I close this book with a story of the late Louise Manfreddi, who got the care that all dying people deserve, and few get. Her “good death” was the fruit of seamless long-term collaboration among her family members, doctors, nurses, and others. She was the daughter of poor Methodist ministers in upstate New York. Her husband, Gene, was a house painter. In the 1950s, they bought a home in Syracuse, where she worked as a school aide and raised two daughters, Anne and Lee. In her spare time, she gardened, read voraciously, started a feminist consciousness-raising group, and loved to talk about politics. When she was in her mid-fifties, she suffered a crippling brain bleed and was never again capable of managing daily life on her own.
After months of despair, Louise built a new life with the help of her family. She learned to walk and talk again, partly by watching Sesame Street, but she never regained the capacity to sequence practical tasks. She could warm a cup of coffee in the microwave, but not make it from scratch. She could read an article, but not a book. She needed her husband or one of her daughters to lay out her clothes in the morning and to help her wash her hair. She had to stop gardening and driving, but she returned to keeping up with politics and seeing family friends. She volunteered as a greeter at her church, always wearing a maroon beret; she often sat in a pew with people who’d come alone.
She died at the age of eighty-four, of pneumonia, in a beautiful oak-paneled hospice on a hill above Syracuse, her home town. As she took her last breaths, her daughters were holding her hands. Her body smelled sweet, thanks to a compassionate orderly who (with the family’s permission) had washed her and anointed her body with fragrant oils.
Many of us hope for good deaths if we fill out advance directives and get comfortable, on a spiritual level, with the reality of death in the abstract. We hope to die at home and avoid intensive care. But a good death often requires more support than the right paperwork and the right state of mind.
Louise got it. Thanks to an innovative federal program, she had the best experience of death, despite a difficult long decline, of anybody I’ve ever known. In her last eight years, she was in the hospital only once. She never spent a single night in a nursing home. She had the extraordinary luck to be diverted from the disjointed medical care experienced by most American elders and into an integrated program that supported her from beginning to end. She died a better death than many people I know with more money and education, and Rolodexes full of influential names.
Her pathway to a good death started, oddly enough, with a botched colonoscopy when she was seventy-six. She was taken to St. Joseph’s Hospital in Syracuse for surgery to remove a perforated section of her colon. There, a perceptive social worker took a close look at her husband. Louise’s daughters had long since married and moved out, and Gene, who’d retired early on Social Security to care for his increasingly dependent wife, was spent. In a tearful family meeting at the hospital, the social worker persuaded Louise to enter the Alzheimer’s unit of a local nursing home.
The stay gave Gene a break. But Louise was bored, miserable, and far more mobile and alert than her fellow residents with classic Alzheimer’s, some of whom spent the day weeping in their wheelchairs. She wanted to go home. But Gene couldn’t manage alone anymore, and he balked at selling their house and using the money to move with her into some form of assisted living. Bringing in private health aides wasn’t an option, because the Manfreddis couldn’t afford them, and in any case didn’t want to give up their privacy.
It was then that Louise’s daughter Lee, a web designer, searched online and found an innovative federally funded program called PACE. The mission of the Program of All-Inclusive Care for the Elderly is to keep people like Louise at home, by providing extensive support to their caregivers. A program was just starting up in Syracuse, as part of Loretto, a nonprofit founded by the local Catholic diocese, that had been looking after the elderly since 1926. Loretto was closely affiliated with St. Joseph’s Health, another nonprofit whose flagship hospital had been named a “best regional hospital” by U.S. News and World Report. The Syracuse program, like all PACE programs, was modeled on a pioneering effort, begun in 1971 in San Francisco’s Chinatown, called “On Lok,” which means “peaceful happy home” in Cantonese. Started by a social worker and a dentist, On Lok was never promoted as a pathway to a good death. Its goal was to keep fragile elderly people healthy, strong, and well-supported enough to stay with their families in the Chinese community, rather than being funneled into hospitals and nursing homes.
