be aged 85 and over (2). Given this increase, adults aged 85 and over are likely to account for an increasing share of hospital utilization and costs in the coming years (3). 

 This is an interesting report – it offers a solid basis for my concern when I hear of one of my old (85+) clients being hospitalized!  When we look at hospital admissions for the old of the old (folks 85 and over), we see the top six causes (for 2010) for hospitalization as: congestive heart failure, pneumonia, urinary tract infection, septicemia, stroke, and fractured hip.  The likelihood of hospitalization for any type of injury for the 85 and over cohort was higher than the rate of either of the 65-74 or 75-84 groups.  The same group of 85 and over was also the least likely to be discharged to home and the most likely of the three groups to be discharged to a long-term care facility or to die in the hospital.  Of note here is the 6% figure for deaths, which is double that for the 65-74 group.

How many septuagenerians and octogenarians plan for or talk with others (from whom they will need support for their decisions and choices) about “a good death?”  Well, I haven’t seen any real statistics on that!  Keep in mind that Medicare recently (in January of 2016) started paying doctors for having an end-of-life consultation with their patients, so that seems like a good start. But there may be a glitch to that simplicity, as information used in a recent Forbes article shows that almost a third of doctors say that they don’t really have a formalized system of talking to patients about such matters and the same percentage (29%) they haven’t had any training on how to talk with patients and their families about such topics.

So with this rather bleak picture of the status quo before us, how is it that we can better come to grips with forging a better – more humane and dignified – path to death?  Where are the sources of this helpful information? Well, we can start by listening to the dying!  Keep in mind that dying isn’t simply a medical process, a failure of intervention or curative   measures – it is a physical process which is inevitable for every living being.  Palliative and hospice care offer  means toward that end in the medical context, but as we know there are often a number of emotional, legal, financial, psychological and cultural obstacles which can appear at the end of one’s life.

I liked this article from The Greater Good which offered the following points under the subtitle “how to die well:”

  1. Experience as little pain as possible;
  2. Recognize and resolve interpersonal conflicts (it lists Dr. Ira Byock’s Four Things here) to say  – I love you; thank you; I forgive you; and please forgive me;
  3. Satisfy any remaining wishes that are consistent with their present condition;
  4. Review their life to find meaning;
  5. Hand over control to a trusted person, someone committed to helping them have the kind of death they desire;
  6. Be protected from needless procedures that serve to only dehumanize and demean without much or any benefit; and
  7. Decide how social and how alert they want to be.

These seven means seem simple enough – but remember the big difference between simple and easy! Can any of us really know when death is near, when the dying part of our life or another’s is taking place?  If we start considering the possibility, then we see opportunities.  But these questions obviously don’t have definitive answers!  For all of our talk about health care self-determination, we – not just the individuals making the advance directives, but also upon those on whom the dying rely for assistance, have precious little experience with really thinking through the “what happens if” and the “what happens when” scenarios.

So I will close this post with two challenging questions –

How difficult will it be for someone over 85 to not be transported to a hospital for treatment at the end of a long and difficult illness  – particularly if the trip to the hospital is for the treatment of an injury that is not related to the terminal or chronic illness?

How difficult is it for us to adjust our thinking about these things as we age and become more frail and less able to withstand the medical interventions which were more likely to be restorative or curative in our younger years?

PS Don’t forget that Friday is Denver’s Senior Law Day! The morning event is scheduled for the PPA Event Center and you can buy your tickets here.

© Barbara E. Cashman 2016   www.DenverElderLaw.org

Dying With Grace, Dying With Dignity, part II

Beaver Lake, Marble, Colorado

This post is the second installment about dying, a personal one for me as it recounts my father’s death.  I began the first post with this quote from a PubMed.gov  article  I found about dying with dignity:

The definition of dignity in dying identifies not only an intrinsic, unconditional quality of human worth, but also the external qualities of physical comfort, autonomy, meaningfulness, usefulness, preparedness, and interpersonal connection. For many elderly individuals, death is a process, rather than a moment in time, resting on a need for balance between the technology of science and the transcendence of spirituality.

Here is a link to the first post which talks about the three psychospiritual stages of dying and I look at the final stage, transcendence, in this post.

