Ideas. Lessons Learned, and Occasionally, Opinions
National Healthcare Decisions Day kicks off on April 16th with a week of planned events to “inspire, educate and empower the public and providers about the importance of advance care planning.”
As a financial professional, you may find clients turning to you for information, especially as they approach retirement or, more likely, when they face issues with aging parents. In order to guide them wisely, it is essential that you are educated on advance directive documents.
In broad terms, an advance directive is any document that allows a person to state “in advance” how they wish to be treated if they are unable to make those choices themselves. The most common advance directive is a living will. Contrary to what many people think, living wills do not always limit treatment or “pull the plug”; they can also be used to request every medical intervention available.
Also, if someone is conscious, capable of making decisions, and able to sign permission forms, there is no need to consult the living will. Living wills only take effect when a patient is unconscious, demented, or otherwise incapable of making their own decisions.
The living will should be the clearest description possible of the person’s desires. Clients often list their wishes based on various situations, as they may want different treatments when imminently dying of cancer than when in a coma from which recovery is likely.
The advantages of living wills:
Common problems of living wills:
But just because there are a number of valid concerns about living wills doesn't mean that financial advisers should discourage their clients from creating the documents. Instead:
When you educate your clients and prompt them to complete a living will, you ease their fears that someone else will dictate their medical decisions. You keep them in greater control and take a burden off their family members. You help them have valuable discussions with those they love. The resulting peace of mind is invaluable to your clients and consequently good for your business.
Let me be clear at the outset: it was Terrance's prerogative to make his end-of-life decisions as he saw fit. It was his prerogative to include his wife Amanda in those decisions apparently as co-equal partner during the long final chapter of his life. With that firmly in mind, let's consider what she has to say about that journey.
In this Ted Talk film (“We need a heroic narrative of death”, October 15, 2013), Amanda Bennett is a fine story teller, occasionally poetic in her own voice and concluding with a quote from and for the ages. There are nuggets of utility in here and her final thesis -- there is a way to have a courageous and graceful goodbye -- is imperative to absorb. Her narrative has an almost connect-a-quote corniness about it despite its obviously heartfelt and sincerely sorrowful nature. However, because most of us know that a long and gradual decline is how we will die, Ms. Bennett's notion of "hope” is flawed, despite some utility.
She says "hope is part of our DNA as humans" but inaccurately and unhelpfully conflates acceptance of her husband’s approaching death with "you're prohibiting me from hoping." Her statement, "it's not a bug, it's a feature," is an intellectual sleight of hand that serves no one because she and her husband were, in fact, in profound denial that Terrance would soon die until the final six days of his life.
Again she says, "[I hoped], you might say irrationally, that I could keep him alive forever." I do say "irrationally" because hoping for what one can reasonably know is impossible is denial. That circle can't be squared. Although Bennett insists she was “redefining hope", in reality she kept extending a singular definition of hope (in this case a cure) until it was long-past possible. There is nothing in her narrative to suggest she was "redefining" hope.
She continues by asserting that "what the experts call denial I call hope." False. Once again intellectual and emotional sleight of hand. "Redefining hope" actually means that hope exists until we take our last breath or until our loved one takes her last breath. But, and this is the necessary and essential notion, hope changes. Initially we hope for a cure. Then, when we know that a cure is impossible, we hope to live until our daughter's wedding or our trip to Norway is complete or we finish painting the boat, or . Then, when that hope is fulfilled, or becomes impossible to realize, our hopes change again, until the final hope is to die in the presence of our most treasured loved ones in peace and in as little pain as possible.
That is what redefining hope looks like.
Here is one more example of the sleight of hand she practiced on herself: She claims "our system isn't built to accommodate it [hope and a graceful goodbye]." Actually, there were systemic accommodations available for Terrance and Amanda and they proactively chose to reject the most obvious one, the services of hospice. That's a textbook, Brittanica-grade example of denial.
Amanda and Terrance's correct response to his oncologist's assertion that "better days are ahead" was "I'll discuss that with my rabbi or priest or spiritual leader. As for you, medical profession, tell me the truth, please. Do so with warmth, compassion, humility, and sorrow for me and what you cannot achieve, but just do it."