For the Manfreddis, the PACE emphasis on living a good life was the first step on the pathway to a very good death. As soon as Louise entered the program, the lives of everyone in her family changed. A nurse came to the house and made sure Gene was strong enough to keep his wife at home with adequate support, and an occupational therapist checked to see that the house itself was safe. (A PACE handyman followed later to make recommended upgrades, such as adding grab bars and railings.) A PACE social worker helped the couple fill out the paperwork to qualify Louise for Medicaid (which, along with Medicare, would pay PACE a monthly lump sum to cover Louise’s care) and got the couple to prepay for funeral plans, which wouldn’t be counted against them in assessing their Medicaid application.
Making burial plans flowed naturally into getting the couple thinking about the end of life. The nurse arranged for a MOLST (Medical Order for Life-Sustaining Treatment) form, signed by a PACE doctor, detailing Louise’s medical wishes. She chose her husband, Gene, and her daughter Lee to make her decisions when she could no longer make her own.
From then on, PACE handled all of Louise’s care in one inclusive package. It made no distinction between curative medicine, rehabilitation, social work, having fun, socializing, and practical support. It provided them all, and it saw her not as a diagnosis, but as a whole person, and it ministered to her body, heart, and soul. Three days a week, a van took Louise to a daycare program in a converted commercial building in Syracuse, giving Gene a break. From there, she and other PACE participants often set out on field trips, to view pumpkin festivals or fall leaves, and to visit casinos and movie theaters.
PACE served everyone lunch and sent Louise home with dinner and food for the weekend. In midwinter, the PACE group toured “Lights on the Lake,” a set of elaborate displays of Christmas lights arrayed around Onondaga Lake. Louise was beloved by PACE attendants, who saw their work as a calling, not a job. The van drivers and home health aides were crucial members of the PACE team, and they were often the first to notice signs of health problems in clients. Their observations helped nip issues in the bud, and they were included in the regular case conferences held to discuss each client.
When Louise developed cataracts, she got surgery. When she was diagnosed with macular degeneration, a PACE van drove her to an ophthalmologist for expensive injections to slow its progress. PACE paid for hearing aids, because hearing well keeps people social, and happily social people are less likely to have their dementias worsen. It covered eyeglasses and dentures, unlike standard Medicare. She could get her hair done for ten dollars at a beauty shop at the daycare program, enjoy visiting musicians and pets, and see a podiatrist and a physical therapist, too—all at no charge to the family. Once a week, a PACE attendant came to the house to help her bathe. A nurse was on call twenty-four hours a day, and when Louise got sick, one came to the house.
PACE paid for an alert device in case she fell. It sent her home with plastic-wrapped packets of her medications, labeled by day, hour, and dose, so that all her husband had to do was rip the packages open and give them to her at the right times. When she became incontinent, PACE delivered the right-size diapers. “What that meant was that my mother could live with my dad, who had no special training,” said her daughter Lee. “He could concentrate on being her husband and keeping the house together.”
In her last year of life, Louise stopped being a greeter at her church and grew increasingly weak and quiet. She lost ten pounds without intending to. Nobody talked about her dying, but it was evident that she was in steep decline. She grew gently delusional, congratulating one daughter for a nonexistent work promotion, and consoling the other about an imaginary financial crisis that was supposedly forcing her to sell her house and to move away. She went to the daycare center less and napped for hours on the couch at home. She lost the ability to swallow vigorously enough to prevent food from entering her lungs, and she endured a bout of pneumonia, which was treated with antibiotics at home.
After she recovered, PACE attendants came to the house three times a day to puree food for her. A nutritionist went to great lengths to stimulate her appetite, and everyone turned a blind eye to the fact that Gene also fed her ice cream. It was a tacit trade-off: to allow her simple pleasures rather than turning what remained of her life into a grim death-postponing project.
Shortly before Thanksgiving in 2015, Gene woke up in terror in the middle of the night. Louise was lying next to him, struggling to breathe, making horrible, rattling sounds. He called an ambulance. Louise had again contracted pneumonia.
At St. Joseph’s Hospital, which cared for all PACE clients, it was touch and go. When they first arrived, Gene wasn’t sure his wife would make it through the next ten minutes. Nurses set up a thin tube at her nostrils to deliver high-flow oxygen, and inserted intravenous lines for antibiotics to fight the infection, and saline to counter dehydration. Louise rallied at first and stopped panting for breath. But she didn’t get better; in fact, each day she got worse. Fluid was building up in the space between her lungs and the chest wall.
