Sickness, ageing and death are as much a part of the lifecycle as birth, youth and health. Yet our attitude and actions suggest that we don’t really understand these life experiences. My purpose in writing this post is to inspire a realistic and proactive attitude towards imminent death and terminal decline. In particular, I wish to highlight the urgent need for an end of life care and treatment plan.
MEDITATING ON IMMINENT DEATH, PLANING FOR TERMINAL DECLINE
Sickness, ageing and death are as much a part of the lifecycle as birth, youth and health. Yet our attitude and actions suggest that we don’t really understand these life experiences. Generally speaking, we believe youth and health to be natural qualities and we loudly celebrate them as our ‘birthrights’. We stubbornly refuse to acknowledge sickness and ageing as equally natural, believing our ‘deathrights’ to be unjust and somehow avoidable.
My purpose in writing this post is to inspire a realistic and proactive attitude towards imminent death and terminal decline. In particular, I wish to highlight the urgent need for an end of life care and treatment plan. I’ll start by mentioning the benefits of meditating on death. Then I’ll discuss more mundane matters, such as the importance of making a will; the practicalities of funeral planning; and the value of writing a ‘living will’ in consultation with family members, friends, and healthcare professionals.
The benefits of meditating on sickness, ageing, and death
“Many things can damage your life: it’s more impermanent than a bubble on a river, tossed by the wind. Any respite (from death) you may have – to breathe out (after) breathing in, and to awaken from having fallen asleep – that’s utterly amazing.” – Nagarjuna 
We really shouldn’t wait until we get old before contemplating death and making preparations. As Nagarjuna’s observation implies, from the moment we’re born we burn like candle flames and the winds of death blow from all directions. At any time we may be snuffed out by all kinds of worldly things that we normally think of as benign. Our beloved body might succumb to infection or disease. We might choke on our favourite food, or be fatally injured while performing our work and leisure activities. A trusted friend or family member might even kill us in a fit of rage. The number of possible death scenarios is incalculable.
Reflecting constantly on the potential imminence of death at every moment may sound like a recipe for depression but like Thanissaro Bhikkhu says, “If you learn to treat all moments as potentially your last, then when your last moment does come you will face it prepared.” 
Frequent recollection of death results in a perspective where our values and worries and everything in life are viewed in proportion, and it brings calm to our troubled minds. As V.F. Gunaratna explains –
“It is the contemplation of death, the intensive thought that it will someday come upon us, that softens the hardest of hearts, binds one to another with cords of love and compassion, and destroys the barriers of caste, creed and race among the peoples of this earth all of whom are subject to the common destiny of death. Death is a great leveller. Pride of birth, pride of position, pride of wealth, pride of power must give way to the all-consuming thought of inevitable death.” 
Planning for death 1: The importance of making a will
“Everyone should have a will, but it is even more important if you have children, you own property or have savings, investments, insurance policies or you own a business.” – The Law Society 
According to the Guardian newspaper, more than 30 million UK adults are failing to make provisions for when they die and ‘apathy’ is cited as the number one reason.  It’s likely that many of these people believe they don’t need a will because they have insufficient assets. They may also object to the trouble and expense of having one written. But if you die without making a will, you are said to have died ‘intestate’. In this situation, the ‘Rules of Intestacy’ will divide your estate in a pre-determined way, and it may not be the most tax-efficient way or what you want for your beneficiaries. 
Some of the more important reasons for making a will are as follows –
- You want to be sure your wishes will be respected after you die.
- You want to prevent family members and solicitors arguing over who gets what from your estate.
- You want to reassure your loved ones and spare them any unnecessary worry.
- You want to protect your assets for future generations.
- You want to reduce the Inheritance Tax bill.
- You want to let people know your funeral preferences.
You can buy will writing packs from shops or online, but it’s probably best to use the services of a solicitor or professional will writer. (The Law Society is the independent professional body for solicitors in England and Wales and you can use their website to find your nearest solicitor). You’ll need to list all the assets – property, vehicles, savings, bonds and shares, etc. – that you want to include in your will. You’ll also need to name your ‘Executor’ – a family member, friend, solicitor or other professional – whom you trust to carry out your wishes after your death. 
