Updated 8/21/2018 

Introduction to Langley Hill Friends Meeting’s 2018 Book:

Planning for and Coping with Decline and Death

Table of contents

Since the 1970s Langley Hill has worked to help its members and attenders prepare for and cope with death. Our most recent effort was a 2014 packet of information and forms entitled Planning for and Coping with Decline and Death. This 2018 book updates the 2014 version.

The 2018 book is available in hard text and is also available here in the electronic version you may be reading now. It consists of this introduction, three documents aimed at different audiences, and samples of the forms relating to each of the 3 main documents. The book was prepared in 2018 by the Langley Hill Care and Clearness Committee, with help from several others.

The first document, Do It Now: Planning for Decline and Death for Yourself or a Loved One, gives spiritual and practical queries, advice, links and references to help you in planning for the inevitable physical death and the possible period before that when you or a loved one might need help from others with important decisions and daily living. Doing that planning now and updating those plans every year or when your relevant circumstances change, will help you approach the end with confidence that you have done what is needed to reduce unnecessary grief and trouble for your survivors. It also gives you an opportunity to begin work to maize any regrets you do not want to take to the grave with you.

This planning document is supplemented, in the following tab, by:

Ø the forms of Advance Directive and Health Care Powers of Attorney for each of the three local jurisdictions
Ø a Five Wishes form that meets advance directive requirements in all these jurisdictions,
Ø medical orders for scope of treatment for each jurisdiction, and
Ø other items of information that only you can prepare for your survivors to help them with practical issues after they cannot consult you any more.
 
The second document, Decline, Approaching Death, and Dying: Some Ways to Meet Challenges, is an approach to help people with an increasingly prevalent situation in which a senior becomes incapable of everyday self-care, and needs assistance. This document doesn’t address aging generally, but gives advice about situations in which an aging person may need others’ help. The document also deals with approaching death and the dying process when death is not unexpected. Links and resources are provided to help with the challenges people face in these situations. The tab that follows this document includes general powers of attorney (primarily relating to financial matters) for all three jurisdictions.

The third document, Survivor’s Guide following a Death, is aimed at helping people with grief, even before death, and with the spiritual and practical arrangements connected with the death and its consequences, such as disposition of the body, ceremonies, and property allocations. Survivor-related resources and links also are provided. A Survivor’s Checklist is provided in the following tab to help survivors in the immediate situation after someone dies.

All three documents link spiritual concerns to practical issues, and they include descriptions of what the Langley Hill Meeting can do to help with each of these situations. Our relevant Committees are always available, with listening ears and a Family Emergency Fund if needed, to help attenders and their families. The packet also includes a topical index to the three documents, as well as a glossary of technical terms they use.

Printed copies of this book of materials, as well as some of the resources referred to in it (marked with an asterisk (*) for Langley Hill’s Library) or a circumflex (^) for the Charlottesville Meeting’s Library) will be available in both Meeting Libraries for the use of members and attenders, and will be available on the expectation of a donation to meet the cost of printing . Also at Langley Hill is a Visitor's Packet in Case of Death containing useful reference materials, and other relevant resources for the Meeting to use when a member or attender dies.

Planning for, and Coping with, Decline and Death
Langley Hill Friends Meeting, 2018

Table of Contents

Introduction

      i. Queries
      ii. Meeting’s help
      iii. Other resources/links
      iii. Information to assemble
      iv. Planning for Decline
      v. Prepare for Death
      vi. Planning resources/links
      i. Wills, etc.
      ii. Give It Away
 
      i. Advanced Directive
         1. VA Advance Directive (PDF)
         3. MD AD Info (PDF)
         4. DC Advance Directive (PDF)
      ii. Medical Orders
         1. POST form (VA) (PDF)
         2. MOLST form (MD) (PDF)
      iv. Accident Information
      vi. People to be notified
      vii. Offices to be notified
      viii. Obituary information
      ix. Financial contacts
      x. Passwords
 
      i. Queries for loved one & self
      ii. Resources/links
      iii. Communications
      iv. Approaching Death
      v. Resources/links
      ii. Resources/links
   d. Power of Attorney Forms
      iii. DC Power of Attorney form
 
      i. Queries
      ii. How to help bereaved
      iii. Resources for Grieving
      iv. Meeting’s help
      v. Resources/links
      i. Death Certificate
      ii.The body
 
 

Do It Now! Planning Ahead for Decline and Death

Top

Contents:

Spiritual Aspects of Planning: Queries, Help from the Meeting, Five Last Things, Ethical Wills, Resources

Planning for body & mind: information needed, advance directives, medical orders, resources, preparation & postponement of decline, preparation for death, resources on planning for decline and death

Planning for property: Wills, Intestacy, avoiding probate, giving it away

Related forms following tab:
VA, MD and DC advance directives and medical orders, followed by Information forms (including accident information, personal information for death certificate, relatives and friends to be notified, offices to be called, information for obituary, outstanding obligations, and passwords, pins, and lock combinations

Introduction

Death can take us at any age, and so can disability, whether by injury, disease, or other causes. This document is intended for anyone who wants to avoid needless suffering for those who survive the reader and anyone who is, or is likely to become, a caregiver for another person with a disability. This is the first of three main documents in Langley Hill’s 2018 book on decline and death. The first of the other two relates to coping with declining physical or mental capacities as one ages, and also about coping with approaching death. The second relates to how survivors may cope with a dear one’s death.

The essential message of this document is that there’s no time better than right now to begin to get ready for death and disability. Death is inevitable, and disability happens often enough to warrant advance planning for the contingency. When one is closer to death or disability it may be much more difficult to assemble the necessary information and authorizations than now, and when one is out of touch due to death or disability it is impossible.

You or a loved one can ease the suffering of your survivors by leaving easily accessed and clear instructions and information about your wishes and other arrangements for the disposition of your body and your property. In addition, your own last years, days or hours are likely to be much less regretful if you know you have done now what you could to help your survivors cope with the problems you may face in your decline and upon your death. Finally, regrets you have about the mistakes you made and the hurts you suffered in your life, often about your relationships, are much more easily reduced or eliminated if you begin now to work on mitigating their effects for the future. For instance, one can seek to forgive and be forgiven, to revise your habits that got in the way of being who you wanted to be, or to redirect the time and attention you were unable to devote earlier to those who are most important to you.

This planning document sets the tone with some queries, originally composed in Langley Hill in 1993, to address the spiritual challenges of preparing for death. Following descriptions of how Langley Hill Meeting and other resources might help with these challenges, the document covers the information your survivors or caretakers will need to be able to cope with your decline or death, the legal instruments (advance directives, wills, etc.) that are used to establish the basic procedures to follow for your decline or death, and some practical advice and resources to help you and your survivors or caretakers in the planning process. You are likely reading the electronic version of the book found here.

So as you read the materials below, including glances through the other documents in this packet, please think of the work that you do now on these issues as an important investment in building a better destiny for yourself and the people you love. If you need help or clearness in this work, please feel free to call on Langley Hill’s Committee for Care and Clearness.

Spiritual Aspects of Planning for Decline and Death.

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a. Queries:

Ø Do I need help now in preparing for my death or decline? Do people close to me need that help?

Ø Death often comes by surprise, interrupting lives in the midst of life's progress. What if I should die before I wake? If I knew my death was imminent, how would I devote my remaining time? Should I do any of that activity now, or on a daily basis?

Ø Am I prepared to meet my Maker? What do I need to do or feel now, to be ready for death? Can I accept that I did all that I did, and can't undo it?

Ø Is there someone, or are there others, whom I would like to help prepare for my death, physical decline or incompetence? Do I want to approach them to offer that help? If so, how?

Ø Are there others in my life who tend to deny the prospect of death, and need my attention to make them more aware of the planning and other activities that need to take place before my passing, or theirs?

Ø If I died today, would I have any regrets? What would I have done differently to avoid regrets? Can I do something now to reduce or eliminate those regrets?

Ø Do I give myself and others enough space and opportunity for forgiveness to take place genuinely?

Ø Are there things I can do now that would ease the experience for those who would suffer or be burdened in the event of my sudden death? Are there words of comfort or pieces of information that I can prepare in advance to help those people with their grief or their new responsibilities when I die?

Ø Are there matters that I want to communicate with others before I die? “In hospices they talk about the five things that need to be said to a loved one: thank you, I love you, please forgive me, I forgive you, and goodbye. The good news is that you can start saying the first four anytime.”

Ø In what kind of relationship do I want to be with others before I die? Are there conflicts that I want to resolve, or people I want to forgive or be forgiven by? How can I restore more healthy relationships with them?

Ø To what extent do I want my nearest and dearest to minister to my needs if I have a long final illness or other incapacitating disability? If outside help would be needed and can be afforded, should it be through home care, assisted living, or a nursing home?

Ø How would I describe a “good death”? What are my hopes and fears for my own death? Is dying at home instead of a hospital important to me?

Ø Do I want to be with one or more of my nearest and dearest as I die? Do I hope to be able to say goodbye?

Ø What has been meaningful to me in my life? How am I giving support to that meaning? Have I communicated those priorities to those people who had a close connection with them, who might survive me?

Ø How would I like to be remembered? What can I do or feel now to create that memory?

Ø Are there other jobs I need to do before I die? What are the most important loose ends that should be tied up before I die or become incapacitated? How important are they? What jobs can I let go?

Ø Do I feel burdened with my material possessions and their disposition upon my death? Have I communicated effectively how they are to be distributed and used? Would parting with some more of them before my death be helpful?

Ø How can I develop a sense of completion about my accomplishments? Can I let go of the uncompleted parts of my life? Can I mentor others to fill in the gaps that would be caused by my death or disability? What can I do now that will make letting go easier or better?

Ø In what contingencies would the quality of living become more important to me than the quantity of life?

Ø What forms of life-preserving care would I be willing to accept? Would I want to be able to control my pain in my last illness? Are there circumstances in which I would not want to have painkillers administered to me? If I needed painkillers that deprived me of consciousness, would I want to have an opportunity for trials of withdrawal and painful consciousness?

Ø If faced with an incurable terminal illness, would I want to be treated for secondary conditions that could kill me if left untreated?

Ø How can I let go of fear of death, in myself and in others?

Ø How can I accept death and living as they coexist in me?

Ø Do I want to have special elements in the ceremonies following my death?

Ø How else do I want to prepare for what follows my death? For me? For others?

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b. Meeting’s help with practical preparations for decline and death:

The Committee for Care and Clearness or the Overseer’s Committee is available to help friends with issues that may arise as part of the planning process. At your request we can convene a clearness or support committee to help you with the process. Individual friends with some expertise or relevant experience also might be called upon, whether the planning relates to your own decline and death or a loved one’s.

If a group of friends wishes to convene a discussion group or working party on some of the matters raised in this packet, particularly the queries above, the Committee also stands ready to facilitate the process.

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c. Five Last Things, and an Ethical Will:

The New York Yearly Meeting’s Workbook of Quaker Values and End-of-Life Decision Making, (2016) described below, suggests (p. 21) for the spiritual side of your planning, Five Last Things, and an Ethical Will:

i) “Five Last Things:

a) Please forgive me.

b) I forgive you.

c) Thank you.

d) I love you.

e) (If you are the one dying) It’s o.k., I’m ready to go . . . . goodbye.”

ii) “Ethical Will:

An Ethical Will or the testament part of “last will and testament” is your opportunity to express your deepest convictions, not just the important events of your life, but also the moral and spiritual foundation of your life, the guiding principles for the decisions you’ve made and the joys and satisfactions you’ve had. You might share it with loved ones before or after your death.”

d. Relevant Quaker Testimonies:

Quaker Values and End-of-Life Decision Making, referred to above and below, cites the following Testimonies in support of advance planning for death:

The Testimony of Integrity is about telling the truth as well as facing the truth, and about having our affairs in order. Having completed a will, power of attorney, and health care proxy is, for many people, a courageous act of Integrity. Facing the reality of our eventual death is equally courageous and in keeping with the Testimony of Integrity.

Friends’ peace testimony asks us to live in a way that avoids the occasion of war. Advance Directives, [wills, and less formal bur more descriptive letters to your survivors (also called “ethical wills”)] avoid arguments between loved ones: your decisions and your chosen agent are known ahead of time.

The Testimony of Stewardship reminds Friends that we have a responsibility to rightly use the Earth, our bodies, our time, as well as our money. This testimony should be central to our burial planning, our use of medical procedures at the end of life, and the expectations we place on our caregivers, proxies, and those to whom we assign our Power of Attorneys.

The Testimony of Community: . . . Parker Palmer has written: ‘The most generous thing we can do is to receive help.’ How can we deny others this opportunity of grace?

The Testimony of Simplicity concerns simple living. That should also include simple dying: We need to reflect on our choices for a Memorial Meeting, casket or coffin, grave liners, vaults, embalming, [and tombstones, as well as obituaries], in light of this Quaker understanding.

The Testimony of Equality (or equity) speaks to Friends’ sense of Justice. Is it fair, just, to withhold organ donation? Every day in the U.S., your donation may help as many as 8 individuals on the organ donation list.

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e. Resources !

Books and articles about the spiritual aspects of planning for decline and death are available on the second shelf down in the corner next to the bathroom in the library at Langley Hill, and in Charlottesville’s library. Resources that are on Langley Hill’s shelf are marked in our resources lists with an asterisk (*), and those in Charlottesville’s Library are marked with a circumflex (^).

Ø *On Aging, a special issue of Friends Journal, October 2013, 59:9. This issue has a number of articles, mainly individual’s stories, about how the Inner Light is present as we age.

Ø Quaker Values & End-of-Life Decision Making: Workbook, (2016), ARCH Program of New York Yearly Meeting, copies available through arch@nyym.org or (212) 673-5750.

Ø Quaker Aging Resources, http://www.quakeragingresources.org, provides numerous links to “spirit-centered resources and information”, including 10 categories of inspiration and insight, and 10 categories in a learning center.

Ø *Arnold, Johann C., 2013, Rich in Years: Finding Peace and Purpose in a Long Life, Walden, NY, Plough Publishing House, 161 pp. An older person’s look at the challenges, consolations, and delights of aging, in accepting the changes that come with it.

Ø *Becker, E. 1975. The Denial of Death, New York, Free Press. 315 pp.

Ø ^Callanan, M., and Kelley, P., 1992. Final Gifts: Understanding the Special Awareness, Needs, and Communications of the Dying. New York, Simon & Schuster, 218 pp.

Ø Deathwise is a nonprofit organization passionately committed to helping people talk about, make decisions and plan for the end of their lives. www.deathwise.org . The website includes a number of planning resources.

Ø The Funeral Consumers Alliance, www.funerals.org, is a national organization to help consumers become fully prepared and protected when planning a funeral for themselves or their loved ones. The Funeral Consumer Alliance of Northern Virginia can be reached by telephone at (703) 271-9240. The Funeral Consumers Alliance of Maryland and Environs, www.mdfunerals.org, can be reached at (301) 564-0006. The Funeral Consumers Alliance of the Virginia Blue Ridge, www.fcavbr.org, can be reached at (540) 953-5589. These affiliates, staffed by volunteers, publish comparative price surveys for local funeral homes in their area.

Ø ^Funeral Consumers Alliance, Before I Go, You Should Know (2017) is a 30-page, detailed form that you can buy and fill out ($15), or fill out online at https://funerals.org/bookstore/ ($9.99), with illustrations by Edward Gorey, to give your survivors all the information they’ll need following your death.

Ø Gawande, Atul. 2014. Being Mortal: Medicine and What Matters in the End, New York, Henry Holt & Co., 264 pp. Dr. Gawande emphasizes the importance of quality in living, as opposed to a medical professional culture striving to keep people alive at all costs.

Ø Go Wish is a game with 36 cards, each intended to start a conversation among the players about the value or goal that might be important to you as you age, such as how to be cared for, who to be with, and planning options. See www.gowish.org, where you can sample the game and buy a pack for $12.

Ø Harwell, Amy, 1995, Ready to Live, Prepared to Die: A Provocative Guide to the Rest of Your Life, Wheaton, IL: Harold Shaw Publications, 155 pp. Written by a cancer patient to inspire others how to live fully, this book includes a provocative checklist of preparations.