About a week after her arrival, her doctors asked her and her family whether they’d agree to a thoracentesis, in which a long, thick needle would be inserted between Louise’s ribs to draw out the fluid and make it easier for her to breathe. It would probably make Louise feel better temporarily, the doctors said. But the procedure itself would be painful, it wouldn’t permanently cure the problem, and it carried risks of its own. As Lee remembers it, “My sister Anne asked the doctors, ‘If it was your mom or your sister, would you do it?’ They [the doctors] danced around it with their words, but with their eyes and their faces, they said ‘no.’ ”
Louise curiously insisted she didn’t have pneumonia and that the fluid wasn’t bothering her, so Anne told the doctors, “Let’s not do it.” She and Lee were guided in part by conversations the family had had around the kitchen table years earlier, expressing sadness over a beloved relative who’d developed dementia and spent years curled up on a feeding tube in a nursing home. They were also helped by the fact that eight years earlier, Louise had expressed her medical preferences when she entered the PACE program. “When in the hospital, it became apparent that this was not going anywhere good,” Lee remembers. “The MOLST gave us exactly the guidance we would have wanted.”
At this point, a medical team with a different philosophy, in a less well-coordinated and more financially driven medical system might have persuaded Louise to submit to the procedure to withdraw fluid. There’d have been good reimbursement for it and the day of reckoning could have been postponed. If the family had resisted, a doctor might have made dire predictions about how she would suffer and die. Doctors could have tried ever more exotic and expensive antibiotics, and powerful drugs to get her blood pressure down. If she’d been a nursing home resident without family to protect her, she might have ended up in intensive care, and died there.
This didn’t happen.
Ten days after entering the hospital, Louise started saying she wasn’t hungry or thirsty; she refused food and water and grew less responsive. She still was on an intravenous saline drip and antibiotics, comfortable, conscious, and not in pain. Thanksgiving came, and after Lee returned from celebrating with her in-laws, a social worker from PACE convened a big family meeting around Louise’s bed. Her husband, Gene, sat in a plastic chair at its foot with his head in his hands. Lee sat on one side of her mother, her sister Anne on the other. Standing near the head of the bed were a young doctor-in-training, his physician supervisor from the hospital’s palliative care team, two social workers (one from the hospital, one from PACE), and a nurse. They were all there to discuss what doctors call “goals of care.”
Her daughter Lee doesn’t remember the words the young doctor used as he made his first fumbling attempt. His supervising doctor stepped in and gave it another try. But nothing they said registered with Gene, who just sat there with his head in his hands. “They were talking medical,” Lee remembers. “They were saying things like ‘We are concerned about her care,’ and ‘we want to keep her comfortable.’ They just danced around it. They were more uncomfortable than we were! They were saying we could move her into a nursing home, and giving a whole laundry list of options as if she was going to live another five months.
“Finally, I got exasperated. I grabbed Dad’s hands and said, ‘Let me see if I can summarize. What these kind people are too kind to say out loud is that we’re discussing what kind of death we’re going to give Mom.’ ”
Everyone exhaled. “The elephant in the room was acknowledged,” Lee said, “and everyone was free to be more specific.” The doctors asked whether the family would agree to take Louise off antibiotics and stop the intravenous saline drip keeping her hydrated. It would make her more comfortable not to be tethered, and it would allow her to die a little sooner and easier. Perhaps the family would like to think about it overnight.
Neither Gene, nor his daughters, felt pressured or even nudged. “If we’d said we wanted them to pull out all the stops [and give maximum treatment] they would have done it,” Lee said. “We were given the time and the opportunity to make our own decisions.” With tears running down his face, Louise’s husband looked up. “What’s the point?” he said. Louise he knew, had always wanted to die before he did. In fact, she’d often joked that if he dared to die first, she’d kill him. “She always wanted to go first,” Gene said. “Let’s give her that. Let’s do it now, take her off the antibiotics.”
Now Lee assumed the role of the family’s chief negotiator. If they said yes to palliative care, she asked the medical team, what were her mother’s options? Classic hospice wasn’t an option unless Louise disenrolled from PACE, and signed up for hospice, which she wouldn’t live long enough to do. In any case, her daughters didn’t think that they, as a family, could make their mother as comfortable as a skilled nursing staff could. “We wanted our job to be present with her as family and not be her care staff,” Lee remembers. “We didn’t think having her die at home would be in our father’s best interests. We couldn’t imagine that he would ever want to sleep in that bed again.”