Planning for death 2: Funeral arrangements
I’m at that age now when life insurance companies feel obliged to send me regular reminders about rising funeral costs and the need for a financial plan, so that when I do eventually die my grieving loved ones will at least be spared the worry of having to find £6000 or more. Having recently received yet another offer of a free Parker pen from one of the more persistent offenders I got to thinking, why should my death be a financial burden upon anyone? A ‘traditional black funeral’ isn’t what I want when I’m dead and I don’t see why my family or friends or anyone else should be burdened with paying for one.
So, I did a little checking and was pleased to discover that in Britain there’s no legal obligation to use the services of a funeral director. There’s no legal requirement to use a coffin for burial and no law against using a homemade coffin if you don’t wish to buy one. There’s no requirement for the body to be embalmed, no requirement to use a hearse for transporting it, no law preventing burial on privately owned land, or any requirement to obtain planning permission so long as no money is being exchanged. However, there are potential problems with home burials and expert advice may be required. 
I’m sure my relatives would give me a DIY funeral if I asked for one but why trouble them unnecessarily when there’s a much simpler option? ‘Direct cremation’ is exactly what it sounds like – a low-cost body collection and disposal service with no ceremony, no mourners, no fuss. 
I’ve told my nearest and dearest that direct cremation is exactly right for me, and all I ask is that my ashes are collected afterwards and scattered around my favourite mountain top. I’ll be long past caring, of course, but nevertheless I like to think that some of my friends and family members will muster the energy to hike their way on up the mountain, scatter my ashes and say a few good words as my mortal remains are carried off by a gentle breeze. Afterwards, they can all meet up in the pub for a well-earned drink and a bite to eat if they want. I believe my funeral plan will prove to be a more jolly and meaningful ceremony than a traditional-style funeral and a lot less troubling for all concerned.
Planning for death 3: The ‘Living Will’
Unfortunately there are other practicalities even more serious than funeral planning to be dealt with.
The UK news media regularly reports cases of elderly and vulnerable persons being abused in their own homes or in nursing and care homes.  Cases of futile medical interventions intended to prolong life rather than assist peaceful dying with dignity are also reported with depressing regularity. 
The brutal truth is, the longer we live the more powerless and defenceless we become as our physical and mental attributes deteriorate, and the only respite from this painful decline is death itself. As Atul Gawande explains in his medical bestseller, Being Mortal –
“Medicine and public health have transformed the trajectory of our lives. For all but our most recent history… it didn’t matter whether you were five or fifty… Life and health would putter along nicely, not a problem in the world. Then illness would hit and the bottom would drop out like a trap door (Fig 1) 
“The pattern of decline has changed, however, for many chronic illnesses – emphysema, liver disease, and congestive heart failure, for example. Instead of just delaying the moment of the downward drop, our treatments can stretch the descent out until it ends up looking less like a cliff and more like a hilly road down the mountain. The road can have vertiginous drops but also long patches of recovered ground… The ultimate course is still downward until there finally comes a time when there is no recovery at all (Fig 2). 
“The trajectory that medical progress has made possible for many people, though, follows neither of these two patterns. Instead, increasingly large numbers of us get to live out a full life span and die of old age. Old age is not a diagnosis. There is always some final proximate cause that gets written down on the death certificate – respiratory failure, cardiac arrest. But in truth no single disease leads to the end; the culprit is just the accumulated crumbling of one’s bodily systems while medicine carries out its maintenance and patch jobs… The curve of life becomes a long, slow fade” (Fig 3). 
The scenario illustrated by Fig 2 is exactly what happened to my mother, who suffered chronic emphysema and was frequently in and out of hospital until she died suddenly and painfully at the age of 62. Fig 3 mirrors the experience of my father, who lived fully and actively with hardly any major illness or injury until his 82nd year, when a cancer diagnosis triggered a sudden and rapid fatal decline in the last few months of his life. My wife’s mother and father also succumbed to cancer and both had life trajectories similar to the one illustrated in Fig 3. My point in relating their stories is this: we’re all destined to have our own unique death experience but will most likely end up in the exact same way – lying helpless in a hospital bed, unable to communicate our thoughts and feelings to anyone.
Until recently I’ve not been giving much thought to the sorts of treatment I might reasonably expect when I’m no longer able to care for myself or communicate my wishes to others. I have to say, I’m not feeling very reassured by what I’ve personally witnessed and the reports I’ve been reading and listening to. Nevertheless, I’m convinced that now is the time to make clear in writing exactly how I want to be treated in certain situations.
