“Children, when I am gone, sing a song of praise to God.” Susanna Wesley whispered these words to her children – including sons John and Charles – just before she took her last breath in 1742 at the age of 73. 

Fittingly, Henry Wadsworth Longfellow’s (1807 – 1882) final words were lyrical: “For the Christian, the grave itself is but a covered bridge leading from light to light, through a brief darkness.” 

American evangelist and publisher Dwight L. Moody awoke from sleep just before he died in 1899 and proclaimed, “Earth recedes. Heaven opens before me. If this is death, it is sweet! There is no valley here. God is calling me, and I must go.”

After sharing these last words of some well-known people, the radio pastor continued his sermon with this perceptive observation: “One no longer hears these deathbed proclamations as often as in times past. A reason may be that death no longer occurs naturally at home, but in a hospital or other medical setting where life-extending interventions are being utilized or medication is administered to the point that death proceeds from an unconscious state.”

His musings reminded me of the importance of planning ahead for the inevitable.

Research indicates that anywhere from twenty-five to fifty percent of Medicare expenditures (about $170 billion) occurs in the last six months of life. About twelve percent of older adults on Medicare experience an explosive or “late rise” pattern of healthcare spending in the final months of life – extending life at any cost.

Having the talk about end-of-life care is difficult for everyone involved, but it is necessary in order to ensure that your loved one receives the desired level of care during the waning days of life. If you do not have this talk while your loved one is still able to make decisions, then the responsibility of making the choices will fall on the person with power of attorney (frequently the caregiver). This can be daunting. I strongly encourage you not to wait. The discussion does not need to be long and drawn out, and handled with compassion, it can be caring and clarifying rather than morbid. The objective is to have your loved one tell you the degree and kind of care he/she wants as his earthly life is ending.  (To make the following more readable, I will just use the masculine pronoun in referring to your care recipient.)

Does he want everything possible done to keep him alive? This would indicate hospitalization. If his major organs fail, would he choose life support interventions such as a ventilator or feeding tube? An insightful nurse once described this scenario in this way: “It does not prolong life; it prolongs death.” (Of course, this does not apply when these are considered temporary treatment measures that would lead to recovery.)

Maybe he feels he would be most comfortable in a hospice facility. If so, make sure the staff is informed of the preferred level of medication. Some patients choose to be pain free while others would rather limit medication in order to be more aware of their surroundings as death approaches. 

Would he prefer to remain at home and die a natural death? This denotes a death that is expected due to the progress of a pre-existing chronic disease. Emphasis is on comfort care and without heroic life-saving measures. Again, the level of medication should be adjusted according to the person’s wishes. (Many hospices provide assistive care at home during the last six months of life.)

I will always remember one of my patients in long-term care. His desire was to have his family around him until the end.  He was adamant that he not be given any medication that would make him less aware. As his breaths became less frequent and more labored, family members waited anxiously for the one remaining son – who lived some distance away – to arrive. His sweet daughter moistened his lips with a swab. The family took turns hugging and kissing their beloved father and grandfather as they spoke tender farewells. Just when we thought the son might not arrive in time to say good-bye, he walked through the door. As the son embraced his beloved dad, a smile crossed the old man’s face. For a moment, his respirations quickened …and then slowed. We all joined in singing one of his favorite songs – I’ll Fly Away. The words were not audible, but his lips moved ever so slightly in an attempt to proclaim his last words, and he did indeed fly away.

Caring Idea: The final words of many people have been recorded and make for interesting reading – especially when you compare the last words of those who adhere to different religious beliefs.