Ø *Honolulu Friends Meeting. 1991. Planning Ahead: Meeting Our Responsibilities When Death Occurs, Including Information for the Survivor. 27 pp.

Ø International End-Of-Life Doula Association (INELDA), www.inelda.org. INELDA is an association of trained doulas, who help with the spiritual and practical issues around the process of dying and coping with death and loss.

Ø *Kavanaugh, R. E. 1972. Facing Death. Los Angeles, CA, Nash Publishing. 226 pp.

Ø *Langley Hill Friends Meeting, 2018. Decline and Death: Planning and Coping. This is a loose-leaf binder with various publications, including queries about the spiritual aspects of planning for death, decline and dying, and death as it impacts survivors. Also available at http://langleyhillquakers.org/death__decline.aspx

Ø *Langley Hill Friends Meeting, 2005. Preparing for End of Life Issues: A Resource Compendium. [loose-leaf binder with various publications]

Ø *Langley Hill Friends Meeting, 1979, 1993. Death Education Resource Packet. [loose-leaf binder with various publications]

Ø Maury River Friends Meeting. 2004. Planning Ahead: A Gift for My Family: Meeting the Responsibilities for Planning the End of Life. [loose-leaf binder with various publications]

Ø Nearing, Helen, 1995, Light on Aging and Dying, Gardiner, ME: Tilbury House Publishers, 153 pp. A lovingly compiled anthology of comforting and challenging favorite passages.

Ø ^Paul, A., and Spring, B., 2016. Quaker Values and End-of-Life Decision Making: Workbook. New York, ARCH Program of New York Yearly Meeting (arch@nyym,org). 21 pp.

Ø *Reimer, J. & Stampfer, N., Eds. 1991. So That Your Values Live On: Ethical Wills, and How to Prepare Them. Woodstock, VT, Jewish Publishing. 237 pp.

Ø Sandy Spring Friends Meeting. 1995. Procedures Pertaining to Death: Planning for One’s Own Death and Ministering to Others in Time of Need. [short document]

Ø Williams-Murphy, M, and Murphy, K. 2011. It’s O.K. to Die, MKN, LLC. 170 pp.

Ø Yungblut, John, 1994 For that Solitary Individual: An Octogenarian’s Counsel on Living and Dying. Wallingford, PA, Pendle Hill. Pamphlet #316.

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2. Planning for the body and mind as they approach decline and death

Talking about death won’t kill you, and it may clear up some long-suppressed emotions so that you’ll feel more centered and emotionally healthy. You have choices to make about what you must do, must not do, or can do, as you approach that event, whether it’s soon or very distant.

While you are healthy it is difficult to think about what information will be needed and what decisions must be faced when you are not conscious and able to communicate your wishes. But by then it may be too late for you to control the decisions or even provide the information. Thus it is important to record in advance the essential information that will be needed for appropriate treatment. Indeed, hospitals are now required to ask if entering patients have filled out an advance directive and to provide a form for one if they have not. The information summarized below is meant to help you understand the general outlines of the papers and programs described, but for more current, accurate and detailed information you should consult the corresponding references in the Resources section below.

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a. Advance Directives and related Medical Orders:

i. Advance directives generally:

The tab following this text includes Maryland and Virginia’s official Advance Medical Directive forms to state your desires regarding medical treatment in the event you are unconscious or otherwise unable to make your wishes known to those caring for you. Although the District of Columbia lacks such a form, one can adapt the Maryland or Virginia form for use in DC.

An easily understood variant of the official advance directive forms, Five Wishes, is accepted as an advance directive in all three jurisdictions, and is included in the tab following this text. An electronic version of the form for each jurisdiction can be found through the links in the Resources section, and Five Wishes can be obtained for a small fee from https://fivewishes.org/ or a corporate sponsor of the form. There is also a variant or supplement for the Advance Directive for people with mental illnesses.

Another option is to go to https://mydirectives.com/, a commercial website that encourages individuals to fill out their form of digital advance directive, which then can be shared with family, friends, medical providers and hospitals. The company charges medical providers and hospitals for their use of the forms, and uses their data (without identification of individuals) to make its profits.

Before using any advance directive forms you may want to check with a lawyer. Lawyer referral services for each jurisdiction are given later in this book in item 3.b.i. of the document on Death: Help for Survivors.

An advance directive includes both a living will and a durable power of attorney. Advance directives require you to designate someone close to you as your “health care agent”, thus creating a durable power of attorney.

Your health care agent needs to be someone you trust to make medical or psychotherapy decisions for you when you cannot do so. If you get into a situation where the wishes you expressed in the directive may need to be implemented, your agent will work with your medical team on issues such as a “do not resuscitate” (DNR) order for your caregivers. You can supplement the formal documents through conversations with or informal, non-binding letters to the person you appoint. It is wise to appoint a successor agent to succeed the appointed agent if he or she cannot be located or is incapacitated. You also will need specifically to authorize your health care agent to have access to your medical records once he/she once she or he is acting as such. This is a separate form, under the Federal Health Insurance Portability and Accountability Act of 1996 (HIPPA).

ii. Why?

An accident or a stroke could put you into a coma with severe brain damage or other conditions that would leave you in a condition that you might not want to continue living, at continuing pain and discomfort, huge medical expenses, and a diminishing expectation of recovery. What would be your wish about the use of life-maintaining treatments if the chances of your recovery were negligible? Or were believed by two or more doctors to be non-existent? In the event of such a tragedy the guidance of such a document can be of tremendous help to your loved ones, the medical care givers, and, if necessary, the courts. More general advice can be found at http://www.putitinwriting.org/putitinwriting/index.jsp and in the Resources section below.

iii. What to do with it, once signed:

It is most important to discuss these documents and your wishes as outlined in them with your primary physician, your nearest and dearest, and specifically with whomever is named in the forms to make decisions on your behalf if you are unable to do so. Many of these people are likely to be involved at a time of a medical crisis. They need to understand your wishes in detail if/when the contingencies arise. Without such discussion and understanding it is quite likely that even your written wishes will be ignored because of the weight of life preservation momentum in the medical establishment and among relatives in shock, regardless of your desire to die with dignity. Give each of these people copies of the documents well in advance, if possible. In particular, a copy of the signed form should be given to your doctor and a hospital when you check in for major surgery or recovery from life-threatening events.

The American Bar Association recommends that you re-examine your health care wishes whenever any of the following occurs:

(a) When you start a new decade,

(b) When you experience the death of a loved one,

(c) On divorce or other major family change,

(d) When diagnosed with a serious medical problem, or

(e) When you have a serious decline or deterioration in your health.

And, if you have previously executed an advance directive and shared copies with others, it’s very important that you ask them to return any previous copy when they get the new one, so that they won’t be confused or mistaken if and when the need arises.

At http://www.oag.state.md.us/Healthpol/adDir_cards.pdf, Maryland’s Attorney General has a card, useful for residents of any State, that you can download, print and put in your wallet to indicate phone numbers for your next of kin, your primary physician, and others with access to your advance directive. Changes in State laws and perhaps in your own wishes indicate that you should review and perhaps change your medical directives at least once every five years, or whenever your address, health condition, or preferences change.

There is a way to assure that your Advance Directive will be available, should it be needed when no one knows where to retrieve a copy. A government study found that this happens 40% of the time! Please keep and distribute a medical directive tracking record, indicating where to find copies of the current directive, to your loved ones, your primary care physician, and any physician or hospital as you check in.

At http://www.connectvirginia.org/adr/, Virginia has an official registry for the advance directives of Virginia residents. Maryland and DC’s only registries of advance directives are through https://mydirectives.com/.

There is a national registry of advance directives, www.uslivingwillregistry.com, that provides registration for a fee and gives access only to medical personnel. Charlottesville or Woodbridge-area residents who have patient relationships with the Sentara hospitals there can have access to the national registry without cost.

iv. Virginia’s Do Not Resuscitate (DNR) form:

Virginia, unlike DC and Maryland, requires a separate form to be signed if you want your health care agent or physician to refrain from CPR or certain other life-saving procedures if you stop breathing or your heart stops beating. If you have a medical order indicating DNR (POST), as described immediately below, this form is unnecessary. See the references below for further information. As with the Advance Directive, the DNR form should be distributed to any who might be involved in the decisions it contemplates, especially including accessible copies in your home on the refrigerator for ENT personnel who might come upon you in those conditions.

v. Medical Orders about Life-Preserving Treatments:

Advance directives sometimes are ignored or not fully followed by doctors, hospitals, or EMT personnel responding to a 911 call. For these situations it may be preferable to have a medical order from a doctor (usually your primary care physician), toward which greater deference is shown by medical personnel generally, and particularly by EMT personnel responding to a 911 call. These medical orders specify whether to resuscitate a person who has no pulse and is not breathing, as well as whether to take comfort measures to relieve pain and suffering, to use or refrain from using intubation or mechanical ventilation, or feeding tubes. EMT personnel are not bound by advance directives, and will resuscitate you unless you have a medical order (or in Virginia, a DNR form) instructing them not to do so.

All three jurisdictions provide for these orders, each in its own form, as you will find from the tab following this text. Virginia’s is called a Virginia Physician Orders for Scope of Treatment (POST) form, https://www.virginiapost.org/ . Maryland’s form is a Medical Order for Life-Sustaining Treatment (MOLST), www.marylandmolst.org. DC has a Comfort Care Order Program (CCO-DNR) for people with terminal illnesses, as described in https://dchealth.dc.gov/service/ems-comfort-care-orderdo-not-resuscitate-program

vi. Planning for disposition of body:

Often, especially in the absence of any statement of preferences from the deceased family member, arguments will take place among the survivors about the funeral and the cremation or burial of the body. To avoid these arguments, Maryland law prescribes a written and witnessed statement by the dead person, indicating the preferences for those matters. A template for such a statement is in the tab following this document.

In the absence of a clear indication of these advance decisions in a will, advance directive, or specific, witnessed statement, Maryland law specifies the order of relatives or agents of the dead person to make these decisions. DC law leaves these decisions to the dead person’s personal representative (e.g., executor) or agent specified in the will. Some kind of advance written specification of the dead person’s desires can influence the representative or agent.

vii. Organ donations

Please note that the Advance Directive includes under "Other Wishes", opportunity to indicate whether you are willing to donate your body, or organs taken from it, for medical purposes. This could be a gift of sight, renewed health or even life to a fellow human being. You are encouraged to consider this opportunity seriously. https://www.directline.com/life-cover/organ-donation may help you in considering these choices.  MD and VA driving licenses now contain indications of willingness to donate organs. DC residents wishing to donate organs can register to that effect at https://www.donatelifedc.org/, and should carry the registration card in their wallets where it can be found if needed. Organ donation decisions also require discussion and understanding with your loved ones and doctor, for the reasons explained above. Some organs can be donated at any age.

pasting

Please note that the Advance Directive includes under "Other Wishes", opportunity to indicate whether you are willing to donate your body, or organs taken from it, for medical purposes. This could be a gift of sight, renewed health or even life to a fellow human being. You are encouraged to consider this opportunity seriously. https://www.directline.com/life-cover/organ-donation may help you in considering these choices.  MD and VA driving licenses now contain indications of willingness to donate organs. DC residents wishing to donate organs can register to that effect at https://www.donatelifedc.org/, and should carry the registration card in their wallets where it can be found if needed. Organ donation decisions also require discussion and understanding with your loved ones and doctor, for the reasons explained above. Some organs can be donated at any age.

viii. Related Resources:

Quaker:

Ø Quaker Values & End-of-Life Decision Making: Workbook, (2016), ARCH Program of New York Yearly Meeting, copies available through arch@nyym.org or (212) 673-5750.

Virginia residents: Please note that these resources are in addition to those provided in the tab following this document.

Ø Eleventh Annual Healthcare Decisions Days in the Commonwealth of Virginia, Tuesday, April 16-22, 2018 http://www.vsb.org/site/public/healthcare-decisions-day . This Virginia State Bar Association website provides links to the official forms for advance directives, and responds to common questions about the directives and the Virginia Health Care Directive Registry. Links to related issue are available at this website.

Ø Virginia Easy Access Community Supportshttp://easyaccess.virginia.gov/community.shtml provides links to downloadable publications on a large variety of questions relating to planning for aging, decline and death.

Ø Virginia State Anatomical Program, 400 E. Jackson St., Richmond, VA 23219, (800) 786-2479; has a form, to be executed in triplicate, to be signed by two witnesses as well as a person wishing to donate his or her body to medical science.

Ø Do Not Resuscitate (DNR) form: To prevent attempts at CPR and other related life-saving procedures, see http://www.vdh.virginia.gov/content/uploads/sites/23/2016/05/Authorized-Durable-DNR-Order-Form-Instructions-udated-61917.pdf . Instructions for this form are at http://www.vdh.virginia.gov/content/uploads/sites/23/2016/05/HowToFillOutDDNR.pdf , and http://www.vdh.virginia.gov/content/uploads/sites/23/2016/05/HowToOrderDDNRBracelets_Necklaces.pdf describes how to obtain necklaces and bracelets indicating to emergency medical technicians that you are not to be resuscitated.

Maryland residents: Please note that these resources are in addition to those provided in the tab following this document.

Ø Maryland Medical Orders for Life-Sustaining Treatment (MOLST) http://marylandmolst.org/pages/consumers.htm is a website with information about advance directives and related medical orders for Maryland residents.

Ø Maryland Medical Orders for Life-Sustaining Treatment (MOLST), http://www.marylandmolst.org/pages/molst_form.htm is the form that your physician or a nurse practitioner should fill in, after a discussion with you or your medical agent (if incapacitated), describing in detail what procedures to follow in various life-threatening contingencies.

Ø Maryland Office of the Attorney General, Advance Directives, http://www.oag.state.md.us/Healthpol/AdvanceDirectives.htm introduces and describes the official Maryland Advance Directive form, which one can download from http://www.oag.state.md.us/Healthpol/AdvanceDirectives.htm.

Ø Maryland Department of Health and Mental Hygiene Dept., Advance Directive for Mental Health Treatment, http://dhmh.maryland.gov/mha/Documents/Advance%20Directive%20for%20Mental%20Health%20Treatment%20july%202008.pdf provides an official form and instructions for an advance directive specific to mental health treatments.

District of Columbia residents: Please note that these resources are in addition to those provided in the tab following this document.

Ø DC does not have its own official advance directive form. Even so, hospitals and other medical services in DC accept the Advance Directive forms from other jurisdictions, as well as non-official forms. Caring Connections, http://www.caringinfo.org/i4a/pages/index.cfm?pageid=3289 has the official forms for every State, as well as one for the District of Columbia that is familiar to DC health care services. Download the form and instructions from http://www.caringinfo.org/files/public/ad/DistrictofColumbia.pdf.

Ø *AARP, 1995. Questions and Answers About Making Health Care Decisions in the District of Columbia.

General resources on Advance Directives:

Ø The NIH/National Institute of Aging has a useful website about advance care planning generally, at https://www.nia.nih.gov/health/advance-care-planning-healthcare-directives

Ø Organ Donation Saves Lives - Know Your Options: https://www.directline.com/life-cover/organ-donation

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b. Informal advice to survivors:

Many people have found it useful to supplement or include with the information described here with personal “love letters” to your survivors, stating in some practical detail your wishes (not legally binding, but helpful to them) about your burial arrangements and memorial services, your obituary, care for your children, disposition of any pets, any particular items of yours that should go to another person on your death, and the practical arrangements for having access to your financial records, your legal documents, your passwords, etc. Sometimes these “love letters” can start with an Ethical Will, as described above.

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c. Information to assemble now for the time of death:

You can facilitate matters at the time of your death by providing in advance essential information that will be needed then by your family. Please let your loved ones know where to find your current, completed information for them to use when you die. Forms for this purpose are in the planning tab following this text. These forms are briefly described below.

Accident Information:

Please fill out and carry with you a paper such as the form in the tab following this text, providing the information that a hospital emergency room will need quickly if you arrive unable to provide it clearly yourself. If you have serious allergies, a rare blood type, or take medications, this information could prevent serious complications or save your life. The larger copy of this form is for your car’s dash compartment. The smaller one is for your wallet or purse. These forms can provide a vital link to your loved ones if you are in an accident and can’t communicate with them directly. The information should include your primary physician’s current phone number and your next of kin’s phone number, so that they can be notified and provide additional information.

Personal Information for Death Certificate:

The attending doctor or funeral director will need this information to fill out the death certificate.

Relatives and Friends To Be Notified:

This is a useful guide to your survivors listing the people whom you wish to be notified of your death, and how to contact them.

Offices To Be Called:

Similarly, this form tells your survivors whom to contact concerning your legal and financial relationships. Often banks and other entities will want copies of the death certificates in order to change the ownership of an account.

Information for Obituary:

This form puts in one place the information you deem relevant to your obituary, if you want to have one.

Outstanding Obligations:

This form summarizes information about your creditors, so that your survivors will be able to pay your estate’s debts in an orderly fashion.

CURRENT Passwords, PINs, and Lock Combinations:

Please put in a sealed envelope whose location is known to your nearest and dearest a list of your current logon IDs, passwords and PINs, and please remember to keep it up to date. This can avoid the loss of much of your important data when you no longer can be reached. Similarly, an accessible record of lock combinations is needed. As people age they often find it harder to remember these details, so a current list can be helpful way before death.

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d. Preparation for and Postponement of Decline

There are many practical ways in which you can postpone the inevitable, and make it much easier for yourself and others when it comes. The documents described above are a beginning of these efforts, but far from the end. Having a fulfilling life with few and diminishing regrets will help you to live longer and more abundantly. A healthy, simple lifestyle, with few and diminishing unhealthy habits, will extend your years and your enjoyment of them. There is an abundance of advice about this general topic, which we won’t belabor, but one aspect of the healthy lifestyle needs to be emphasized. That is the importance of nurturing your network of support, and communicating with those who matter to you how you would like to live and die.

There is much contingency planning that you can do to prepare for your own or a loved one’s decline due to a physical or mental disability. Such a disability can be as short as a few days or as long as several years, but planning for it ahead can minimize its disruptions. If you or a loved one feels frail or in fragile health because of age, you can be justified in being skeptical about major surgery involving a general anesthetic, as these shocks to the system often bring about increasing dependency for people who have lost the ability to bounce back, and may risk death. Generally, anything requiring a stay in the intensive care unit (ICU) of a hospital is not recommended for any chronic diseases of the elderly from which recovery is unlikely. Often doctors will provide inflated estimates of life expectancy, out of a reluctance to provoke despair.

Nobody knows in advance just when a decline will strike someone, and usually nobody knows just how long it is likely to last or what kind and amount of care it will require. Hence all planning in this area is for contingencies that may never happen. Elderly people often become frail, which puts a burden on their caregivers and may last for a long time, but usually will not require assisted living. Most physical disabilities, even for the bedridden, will not deprive the person of the ability to pay bills and manage assets. Most age-related mental disabilities will require someone to step in to perform those functions. But mental disabilities alone, especially in the early stages, do not require special care of the body of the invalid, at least until physical complications such as incontinence begins.

i. Long term care and insurance for its expenses

Incapacity or disability, either physical or mental, is a topic few people want to address, but in today’s life they happen more often as people age beyond their parents’ life expectancies. Often these symptoms of a declining life involve substantial expenses for medical treatments and care for an incapacitated individual. Having a family member or friend who is willing to look after you can help to avoid or postpone institutional care, but the risks of major costs cannot be avoided entirely. Medicare and Medicaid pay for some of these expenses, but not for long-term care. So part of your planning may well involve decisions about long term care insurance. Most policies provide coverage for a limited duration of care, depending on the terms of the policy. That insurance becomes much more expensive to initiate as one ages, and many insurance companies have discontinued issuing policies for new customers. This is an element of planning that many of us may need to undertake well before any retirement. For more advice, see, e.g., https://longtermcare.acl.gov/costs-how-to-pay/what-is-long-term-care-insurance/.

ii. Downsizing and simpler housing

One important part of planning for decline is thinking about downsizing or moving, especially if an aged person lives in a house with stairs and more room and stuff than is needed. Among the many guides available about the topic, one might start with https://www.caring.com/articles/getting-rid-of-seniors-junk. Many older people, especially those who are frail, can easily feel overwhelmed by the difficult decisions that need to be made about where to move and what to get rid of, so help from the next generation or from professional moving consultants can make the move possible, and even comfortable.

Moving to a more accident-proof environment in a smaller house or apartment is one option, often used by those who are still quite capable of managing their own lives and packing and moving boxes and small furniture. But this can be disrupted if decline or disability indicate the need for a continuum of care.

Others may wish to contemplate moving to a continuing care community, which includes independent living, assisted living, and skilled nursing care. Particularly for continuing care, it is important for such moves to be planned well before a disability sets in, as vacancies arise in those communities only when someone dies, becomes disabled, or (more rarely) moves out. Many continuing care communities require new residents to be in good physical and mental health before moving in. Many such communities, and most ownership arrangements for houses and apartments, require substantial capital investments at the outset, usually financed by the sale of the previous home.

iii. Help in following Decline document

The second document in this book, “Decline, Approaching Death, and Dying: Ways to Meet Challenges” describes and refers to many resources on aging generally and about specific options for someone who is needing another’s care. You may want to consult it about those options, including the use of a general or durable power of attorney to allow a loved one or trusted friend to take care of an aging person’s finances.

e. Planning for Death

Your survivors will want to know how to find your advance directive, your will, and other vital documents such as birth and marriage certificates. Usually safe deposit boxes are locked when the bank hears that the owner has died, so it would be helpful to have the information located elsewhere. Telling your loved ones in advance whom to notify in the event of your death is really helpful, as is letting them know how to find your computer passwords, the keys to your locked places, and your insurance policies, financial accounts and address books. They would like to know your preferences on cremation or burial, your preferred ceremony to commemorate your life, your place of burial or ash deposit, any charity you favor for memorial contributions, etc. It would really help them if you draft an obituary while you are alive and well. These letters or other written documents will need to be reviewed and revised every few years.

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f. Resources on Preparing Mind and Body for Decline or Death:

Ø Aging with Dignity, http://www.agingwithdignity.org, has a very popular publication, Five Wishes, about end-of-life and health care decisions, that can be ordered through its website.
 
Ø ^Berman, P.L., Ed. (1989) The Courage to Grow Old.
 
Ø Caring Connections, http://www.caringinfo.org, 901 Moorfield Park Dr., #100,, Richmond, VA 23236, (804) 327-1111, is a good source of general advice about health care planning and related decisions, especially including hospice care.

Ø Deathwise is a nonprofit organization passionately committed to helping people talk about, make decisions and plan for the end of their lives. www.deathwise.org . The website includes many planning resources.

Ø https://www.everplans.com, http://www.thedigitalbeyond.com/online-services-list/, and several other websites offer advice, forms, and links to resources like this book does, to help people plan to minimize the disruptions when they die. Some of them, like http://aftersteps.com offer, for an annual fee, encrypted storage of forms and documents that result from this planning, together with guides about how to put them together and how to let your survivors know how to get access to them. These websites are described in a New York Times article at http://www.nytimes.com/2014/03/29/your-money/navigating-the-logistics-of-death-ahead-of-time.html?ref=business&_r=1 .

Ø Park, J., (U. of MN), Best Books on Preparing for Death, an annotated bibliography of 15 books offering advice and materials about preparing for death, can be found at http://www.tc.umn.edu/~parkx032/B-PREP.html. The site also has links to bibliographies on advance directives, voluntary death, terminal care, helping parents to die, right to die, and opposing the right to die.

Ø ^Paul, A., and Spring, B., 2016. Quaker Values and End-of-Life Decision Making: Workbook. New York, ARCH Program of New York Yearly Meeting (arch@nyym,org). 21 pp.

Ø Corr, Charles A., Clyde M. Nabe, and Donna M. Corr, 1994, Death and Dying. Life and Living, Pacific Grove, CA: Brooks/Publishing Co., 482 pp. + references. A comprehensive textbook on all the issues associated with death and dying.
 
Ø Harwell, Amy, 1995, Ready to Live, Prepared to Die: A Provocative Guide to the Rest of Your Life, Wheaton, IL: Harold Shaw Publications, 155 pp. Written by a cancer patient to inspire others how to live fully, this book includes a provocative checklist of preparations.
 
Ø *St. Francis Burial and Counseling Society, How to Make Your Own Coffin. 4 pp.
Last things, a website primarily for Maine residents, advises about home funerals, simple burials, and coffin construction. https://www.lastthings.net/coffin-building-workshop.

Ø *Virginia State Bar. (2013). Senior Citizen’s Handbook: Laws and Programs Affecting Senior Citizens in Virginia. https://www.vsb.org/site/publications/senior-citizens-handbook

Ø ^West, Jessamyn. (1976) The Woman Said Yes: Encounters with Life and Death: Memoirs.

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3. Planning for Property Disposition at or before Death:

a. Wills, intestacy, trusts, beneficiaries

i. Why Have a Will?

It is important to prepare a will or other formal document indicating the disposition you desire for your property in the event of your death. Lack of a will often leaves confusion and controversy, and is likely to cause unnecessary trouble for your survivors. It is the basic way for you to assure that those you wish to be the beneficiaries of whatever you leave behind will in fact receive the shares of your estate that you intend, or to make clear your bequests of specific items. In the absence of a will or other such document, this disposition will be carried out as dictated by State law, which may be very different than your wishes and lead to unnecessary hardship and resentment for your survivors.

The provisions of DC, Maryland and Virginia laws for interstate succession are summarized on the next pages, but these summaries are not the complete laws, and an estate lawyer’s advice is advised before you commit to any particular course of action. Links to local lawyer referral services are in item 3.b.i. of the document on Death: Help for Survivors in this volume.

If you have minor children, another major reason for having a will is to designate whom you want to be their guardians in the event that you and your spouse are no longer available. Here again, State law may designate guardianship succession that is different from what you would want.

A will need not be complicated, but its signature must be duly witnessed, usually by at least two non-relatives. This is often done in a lawyer's office so that the witnesses would be available in case of need to testify that you were of sound mind when making the will. Many local lawyers are available to help write wills, and standard formats are also readily available in libraries and on computer programs.

“Avoiding Probate”, on a subsequent page, includes a brief discussion of two ways to avoid the court-supervised probate process required for property covered by a will. Court-supervised probate may be time-consuming and is often quite expensive in some jurisdictions. Alternatives include a designation of beneficiary, or a Living Trust. The latter alternative has advantages over a will, some of which may be important to you, but needs to be carefully crafted and would be more expensive to prepare than a will.

For anyone desiring them, copies of a standard, lawyer-drafted will form covering many options, and of a living trust form, both taken from the Quicken Family Lawyer computer program, are available from the Committee for Care and Clearness.

If a couple has a prenuptial agreement, their wills need to respect that agreement unless they amend it explicitly, to avoid legal issues after the death of one of them.

ii. Local Laws on Intestate Succession: Is this what you want?

If you don’t have a will or property distribution trust at death, your survivors can expect this (as of mid- 2017):

District of Columbia: (See DC Code, §§ 19-301 – 19-316, https://code.dccouncil.us/dc/council/code/titles/19/)

Ø All to the spouse or domestic partner, if no descendent or parent remains.

Ø Three-fourths to the spouse or domestic partner, if no child remains but a parent does;

Ø Two-thirds to a spouse or domestic partner with shared living descendants, if there are no other surviving living descendants of either.

Ø One-half to a spouse or domestic partner who has surviving shared descendants as well as descendants not of the decedent;

Ø One-half to the spouse or domestic partner who does not share parentage of a surviving descendent of the decedent;

Ø If no spouse or domestic partner, or after his or her share, to the children or their descendants in shares equal to the number of alive children (legitimate or otherwise) and any dead children’s descendants as a descending group for each dead child (a child being considered “alive” if a descendant if the spouse or domestic partner is pregnant at the time of death);

Ø If no spouse, domestic partner or descendants, then to surviving parents;

Ø If no parents, then to siblings equally or dead siblings’ descendants;

Ø If no siblings or their descendants, then to all more distant relations to the fifth degree then alive, in equal shares;

Ø If no near or distant relations, then to surviving grandparents in equal shares;

Ø If real estate in a trust is vested in a trustee who dies intestate, then it shall be vested in the beneficiaries of the trust.

Ø If none of the above, to the DC government.

Maryland: (See Maryland Code, Estates & Trusts, Title 3, §§ 3-101 - 3-105, http://statutes.laws.com/maryland/estates-and-trusts/title-3/subtitle-1).

Ø All to the spouse, if no descendant or parent survives at least 30 days;

Ø If there are minor children, one half to the spouse, 1/2 to children or their descendants, in equal shares for each generation or, if dead, their progeny;

Ø If no minor children, $15,000 plus ½ of remaining property to spouse, rest to descendants as indicated above;

Ø If no children or their descendants, $15,000 plus ½ of remaining property to spouse, remainder to any living parents of the deceased in equal shares;

Ø If the spouse does not survive at least 30 days, all to the decedent’s children and their progeny, in equal shares for each generation;

Ø If no spouse or descendants survive, then to surviving parents and their descendants, equally for each generation, then the grandparents and their descendants, similarly, and the great grandparents and their descendants, similarly;

Ø If no blood relatives survive, then to any step-children or their progeny in equal shares

Ø If none of the above, to the County Board of Education unless the decedent was on long term care under Medicaid, in which case it goes to the Department of Health & Mental Hygiene to the extent of the expenses incurred for the decedent’s care.

Virginia: For Virginia’s laws of intestate succession, see https://code.dccouncil.us/dc/council/code/titles/19/ The rules may be described as follows, in order priority

Ø All to the spouse, unless some of the decedent’s children or their living descendants also came from another parent, in which case the spouse takes 1/3 and those descendants take 2/3 in equal shares per generation.

Ø If there is no spouse, all goes to the descendants in equal shares per generation.

Ø If there is neither spouse nor descendants surviving, all goes to:

Ø the parent or parents, or if not surviving,

Ø the siblings and their descendants, in equal shares per generation, or if not surviving,

Ø then ½ to paternal kindred, and ½ to maternal kindred, if any exist; otherwise, all to the kindred as follows:

Ø grandparents or grandparent; uncles and aunts, and their descendants; great-grandparents; siblings of the grandparents, and their descendants; and on, to the nearest lineal ancestors and their descendants.

Ø If there are no blood relatives, all goes to the kindred of the decedent’s spouse who predeceased him or her married to him or her.

Ø If none of these come forward, the property escheats to the Commonwealth.

Ø Collateral blood relatives of the half blood shall inherit only ½ as much as those of the whole blood.

Ø Children conceived before the death or resulting from assisted conception born after the death and determined to be his or her children shall inherit as if born during the decedent’s lifetime.

Ø A surviving spouse and minor children may collect up to $1,500 per month or $18,000 as a lump sum, to cover living expenses pending administration of the estate, and a surviving spouse or minor child may receive up to $15,000 value in personal property, within a year of the death.

iii. Avoiding Probate

When using either of the methods below, you still need a 'pour-over' will to cover anything not covered by designation of beneficiary or trust.

Designation of Beneficiary:

One method of keeping designated assets out of probate and speeding and simplifying their transfer at your death is to designate beneficiaries of specific securities or accounts. This is standard practice with insurance policies, IRAs and pensions or annuities. It is also possible with bank accounts, broker accounts and other real and personal property in those states that have adopted the Uniform Transfer on Death Security Registration Act. These states include Maryland and Virginia, but not the District of Columbia. Banks, brokers etc. are not required to provide this service, but if they do, they will provide the requisite registration form. The Committee for Care and Clearness has a copy of the Act available for review. For accounts held jointly with a spouse in the three jurisdictions, no independent designation of beneficiary is needed, as the spouse automatically inherits all property held jointly.

