Being clear about your last wishes can make death easier for you and loved ones

A living will can lessen grief and stress, studies suggest. Jacob Lund/Shutterstock.com

Barbara Bush’s recent death and the way she prepared for it remind us that death can be peaceful and marked by family togetherness rather than conflict.

Mrs. Bush chose palliative, or comfort, care over aggressive medical treatment given her age and overall health status. Her family agreed to support her decisions.

It does not always work this way, but it could.

I recently published a book with Dr. David P. Schenck entitled “Communication and Bioethics at the End of Life: Real Cases, Real Dilemmas.” We include several cases in which such family discussions did not occur. This lack of information led to an unfortunate cascade of events that made the patient’s deaths more difficult, and left lasting scars on both family members and clinicians.

Most of us won’t die at home

While we might hope for a quick death at home, a majority of us will die from a chronic condition like heart disease, cancer, or respiratory disease, and nearly 80 percent will die in an institutional setting, following an explicit decision to suspend life-sustaining treatment.

Advance directives or living wills are made to ensure their preferences guide decisions should the person be unable to communicate them.

Studies have shown that discussions between family members can greatly improve end-of-life planning and decision-making. Patients who have discussed end-of-life care with their families generally have shorter stays in intensive care units and more timely “do not resuscitate” orders. These can prevent attempts to perform cardiopulmonary resuscitation and instead allow a natural death to occur. Patients and family members who are prepared experience lower rates of depression and anxiety when a family member nears death.

On the other hand, neglecting to discuss such issues can result in longer hospital stays, a greater likelihood of continuing life-sustaining treatment against a patient’s preferences, and poorer quality of life for patients and family members.

Changes have been in the works

Congress passed a law in 1991, when George H.W. Bush was president, making it mandatory to ask patients if they have a living will.
Mark Reinstein/Shutterstock.com

Congress passed a law in 1991, while Bush’s husband was president, that made it mandatory for hospitals to ask patients if they had an advance directive upon admission. But even before the law, called the Patient Self-Determination Act, was passed, physicians had been encouraged to talk to their patients about end-of-life care.

Medicare billing codes introduced in 2016 allowed physicians to charge for time spent in end-of-life conversations with patients.

Despite these legislative and policy initiatives, physicians remain reluctant to discuss dying with their patients. Even if they do, it is unlikely that one’s primary care doctor will be present when deciding about a patient’s end-of-life care.

And most American adults have not completed an advance directive or living will; about 33 percent do. This leaves two-thirds of families without the information they need to guide end-of-life decisions with or for a family member.

A buzz-kill conversation, but a crucial one

Our medical system is geared to keep people alive, and death is often deemed a failure, the author writes.
kotin/Shutterstock.com

Conversations about death and dying are difficult. We Americans live in a society that seems to deny death and receive care in a medical culture that views death as failure. Conversations about death are difficult because they are multifaceted and complex. Simply bringing up the topic of dying can trigger a range of interpretations and concerns. For example, if you ask your mother what her end-of-life treatment goals are, she might perceive you as caring, or she might think you are questioning her capacity to manage her own affairs.

How might family members pursue such difficult conversations, what dilemmas and barriers exist, and what strategies might allow high-quality conversations to take place?

My research assistant, Philip Barrison, and I recently undertook a study, which we intend to submit to an academic journal called Health Communication, to address these crucial questions. We conducted an online survey asking people to respond to a hypothetical scenario: “A family member has asked you to make medical decisions for them if they are unable to make them for themselves, but has not given you any guidance. You want more information about their end-of-life wishes, so how would you proceed to have this conversation?”

We asked participants to write about their goals, the barriers they think they would encounter, and strategies that might be useful.

Our data revealed four goals associated with these conversations: compassion, comprehension, conflict and commitment. Compassion reflects participants’ desire to make their family member feel wanted and needed, even while discussing a time after which they would no longer be around.

Comprehension relates to the need to be forceful about soliciting specific information while at the same time being gentle and respectful.

Conflict refers to the practical necessity of designating a single decision maker without provoking disagreements among family members. Commitment describes the tension between the honor and burden of being trusted as a decision-maker for a loved one.

Strategies that emerged from our analysis for achieving these goals included using humor when appropriate; discussing end-of-life issues more generally within the family rather than focusing on the person most likely to need assistance; reading a book, watching a relevant television show or movie, or discussing the end-of-life situation of another person; or suggesting some specific ideas and asking for a response.

While every family is different, family members should and often do find creative ways to have these conversations and avoid future problems.

Our results showed that family members have similar concerns whether they imagined talking to a parent, sibling, or other relative. Only when participants imagined talking to a spouse or partner did another strategy emerge: allowing one’s partner not to discuss their end-of-life preferences if they chose not to.

When a person imagined talking to a parent or other family member, the theme of needing to push to get information was pervasive. When adult children are making decisions for a parent, for example, the possibility of family conflict is ever-present. That may have led our would-be decision makers to believe they would need to press for more information even if they encountered substantial resistance.

Our sense is that spouses know they are likely to be the uncontested decision makers for one another, being in a position to both know the other person very well and to be most directly affected by their spouse’s life or death.

