After presenting a webinar on our book Love’s Way: Living Peacefully With Your Family As Your Parents Age, I realized that little of what I discussed about having “The Conversation,” or transparency, or naming a healthcare proxy applies to persons with no family connections.

What recourse has an older adult with no one to serve as her power of attorney or executor of his will or someone to call in case of illness or medical emergency?  Whom do these people (often referred to as “solo agers” or worse, “elder orphans”) rely on for these and countless other supports?

According to a 2016 study these issues confront an estimated 22 per cent of adults 65 years or older in the U.S.^* Many live in isolation although they may reside in populated areas. Even if they don’t experience a major accident or chronic illness, what about their emotional and psychological health? Imagine: No spouse. No kids. No one to turn to if their health deteriorates. 

Last month the National Academy of Science, Engineering, and Medicine (NASEM) released a study titled: “Social Isolation and Loneliness in Older Adults: Opportunities for the Health Care System.”

Among the study’s findings:  

• Nearly one quarter of Americans aged 65 and older who live in community settings are socially isolated, meaning they have few social relationships or infrequent social contact. 
• A significant proportion of adults in the United States (35 percent of adults 45 and older, and 43 percent of adults aged 60 or older) report feeling lonely.
• Older Americans who reported being lonely are twice as likely to die prematurely than those who aren’t.
• Conclusion? Social isolation and loneliness represent significant health concerns for older adults that put them at higher risk of developing serious medical conditions.

While the NASEM study doesn’t address solo agers, I believe there must be significant overlap. 

Where do these folks turn for support, companionship, for social survival? 

• I found an Elder Orphan Facebook group with more than 8,500 members.  
• Spread around the country are more than 240 villages in 41 states designed to help seniors age in place.** 
• More than 600 Area Agencies on Aging throughout the 50 states aim to help vulnerable adults aged 60 and older “live with dignity and independence in their homes and communities for as long as possible.”

Important as these resources are, they are too few to dent the growth in solo agers, increased isolation among older Americans, and an aging U.S. population.

These facts may not signal a crisis, but certainly a critical need for innovative approaches to a serious issue.

*“Elder Orphans Hiding in Plain Sight: A Growing Vulnerable Population.”  Maria T. Carney, et al. Oct. 2016. Current Gerontology and Geriatrics. Oct. 2016.
**vtvnetwork.org

I recently attended an End-of-Life Expo. Organized by Washington, DC-based IONA Senior Services, a highly respected nonprofit dedicated to improving the lives of aging persons, its notice about the expo tweaked my interest: “When you express how you want to die, you reveal how you want to live.”

The day-long expo offered 12 sessions from dementia planning and organ and body donations to writing your own obituary and DC’s Death With Dignity Act. (In 2016 the District of Columbia joined seven other jurisdictions* and enacted a Death with Dignity law that enables terminally ill DC residents to take their own lives with two doctors’ approvals and after meeting a host of other requirements.) More on this below.

The meeting spaces were filled to capacity and late registrants were wait-listed. Attendance at most sessions was standing room only. The speakers were well-prepared and engaging. 

My first session focused on writing one’s own obituary. What a great idea! Instead of having your relatives hurriedly piece together a summary of your life, why not do it yourself before you die? It takes a weight off your loved ones who may be absorbed with de-cluttering your home or coping with unanticipated financial complications. I didn’t know that (at least in Washington, DC) one has to pay a line-by-line charge for their obituary notice to appear in The Washington Post. By writing my own obit, it will contain what I want included.

Another session dealt with starting and talking about life and death matters. Drawing on “The Conversation Project,” a project of writer Ellen Goodman, the speaker offered suggestions for initiating and engaging loved ones in learning one’s end-of-life wishes: Do I want doctors to take heroic measures to extend my terminally ill life for a few weeks, or do I want to die without tubes and wires sprouting from my body — all working to add a few days or weeks to my diminishing time on earth?

The Death with Dignity session was the most attended. People need clarity on what the Act permits. For example, one has to be terminally ill and in the last six months of their lives to qualify for lawfully taking their own life. A person with dementia cannot take her own life. Only persons with “the ability to make and communicate health care decisions to health care providers” qualify for this program. Other provisions call for the terminally ill to submit a written and witnessed request to his attending physician before a “covered medication” can be prescribed; that the cause of death is the illness the patient suffered from NOT suicide; and the terminally ill person must ingest the lethal medication by him or herself without assistance from a medical professional.