At that point, the PACE social worker suggested “a wonderful ward on the top floor” of The Cunningham, a high-rise nursing home, and a beautifully integrated part of Loretto’s care system. Cunningham had adopted an acclaimed innovation in nursing home culture called the Eden Alternative, which eliminates industrialized, division-of-labor approaches to nursing home care, and clusters residents instead in small groups where they can build deeper relationships with a few staff members, and with each other. PACE would cover Louise’s bills there, just as they had at St. Joseph’s. And thanks to a federal grant of more than a million dollars, the top floor of Cunningham had been turned into a beautiful, long-term palliative care, nursing, and hospice unit. Lee pressed the hospital staff hard: if they agreed to let Louise leave the hospital, would the team guarantee that Louise got a bed on the top floor of Cunningham? The PACE social worker paused and said she would do her best.
From then on, things moved rapidly. The hospital’s discharge planning department sprang into action, pressing to serve the institutional goal of freeing up Louise’s bed. Only a few beds on the top floor of Cunningham were earmarked for dying patients, and at that hour none was empty. The discharge planner decided to send Louise to an open bed on another nursing floor of Cunningham, one with none of the palliative floor’s amenities. Louise could move to the top floor, the discharge planner said, as soon as a bed opened up. The ever savvy and vigilant Lee objected. She immediately called Medicare and filed an appeal against the “discharge plan.” The appeals process automatically bought Louise an extra day in the hospital, and during that time, someone died on the top floor of Cunningham. To the relief of her family, Louise was moved there by medical transport van.
Dying can be ugly, and families and friends thirst for beauty. A good death is judged not only by the peace and comfort of the dying person, but by the memories that inhabit, or later haunt, those who survive it. Lee vividly remembers the Cunningham’s oak paneling and its expansive views of the valley. The husbands, sisters, children, and wives of the dying weren’t huddled around a vending machine drinking bad coffee and anticipating worse news. Instead they gathered around a fireplace in the living room, prepared meals in a common kitchen, and ate family-style in a dining room around a long Mission Oak refectory table. The attendants weren’t called “certified nursing assistants,” but anam cara, which means “soul friend” in Gaelic. They were encouraged to focus on nurturing their relationships with residents, not on punching out a list of tasks. The walls, the paneling, the furniture, the kitchen, everything said: you are not a patient. Those who love you are not visitors. Your dying is a human, not a medical, event. You and those you love will be cared for, and you will die in beauty.
In this institution, funded by the government, medicine was fulfilling its last forgotten duty: to attend the dying. Louise’s room was as big as a luxury hotel room, spacious enough to hold two cots, and there Lee and her sister Anne slept during the four days it took their mother to die. In the daytime, they would wheel their mother’s bed over to the window and sit on either side of her for hours, each holding one of her hands. The sisters could take a breath and look out at the clouds, hills, lakes, and valleys that surround Syracuse. They heard not the beeping of cardiac monitors, but music Louise loved—recordings of strings, flutes, and Christmas music that Anne played on a boom box that her sister Lee borrowed from staff on the thirteenth floor.
Each day, staff members brought the sisters food, so they only left their mother’s side when they needed to step outside for some fresh air. Every two hours, attendants—the anam caras—came in to gently wash and turn Louise so she was kept clean and comfortable, and her skin didn’t break down.
Louise didn’t look beautiful. She’d lost some weight in her final year, more in the hospital, and even more since she’d stopped eating and drinking. Her skull showed through her skin. Strands of her thin gray hair were plastered to her head. A plastic oxygen tube trailed from her nostrils to soothe air hunger. She was incontinent. Her body was skeletal. She sunk into herself and said less and less. But there was a pink quilt on the bed and her hand was curled around a pillow, embroidered with a heart, brought in by her daughter Anne. The emotional and spiritual needs of the family remained at the center of things, and frantic medical attempts to ignore or forestall death had no place.