Indicting an entire group of people is seldom efficacious and never fair but for expediency I do so here: The medical profession is flagrantly wrong to use phrases like "there's nothing more we can do for you” (the dying person) because there is always more we can do for a dying person. It may be true that there is nothing we can medically do but there is always something we can do to achieve Ms. Bennett's goal for each of us "… bid her farewell the Alexandria you are losing."
Have you ever seriously worried about having to live on the streets? Interestingly, that is one of the most common fears of a widow, even if she has more money than she’s ever had due to insurance proceeds. She is afraid it will somehow disappear and she will become a bag lady. In some cases, her situation is precarious enough that the fear is justified and you have to work carefully to preserve whatever funds she has. In many cases, though, the fear is irrational
Allow me a parallel example. My son Steven threw fits at bedtime, because he was convinced the ghosts in the closet would come out at night and “get” him. I used all the logic at my disposal. We turned on the lights and examined every square inch of the closet without finding any ghosts. I sat with him for hours in the dark waiting in vain for ghosts to appear. I garnered the testimony of his older brothers. Nothing worked.
Finally, instead of trying to talk him out of his belief, I acknowledged it as if it were true. “OK, Steven, since there are ghosts in the closet who could come out at night and get you, what would help you feel safe?” We brainstormed ideas until he decided he needed two things: a night light by his bed, and an adult to firmly close the closet door and tell the ghosts they had to stay put until morning. When I implemented his simple solutions he peacefully drifted off to sleep.
With a widow or with any other client with irrational fears, then, do not try to talk her out of being afraid, no matter how compelling the evidence of her safety. She will not feel heard or understood by you unless you acknowledge her fears and find ways to help her feel safe.
This strategy may help:
When you follow this simple procedure, you provide something for a fearful client that few others ever do. You hear her, take her fears seriously, and develop effective strategies for coping with them. That is a sure way to build long-term trust and lifetime loyalty.
Continue this pattern, always asking questions based on what the client is saying. You will notice the pitch of the voice lowering, longer pauses and slowed breathing as the anger gets spent and the client calms. Only then can you begin talking about what you can do together as you go forward. Ask what steps the client would like to take. Make appropriate suggestions for portfolio review, redistribution of assets, or simply keeping in contact every week or two.
At the end of the conversation, make sure you thank clients for being honest with you. Tell them your door is always open, and you will listen even when it is hard. Reassure them that although times are really tough right now, you can weather the storm together and come out on the other side.
If you can master these skills, your clients will come out of even angry conversations feeling heard, supported, and most of all, loyal to you.
We have an unprecedented crisis happening in our country. Every day, 115 people die of an opioid overdose. From 1999 to 2016, 350,000 people have died. A recent survey by the AP and Center for Public Affairs Research found that 1 in 10 Americans know a relative or close family member who died of an opioid overdose. In April, the Surgeon General issued the first national health advisory since 2005, urging families and friends of addicts to carry naloxone, the drug that can reverse the acute effects of an overdose and give a greater chance of survival.
Clearly, we have a huge public health problem with more people dying per day due to opioids than were dying of AIDS at the height of that epidemic. Just as we found the will and resources to combat AIDS over 30 years ago, we need to do it now for opioids.
In addition to scope, there is another aspect of these two epidemics that is similar. When people died of AIDS, their family members were often reluctant to tell others the cause of death because of the stigma. The same is true with the opioid crisis, leaving families unsupported and isolated. It’s bad enough that our society knows so little about how to effectively support the survivors of a loved one’s death; with a stigmatized death, the situation is exponentially worse.
Many people don’t realize that opioid addicts generally begin taking the drugs to relieve intense pain from a medical condition, not to get high. Yet one of the ways opioids work is to increase the levels of dopamine in the body, resulting in a feeling of euphoria while relieving some of the pain. Even if all the pain is not relieved, that which remains seems tolerable because of the underlying “high”.
Addiction begins when the drug rewires the reward centers of the brain, causing the person to perceive anything less than the euphoria as being painful and creating a physiological craving for more of the drug. Tolerance requires higher doses, the euphoria increases, the drug continues to affect the brain, and the addict sinks into an ever-deepening need for opioids just to feel normal. For those who try to reduce or quit, withdrawal symptoms are intense, and they often give up, relapsing into drug abuse to eliminate the pain. It reaches the point where an addict will do anything to get the next hit.