Clearly many people are hungry for this information. They want to know how to die, not just when they’ll expire. Professionals in the aging arena should not underestimate people’s desire to learn more about what to expect as illness takes its toll and the need to prepare for death looms larger on the horizon.

Congratulations to IONA Senior Services for coming up with this remarkable program. It’s time comparable organizations and government agencies begin preparing us for the final season of our lives.

* Vermont, Colorado, California, New Jersey, Oregon, Hawaii, and Maine

When thinking about planning, I typically see a maze of legal twists and turns, forms to complete, conversations to conduct — an obstacle course with no finish line. But if I “de-construct” planning, it becomes more doable and less overwhelming. Here’s how I approach it:

Advance Care Planning

I start with my advance care directive comprising my living will and health care power of attorney (POA) or proxy.  These inform my loved ones and medical professionals how I wish to be treated if I have a life threatening illness or accident. The health care POA designates who should make health care decisions for me should I lack capacity to do so. Also included are a list of my doctors, prescription medicines, and other medical information.  

Of course, none of these documents are really operational without a conversation with those to whom I entrust my care. Advance care planning can extend to care-giving, whether provided by loved ones or hired aides. I also include a “dementia-directive”* which sets out my preferred levels of care should I lack capacity to make health care decisions for myself.

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Earlier I discussed how important medical advocacy is when a loved one or friend is hospitalized. As someone’s medical advocate, you want to ensure the hospital staff is serving her as well as possible. Especially at discharge. No one should ever be discharged from a hospital without an advocate, or at least a friend or caregiver, present to hear a discharge nurse’s instructions and review the paperwork that most discharged patients rarely have the capacity to absorb.

Following her hospital discharge your loved one (who has Medicare) may require skilled nursing care (SNC). She qualifies for SNC if: 

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A friend recently arranged to have his will prepared.  He told me he planned to bequeath his one piece of real property in three equal measures to his brother and his two sons.  In other words, three persons would become co-owners of one property. 

I asked whether he planned to discuss with them the terms (not the value) of his bequest.  He replied that they refused to discuss the matter. He said their unwillingness to discuss the bequest almost guaranteed a dispute over the distribution of the property after his death.  He acknowledged that from past experience he was powerless to avert this outcome. Discussions about death or money were out of the question. 

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Trust

Parents need to know their adult children will, to the best of their ability, ensure they receive appropriate care in a hospital, assisted living, or skilled nursing residence. They hope their kids will look out for their safety without diminishing their autonomy and independence, but enough to keep them safe.

Transparency

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A friend recently had spine surgery that took 5+ hours. After regaining consciousness, she found herself in the recovery unit…for the next 26 hours! Groggy from the anesthetic and not knowing whom to talk to, she languished there until a friend arrived and raised hell. She subsequently learned that private rooms were available throughout the 26 hours, but somehow the Recovery Unit staff wasn’t aware of any. When they finally wheeled her to a private room, she waited another hour for the room to be cleaned.

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Like many of you, I have an Advanced Care Directive comprising a Living Will and Health Care Proxy (or Power of Attorney) to make decisions for me if I lose my capacity to do so. I live in a jurisdiction (the District of Columbia) that permits physician-assisted death. My family and I have discussed my health care values and preferences. If I ever have a mind crippling illness and had earlier told my family and physician my preference not to continue living in that situation, my family and doctor know what to do. Right? Wrong!

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My last blog listed types of listeners. From the ‘pouncer’ to the ‘monopolizer.’ Now, on a more positive note, this post suggests ways to enhance conversation. The first (and for me) most challenging step calls on us to become empathic listeners. I came across this term in an article by Dr. Tammy Lenski* who attributed it to author Steven Covey. For Covey “empathic listening is listening from the other person’s frame of reference. Only empathic listening comes from a desire and commitment to listen without an agenda (emphasis added).”

Developing the “mental muscle” to listen empathically takes practice. Give it a shot the next time you’re engaged in dialogue. In addition, consider these techniques to enrich your exchanges:

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One of the topics Carolyn and I discuss in our presentations about our new book Love’s Way involves Listening.  Most of us don’t listen well. And even when we think we are listening, we sometimes fall into one of the following categories:

The Pouncer: This non-listener is waiting for the other speaker to pause just long enough to inject his point into the conversation.   The speaker may be in the middle of conveying a thought, but hesitated to take a breath or sip some water. That’s the moment the pouncer has been waiting for: to take charge of the conversation.

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