Thursday, April 27, 2017

March 2015

It’s time for better endings
No effort has been spared as ag media worked to educate farmers about estate planning. However, this worthwhile effort glosses over the key event in the “transition” process: somebody dies.
Like most Americans, farmers don’t talk much about dying. So while our affairs may be in calculated readiness, the actual process we face is studiously ignored until thrust upon us. One result, as noted in my book review in this issue, is we often lose control of important aspects of our lives during the final days. In short, we have too many bad endings.
The issues raised by Dr. Gawande are often intensified for farm families. Distance is the greatest difficulty. Caregivers are often far and few. Their duties and authority, if not well understood, can frustrate the best-intentioned efforts. Newer services, such as modern hospice programs will be harder to obtain and more expensive. Far from support services, the cost of dying can escalate rapidly. Time in transit consumes the waning time of the patient and taxes the caregiver.
As rural communities depopulate and age, the social network that has added so much to final times is incomplete or missing altogether – church families, fraternal organizations, recreational groups, etc. Support ministries like funeral dinners are quietly switched to professionals, unavoidably altering the traditions of passing.
Our willful ignorance of the art of dying, as it was called for centuries, leaves us with little guidance and unrealistic expectations. But we can do more to make final days the best they can be.
One pervasive fear is leaving our homes, but we do little to prepare for our decline, often to avoid acknowledging the inevitable. Downstairs bedrooms and easy-access facilities can’t be added at the last second. Accommodations for live-in caregivers should be a consideration.
Simple efforts to embrace alternative connections can minimize anger at seeming abandonment. Master simple Facebook skills, switch to a Kindle for a fingertip library, and start e-mailing friends for important social contact. Smartphones allow grandchildren to text and send photos.  Avoiding non-stop TV seems to be an important step to prevent unhappiness.
Difficult discussions about your hopes and fears are imperative. Unworkable expectations of support can add resentment and guilt to an already troubled time. Caregivers must take time to ask the right questions, such as “What do you fear most?” and “What tradeoffs are you prepared to make?” in order to manage an inherently aggressive medical system. Most of all, we must listen patiently to the dying to learn what they think is important, which is often not safety or added lifespan.
Farm families have another struggle, as amid grief and worry, oncoming generations may be anxious about the farm business. Many estate plans crumble during a lengthy final illness like Alzheimer’s. Those who have created a plan for the cost of such an outcome need to understand the underlying assumptions. For example, Medicaid currently pays nearly 2/3 of US long-term care costs. Gaming Medicaid, now common to protect farm assets, won’t help much if the program is a casualty of ideological warfare.
Avoid a managerial limbo during a protracted decline toward death. Inability to deal with unexpected business possibilities can mean lost opportunities or aggravated problems while the management is “on hold”. Tensions between financial custodians, health caregivers and distant family can add suspicion to grief – a bitter mixture. An unhelpful effort to unreasonably prolong life can transfer too much authority from loved ones to physicians, attorneys, and accountants, while neglecting the possibilities for a more positive ending.

As Baby Boomers die in larger numbers, our support system will be taxed across the nation. In rural America, as we have learned on so many issues, unless we take responsibility to build a better response to dying, most helpful programs will be diluted or unfeasible. Absent better end-of-life education and realistic planning, the default will be too often an unhappy, exhausting descent into a medical establishment that struggles to say when.