Here in the UK the term ‘living will’ usually refers either to an advance decision or an advance statement. These are the two most common methods that people use to communicate their healthcare wishes to doctors and others who may need to be involved. Age UK explains the difference as follows:
“An advance decision offers a way for you to make a decision now, about a specific medical treatment you would want to refuse in the future… if you want to refuse life-saving treatment, it must be in writing, must be signed and witnessed, and state clearly that you wish it to apply, even if your life is at risk.” 
“An advance statement allows you to make more general statements describing your wishes and preferences about future treatment and care. It can reflect your religious or other beliefs or any aspects of life that you particularly value… An advance statement is not legally binding but staff should take it into account if they need to make a ‘best interests’ decision on your behalf when you are unable to tell them what you would like.” 
There are of course potential problems with living wills.
Generally I don’t have trouble discussing important sensitive issues with my own family, but many people will find it very difficult to persuade their family members to sit down calmly for a grown up conversation about end of life care and treatment preferences. Age UK offers the following suggestions –
- Choose a time and place where you won’t be disturbed or rushed.
- Give your family advance warning that you want to talk about the end of your life so the conversation doesn’t take them by surprise.
- Don’t worry about covering everything in one conversation. It can take time to fully discuss all your wishes and you shouldn’t try to rush this process.
- Consider writing notes beforehand about what you want to discuss. This will help you stay focused and will make sure you cover everything you want to.
- Don’t be embarrassed if you get emotional. Be honest and talk about all your feelings, not just the positive ones. 
When making an advance decision to refuse medical treatment under certain circumstances you’ll need to discuss it with the relevant authorities. It’s important to try and anticipate new developments and to avoid any ambiguities. It’s important because care professionals can provide treatment if they believe it’s in the patients’ best interests and if there’s any doubt about the existence or validity or applicability of an advance decision.  When writing an advance statement you should also consult with your doctor and any other professionals whom you may be relying on, and make copies available to them. You may also wish to consider making a ‘Lasting Power of Attorney’ that gives someone you trust the legal authority to make decisions on your behalf if, in the future, you should lose the ability to make or communicate your own decisions, or you no longer wish to make decisions for yourself. 
It would be naive to think that the living will is a foolproof solution for reducing the stresses of sickness, ageing and death. Nevertheless I do believe that writing one would be therapeutic and less troublesome than ignoring the facts of life, silently hoping that whoever does eventually take on the caring responsibility will get things exactly right.
Meditating on the fragility of life and accepting the possibility that we may die today helps prepare our mind to face the inevitable.
A ‘Last Will and Testament’ is the surest way to guarantee that our wishes will be respected after we die.
Planning our own funeral can ease the financial burden and the worry of uncertainty for those we leave behind.
The longer we live the more our physical and mental powers deteriorate; we become less able to look after ourselves and communicate with others. Our wishes and preferences for end of life care and treatment are more likely to be respected if we write a ‘living will’.
 Letter to a Friend by Nagarjuna (translated by Alexander Berzin, March 2006).
 ‘Educating Compassion’ by Thanissaro Bhikkhu. Access to Insight (Legacy Edition), 5 June 2010.
 ‘Buddhist reflections On Death‘ by V.F. Gunaratna. Access to Insight (Legacy Edition), 6 June 2010.
 ‘Making A Will’, The Law Society, 2016.
 ‘30m UK adults have not made a will‘ by Mark King, The Guardian, Saturday 23 October 2010.
 ‘Making A will’, The Law Society, 2016.
 The Natural Death Centre (Registered Charity Number. 1091396).
 ‘Cash-starved, demoralised and sometimes cruel: how England’s social care system fails the most vulnerable‘ by Daniel Boffey, The Guardian, Saturday 8 August 2015.
 ‘Acutely ill patients prevented from dying with dignity in hospital‘ by Sarah Bosely, The Guardian, Friday 1 June 2012.
 Being Mortal: Illness, Medicine, and What Matters in the End by Atul Gawande, London: Profile Books Ltd, 2015. (pp. 25-26)
 Ibid (pp. 26-27)
 Ibid (pp. 27-28)
 ‘Advance decisions, advance statements and living wills (Fact Sheet 72)‘, Age UK, September 2015. (p. 4,)
 Ibid (p. 6.)
 ‘Before you go: Planning and support for the end of life‘, Age UK, May 2015. (p. 4)
 ‘Advance decisions, advance statements and living wills…’, Age UK. (p. 5)
 ‘Before you go: Planning and support for the end of life’, Age UK. (pp. 14-15)