How to Help
After an overdose death, the grief is profound. The family loses a beloved family member. They lose the future they hoped for with that person and the unique place that person held in the family structure. They have exhausted themselves with worry and attempts to help. There are feelings of guilt and inadequacy that the loved one couldn’t be saved. These reactions are combined with anger at the lack of resources for addiction and resentment towards the addict who wasn’t able to kick the habit despite whatever help the family could offer. At the same time, rather than the outpouring of support they would receive if their loved one died of something like cancer, the support is muted, tentative, or absent, replaced by judgment or simply the would-be comforter’s inability to know what to say.
Here are a few suggestions on how you can help a client, friend or family member dealing with this kind of loss:
The president and CEO of a prominent asset management firm recently proposed that although sex was a taboo subject for a long time, the last remaining taboo in our society is money. I’d like to take issue with that assertion.
It does seem that sex is no longer taboo, at least in the public arena. Sex is used to sell everything from clothes to vacations, sex education is required in schools, and sex is the subject of more web sites than any other topic. There are a number of gurus dispensing advice on sexual matters, and in recent years companies selling remedies for sexual dysfunction have recruited prominent politicians and entertainers as spokespeople. Indeed, sex is no longer taboo.
Yet money seems to be in a similar category. It is the subject of endless conversations, speculation, and media coverage. Well-known pundits spout opinions and give advice on all things financial. Morning news shows regularly interview investment experts. Magazines, newspapers, and online columns wax eloquently about economics, savings rates, the best stock picks, and IRA’s. Political candidates consider money – who has it, who spends it, and where it is spent – to be a central issue. Money hardly seems a taboo subject.
What, then, IS the final taboo? What issue has no talk show pundits or advice columnists offering tips? What is generally pushed out of our collective consciousness, suppressed, denied, and avoided?
Check your own response when you read the word "death". If you are like most people, you recoil at the very thought of it. There are no key spokespersons giving information and advice about the process and how to deal with it. Elisabeth Kubler-Ross was long recognized as an expert, but her book On Death and Dying was published in 1969 and Elisabeth herself died several years ago. She temporarily opened the topic, but most of us simply avoid talking about death or facing its inevitability.
The interesting thing is that death used to be familiar. In generations past, grandparents lived with or near their kids and grandkids. When elders got sick, the family cared for them at home. When they died, family members lovingly washed and clothed the body, and the wake occurred in the living room. Children were exposed to death as a natural and normal part of life as the entire clan gathered to remember the one who died.
In recent generations, families began to scatter and both spouses started working. With no fulltime caregivers at home, sick and dying people were moved into hospitals and nursing homes. Medical technology prolonged life, often seemingly conquering death. Once death did occur, care of the body was shifted to funeral home personnel who quietly performed their duties out of sight.
As a result of these changes, public perception shifted. Death was no longer considered a normal, natural, and expected part of life. It became the unexpected and unnatural interruption to normal life. In modern society, we seem to believe that death is not inevitable, that it won’t happen to us or to anyone we love (at least not until we’re 99 years old and ready to die anyway). We actively avoid talking or even thinking about it. When death happens, we are shocked and look for someone to sue.
The last taboo, then, is not sex or money. It is death. This means most people you encounter, both professionals and clients alike, are unconsciously ignorant about what to say, what to do, and how to support someone who is facing death or grieving the death of a loved one. The flip side of the equation is that if you do know what to say, what to do, and how to support grieving people, you immediately distinguish yourself in the field. You serve your clients more compassionately, genuinely, and effectively, and build a reputation for understanding a client’s experience in a way that few other professionals do.
It is very good for your clients, and consequently it is very good indeed for your business.
It’s almost time to send out holiday greetings to your clients. Yet what if your client’s family member died this year? If you send them a card wishing "Happy Holidays", then at best you tell them you treat your clients generically, sending the same card regardless. At worst, it lets them know you don’t understand at all and, like the rest of society, expect them to paste on a smiley-face and “be happy for the sake of the season”. In either case, the card heads straight to the trash, never to be remembered.
It is never a good idea to wish “Happy Holidays” to people going through the toughest time of their lives. Instead, you can offer authenticity and genuine comfort, distinguishing yourself from everyone else and helping your client at the same time. The first step is to choose a card that does not say Happy Hanukkah, Merry Christmas, Happy Holidays, etc. Choose one that either has no words or that wishes peace or hope. Then include a hand-written note inside and consider including a gift card for a cup of coffee, a movie, a massage, or something else comforting.
Here are some possibilities: