Before you pass the pie, please tell me; how do you want to die?

Four ingredients to help talk turkey with older Americans


Looking back, it’s hard to believe how long it took me to start a conversation with my mother about what she wanted — and didn’t want — in her last years, last hours.

The idea was sparked at a conference on elder justice just before Thanksgiving in 2011. A nationally recognized speaker—Bonnie Brandl, Director of NCALL, @ncall_us—ended her presentation by saying that, when with family at Thanksgiving, she turns to older loved ones and asks, “Before you pass the pie, please tell me; how do you want to die?”

A few weeks later my octogenarian mother and I made Thanksgiving dinner together — and plans to formalize her end-of-life wishes.

The prospect of such conversations may be daunting — but the regret of a missed opportunity can be worse. Without clear instructions, a senior’s hopes and wishes may be supplanted by conflicting advice offered with the best intentions by family, friends, and professionals. In fact, many seniors are relieved and empowered once a conversation starts. The same can be said by any of us, at any age.

We may deny ourselves such enriching, critical conversations because we are scared to death — of death. Fear of mortality is omnipresent. In Denial of Death, Ernest Becker speaks of such fear as “a mainspring of human activity.” But, to “deny our destiny” is to deny the preciousness of human life—every moment, every day.

Honest conversations with my mother led to formalized end-of-life wishes. This provided her the comfort of knowing she’d be able to live her final days on her own terms. Which she did.

Let’s look at four ingredients to help plan an end-of-life conversation, understand pertinent legal documents, express specific wishes, and include all adults, starting at age 18.

1. Begin an end-of-life conversation

“One conversation can make all the difference,” notes The Conversation Project, a national public-engagement campaign dedicated to helping people talk about their wishes for end-of-life care.

To help people talk about their wishes, The Conversation Project offers a Starter Kit and stories shared by people who had the conversation, want to have the conversation, or wish they had the conversation.

Don’t hesitate ­– until it’s too late.

Survey results of a 2012 study, Final Chapter, concluded that while a large majority of Californians (82%) say it is important to have end-of-life wishes in writing, only 23% say they have done so.

2. Understand legal terms and documents

A number of legal documents are available. These vary, based on state law and individual preferences.

A health care proxy may be the most important document, as it appoints someone else to make your health care decisions if you can’t. But your wishes should be known and formalized, too.

The most important terms, legal documents, and myths are identified by Charlie Sabatino in his Top Ten Myths and Facts About Health Care Advance Directives, published in 2015 in Bifocal: A Journal of the American Bar Association Commission on Law and Aging.

3. Express your wishes

While these documents are instrumental as a legal means to achieve our goals, it’s the process of exploring and expressing our beliefs, values, and wishes through conversation that empowers us.

More than 25 million people and 40,000 organizations have used Five Wishes, developed by Aging with Dignity, whose mission is to safeguard the human dignity of people as they age or face serious illness.

Available online and in print, Five Wishes provides a clear framework, multiple options, and an opportunity to add specific personal details. Five Wishes meets the legal requirements for an advance directive in 42 U.S. states and the District of Columbia. In the other eight states, a completed Five Wishes can be attached to a state’s required form.

4. Include everybody in the conversation

Constructive conversations about end-of-life wishes should include all adults in the family. Legally, parents lose decision-making authority once their child turns 18.

Isabel Merrin, a student at Tufts University, emphasizes, “We should be engaging in conversation with each other and with older generations about how we and they want to die.”

Merrin works in hospice care and interned with The Conversation Project. Her work and subsequent engagement with fellow students lead her to present Let’s Talk About Death at TEDxTufts.

Merrin continues, “By bettering the relationship with elders in our lives and by asking them to talk about these topics, we can facilitate an open dialogue about their path, their fears, and their own mortality. These conversations can be empowering.”

Thanksgiving provides an opportunity to plant the seeds for future conversations with all adults about our end-of-life wishes. And to give thanks for our shared support along the way.

Let me know how it goes.

Philip C. Marshall, Founder, Beyond Brooke: Advancing elder justice