Living Trust:

Unlike a will, a Living Trust is not a matter of public record in its details, it is not probated in a court (saving time and, especially in DC, much expense), and the Trustee does not act under court supervision. The Trustee is whomever you designate, usually yourself so long as you are able, thereafter your spouse, child, friend and/or financial advisor as you specify in the Trust document. The Trustee has full control of the property in the Trust within the terms of the Trust.

One advantage of a Living Trust over a will is that should an accident or dementia make you no longer able to manage your assets, your spouse or other designated follow-on trustee can take over that management without going to court, simply by showing a doctor's certificate of your incapacity and the trust document to the trust's bank, broker, etc. The Executor of your will would have to wait until you died and then go to court to be empowered. A Living Trust can be changed or revoked by you at any time. It becomes irrevocable at your death or established incapacity.

Another advantage, if your estate is larger than the exemption from Federal estate tax (more than $10 million in 2018, but linked to the Consumer Price Index), is that your children can be named as heirs of the property in your trust, but to receive it only following the death of your spouse. That property in your trust would be covered by your estate tax exemption. While the transfer of your property to your spouse at your death in the absence of a Trust would be tax-free, only the spouse's exemption would be available when the estate is passed on following his/her death. Thus, use of the Trust can preserve the applicable estate tax exemptions of both husband and wife, one of which would be lost if ownership of the estate simply passed at the first death to the surviving spouse. This could be a matter of concern, if you own your home and have paid off all or most of the mortgage. If it is owned jointly, its full value becomes part of the estate of the surviving spouse.

Another feature of a trust is that property put into a trust is valued for your Gift/Estate tax purposes at the time of gift to the trust. Any later appreciation in its value does not become part of your estate for tax purposes, though any income taken from the trust is subject to the recipient's income tax. But the trust’s beneficiaries will need to accept its property at the value it had when the trust was created, rather than at the time of the trust’s donor’s death. That might increase capital gains taxes when the property is later sold.

What makes the Living Trust possible is transferring title to property as a gift: from you to the Trust, you as Trustee retaining control. Such gifts are tax-free up to the amount of your estate tax exemption.

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b. Give it away with warm hands.

We come to realize, as we age, that every gift is a burden, every burden a gift. One very productive way to spend time after retirement is in downsizing one’s material gifts/burdens that are no longer needed to secure your own future. If you have enough stuff to be able to live a good, simple life, why not give the rest away so that you can enjoy others’ use of it while you are still able to do so? Look around your living quarters: How much of it do you use, or will you need to use in the foreseeable future?

One must pay gift taxes for very expensive gifts, and capital gains on gifts that have appreciated in value before you gave them away. Consultation with a tax attorney or CPA is advised before you make a gift with a 2018 market value exceeding $15,000.

If you don’t want to give it away, you can sell it or throw it away. Some friends downsize with the help of a dumpster, and others have big “moving sales”. Charitable organizations can be found in most jurisdictions that will accept, and may come to your residence to pick up, furniture and other useful items for living. The point of this is to reduce your own burdens in caring for things you don’t need or use, and to reduce the burdens of those who survive you in deciding who should get what and how it should be used.

4. Assembling planning documents, and letting your likely survivors know how to find them:

An important final step in planning is to assemble all the signed originals of the documents referred to above, and all the information you have prepared relating to your decline and death, into one safe place where they can be found and used once you no longer can locate them. Then you need to let your nearest and dearest know where they are and how to find them. Annual reminders to that effect would be helpful, as well as reminders when your health condition changes for the worse.

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List of Forms:

Advanced Directive

VA Advance Directive (PDF)

Declaration of Final Arrangements/Disposition of Last Remains

MD AD & Form Info (PDF)

DC Advance Directive (PDF)

Where is your Advanced Directive?

Medical Orders

POST form (VA) (PDF)

MOLST form (MD) (PDF)

EMS COO form information (DC) (PDF)

Accident Information

Personal Information for Death Certificate

Names, Addresses, and Phone Numbers of Relatives and Friends To Be Notified

Names, Addresses, Account Numbers and Phone Numbers of Offices to be Notified

Information for Obituary

Outstanding Financial Assets and Obligations

Passwords and Combinations

Accident Information

Name Tel ( ) -Work( )

Address

Date of Birth Social Security No.

Contact Name Tel ( ) -Work( )

Contact Address

Physician Tel. ( ) Medicare? A? B?

Med. Insurance Religion

Blood Type__ RH Allergies:

Medications

Advance Directive executed? [ ]Yes [ ]No Durable Power of Attorney held by:

Name Tel ( ) -Work( ) .

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Personal Information for Death Certificate

Full Name

Residence Street Address

County, City, or Town State Zip

Date and Place of Birth

Citizen of State or Country of Birth

Social Security No. Last Occupation

Last Employer Length of Employment:

Ever in Armed Forces? ¢Yes ¢No If yes, rank, branch, & dates of service:

Race or Ethnic Identification:

Name & Birthplace of Father

Maiden Name & Birthplace of Mother

Marriage status Name of Spouse Living?

Next of Kin (if other than spouse) & Relationship:

Occupation of Spouse or Next of Kin:

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Names, Addresses, and Phone Numbers of Relatives and Friends To Be Notified:

 

 NAME  ADDRESS  E-MAIL  TELEPHONE
       
       
       
       
       
       
       
       
       
       
       
       
 

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Names, Addresses, Account Numbers and Phone Numbers of Offices to be Notified

In most cases these financial offices will need an official copy of the death certificate and designation of the executor or trustee.

Social Security

Pension

Bank

Insurance, Life, Car and House

Mutual Funds/Broker

IRA

Credit Card

Frequent Flyer Miles

Other



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Information for Obituary

(You may want to make this a narrative document, rather than a list.)

Parents’ names, birthplace and date

Education

Military Service

Career, with dates and positions

Major accomplishments and awards

Volunteer service, and charities

Religious affiliation

Organization memberships

Publications


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Outstanding Financial Assets and Obligations

Assets:

Bank Accounts:

Other Debts Owed You (including where the note is located)

Credit Balances Carried:

Other:

Liabilities:

Mortgage/Deed of Trust

Car loans

Home Equity Loan

Credit Cards

Other


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Passwords and Combinations

[Keep this in a safe place, known to your survivors, and try to keep it up to date.]

Website or Account

User Name

Password

     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     

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Decline, Approaching Death, and Dying: Ways to Meet Challenges

Contents:

Spiritual aspects: queries, Langley Hill resources, other resources

Care for Body and Mind: advance directive provisions, practical care arrangements (including senior-friendly residence, in home care, assisted living, skilled nursing home, hospice services, continuing care communities, Medicaid), related resources,Communications and The Dying Process, related resources

Care for Property: general powers of attorney

Related forms in pocket: VA, MD and DC general powers of attorney

This, the second of three documents in Langley Hill Friends Meeting’s packet on decline and death, provides advice and resources on the spiritual, physical, mental and property challenges that arise during a person’s growing incapacity to manage his or her own life, and during the approach to death and the dying process. As a person grows over 75 or 80, frailty usually sets in making the person less able to cope and more susceptible to disease and injury. This document is aimed at helping those who are anticipating or coping with an incapacitating decline or is helping someone in decline.

As with the other documents, this one is arranged with spiritual issues considered first, practical aspects of the body and mind second and property-related issues third. Although the challenges faced during a decline leading toward death are similar to those faced with a major disability at any age that limits a person’s ability to take care for one’s self, this document focuses on the gradual loss of physical or mental capacities that often precedes death. Unlike the first and third documents, this one might not be relevant for many of us.

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1. Spiritual aspects of Decline:

a. Queries Concerning Your Loved One’s Decline or Dying

Ø How can I recognize that someone is increasingly dependent on me for help with basic daily self-care tasks, like getting dressed, bathing, toileting, remembering routines and important timing for things like a dish on a hot stove? If I am not in a position to be with that person, do mishaps take place often enough to raise questions that the person may need expert help? To whom can I turn for advice on how best to help this person?
 
Ø If I am the primary caregiver for someone in decline, how can I muster others’ support for his or her needs as well as my own? Can I call on friends or other caregivers to give me an occasional respite? What other kinds of paid or volunteer help do we need?
 
Ø How can I arrange my life to give myself timely opportunities to work through my grief? How do I accept that others may need a different amount of time, or different conditions to work through their grief? How can I get others to understand my grieving needs, and how can I learn to understand theirs? 
 
Ø How can I help a dying person who denies any negative feelings about weakness or his own impending losses to come to terms with the inevitability and closeness of his or her death?
 
Ø Anyone who depends emotionally on someone who has become incapacitated or is approaching death will grieve. Grief can take months or years to subside, and it may last longer if suppressed. Can I allow myself to vent my grief? How, and with whom? Whom shall I call upon to help me to survive and emerge from the depressing times ahead? How can I help others who are going through this same process with me? Is professional counseling needed?
 
Ø Is my support for someone who grieves confined to conventional comforting? How can I persist in my support for someone who is grieving for an extended period of time, or whose grief returns? How can I communicate a real willingness to be available for help? How can I best be supportive if I feel I can’t or won’t take on much of the responsibility to help another work through grief? How can I communicate that support?
 
Ø How can I make asking for help more comfortable, after others appear to have resumed their normal lives?

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b. Queries about your own possible decline:

Ø If I sense my own physical or mental capacities are declining, how can I express that concern to others in a way that will help us get a more objective assessment of my condition, while avoiding unnecessary fears or exaggerated expectations?
 
Ø If someone close to me suggests that my physical or mental capacities are declining in some way, how can I respond in a way that takes the suggestion seriously and neither exaggerates nor downplays my own sense of my condition?
 
Ø Am I emotionally prepared to seek and obtain a medical or psychological assessment of my condition from a trusted and objective source, if I feel or others express concerns about that condition? Can I ask the doctor for a realistic appraisal of the likely outcome of any treatments? Would I want a second opinion as well?
 
Ø In obtaining that assessment, if it confirms a decline, can I ascertain the extent that it is reversible, and my own willingness to participate fully in efforts to reverse it? If it is not reversible, or if I am unable or unwilling to try to reverse it, can I fully explore with others my choices for care for the rest of my life? Can I make those choices, and try to follow through with their consequences? Am I aware that at any time I can instruct that my treatments be terminated?
 
Ø If I was terminally ill, with only 3 months of life left, what would I want to do with the time left to me?
 
Ø Have I made advance arrangements to shift my collective burdens onto other capable and not unwilling hands, to the extent required by the likely progress of my decline, if and when it may happen? Are others fully aware of and trained in handling those burdens? Are the proper authorizations, task descriptions, passwords and other incidents of that work available to those who will take on the burdens?
 
Ø If an irreversible decline is likely, have I adjusted my advance directive, powers of attorney, medical orders for end of life care, and other authorizations to fit my current wishes and the likely progression of my decline?
 
Ø If I will need care for my condition, how can I ask someone to provide that care? Can that burden be shared? If so, how can assets, time and energy be mustered to build a mutually compatible arrangement between us all?
 
Ø If someone near and dear to me is willing to undertake being the primary caregiver for my infirmities, how can I help to ease the burdens of that work on him or her, now and as my decline continues? While able, can I actively help to find respite care for that person and me?
 
Ø To whom, when, and in what detail, shall I/we communicate with others about my condition, its prognosis, and the arrangements I/we are making or have made to deal with this condition? If I don’t communicate in detail now about these matters with my immediate survivors, will they be able to act on my behalf according to my wishes as my condition worsens, and following my incapacity and death?
 
Ø If my care, as my decline progresses, will or may require assisted living or skilled nursing care, can I help to make advance arrangements for those contingencies before they happen, knowing that some difficult choices may be involved? If a downsizing or move to another location will be involved, how can I facilitate that now?
 
Ø How can I arrange to keep in touch with people for whom I care, as my decline progresses?
 
Ø Are my nearest and dearest familiar with my wishes for what follows my death? Have I prepared plans for those events? Do they understand my religious, spiritual, ethnic and cultural beliefs and practices, my thoughts about life in general, and what I feel has given meaning to my life?

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c. Resources: Meeting and other

i. Meeting Resources:

If requested, the Clerk of the Committee for Care and Clearness will appoint a clearness or support committee to meet with family members faced with difficult questions, such as terminal illness, lasting coma, serious brain damage, chronic pain, grief, or the logistical, practical and emotional problems of life, with or without the person who is in a decline or approaching death.

If the next of kin are stretched thin financially by the expenses of illness or of the burial or funeral expenses, or otherwise because of the death, they might approach the Care and Clearness Committee for help from the Family Emergency Fund.

ii. Other spiritual resources:

(Also see grieving resources in the document on Death: Help for Survivors.)

Ø ^Albertson, Sandra H., (1980). Endings and Beginnings.
 
Ø ^Arnold, Johann C. (1996). I Tell You a Mystery: Life, Death, and Eternity.
 
Ø Becket, Marilyn R., 1992, Last Touch: Preparing for a Parent's Death, Oakland, CA: New Harbinger Publications, 143 pp. A short set of intimate stories about how one family coped with their aging father's passing away.
 
Ø *^Callahan, M., & Kelley, P. [1992] 1997. Final Gifts: Understanding the Special Awareness, Needs and Communications of the Dying. New York, Poseiden Press. 239 pp. (2 copies at LH, 1 at C).
 
Ø Friends Journal, (August 2017, 63:7), The Art of Dying and the Afterlife, has several articles with stories of Quaker perspectives on grieving a death. https://www.friendsjournal.org/2017/art-of-dying/
 
Ø Boyce Upholt’s Unaccompanied, pp. 6-7, is about finding Light in the grief of loss.
 
Ø Shannon Zimmerman’s A Quaker’s Passing: My Father’s Way, pp. 8-10, writes about God being with us as her father passed.
 
Ø Michael Resman’s Heaven-based Living, pp.11-12, perceives a universal Heaven that can infuse life and death on Earth with joy and gratitude.
 
Ø Robert Stephen Dicken’s A Simple State of Being that Never Truly Dies, pp. 13-15, regards death as our consciousness, taken to a heightened level of spirituality.
 
Ø Children and Death, by John Graham-Pole, explores a physician’s personal experience of his own child’s death and the grief that followed, and stories of how he later helped other children move toward a death in unity with the Spirit. pp. 16-18, 38-39.
 
Ø Betsy Blake’s Weeping to Joy pp. 20-22, tells of her moving on following her sister’s death, reaching out for connection in any place or person where the Spirit may be found.
 
Ø Dodson, L.S., The Dying Process of a Conscious Woman — Virginia Satir, pp. 179-187, and Brothers, B.J., Healing Virginia, in Brothers, B.J., Ed. (1991 Virginia Satir: Foundational Ideas. Binghamton, NY, The Haworth Press.
 
Ø ^Gawande, Atul (2014). Being Mortal: Medicine and What Matters in the End. A doctor’s excellent appeal for the quality of life, when medical personnel often prefer to prolong it despite great costs and suffering.
 
Ø *^Kavanaugh, Robert E., 1972, Facing Death, Los Angeles: Nash Publishing, 226 pp. This personal and sensitive account by a priest explores mourning in America and the complex feelings associated with the end of life. First the dying person needs to receive permission to pass away from every important person he will leave behind. Only then can he voluntarily let go of every person and possession he holds dear.
 
Ø ^Kubler-Ross, Elisabeth (1974). Questions and answers on death and dying.
 
Ø ^Lampman, Greg R. (1994). Magic and Loss : In Letters to His Young Daughter, a Father, Suddenly Facing Death, Rediscovers Life.
 
Ø ^Levine, Stephen (1982). Who Dies? An Investigation of Conscious Living and Conscious Dying.
 
Ø *Smith, Bradford, 1965, Dear Gift of Life: A Man's Encounter With Death, Wallingford, PA: Pendle Hill Pamphlet No. 142, 38 pp. As the author faces his final months with cancer, he shares deep meditations on the meaning and wonder of life; the intensity of life in finite time. "If we cannot speak freely of death, we cannot really speak freely of life."
 
Ø http://www.wikihow.com/Prepare-for-the-Death-of-a-Loved-One . This Wiki is an accumulation of advice about the steps that help to ease the impact of an impending death.
 
Ø National Caregivers Library, a website of a for-profit Family Care America, Inc., provides an abundance of materials, books, advice and advertising for those who must care for another. http://www.caregiverslibrary.org/home.aspx .
 