Transcendence   Just a couple days after returning home, he started slipping away.  My dad went through most of the “classic” aspects of the nearing death phase of surrender and transcending.  I remember telling someone who was visiting him why he was either swaying back and forth, like a kid on a rope swing, or why he put his legs in the air and held his arms out in front, as if he were riding a bicycle.  I explained that he was travelling, back and forth if you will, and that this movement was part of the letting go of surrender, moving in the direction of the end.  I remember a conversation I had with Diane, a family friend, who related a late friend’s similar movements towards the end of his life – but he was driving his car to that destination.

Dad passed away less than a week after returning home.  As his time grew nearer that Monday evening, my brother asked me if it was time for the scheduled syringe of oral medication.  I checked the progress of his breathing, which seemed so shallow at that point as to be just a couple inches into his throat.  I knew that the time was near.  My other brother came into the room then and we all grew quieter.  I left the room to find my mom and got a seat for her in the corner of the bedroom.  I was near the foot of dad’s hospital bed and my brothers were on either side of dad’s head when they heard my mother mutter something – almost under her breath.  My brother asked “what did you say Mom?”  I responded without hesitating:  “she said, she forgives you for dying.”  At that point, dad took his last breath.  I’m sure that it was what he was waiting to hear, after all that time.

So what is letting go? Kierkegaard observed that faith is the end of hope.  Faith is what you come to after hope is . . . . abandoned (yes in Dante’s Inferno terms).

When we can let go into another’s dying process, it is possible that we can make it easier for them, giving them “permission” to leave.  The dying person’s letting go, Singh observes at 203, is “not a choice.  None of these transformations of the dying process has been a choice.  Human consciousness unfolds itself as it will unfold itself.”

There is no denial in the heart, only in the mind – the mind is the seat of the egoic control center.  The heart maintains no such illusions!   At the time of surrender, the person’s consciousness unites, or reunites with the ground of being.   I like Megory Anderson’s description here, that “in the sacred act of dying, time is better understood as kairos, God’s time, than as chronos, our own chronological view of time.”  The late poet e.e. cummings was perhaps describing kairos here:

Whenever you think or you believe or you know, you’re a lot of other people; but the moment you feel, you’re nobody-but-yourself.

In her book “Sacred Dying,” Megory Anderson describes different ways to honor the end of life with honor and dignity, and to facilitate a sense of reconciliation and peace.  I recently spoke with someone who works for a local hospice.  This was in the context of a discussion of the importance of an advance directive for a family member, but I asked him about conflict at the end of life – and he assured me that it is unfortunately a frequent accompaniment to hospice care.  How could we honor a person’s dying by owning our own ambivalence and not denying our own or another’s mortality?  For most of us, I think we have a distance to travel here.

I will return briefly to some observations from “The Grace in Dying” that I have written in a manner that may help us, those accompanying a dying person in their journey, to face the process with our fullest being:

  • May I learn to know the difference between the time of sickness and the time of dying;
  • May I learn to listen with the ear of my heart in its true compassion when a loved one is facing death;
  • May I have the strength and discernment to communicate that it is okay to let a loved one go;
  • May I be of assistance in helping a dying person face death and not retract in fear or distraction; and
  • May I have the inclination to not just do something, but to stand there – to simply be when the time comes.

Perhaps if we can reclaim our sense of participation in mortality, in our living and in our dying, this sense of being “out of control” and at odds with a situation can be mitigated.  I’ll quote from my favorite ancient Greek philosopher, Heraclitus:

Out of life comes death, and out of death, life.

Out of the young, the old, and out of the old, the young.

Out of waking, sleep, and out of sleep, waking,

the stream of creation and dissolution never stop.

I will close with a few things to consider if you are visiting someone who is dying.  In the final days of my father’s life many family members and friends came to pay their respects.  Some were at a loss of what to do, just being with a dying person and in such close proximity to death is very difficult for many of us.  I decided to have a copy of John O’Donohue’s book “To Bless the Space Between Us” on hand and encouraged a couple people to pick it up and read one or more of its beautiful blessings aloud if they were so moved.

©Barbara Cashman 2013     www.DenverElderLaw.org