There is no perfect template for an advance directive, or a foolproof guide to family conversations about death and dying. It may be emotional, there might be conflict, and it is unlikely that families can anticipate every end-of-life situation.

However, there is great benefit to starting these conversations at your next family gathering and keeping the conversation going as parents and spouses age. We can all aspire to a death as dignified as that of Barbara Bush, and talking to your family in advance is a clear step in the right direction.

The Conversation

Lori A. Roscoe does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.

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The Second Half: Talk to mother-in-law

Dear Tracey >> I found your blog online when I was trying to find answers to my problem. I ended up reading some of your columns, which I enjoyed even though I’m only 34.

I figured you might be the perfect person to give me some advice. I need an older woman with your background, a therapist who must have dealt with a mother-in-law and it looks like you are a mother-in-law, too?

My mother-in-law is driving me nuts.

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Australian millennials’ incomes have grown more than baby boomers and millennials in other countries

Those born between 1941 and 1950, show an increase in average incomes between 1995-96 and 2005-06, and then a decline as they enter retirement. velvettangerine/Flickr, CC BY-NC-ND

Life has changed significantly for young Australians over the last 40 years. Millennials now delay marriage and childbirth, increase their years of study and have much greater rates of part-time work.

As a result, millennials might be feeling a little hard done by, but Australians aged from 25 to 34 have actually enjoyed increases in their incomes compared to the population average. They have also done better than people the same age in other countries.




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These are some of the findings of a report from the Committee for the Economic Development of Australia: How unequal? Insights on inequality. It questions whether young people today are likely to do as well economically as previous generations.

Early millennials, born between 1981 and 1985, experienced household income growth 27% higher than the Australian average up to 2010, while households with a head aged 70 to 74 enjoyed growth only 2% higher than the national average.

Although incomes might be higher, the picture of household wealth is different. The wealth of older Australians has increased much more rapidly than that of younger generations, due to both increasing superannuation wealth and increasing property wealth.

Incomes are better for Gen Y in Australia

Work by the Luxembourg Income Study found that in the United Kingdom, households with a head aged 25 to 29 years saw income growth 2% less than the overall national average in the three decades up to 2010. They also found households with a head aged 65 years and over enjoyed income growth more than 60% higher than average.

In brief, in the UK older households became much better-off and younger households became slightly worse off than the population as a whole. Similarly young Americans experienced income growth 9% less than the national average, those in Spain 12% less and in Italy 19% less. In all these and other countries, older households have done better than the national average, although none as well as in the UK.

In contrast, younger Australians did better than the national average in income terms, and better than older Australians.

ABS data show that in 2016, Generation Y Australians had higher incomes between the ages of 25 to 34 than the preceding two generations – about 18% higher than those born a decade earlier. However, the real increase appears to have slowed compared to the previous decade, that cohort had incomes 65% higher than those a decade earlier (due to the mining boom).

Older Australians, born between 1941 and 1950 (including the first “baby boomers”), show an increase in average incomes between 1995-96 and 2005-06, and then a decline as they enter retirement. Middle baby boomers, born between 1951 and 1960, show a marked increase in real incomes between the age of 35-44 years and 45 to 54 years (from A$1,370 per week to A$2,200 per week). But they only experienced a very small increase in the next decade, because some of them retired before the age of 65.




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Baby boomers born between 1961 and 1970 show substantially higher incomes than those born a decade earlier – more than 20% higher in real terms at the age of 45 to 54 years. Generation X born between 1971 and 1980 show large increases in real incomes – nearly 45% – across the last decade and are about 34% better off than the preceding cohort were at the same age.

What has happened to wealth

Households with people under 35 years of age were actually slightly worse off in wealth terms in 2015-16, than a decade earlier, with their net worth falling by around 8%, according to Australian Bureau of Statistics data. But for those aged 65 and over, there were increases closer to 40% in real net worth.

The value of owner-occupied housing fell for Australia’s youngest age group, but older households enjoyed large increases in the value of their homes and large increases in the value of other property they own.

Overall, all age groups saw real increases in the value of their total assets, including the youngest age group. This means that falls in wealth are due to an increase in their debts.

ABS data also shows that at all ages there has been a fall in the share of outright home owners, and also in the share of the youngest age group with a mortgage. For younger age groups an increasing share are private renters. This was a significant increase from 43 to 53% for those aged 25 to 34 years and from 26 to 31% for those aged 35 to 44 years.

For those 65 years and over, there has been little change – around 85% of households aged 65 years and over were owners or purchasers in both 2005-06 and 2015-16.

Younger households have seen both declining rates of home purchasing and higher overall indebtedness. Rental costs have also increased faster than the costs of home ownership, and this may have increased the barriers that younger generations face in establishing themselves in home ownership.

But when it comes to incomes, millennials in Australia have continued to progress.

The Conversation

Peter Whiteford has received funding from the Australian Research Council and the Department of Social Services. He is a Fellow of the Centre for Policy Development.

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Gray Matters: Art show celebrates healthy aging

Local photographer Martin Swett has been named as the judge for the sixth annual “Being Here Now” art show in May.

Swett bought his first camera in 1992 in preparation for a 600-mile hiking trek with his best friend along the Pacific Crest Trail. He confesses that his pictures from the trip were pretty bad, despite the beauty of the landscape.

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