Ø *Ostrow, W. 2006. In God We Die Pendle Hill Pamphlet 385. 36 pp.
 
Ø *Taylor, P. [1981] 1989. A Quaker Look at Living with Death and Dying. Philadelphia Yearly Meeting. 32pp. Papers form PYM Death and Dying Conference in 1981.
 
Ø ^West, Jessamyn (1976). The Woman Said Yes: Encounters with Life and Death: Memoirs.
 
Ø Yungblut, J., 1990. On Hallowing One’s Diminishments. Wallingford, PA, Pendle Hill, Pamphlet #292.
 
Jim Bond, a member of Langley Hill, was facing his final days when he wrote this poem in 1998:
Let go, he said, and fall
Into the everlasting arms; 
Your frantic grasp upon the edge
Of sullen life is useless now. 

Unhand the day, and unheeding fall
Into Eternal care.
But no, I plead; 
I sense no sure embrace.

I fear an everlasting fall
Into a cruel and empty space.
Remember yet, he said, 
The gentle curvature of space,
Encircling time and you;

Hold, in its arms
The wholeness of us all,
And tenderly, returns your fall.
Let go, he said, and rise
Into the endless skies.

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2. Body and Mind aspects of Decline:

a. Advance Directive Provisions:

An Advance Directive, as described more fully in the accompanying document on Planning Ahead for Decline and Death, provides for the appointment of an agent to act on behalf of the signer if he or she becomes incapacitated. The agent then can make decisions relating to the care of the individual, based on the best interests of the person as the agent sees them, subject to the person’s specific instructions about his or her care. It is worthwhile for anyone appointed in an Advance Directive as an agent to consult all of those most interested in the person’s welfare, including any physicians, when called on to make significant decisions under the Advance Directive.

Unless or until a decline makes a person unable to make decisions for oneself, she or he can change an advance directive or medical order to meet changing attitudes and conditions.

In the absence of an advance directive, informal care arrangements can work either until decisions have to be made about care arrangements with the knowing consent of the individual being cared for. If that person cannot or will not do so, a “next of kin” or other primary caregiver must be designated for assistance with care decisions, payments, etc. Very often in these situations legal arrangements must be made quickly, and at considerable expense.

b. Practical care arrangements:

Anyone facing decline or approaching death will need to consider the available options for life support during that period:

(i). Moving to a More Senior-Friendly Residence:

As we age we become increasingly less able to manage stairways, loose rugs and other floor irregularities that cause falls; driving a vehicle; remembering things such as a stove burner left on or a door unlocked; walking long distances or standing for a long time; and a variety of other daily challenges that we had navigated easily until recently. We also find ourselves newly feeling burdened with the daily chores of managing a home, cooking our meals, and doing routine repairs, maintenance, and gardening. A common response to this is to move to simpler, smaller quarters such as an apartment near public transportation, hospitals, etc. Such a move can provide a degree of freedom and confidence that one can continue to be relatively self-sufficient for much of the rest of one’s life. Even so, such a move disrupts the continuity of familiar quarters and neighbors, and requires the establishment of new routines and friendships. The disposal of most of a lifetime’s accumulation of possessions can be burdensome and very time consuming. As with planning generally, it is best to make such a move well before the challenges become insurmountable. Often seniors in declining health feel incapable of unloading a lifetime’s accumulation of stuff and making a move that would improve their prospects for quality of life. The longer time these decisions are put off or fail to be implemented, the more difficult the actual move becomes.

(ii). In Home Care:

For any decline there are several kinds of care that involve varying demands on the principal caregiver (usually a loved one). According to the Center for Disease Control (CDC), 90% of Americans who need long term care get it from unpaid family members. That puts a strain on relatives who have neither enough time nor the training to care for loved ones. Home care, with the caregiver in residence and the person with a disability living as close to his or her accustomed way of life as the disability permits, is the simplest and least expensive option. But the demands of helping the disabled person may be more time-consuming or more specialized than the caregiver is able or willing to provide, so home care services can be obtained from individuals or agencies in the locality. (See references below for local resource and referral agencies). These services can range from medical alert lanyards, worn constantly to allow immediate notice to emergency services in case of a fall or other emergency, to constant attendance by trained nurses. Medicare pays only for home care for 60 days for each episode in which it is needed for health conditions that make unassisted transportation from the home difficult.

(ii.a). Related Resources:

Ø https://www.caring.com/caregiving-resources Caring.com offers a wide array of resources to help family caregivers.
 
Ø Family Caregiver Alliance, Family Care Navigator, https://www.caregiver.org/family-care-navigator This website offers State-by-State guides to all kinds of help for people caring for family members, whether public, private, or nonprofit.
 
Ø Montgomery County Government, Information & Assistance for Seniors, (240) 777-3000, provides free advice to Montgomery County residents about finding and selecting home care and support services.
 
Ø Montgomery County Government, Telephone Reassurance Program for Caregivers over 60, 240-777-2600, offers informal advice and support for older caregivers.
 
Next Steps in Care:
 
Ø https://www.nextstepincare.org/ This website offers step-by-step guides to caregivers and health care professionals about easing the transition from one level of care to the next.

Virginia:

 
These are some available caregiver training options:
 
Ø The Alzheimer's Association has several free, online tools to help caregivers find answers, local resources and support.

Ø The National Parkinson's Foundation has a list of resources for caregivers at http://www.parkinson.org/Living-with-Parkinsons/For-Caregivers for a list of caregiver resources and a free manual called Caring and Coping.

Ø AARP has several free on-line seminars on family caregiving topics such as housing options, the basics of handling caregiving, providing the care, and planning for the care of aging parents.

Ø AARP has also prepared comprehensive materials for caregivers called "Next Step in Care." Although the focus isn't on nursing-style caregiving tasks, three might be useful: a self-assessment tool for family caregivers, a medication management guide, and a guide to hospice and palliative care.

Ø The American Red Cross offers a training manual for caregivers that has a DVD explaining the mechanics of transferring another person from bed to chair and back, and a few other complicated tasks.

Ø Also, some videos are available for free at www.mmlearn.org, a Web site that says its mission is to provide caregivers with online training and education.

In addition, the best way for caregivers to learn caregiving techniques is to ask a professional for help. If your loved one is in the hospital, make sure care instructions are clearly explained to you before discharge. If you don't get them to your satisfaction, don't sign the form that says you have been given instructions on what to do. The hospital is legally obligated to ensure that discharges are safe, and this operates in a caregiver's favor. The same goes for the pharmacy: don't sign that sheet that the pharmacist hands you indicating that you have been adequately informed about the medications you are purchasing if you haven't been.

U.S. HHS Administration on Aging, 1 (800) 677-1116: Eldercare Locator: Connecting You to Community Services. https://eldercare.acl.gov/public/index.aspx . This phone number or website helps people to find local sources of the kinds of care or advice that they or their loved ones need as they begin to make decisions about caring for infirmities.

(iii). Assisted Living:

The next step up the ladder of services, expenses, and disruptions, is assisted living, in a building with others needing this same kind of help. Attendants provide basic assistance for daily living tasks that the disabled person requires, such as washing, toileting, dressing, eating, moving, etc. Expert nursing services usually are not part of this arrangement, although limited services of a nurse, such as the administration of medications, is usually provided. Usually the spouse of someone in assisted living is not allowed to cohabit there without paying for an unnecessary level of services.

(iv). Skilled Nursing Home:

A third step of intensity is a nursing home, where the assistance is more intensive, accompanied by expert nursing services, various forms of therapy, and monitored attendance. A variant of these services is provided for those suffering memory losses and other symptoms of dementia, with reduced physical care and more dementia-related therapy. Medicare rates these facilities according to their compliance with regulations, staffing, quality measures, and overall. You can make closer comparisons by entering your residence location at http://www.medicare.gov/quality-care-finder/#nursing-home-compare. The care can be quite expensive, and Medicare only pays for 90 days of assisted living or nursing home care, apart from hospice care. Medicaid can pay for these expenses for individuals with low income and not many assets, if one meets the very complex rules for that coverage. You can check with your local offices that administer Medicaid to explore these issues further.

(v). Intensity of medical interventions:

As we age, we become less resilient in terms of recovery from aggressive life-saving or life-prolonging measures often taken in hospitals. People aged in their mid-80s and older usually will not benefit from the intensity of services provided in intensive care units for more that the time necessary for resuscitation and related services, especially for chronic conditions or treatable diseases. More limited medical care, including intubation, dialysis, and blood transfusions, should be discussed with family and physician in the light of the patient’s condition and opinions about quality of life. A patient has the right to order that any medical treatment be stopped, even if that will result in a much quicker death. The end of life is not just a medical issue.

28 percent of Medicare costs are spent on the last 6 months of life. Cardio-Pulmonary Resuscitation (CPR) is an emergency procedure to save a life by restoring a heartbeat. It restores functional life about 15-20% of the time in the hospital, 10-12% in most non-hospital settings, and 2% in a nursing home. Patients with osteoporosis usually have their ribs broken in this process. The rate of survival for resuscitation using electric paddles (AED) is less than 3% for those over 70, and less than 20% for those over 50.

(vi). Hospice Services:

Normally doctors tend to express overoptimistic estimates of life expectancy for their patients, in attempts to keep the patient’s hopes up, but often palliative care through hospice services can make a person’s final months, weeks, and days have a much higher quality of life than full medical attempts to sustain life at all costs.

All of the forms of professional care described above can be provided as hospice services. Medicare Part A pays for those people whose conditions have been diagnosed as terminal, with a life expectancy of less than six months in their normal course, including palliative care to reduce the pain and inconvenience from the terminal condition and its medications, without unusual efforts to prolong the patient’s life. The services can be extended for repeated six-month periods with a similar certification. Hospice services are provided on the condition that the patient will not request or require treatments designed to reverse or cure the life-threatening condition. Medicare pays for most hospice services for those with Medicare Part A benefits, Hospice service can be provided in one’s home or in any of the other living arrangements described above, including a hospital. Usually hospice services are coordinated by a multidisciplinary team including chaplain, physician, nurse, social worker, etc., who serve the family as well as the patient. Medicare continues to pay the expenses of supporting families in their grief for up to 12 months following a death.

(vi.a). Related Resources:

Ø The National Hospice and Palliative Care Organization has a “search” function with which you can find a list of local hospice and palliative care organizations. https://netforum.nhpco.org/eWeb/DynamicPage.aspx?Site=NHPCO&WebKey=a9338cdd-546a-42f5-9061-6b91dbdb31da.
 
Ø Hospice Link, (800) 331-1620, provides resources and referrals to hospices.
 
Ø www.americanhospice.org offers advice and links about hospice care.
 
Ø http://www.caringinfo.org, the website of the National Hospice and Palliative Care Association, based in Alexandria, VA, provides medical advance directive forms tailored for local jurisdictions and kept current with legal developments.
 
Ø Acquavia, K. D. (2017) LGBTQ-Inclusive Hospice and Palliative Care: A Practical Guide to Transforming Professional Practice. Harrington Park Press. 250 pp. “This manual is a must read if you are involved with efforts to help caregivers examine their ideas and feelings about seeing LGBTQ patients as simply part of the general population and not some special group”. [Friends Journal (Oct. 2017), p. 32]
 
Ø Gawande, Atul Being Mortal: Illness, Medicine, and What Matters (2014) New York, Henry Holt.
 
Ø Maryland Department of Health, Am I eligible for Medicaid Services? https://mmcp.health.maryland.gov/Pages/Apply%20for%20Medicaid.aspx
 
Ø Virginia Department of Social Services, Medical Assistance Programs. http://www.dss.virginia.gov/benefit/medical_assistance/index.cgi  In May 2018 Virginia changed its Medicaid eligibility standards substantially. It would be worthwhile to call (804) 726-7865, to inquire about ones own eligibility
 
Ø DC Dept. of Health Care Finance, Medical Assistance Programs: Information and Eligibility. https://dhcf.dc.gov/page/medical-assistance-programs-information-and-eligibility
 
(vii). Continuing Care Communities:

Often all four of the above forms of care are provided in continuing care communities, which provide for independent living for seniors as well as these other forms. The Medicare Nursing Home rating system referred to above includes continuing care communities, and can be helpful in making these choices. In addition, accreditation by CARF (see below) is a strong indication of quality.

(vii.a). Related Resources:

 
Ø Leading Age, http://www.leadingage.org, is an organization of those who work “to expand the world of possibilities for those who are aging”. Its website has a search function to find continuing care communities, etc.
 
Ø Friends Services for the Aging, http://www.fsainfo.org, is the Quaker equivalent of Leading Age for Friends-related aging services.
 
Ø CARF International, www.carf.org/home/, accredits nursing homes, assisted living facilities, continuing care communities, and other providers to seniors. CARF accreditation signals a service provider's commitment to continually improving services, encouraging feedback, and serving the community. This is a relatively objective way of assessing the quality of these facilities.
 
(viii). Medicaid:

Medicaid will pay for the expenses of any of these forms of care for patients who meet the State requirements to qualify for Medicaid coverage. These requirements often include complex, changing limits on the annual income and the net assets of the Medicaid applicant. For the current requirements for Medicaid eligibility and other details, see the websites below. Any application for Medicaid assistance will require both the application forms and documentation, as well as a personal interview.

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c. Communications:

Dr. Gawande (see resources below) emphasizes the tendency of medical professionals to sugar-coat their estimates of a dying person’s estimated life expectancy. It is important, well before death begins to come near, to emphasize to one’s primary care physicians and others that you want to be given their most accurate estimates of the prospects of death or recovery as a condition progresses. It is also important that they hear about your goals and your needs from them. This foundation for the professional relationship gives the patient, family and friends the time that they need to prepare for the event of death. In addition, Medicare will pay for hospice care if a patient has received an estimate of a life expectancy of six months or less. So, you should communicate specifically to the appropriate medical professionals your feelings about hospice care well before the need for it arises.

Almost everyone has important supportive relationships with other people. When someone becomes incapacitated or is approaching death, family and friends need to know about it and usually want to be supportive. This support can be very concrete, such as providing food for the family or substitute care for the incapacitated person so that the normal caregiver can have a respite. Perhaps even more significantly, supportive friends can provide spiritual and other compassionate support to the dying person and the caregiver. Both the person on the receiving end and the giver benefit from this support. Such support often makes the decline or final days a much lighter burden to carry on either side.

In a few lucky cases, the indisposed person will have prepared a list of those to be contacted when they die or their medical condition changes significantly, but that is relatively rare. People planning to communicate with a larger community need to keep in mind the disabled person’s preferences regarding privacy, and if the person is conscious and able to express these preferences, that conversation should be held before any non-obvious communications begin. Often the best arrangements for communication are to designate one person to act as a channel from the next of kin to the rest of the family, friends and colleagues of the incapacitated person. Sometimes the next of kin is too overwhelmed emotionally to cope with this duty. In other cases the communicator has to use his or her best understanding of the indisposed person’s sense of privacy and closeness of ties to decide whom to contact. The indisposed person’s address book or rolodex can be a starting point for composing a list of people to contact or, if possible, one can find representatives of each group of family or friends to relay significant news. Social media, if the communicator has access to the indisposed person’s account, can be helpful. Www.caringbridge.org is one website that many have used in these circumstances.

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d. Approaching Death:

When death is near, there often is a clear transition from decline toward death. Some of the earlier signs include withdrawal from people and activities, less communication, less food and liquid intake, difficulty in swallowing generally and in taking medications particularly, and more sleep. Within a week or two of death, often there is frequent disorientation and confusion, symbolic language (such as “I want to go home.”), talking to people not in the room, and changes in pulse rate, blood pressure, skin color, breathing, and body temperature, in a total body deterioration process. Usually, with this gradual shutting down, pain is not felt as acutely as before. Palliative care to make the patient more comfortable often is the preferred option. Toward the end there may be restlessness, bursts of energy or clarity allowing almost normal communication. If the person, in his or her confusion, feels a fright or threat, some mild sedation may be appropriate. As death comes close breathing may be shallow, with long pauses, and the person may become unresponsive, with the skin becoming mottled and cooling.

