When many of us contemplate the last months or years of our lives, we hope to spend that time at home instead of in a hospital. That hasn’t always been the case though. If you are among those who hope to experience a “good death,” you need to plan ahead, says an elder law attorney at Nash Bean Ford & Brown, LLP.
A “Good Death”
According to a recent New York Times article, people’s attitudes about what constitutes a “good death” have changed dramatically over the years. Around the turn of the 20th century, researchers tell us that about two-thirds of people died at home. By the 1950s, the majority of Americans died in hospitals, and by the 1970s, at least two-thirds did. The reason for the dramatic shift can be attributed to beliefs regarding which option offers a “good death.” Those attitudes have changed yet again in the last 50 years. By 2017, 29.8 percent of deaths by natural causes occurred in hospitals, and 30.7 percent at home, according to a report in the New England Journal of Medicine. Experts predict that the trend will continue for some time to come, with even more people preferring to age in place. Aging in place, however, requires planning and preparation.
Talking about Your Wishes
If you prefer to spend your final months or years at home, now is the time to have difficult conversations about end-of-life care with your loved ones. It may not be easy to sit down and discuss your wishes; however, it is important that the people who will be caring for you at the end of your life know how you feel about important matters, including end of life medical decisions. Less than half (approximately 45 percent) of older people have completed advance directives, which often specify that doctors should not take extreme measures to prolong life.
Hospice care, usually delivered at home, is more available than ever before. Some 1.49 million Medicare beneficiaries received hospice care in 2017, a 4.5 percent increase from 2016, according to the National Hospice and Palliative Care Organization. “There has been a kind of cultural shift that has romanticized dying at home and made it the only way to die,” said Carol Levine, an ethicist at the United Hospital Fund in New York.
At the same time, hospitals have long had financial incentives not to keep Medicare patients for long periods, noted Dr. Diane Meier, a professor of geriatrics and palliative medicine at the Icahn School of Medicine at Mount Sinai in New York. Typically, Medicare pays hospitals per diagnosis per patient, not for the number of days a patient is in the hospital. Administrators “don’t want it to go on for a long time,” Dr. Meier said. “We send very very sick, complicated patients home under the care of family members who are not trained professionals,” she added. Consequently, many terminally ill patients wind up in the care of family members who may be unprepared to handle that care.
The Stress on Families
It is completely understandable that people want to spend their last weeks, months, or years at home or in the home of a family member. Planning ahead, however, becomes crucial because of the stress it can put on loved ones. “We are, perhaps appropriately, shifting the site of care to where patients and families say they want to be,” said Dr. Sean Morrison, chair of geriatrics and palliative medicine at the Icahn School of Medicine at Mount Sinai in New York. But, he added, “We have put a tremendous burden on families in the type of care they have to provide and the type they have to pay for.”
Even with the assistance of hospice, caregivers can still be overloaded. “Hospice is asked to do a big lift,” he said. “They get a fixed payment, a daily rate for patients, so they cannot offer many services. They are asked to be very effective but on a razor-thin budget.”
“I don’t think families or caregivers understand what it’s like to die at home,” said Dr. Meier. “They will need to understand how to manage symptoms, like pain or shortness of breath or confusion. They are on-call 24/7 and have to be alert to changes at all times. They don’t get to go home after an eight-hour shift.”
Contact Elder Law Attorney
For additional information, please download our FREE estate planning worksheet. If you have questions or concerns regarding advance directives or other elder law issues, contact an experienced elder law attorney at Nash Bean Ford & Brown, LLP by calling 309-944-2188 to schedule your appointment today.