A few people want to die alone, but most are grateful for the caring presence of their nearest and dearest at their bedside. Visits from casual acquaintances should be brief if at all, especially if the dying person seems overwhelmed. Simple presence is more important than what is said or done, although some aspects of comfort care, such as moistening a dry mouth, can help. If the person is unconscious, people nearby should speak as if the person was awake and listening, as hearing is one of the last senses to go. Sometimes it helps for those near and dear to affirm that it is o.k. for the person to die, that loved ones will carry on afterwards. Professional end-of-life counselors, or doulas, are available in many locations (see Resources below).

As death approaches, those who are closest to the dying person need to think about the choice of the funeral director, undertaker, or cremation service, and the plans for any ceremonies following death. Making these decisions in consultation with the dying person, if possible, can ease that person’s mind about those post-death arrangements.

In some religions these last hours of a person’s life are commemorated with special prayers. Quakers sometimes hold a meeting for worship at the bedside. Soft music and dimming lights may ease the release from life.

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e. Resources on the body and mind in decline and dying:

Ø AARP, Staying Sharp: Current Advances in Brain Research:

Ø Memory Loss and Aging (2005), 16pp. includes a list of relevant resources
 
Ø Quality of Life (2005), 20pp. also has a list of relevant resources
 
Ø Avonheim, Dr. Judith and Doron Weber, 1992, Final Passages: Positive Choices for the Dying and Their Loved Ones, New York: Simon and Schuster for the Philip Lief Group, Inc., 285 pp. A sympathetic guide to various end-of-life choices, with lots of good reference materials listed.
 
Ø *^Callahan, M., & Kelley, P. [1992] 1997. Final Gifts: Understanding the Special Awareness, Needs and Communications of the Dying. New York, Poseiden Press. 239 pp. (2 copies at LH, 1 at C).
 
Ø Caring Bridge, www.Caringbridge.org is a website that facilitates communications about people who are ill, dying, or recently deceased. One can use the website as a basis for, and record of, communications between the nearest and dearest to others who care for and about the person.
 
Ø Caring Connections, (800) 658-8898, is a project funded by the Robert Wood Johnson Foundation, housed in the National Hospice and Palliative Care Organization, http://www.caringinfo.org. It provides free information, resources and motivation to learn actively about end of life issues, as a consumer outreach effort. Its advance medical directive forms, available on its website, are kept up to date with local legal requirements, and are recommended for use, perhaps with some modifications to indicate specific preferences.
 
Ø Corr, Charles A., Clyde M. Nabe, and Donna M. Corr, 1994, Death and Dying. Life and Living, Pacific Grove, CA: Brooks/Publishing Co., 482 pp. + references. A comprehensive textbook on all the issues associated with death and dying.
 
Ø Cox, Donald, 1993, Hemlock's Cup. The Struggle for Death With Dignity, Buffalo: Prometheus Books, 3 11 pp. A history of the evolution of the right-to-die movement, analyzing many of the issues involved.
 
Ø Compassion and Choices, P.O. Box 101810, Denver, CO 80250, (800) 247-7421, www.compassionandchoices.org, formerly the Hemlock Society and its Foundation, Compassion & Choices improves care and expands choice at the end of life. It supports, educates and advocates.
 
Ø Dodson, L. S. (1991) The Dying Process of a Conscious Woman — Virginia Satir. Haworth Press.
 
Ø *Dunn, H. 1994. Hard Choices for Loving People: CPR, Artificial Feeding, Comfort Measures Only, and the Older Patient. Fairfax, VA. A&A Publishing. 48 pp. (2 copies).
 
Ø Death With Dignity National Center, 520 SW 6th Avenue, Suite 1220 Portland, OR 97204 Phone: 503-228-4415 Fax: 503-967-7064. See more at: http://www.deathwithdignity.org . Suicide and materially helping another to commit suicide are criminal acts in Virginia; even so, this organization offers information on expanded end-of-life choices and promotes legislation to provide options for the dying to control their own end-of-life care.
 
Ø Dying in America, Institute of Medicine, National Academies Press (2015).
 
Ø End of Life Doulas: Professionals who help people end their lives in love and harmony. http://inelda.org/ . Patricia Sepulveda of the Charlottesville Meeting is certified in this capacity.
 
Ø Gawande, Atul Being Mortal: Illness, Medicine, and What Matters (2014) New York, Henry Holt.
 
 
Ø Hospice Foundation of America, A Caregiver’s Guide to the Dying Process, https://hospicefoundation.org/hfa/media/Files/Hospice_TheDyingProcess_Docutech-READERSPREADS.pdf
Ø http://www.wikihow.com/Prepare-for-the-Death-of-a-Loved-One . This Wiki is an accumulation of advice about the steps that help to ease the impact of an impending death.
 
Ø http://dying.about.com/od/thedyingprocess/tp/Preparing-For-A-Death.htm , a commercial site that has much advice and links for more help in preparing for a loved one’s death.
 
Ø *Kavanaugh, Robert E., 1972, Facing Death, Los Angeles: Nash Publishing, 226 pp. This personal and sensitive account by a priest explores mourning in America and the complex feelings associated with the end of life. First the dying person needs to receive permission to pass away from every important person he will leave behind. Only then can he voluntarily let go of every person and possession he holds dear.
 
Ø *Kubler-Ross, Dr. Elisabeth, 1969, On Death and Dying, New York: Macmillan Publishing Co., 289 pp. Based on interviews of terminally ill patients, this classic study outlines the six stages through which dying patients progress -- denial, anger and resentment, depression, acceptance, and hope. "The more we are making advancements in science, the more we seem to fear and deny the reality of death."
 
Ø Kubler-Ross, Elisabeth -- a variety of titles stemming from her classic, On Death and Dying (see above).
 
Ø *Levine, S. 1982. Who Dies? An Investigation of Conscious Living and Conscious Dying. New York, Doubleday. 317 pp.
 
Ø Newman, A. Dying in America Harvard Divinity Bulletin (Summer/Autumn 2015) “Good endings are reserved for a privileged few, while caretakers are often underpaid and unappreciated.”
 
Ø Scott, P. S., Is Hospice Right for You or a Loved One? The 9 Facts You Need to Know. AARP Bulletin, (11/2015), pp. 28-29. http://www.aarp.org/home-family/caregiving/info-2015/hospice-what-you-need-to-know.html
 
Ø   http://www.practicalbioethics.org/resources/aid-in-dying.html offers advice and resources about end-of-life decisions.
 
Ø ^Tallmer, Margo, Ed. (1984). The Life-Threatened Elderly.
 
Ø ^White, John W. (1980) A Practical Guide to Death and Dying.
 
Ø Williams-Murphy, Monica, It’s O.K. to Die When You Are Prepared (2011). www.oktodie.com

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4. Care for the Property of Someone Who Is Incapacitated:

When a person is unable, for reasons such as senile dementia, to pay bills and manage his or her property, other trusted relatives, friends, or financial fiduciaries are needed to perform these functions. One can establish joint accounts with rights of survivorship with spouses and others to serve this function, or with an attorney’s help one can create a living trust or draw up a power of attorney to authorize someone else to pay bills and manage property. This kind of arrangement can be set up at any time, and one can arrange with one’s substitute to leave it on hold or implement it then or at any later time. This flexibility allows one to manage financially as long as one wants to. But powers of attorney customarily expire when one becomes incapacitated, unless the document expresses the intent that they should continue uninterrupted thereafter. These are called “durable” powers of attorney. Even so, all powers of attorney expire at death, as do joint or common holdings unless they have a right of survivorship, as is customary between spouses.

The living trust arrangements described in the Planning document above can be used for the purposes described here, if established before the incapacity began.

Statutory General Power of Attorney forms for Virginia and Maryland, as well as a DC Power of Attorney provided by a DC pro bono law service, are provided in the tab behind this document. Other copies of these forms may be downloaded from the resources listed below. You may want to check with a lawyer before going forward with one of these documents. Links to local lawyer referral agencies are near the end of the document, Death: Help for Survivors.

Generally the person paying another’s bills and managing his or her property is liable to the beneficiary for all financial decisions, and should avoid any use of the assets for his or her own needs to avoid lawsuits by the beneficiary, the beneficiary’s estate or family, and State and local governments. Expenses of administering another person’s property, including accountants’ and lawyers’ fees, can be billed to that property. Proper accounting procedures should be followed. These requirements are much more rigorous for professional financial fiduciaries, who charge accordingly. Of course this kind of asset control includes a duty to meet all of the beneficiary’s tax obligations. Other reporting requirements vary by local jurisdiction. Before one does this kind of asset management for another, it is helpful to get the advice of an accountant or attorney about how to manage the property, pay the bills, keep the necessary records, and file the necessary reports.

a. Resources on Property of the Incapacitated:

Ø U.S. Consumer Protection Financial Bureau, Managing Someone Else’s Money. https://www.consumerfinance.gov/consumer-tools/managing-someone-elses-money/ Easy-to-understand guides for people exercising powers of attorney, by topic and by State.
 
 

Powers of Attorney Forms:

Virginia:

Advice on General Powers of Attorney in Virginia:

 
Ø Durable General Power of Attorney form

Maryland:

Ø Maryland Code, Estates and Trusts Article 17-202: Statutory Form, Personal Financial Power of Attorney: http://www.marylandattorneygeneral.gov/Courts%20Documents/17-202.pdf
 
Maryland Durable Power of attorney form:
 

District of Columbia:

Statutory General Power of Attorney:
 

Advice about Powers of Attorney:

Power of Attorney Forms

 
 

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Death: Help for Survivors

Contents:

Spiritual: queries, how to help the bereaved, resources about grieving, spiritual resources, help from the Meeting, other resources

Essential Practical Matters: disposition of the body (including cremation or burial), life-commemorating ceremonies, resources

Property disposition: basic provisions for distribution, resources for probate or other issues (including lawyer referral services), computer passwords

Related form: Checklist for Survivors When Death Occurs (following tab)

This is the third of the three documents in Langley Hill Friends Meeting’s Decline and Death book. The first document was about planning for decline and death, and the second was about meeting the challenges during a decline in capacities leading to death. This document is aimed at helping the loved ones of a person who has died to meet the spiritual, physical, mental and property-related challenges due to the death. As with the other documents, this one is available online at http://langleyhillquakers.org/death__decline.aspx, and additional resources about recovery from a death, marked in this document with an asterisk (*), are available in Langley Hill’s library for consultation.

Everyone who survives the death of a loved one faces a sense of loss, of a gap in his or her life because the dead person is no longer there. The advice and resources offered here can help to mitigate that sense of loss, but not eliminate it. In the tab following this document is a check-list for survivors of tasks that need to be done, starting at the moment of death.

Additional challenges arise when death is sudden and unanticipated, especially when the death comes from violence, suicide, or accident. Death of a young person also raises additional challenges. In these situations one may feel guilt or anger as well as grief, for which professional counseling may be appropriate, supported by the acceptance and comfort of friends and family, including those in the Meeting.

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1. Spiritual:

a. Queries on Recovering from Another's Decline or Death

Ø How shall I honor the life of someone I love? How can I live best with the consequences of the rough edges of my relationship with the person who died? How am I going to remember him or her? What will I cherish about the spirit of that person? Can I picture the essential goodness of the person? Can I accept the features of that life with which I disagreed?
 
Ø Anyone who depended emotionally on someone who died will grieve. Grief can take months or years to subside, and it may last longer if suppressed. Can I allow myself to vent my grief? How, and with whom? Whom shall I call upon to help me to survive and emerge from the depressing times ahead? How can I help others who are going through this same process with me? Is professional counseling needed?
 
Ø How can I arrange my life to give myself timely opportunities to work through my grief? How do I accept that others may need a different amount of time, or different conditions to work through their grief? How can I get others to understand my grieving needs, and how can I learn to understand theirs? How can I make asking for help more comfortable, after others appear to have resumed their normal lives?
 
Ø How shall I help myself and others live with the loss of someone very close?
 
Ø Whom can I ask to help fill the gaps left by the loss? In practical matters? In spiritual guidance? In being with me and with others affected by the loss? What can I take on myself?
 
Ø Is my support for someone who grieves confined to conventional comforting? How can I persist in my support for someone whose grief does not subside for an extended period of time, or whose grief returns? How can I communicate a real willingness to be available for help, or sympathy when I feel I cannot help?
 
Ø How can I best be supportive if I feel I can’t or won’t take on much of the responsibility to help another work through grief?

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b. How to Help the Bereaved After a Loved One’s Death

People who have suffered a death of someone close to them need support. Such comforting often includes help with the immediate care of the family and planning for the funeral or memorial service, as well as spiritual and psychological aspects. Especially after religious services have concluded and mourners have departed, the bereaved continue to need to feel loved by listening, caring friends. Then they can better work through the grieving process.

If you are outside the closest family or friends, one of the first things to do that will help is to send or deliver a heartfelt condolence card or note, especially if it recounts positive shared memories about the deceased. Immediate help may be in the form of food for the family and offers to take children for a visit or to a movie. An important service is for someone to answer the telephone and to call others who need to be notified, to accompany the bereaved to a funeral home, or to house-sit during absences for the memorial service. If you are offering help, suggest something specific like fulfilling a grocery shopping list, etc., rather than a general offer to be available.

 
Ø The presence of a caring friend is most important. If you want to say something, the simplest expression is best: "I am sorry." DO NOT say "I know how you feel." or "It is God's will."
 
Ø Become a listener. If the bereaved person finds it difficult to talk, you may ask very careful and gentle questions, starting perhaps with less important details of the memorial service.
 
Ø If the person asks "Why?" you do not have to answer. No one knows the answer to this question.
 
Ø Be reassuring: "It's good to cry. Crying is healing."
 
Ø Familiarize yourself with the various stages of grief so you can help your friend to know what to expect.
 
Ø Another later approach can be "Many people normally feel anger mixed with grief at this time. This is not bad. You need to understand it."
 
Ø Make it clear that you accept whatever your friend says or feels. Be prepared to recommend against the inappropriate use of alcohol or other drugs, which only mask and postpone emotional pain.
 
Ø If thoughts of suicide are expressed, do not show shock or rejection. Suggest counseling or support groups where one can get sympathetic support and understanding.
 
Ø Suggest postponing moving or other major decisions, and encourage exercise that helps with relaxation and sleep.
 
Ø Remember that grief can last for years, and that thoughtful notes, calls, invitations and little gifts will be very welcome until it lets up. All too often there is an abundance of help right after a death, but it tapers off very quickly and the resulting feelings of abandonment are intensified.
 
Ø Personal notes and condolence cards with heartfelt messages sharing positive memories can be helpful and supportive to a grieving person, as they don’t require the recipient to “perform”.

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c. Resources about grieving:

Ø ^Baird, William R. & John E., (1966) Funeral Meditations.
 
Ø ^Berkus, Rusty (1986) To Heal Again: Towards Serenity and the Resolution of Grief.
 
Ø ^Bozarth, Alla R. (1982) Life is Goodbye, Life is Hello: Grieving Well Through All Kinds of Loss.
 
Ø ^Brener, Anne (1993) Mourning & Mitzvah: A Guided Journal for Walking the Mourner’s Path Through Grief to Healing.
 
Ø *Cassidy, T. (1991). Sharing the Darkness. Maryknoll, NY, Orbis Books.
 
Ø Ehmke, R. Helping Kids Deal with Grief. https://childmind.org/article/helping-children-deal-grief/ Child Mind Institute. This website offers several simple suggestions to help children understand and gradually ease the pain of a major loss.
 
Ø ^Colgrove, Melba, Bloomfield, Harold H., & McWilliams, Peter (1976). How to Survive the Loss of a Love: 58 Things to Do when there is Nothing to be Done.
 
Ø Collins, S.K. (2013). Warrior Mother: Fierce Love, Unbearable, Loss, and Rituals that Heal. Berkeley, CA. She Writes Press.
 
Ø Fitzgerald, Helen, The Mourning Handbook- The Most Comprehensive Resource Offering Practical and Compassionate Advice on Coping with All Aspects of Death and Dying, New York: Simon and Schuster, 317 pp. An excellent survey of ways to cope, punctuated with first-person accounts, and enriched by a good bibliography and other references.
 
Ø Friends Journal, (August 2017), has several articles with stories of Quaker perspectives on grieving a death. Unaccompanied, by Boyce Upholt, and A Quaker’s Passing: My Father’s Way, by Shannon Zimmerman, plumb the depths of grief and the ways the authors emerged from it. Children and Death, by John Graham-Pole, explores a physician’s personal experience of his own child’s death and the grief that followed, and stories of how he later helped other children move toward a death in unity with the Spirit. Other articles in the same issue involve death as a spiritual experience.
 
Ø *Fuller, Dorothy Mason, 1971, Light in Hours of Darkness, New York & Nashville: Abingdon Press, 80 pp. This anthology provides passages of comfort for the grief-stricken. E.g., "Death is but Crossing the World, as Friends do the Seas; They live in one another, still." William Penn:
 
Ø ^Grollman, Earl A. (1981). What Helped Me when My Loved One Died.
 
Ø Haugk, K.C. (2007). Don’t Sing Songs to a Heavy Heart: How to Relate to Those Who Are Suffering. St. Louis, Stephen Ministries. Based on over 4,000 interviews, this book, aimed at Christian counselors, give Biblical foundations and practical advice on helping those who suffer. Stephens Ministries also offers four short books for those grieving, at 3 weeks, 3 months, 6 months, and 11 months after the loss.
 
Ø Huntley, T.M. (2002). Helping Children Grieve: When Someone They Love Dies (Revised Edition). Augsburg Fortress. This book offers suggestions to adults on how to relate to children who are grieving a loss.
 
Ø *James, John W. and Frank Cherry, 1988, The Grief Recovery Handbook: A Step-by-step Program for Moving Beyond Loss, New York. Harper and Row, 175 pp. Written by the founders of the Grief Recovery Institute, this manual emphasizes honesty, preparation, and emotional sensitivity. "Grieving is a growth process." They give specific steps, to be explored with a partner, to get beyond debilitating grief.
 
Ø ^Kelsey, Morton T. (1979). Afterlife: The Other Side of Dying.
 
Ø ^Kennedy, Alexandra (1991). Losing a Parent: Passage to a New Way of Living.
 
Ø ^Klopfenstein, Janette (1976). My Walk Through Grief.
 
Ø ^Kubler-Ross, Elisabeth (1975). Death: The Final Stage of Growth.
 
Ø ^Marsh, Michael (1985). A Matter of Personal Survival: Life after Death.
 
Ø ^Moody, Raymond A. (1983). Life after Life. One of the first serious studies of near-death experiences, and how they might affect our sense of what happens after death.
 
Ø *^Morgan, Ernest, 2001 (Fourteenth Ed.), Dealing Creatively with Death: A Manual of Death Education and Simple Burial, Hinesville, VT, Upper Access, Inc., 160 pp. This is a classic, frequently updated, on the subjects indicated, with lots of good, practical advice about coping with the problems associated with death. (4 copies)
 
Ø ^Neeld, Elizabeth H. (1997). Seven Choices: Taking the Steps to New Life after Losing Someone You Love.
 
Ø *Philadelphia Yearly Meeting. 1959. Shadow and Light in Bereavement. 64 pp.
 
Ø ^Price, Eugenia (1982). Getting Through the Night: Finding Your Way after the Loss of a Loved One.
 
Ø Rando, Therese, 1991, How to Go on Living When Someone You Love Dies, New York:
Bantam Books, 339 pp. A compassionate roadmap to grieving.
 
Ø   http://www.griefspeaks.com/id76.html has a useful national list of grief support services, as well as other grief-related resources.
 
Ø *Stein, S.B. 1974. About Dying: An Open Family Book for Parents and Children Together. New York, Walker & Co. 47 pp.
 
Ø The Compassionate Friends, P.O. Box 3696, Oak Brook, IL 60521; www.compassionatefriends.org., provides peer support for bereaved parents.
 
Ø International Theos Foundation, 322 Boulevard of the Allies, Suite 105, Pittsburgh, PA 15222, provides peer support for widowed persons and their families.
 
Ø Widowed Persons, 1909 K. St., NW, Washington, DC 20049, provides peer support to widowed persons in the DC area. There are other Widowed Persons organizations in some other locations.
 
Ø Crossings: Caring for Our Own At Death, P.O. Box 721, Silver Spring, MD 20918, (301) 593-5451, crossingcare@earthlink.net, http://www.crossings.net/. This organization helps families at the time of death and afterwards, working to “integrate dying and after-death care back into our family and community life”, creating “opportunities for families to complement the loss and grief of death with healing and love”. It facilitates home funerals and green burials.
 
Ø *Viorst, J. 1986. Necessary Losses. New York, Simon & Schuster. 447 pp.
 
Ø Wendt Center for Grief and Loss, http://wendtcenter.org, 4201 Connecticut Ave. NW, Suite 300, Washington, DC 20008 | Tel 202.624.0010 | Fax 202.624.0062 is perhaps the oldest and best-equipped center in the DC area for counseling people suffering grief from any cause, especially death.

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d. Spiritual Resources following death:

i. Meeting Services

The Clerk of the Committee for Care and Clearness will contact the family concerning immediate needs. If requested, the Clerk will appoint one or more persons to assist the family with such matters as registering the death, notifying friends, notifying newspapers, banks, pensions, insurance companies, etc., answering the telephone, and helping the living to continue.

The Ministry and Worship Committee will work with the family and the Building Use Committee on planning a memorial service in line with the wishes of the family and the deceased. The Ministry and Worship Committee will help prepare a memorial minute in consultation with the family.

If requested, the Clerk of the Committee for Care and Clearness will appoint a clearness or support committee to meet with family members faced with difficult questions, such as grief or the logistical, practical and emotional problems of life without the person who died.

If the next of kin are stretched thin financially by the expenses of the last illness or of the burial or funeral expenses, or otherwise because of the death, they might approach the Care and Clearness committee for help from the Family Emergency Fund.

i(a). Related Resources:

Ø *Langley Hill Friends Meeting. 1993. Visitor’s Packet in Case of Death. This includes the Meeting’s procedures following an attender’s death, and advice to visitors to the family.
 
ii. Other Spiritual Resources following death:
 
Note: Resources about grieving are in item 1.c above.
 
Ø *Brookes, T. [1997] 2000. Signs of Life: A Memoir of Dying and Discovery. Hinesburg, VT, Upper Access. 269 pp.
 
Ø *Child Center and Adult Services. Telling Children About Death. (Brochure)
 
Ø *Lyman, Mary Ely, 1960, Death and the Christian Answer, Wallingford, PA: Pendle Hill Pamphlet No. 107, 16 pp. In the face of our society's general denial about death, hers is an appreciation of mortality, an explanation of Christ's holistic life-giving assurances based on faith and God's love. " ...The Christian view of the human spirit makes growth in love the central and crucial principle of its life."
 
Ø Moller, David Wendell, 1996, Confronting Death: Values, Institutions, and Human Mortality, New York. Oxford University Press, 305 pp. A readable sociological survey of how our society got to this point concerning how we deal with death.

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2. Essential Practical Matters

The Checklist for Survivors When Death Occurs, in the tab immediately following this document, has detailed information of help to the survivors in the event of a death. The current document provides more general advice and resources for those circumstances.

The main practical problems that arise after a person’s death generally concern the death certificate, the disposition of the person’s body, the ceremonies and other observances to hold, and the distribution of the person’s property. All of these issues are more easily addressed when the person leaves detailed written or otherwise recorded indications of his or her wishes about these topics. Problems still can arise when one or more of the surviving family of the deceased person disagrees with the wishes as expressed.

When survivors feel neglected by the deceased person in those wishes or by other survivors in making decisions about these issues, bitter disputes can arise. The Meeting’s Care and Clearness Committee can respond to requests for help in reaching amicable solutions to these disputes, but we cannot prevent them from festering when one or more parties is unwilling to consider the others’ points of view. We can support those engaged in such disputes emotionally and spiritually, in the light of the life of the deceased person.

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a. Death Certificate

In all cases of death, the person must be declared dead, cause of death determined, and a physician's or coroner's signature obtained to legalize the death certificate, which is then recorded and filed with the appropriate State agency within a few days of death. At least 20 copies of the death certificate will probably be needed (e.g., for insurance filing, bank accounts, Social Security, etc.). The following information may be needed for the death certificate, depending on the jurisdiction:

v First, middle, and last name of deceased, address, and phone number
v Date and place of birth
v Race or ethnic identification
v Country of citizenship
v Last occupation of deceased; employing firm; length of employment
v Marital status, and name and occupation of spouse, if married
v Next of kin (if other than spouse) and relationship
v Name and birthplace of deceased's father
v Maiden name and birthplace of deceased's mother
v Social Security number
v Highest level of education
v (If veteran: rank, branch and dates of service, and serial number)

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b. Disposition of the body: donation, cremation, burial

If the deceased person is an organ donor or has left instructions giving his or her body for medical purposes, the designated organization should be notified as soon as possible after the death, as well as any funeral director or crematorium.

Quaker practices may help in these decisions about the bodies of Friends. Our Testimony of Simplicity would indicate that wakes, viewings, formal funerals and receptions, burial ceremonies, embalming, coffins, large tombstones, etc., are not common among Friends. The Funeral Consumer organizations described below as related resources can help survivors find suitable, relatively inexpensive arrangements to honor the decedent’s wishes and complete the cremation or burial process.

Many funeral homes market prepaid services, which lock in a price but are inflexible if your plans change or if you or your survivors want a refund. The funeral consumer organizations below recommend, if you want to set aside funding for funeral/cremation/burial arrangements, that you set aside funding for this purpose in an account in your own name, but not limit its use to those payments, so that the funds will be available in an emergency.

If someone dies away from home, complications arise. If one is in a foreign country, the nearest U.S. Consular Office can provide you a “Report of Death”, which functions officially as a death certificate in these circumstances. If the death is in a U.S. jurisdiction where the dead person didn’t reside, local officials provide the death certificate. The biggest complication of a death away from home is, if a burial near home is wanted, it’s very expensive and administratively burdensome to transport the body home, following local embalming. A local cremation is much easier, and the cremains can be carried home with you or mailed home. If mailed, a U.S. Postal Service Cremated Remains label (Label 139) is required, along with a slip of paper inside indicating the sender’s and recipient’s addresses. Use Express mail.

b (i): Related resources (in addition to those in Planning Ahead):

 
Ø ^Consumer Reports, Ed. (1977). Funerals: Consumers' Last Rights: The Consumers Union Report on Conventional Funerals and Burial ... and some Alternatives, including Cremation, Direct Cremation, Direct Burial, and Body Donation.
 
Ø ^Enright, D. J. (1983). The Oxford Book of Death.
 
Ø *^Morgan, E., 1971 [14th Edition, 2010], Dealing Creatively with Death: A Manual of Simple Burial. Hinesburg, VT, Upper Access, Inc. 157 pp. This classic book goes into specifics about providing simple ceremonies and procedures following a loved one’s death to honor the life and cherish the memory, without undue cost or frills. Anatomical gifts are also discussed. (4 copies)
 
Ø *Federal Trade Commission, Funerals: A Consumer’s Guide, Washington, DC, (877) FTC-HELP; www.ftc.gov, 22 pages. The Government’s consumer guide to funeral services, outlining rights and types of funerals and associated financial arrangements. Also consult its webpage at https://www.ftc.gov/news-events/media-resources/truth-advertising/funeral-rule for further resources and current development.
 
Ø Funeral Consumers’ Alliance, Inc.; 33 Patchen Rd., S. Burlington, VT 05403; (802) 865-2626; fca@funerals.org; www.funerals.org; This organization offers through its local affiliates and website a large number and variety of very useful resources, including funeral price surveys, advice on what to ask for when seeking a simple burial or cremation, and other consumer rights relating to dealing with physical remains. Its local affiliates, which charge modest dues for membership and materials, include:
 
Ø Funeral Consumers Alliance of Maryland and Environs (FCAME), 9601 Cedar Lane, Bethesda, MD 20814; (301) 564-0006; info@mdfunerals.org, www.mdfunerals.org
 
Ø *FCAME, Facts to File about Funerals: A Question and Answer Guide. (2 copies)
 
Ø Memorial Society of Northern Virginia; 4444 Arlington Blvd., Arlington, VA 22204; (703) 271-9240.
 
Ø Funeral Consumers Alliance of the Virginia Blue Ridge (FCAVBR), P.O. Box 10082, Blacksburg, VA 24060; (540) 953-5589; https://www.fcavbr.org/ .
 
Ø FCAVBR has on its website a 2018 funeral price survey, as well as a cemetery price survey.
 
Ø Virginia Dept. of Motor Vehicles and Virginia Transplant Center 1987. Something Important is Hiding in Your Driver’s License (brochure about organ donations)
 
Ø ^Vuillamy, C. E. (1997). Immortality: Funeral Rites and Customs.
 
Ø ^White, John W. (1980). A Practical Guide to Death and Dying.

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c. Life-commemorating Ceremonies:

Within Langley Hill Monthly Meeting, the Care and Clearness Committee will work with others to ensure that attenders and other Friends who knew the person are notified of his or her death, and the Committee for Care and Clearness often helps the survivors in notifying those outside the Meeting of the death. Friends customarily hold a memorial meeting for worship for a deceased friend, at a time convenient for the friend’s close family and friends. At the meeting a memorial minute usually is read, and at Langley Hill a copy of the minute usually is placed in the Meeting’s Memorial Minute Book. The minute also may be communicated to Friends Journal for its Milestones Department. Open caskets, though not often found in Friends’ memorial meeting for worship, can be traumatic for children and some others.

c. (i): Related resources:

 
Ø *The Conduct of Funerals for Friends, Philadelphia Yearly Meeting, a small, 6-fold pamphlet on this topic, often provided at memorial meetings as a guide to those unfamiliar with Friends’ procedures.
 
Ø *A Friends Memorial Service, Friends General Conference, a small, 3-page handout for memorial services.
 
Ø FCAME, Home Funerals Need Planning & Assistance. In Plain Talk: FCAME Newsletter, Spring 2016. http://www.mdfunerals.org/wp-content/uploads/2016/05/Spring-2016-newsletterV2.pdf
 
Ø http://www.pbs.org/pov/pov2004/afamilyundertaking/resources_03.html. This website, a summary of a PBS program in 2004, provides resources relating to funerals conducted at home. See Crossings, above.

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d. Obituaries, notifications, etc.

If the deceased does not want to have a formal obituary, that desire should be honored. If the deceased did not prepare a draft of his or her obituary, family members, friends and professional colleagues can be called upon to help with the process. Elements from the resulting obituary can be incorporated into the Meeting’s memorial minute, which usually is forwarded to Friends Journal.

d. (1): Related resources:

Ø The Washington Post, a typical newspaper, offers survivors a chance to post a death notice, with details about funeral arrangements, etc., as an advertisement. Copy for the notice should be sent to deathnotices@washpost.com. For a news obituary, a request must be submitted online at http://www.washingtonpost.com/wp-srv/local/obituaries/submit/ , meeting the Post’s guidelines for these news articles.

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3. Property

a. Basic provisions for property distribution

Other main documents in this packet deal with the choices a person makes before death about the disposition of his or her property through a will or other documents. If there is not a will and there is substantial property, the laws of intestate succession for the jurisdiction of residence will dictate its distribution in terms of the people to receive fractions of the net estate after payment of debts.

Once the death has taken place, the dead person cannot be consulted for further instructions. This places a burden especially on those who did not get detailed expressions of the dead person’s wishes, about how to use or transfer the personal property that may not have high market value but has strong sentimental value for more than one of his or her survivors. Other problems can arise when one or more of the surviving family of the deceased person disagrees with the wishes as expressed or required by law.

When survivors feel neglected by the deceased person in those wishes or by other survivors in making decisions about these issues, bitter disputes can arise. The Meeting’s Care and Clearness Committee can respond to requests for help in reaching amicable solutions to these disputes, but we cannot prevent them from festering if one or more parties is unwilling to consider the others’ points of view. We can support those engaged in such disputes emotionally and spiritually, in the light of the life of the deceased person.

Paragraphs 2 and 7-10 of the Checklist for Survivors When Death Occurs, that is in the tab following this document, have detailed recommendations relating to the procedures to be followed concerning the distribution of the dead person’s property. It is best to have the help of a qualified estate lawyer in the jurisdiction where the dead person resided to guide you through these processes.

Even before you consult an estate lawyer, you may want to try to assemble such property records as are available to you, including life insurance policies, bank and other financial statements, deeds, notes and mortgages or deeds of trust, etc. Credit card issuers and other official or financial offices should be informed about the death. Bank officials will secure any safe deposit boxes belonging to a person who has died upon learning of the death, and may limit access to his or her bank or other financial accounts, although the rules about this may vary between jurisdictions.

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b. Resources for probate and other issues about property:

b. (i). Legal Services

Ø Virginia State Bar, Virginia Lawyer Referral Service, (804) 775-0808, will refer you to a lawyer in Virginia who specializes in wills, estates, and trusts. The initial consultation will cost you $35 for up to ½ hour. See http://www.vsb.org/vlrs/index.php/public/vlrs/
 
Ø DC Lawyer Referral Service of the Bar Association of the District of Columbia provides referrals by telephone for DC lawyers with a specialty in estates and trusts. Call (202) 296-7845 between 8:30 a.m. and 6:30 p.m. M-F. See http://badc.org/public-services/lrs/.
 
Ø District of Columbia Bar has a free advice and referral clinic every Saturday morning from 10-12 a.m. at Bread for the City, 1525 7th St., NW, and Max Robertson center, 2301 Martin Luther King, Jr. Ave., SE. with services as described in https://www.dcbar.org/for-the-public/help-for-individuals/advice.cfm
 
Ø The Maryland State Bar Association provides a County-by-County list of phone numbers for local bar association lawyer referral services, at https://www.msba.org/for-the-public/lawyer-referral-information/. The number for Montgomery County is (301) 279-9100.

b. (ii). Help with Social Security death benefits

Ø U. S. Social Security Administration Offices:
 
Phone 1(800) 772-1213; www.socialsecurity.gov. (open M-F, 9 a.m. – 4 p.m.):
 
o 6295 Edsall Rd., Alexandria, VA
o 2300 S. 9th St., Arlington, VA
o 11212 Waples Mill Rd., Fairfax, VA
o 8700 Centerville Rd., Manassas, VA
o 1470 Pantops Mtn. Pl., Charlottesville, VA
 
o 333 Hawaii Ave., NE, Washington, DC
o 2100 M Street, NW, Washington, DC
o 3244 Pennsylvania Ave., SE, Washington, DC
o 1905-B 9th St., SE, Washington, DC
 
o 6400 Old Branch Rd., Camp Springs, MD
o 337 Brightseat Rd., Landover, MD
o 7701 Greenbelt Rd., Greenbelt, MD
o 51 Monroe St., Rockville, MD
o Wheaton Plaza, 11160 Viers Mill Rd., Wheaton, MD
 
Social Security Benefits for Widows and Widowers: https://www.ssa.gov/planners/survivors/ifyou.html

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b. (iii). Computer Passwords:

Apple’s Macintosh computers have Safari as an Internet browser. In the Safari menu, if one clicks on “Preferences”, then in that box clicks on “Passwords”, a list of all the user names and passwords used on Safari will pop up. Similarly, with Google Chrome, if the user allows Google to autofill passwords, there’s a list of the login IDs and related passwords at chrome://settings/passwords If one enters the password for computer updates, etc., these passwords with letters instead of asterisks (*) will show up. Many of these passwords will be outdated, but the list will include all in Safari’s or Chrome’s history, even if the list of websites visited has had its history cleared. One may clear the list of user names and passwords by clicking the appropriate button.


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Checklist for Survivors When Death Occurs

This outline is intended as a guide for a number of decisions to be made and actions to be taken when a person dies. It is highly desirable that the decisions be discussed with the individual before death occurs if possible, so that the individual's wishes may be carried out.

The hours and days immediately following a death can be a time of confusion, as well as sorrow, and a time when the family welcomes the presence of an assistant, a close friend, relative, or member of the Meeting. This person can act either as a consultant or as one who will take charge of necessary matters, delegating some responsibilities, insofar as possible, while coordinating efforts to avoid duplication or omissions. The checklist provided below can be helpful to the family and the assistant to ensure that all matters are addressed in the days immediately following death. The items are presented in rough chronological order.

1. Immediately after a person dies, professional personnel and next of kin should be notified as appropriate under the following circumstances:

If the body or its organs are to be donated: Notify the attending physician and other medical staff immediately.

Ø Death in the Home (unexpected, or following an illness): Call:
   o Primary care physician, if known
   o Paramedics or police (911)
   o The physician, paramedics, or police may call a coroner if required
   o Next of kin
Ø Death in a Hospital or Nursing Home: Call:
   o Primary care physician (staff should call)
   o Next of kin
Ø Death in an Accident:
       o Paramedics or police will see that the body is sent to a hospital or coroner

2. In all cases of death, the person must be declared dead, cause of death determined, and a physician's or coroner's or medical examiner’s signature obtained to legalize the death certificate, which is then recorded and filed with the appropriate State agency within a few days of death. At least 20 copies of the death certificate will probably be needed (e.g., for insurance filing, bank accounts, Social Security, etc.). The following information may be needed for the death certificate, depending on the jurisdiction:

Ø First, middle, and last name of deceased, address, and phone number
Ø Date and place of birth
Ø Race or ethnic identification
Ø Country of citizenship
Ø Last occupation of deceased; employing firm; length of employment
Ø Marital status, and name and occupation of spouse, if married
Ø Next of kin (if other than spouse) and relationship
Ø Name and birthplace of deceased's father
Ø Maiden name and birthplace of deceased's mother
Ø Social Security number
Ø Highest level of education
Ø (If veteran: rank, branch and dates of service, serial number)

3. The next step immediately after death is to determine the removal and disposition of the body, after the physician or coroner has released it. If a copy of the deceased's wishes and instructions is available, the family and assistant should consult it. Available options include:

Ø Organ donation: The body will be removed to a hospital.
Ø Willed to science: The body will be removed to a medical school of prior choice. In some jurisdictions this decision must be agreed to by the next of kin.)
Ø Cremation: The body will be removed either to a mortuary or immediately to a crematorium. In Virginia, the body must be seen by a medical examiner before cremation.
Ø Burial: The body will be removed to a mortuary.
Ø Home Care: In the DC Metropolitan area families can get assistance and support in preparing the deceased at home for cremation or burial. See section V.A of the Resources section, below.
 
The survivors should determine which choice meets the wishes of the deceased and fits the circumstances of the death, then immediately notify that choice to those with custody of the body.

4. The Committee for Care and Clearness, through a specified individual, will try to assist the family during the hours and days following the death, as requested. Soon after a death a family member or the designated contact with the Meeting should notify the Clerk of the Meeting or the Clerk of the Committee for Care and Clearness, who will notify the Meeting’s attenders of the death.

5. The assistant can then help the survivors in making arrangements for the next few days, including such items as:

Ø Coordinating the supplying, cooking and serving of food;
Ø Making a list of immediate family, close friends, employer, and business associates. This information may be available from the deceased's personal phone directory and also the forms under the planning tab of this packet. The family member or assistant should notify each person by phone or arrange to have some of them call others.
Ø Determining whether flowers will be accepted. In substitution or addition, determine a memorial or charity to which gifts may be made, especially one which was identified by the deceased.
Ø Keeping a log of visits and calls about the death.
Ø Arranging for appropriate child care and other special needs of the household, such as cleaning or transportation, which might be done by family or friends.
Ø Arranging for family members or friends to take turns answering the door and telephone, keeping a careful record of calls and gifts (e.g., flowers).

6. The family should arrange for a funeral and/or Memorial Meeting, and interment in accordance with the deceased's wishes. The Clerk of House and Grounds Committee should be notified if the Meeting House will be used for a Memorial Meeting for Worship, and the Clerk of Ministry and Worship should be contacted for assistance in scheduling the Memorial Meeting and in preparing the Memorial Minute.

7. Within a week or two following death a family member should notify the deceased's lawyer and the personal representative such as the will executor, if known. If there’s a current will, the original should be given to the lawyer and copies to the executor or trustee. Efforts should begin to collect information about the financial and other assets and liabilities of the dead person.

8. In the same time frame, the family member should notify insurance companies, including auto and property insurance. Be sure to check all life and casualty insurance and death benefits, including Social Security, Veterans Administration, pension, credit union, trade union, fraternal, etc. Also check on income for survivors from sources such as Social Security.

9. Banks, credit card companies, and others with which the dead person had financial accounts should be notified. Automatic payment authorizations unique to the dead person should be stopped, unless they also apply to other living loved ones. Similarly, creditors can be asked to postpone debt payments if needed.

10. Within a few days of the death, the family member or assistant should assemble the information needed for an obituary, including:

Ø Name
Ø Age
Ø Place of birth
Ø Cause of death
Ø Occupation
Ø College degrees
Ø Memberships held
Ø Outstanding works
Ø List of survivors the immediate family
Ø Time and place of Memorial Meeting for Worship
Ø Note whether flowers will be accepted
Ø Note preferred charity to receive gifts

The information should then be phoned or faxed to newspapers. There may be a charge for the obituary. Organizations with whom the deceased was connected also may want to receive the same information.

10. If the dead person lived alone, contact any landlord, utility companies, postal service, and newspaper deliverers to cancel those contracts. A house sitter will be needed while family members attend the funeral, memorial meeting for worship, or interment services, especially if the death notice includes notice of the memorial service.

11. The family or assistant should arrange for the disposition of flowers sent to the home or the Memorial Meeting for Worship.

12. The family or assistant should prepare a list of distant persons to be notified by letter or printed notice, prepare the letter or notice, and mail as appropriate.

13. The family or assistant should prepare a list of persons to receive acknowledgments of flowers, calls, food, or other assistance. Appropriate acknowledgments should then be sent.

14. The family should check promptly on all debts and installment payments. Some may carry insurance clauses that cancel them. If there is to be a delay in meeting payments, the family can consult with creditors and ask for more time before payments are due.

15. If the deceased was living alone, the family should notify the landlord and utility companies, and tell the Postal Service where to forward mail. If a pet is present, someone needs to care for it. The family should also take precaution against burglars until the deceased's possessions have been disposed of.

16. As the memorial meeting approaches, ensure that close family and friends have accommodations and transportation.

17. The Committee for Care and Clearness should consult with the Meeting’s Recorder to arrange to have the death recorded in the Meeting's records.

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Glossary for 2018 Book on Decline and Death

This glossary is intended to help friends to understand the meaning of technical terms used in the book. If there are additional terms that you want to have included in the book, or if the definitions given here seem unclear, please contact a member of the Committee for Care and Clearness. Thank you.

Advance Directive is a document that states in advance a person’s wishes regarding the kinds of medical interventions that might be needed to extend his or her life in a situation where he or she won’t be conscious or otherwise able to tell the medical personnel his wishes at the time. It also designates a named individual to make decisions to implement and apply those wishes if needed in a later medical emergency when the person is incapacitated. A variant of the advance directive is the Advance Directive for Mental Health Treatment, which similarly states an individual’s wishes for his or her mental health treatments in conditions where his or her wishes cannot be coherently communicated with a sound mind. The advance directive incorporates what some people have written in a Living Will and in a Durable Power of Attorney, which perform the same functions as an advance directive. Those documents may still be effective in some jurisdictions in most circumstances, but might be not as convincing to medical personnel as a more current form of advance directive.

CPR is cardio-pulmonary resuscitation, which involves manual chest compressions to restore heartbeats in someone whose heart has stopped beating. An alternative is to use an AED, or atrial defibrillation device, which revives a heartbeat through timed electrical impulses, and avoids the risk of broken bones in the ribcage that often accompany CPR. An advance directive or medical order can reflect the patient’s choice for DNR, Do Not Resuscitate. In many jurisdictions Emergency medical technicians (EMT) who come upon a person whose heart is not beating are required to begin CPR or use an AED unless they are aware of a Physician-Ordered Scope of Treatment (POST) indicating DNR.

Decline describes the process by which an older person often approaches death, gradually losing physical and/or mental capacities with age, disease, and infirmities. We all decline as we age, but decline becomes a matter of concern in the current context only when an individual’s infirmities require the frequent, perhaps daily, attention of a caregiver. When, in the process of decline, an individual’s abilities to perform daily self-care tasks and communicate coherently are impaired sufficiently to require others to make decisions for that person, then the legal arrangements for an advance directive agent or a durable general power of attorney come into play. The individual can authorize those decisions by others in advance of those incapacities.

Designation of Beneficiary under a life insurance policy, employee benefit plan, or other financial contract is the identification by an individual of who is to receive an identified benefit on his or her death.

Durable Power of Attorney is an explicit designation, most often now seen as the appointment of an agent in an advance directive (see above) or general power of attorney (see below), to make health care decisions for an individual when that individual is unable to make them him or herself.

Ethical Will is a “love letter to survivors” that tells them how you hope to be remembered through their lives, especially in terms of their relationships and their values. Although it is not legally binding, it communicates what was important to you as you lived.

Five Wishes is one variant of an Advance Directive.

General Power of Attorney is an individual’s authorization to another individual or institution to act on his or her behalf in a specified area, with limits of duration and scope of activities usually spelled out in detail. Usually it refers to management of financial accounts, assets and obligations. A general power of attorney can be revoked at any time, but it survives an incapacity if that is indicated through a Durable Power of Attorney. It must end at death, however. The person who is designated to hold this power of attorney is primarily responsible to the individual who created the power of attorney to carry out its instructions faithfully.

Hospice care, usually when a patient’s life expectancy is 6 months or less, provides an array of integrated services to help the patient have as high a quality of life as is possible in his or her remaining time. It can be in-home or residential.

Incapacity is an inability to perform daily tasks or make sensible decisions. It can be life-long, as with a disability, or it can come with aging and decline (see above). It marks the turning point from self-care to care of another for the incapacity.

Intestate or Intestacy refers to dying with property but without leaving a duly witnessed will or other instruction (such as a designation of beneficiary, trust, or other legal arrangement) to allocate that property according to the dying person’s wishes. The laws of each jurisdiction specify how that property is to be distributed by its probate court (see below).

Living Trust is a contract that places an individual’s property beyond his or her control in a legal status known as a trust, to be managed as specified in the trust instrument by one or more trustees. Unlike a testamentary trust, which puts a dead person’s designated property into a trust relationship as part of a will, a living trust is valid during the lifetime of the person who created it, and that person may be the trustee during his or her lifetime if the trust instrument states that. A living trust can be used to avoid the expenses, inconvenience, and accountability of probate proceedings (see below), and in some situations it may help to reduce estate and inheritance taxes as well.

Living Will is the old form of an advance directive (see above), that specifies for an individual what medical interventions the person wants in the event he or she is unable to communicate his or her wishes to medical personnel at the time they are called for to save or extend his or her life.

Medical Order for Scope of Treatment is a doctor’s instruction to other doctors and medical personnel such as emergency medical technicians (EMTs), with the patient’s consent, to indicate and reinforce the patient’s wishes regarding palliative, pain-reducing care, resuscitation (through CPR or AED), or tube feeding or breathing, or other specified medical interventions in prescribed circumstances.

Palliative care can be provided at any time a patient’s pain needs to be minimized, including a time of decline.

Primary Caregiver is the person who has taken primary responsibility for the care of an individual who suffers from an incapacity or decline (see above).

Probate is the legal, court-supervised process used in the 3 local jurisdictions to supervise the management of the distribution of an individual’s property and the payment of any remaining obligations, in accordance with his or her will (see below).

Will is a legal document, signed by an individual in sound mind, dated and witnessed by others of sound mind, that states his or her wishes relating to the disposition of his or her property and the management of issues such as the guardianship of his or her minor children. A will must be authenticated, recorded and presented to a probate (see above) court as the most recent will of an individual in order for its instructions to be followed under the court’s supervision.

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