Louise had always believed in a loving God, but she’d never placed much stock in the notion of hell. “Do you think there’s a heaven?” she’d often asked her daughter Lee. “I don’t think there are fluffy clouds,” Lee had said. “But the energy is never lost.” When Louise was near death, Lee asked her mother if she was afraid of dying. “You could see her gathering all her resources and pulling herself up to consciousness. She said ‘no.’ ”
On the morning of the fourth day, Louise’s hands and feet turned a dusky blue. Her breathing grew slow and ragged. After washing her and cleaning her bed, one of Cunningham’s attendants, a man named Cesar who’d been born in Puerto Rico, asked her daughters, “Is it okay with you if I pray for your mom?” After they said yes and stepped aside briefly, Cesar anointed Louise’s head and body with fragrant oils and conducted a small service, reading to her softly from his Spanish Bible.
A few hours after Cesar finished, Lee saw that Louise’s breaths were coming farther and farther apart. She took her dying mother’s hand again and told her, as her sister had earlier, that she’d been a good Mom and it was okay to go. Lee held a phone up to Louise’s ear. Louise’s husband, Gene, who’d found it too painful to be at her side for more than a few hours a day, was at home, too far away to make it back in time. He told his wife again how much he loved her. Hearing Gene’s voice, Louise took her final breath. She was eighty-four.
Lee took out a vial of colored consecrated sand that had been given to her by Tibetan monks during a mandala ceremony at a nearby Native American cultural center. She sprinkled a few grains on her mother’s body. She took off her mother’s wedding rings and put them in her pocket.
It had been cloudy all that day. Outside the window, a hole in the clouds broke open and the sun came streaming through. Then the opening slowly filled with clouds again. This came, for the Manfreddi sisters, at exactly the right time. “We felt that was how and when our mother finally left her body,” Lee said. “That was when heaven, the universal consciousness, or whatever you believe comes next, opened to embrace her.”
Fifteen minutes later, a nurse came into the room. She listened for a heartbeat, confirmed to the sisters that their mother was dead, and accepted their report of the time of death without intrusion, drama, or bustle. “It was empowering because our word wasn’t challenged, and we weren’t berated for not calling in an “authority,” Lee remembers. “It made her death and our vigil feel like a personal and familial rite of passage, not a legal event.” The nurse let the sisters know she’d call a doctor, get the death certificate signed, and notify the funeral home. “She was gone. It was like a switch had been flipped.” They kissed their mother’s body goodbye, tucked the covers under her chin, and left to be with their father.
This is what a collaborative death can look like. Louise’s family was neither exhausted nor broke. From the day she entered the PACE program until she took her last breath, the care she got—far broader than what we usually think of as “medicine”—had been attuned to her needs, and had never ignored what she and her family valued. With one minor exception, her family had never had to fight with a doctor, a hospital, or a government agency.
The aftertaste of her death was not bitterness or bewilderment, but gratitude. “It brings tears to my eyes to think about her passing, but they are tears of feeling the loss, not about how or why she died or anything we did or didn’t do,” said her daughter Lee. “She didn’t have to suffer through a long nursing home residence or hospital stay. I am comforted that our family and our community could give her a good death, without pain, and almost in her own bed. We have no regrets and only hope we are privileged to make our own departures with as much grace. It was a perfect storm. Everything broke her way.”
Louise’s death is a model for the nation. Everyone facing the end of life should have access to this level of coordinated medical and practical, even spiritual, care. It is a travesty that our society spends so much money on futile, painful high-technology medical care near the end of life, while depriving so many of the simple supports they need to die peacefully. I wish this book could promise that you, and those you love, will pass through the difficult passages of later life as well as Louise did. But I can’t. She had the good luck to live in Syracuse, which is blessed by an excellent integrated health system, started by altruistic people with something other than profit in mind. She had an assertive, diplomatic daughter with a backbone to act as her medical advocate. And finally, she had the PACE program, which places its clients, not institutional convenience, at the heart of its mission.
For many of the rest of us, our final years will probably be, at times, chaotic. PACE currently serves only forty thousand frail elders nationwide. It has friends in Congress, but it doesn’t have an army of highly paid lobbyists, and it’s not high enough on the national agenda to be significantly expanded. It is widely acknowledged that in most parts of the country, the conventional medical system—at least in its approach to the aging, incurably ill, and dying—is broken. You and those who love you are walking a labyrinth full of blind alleys, cracks, and broken steps. You may not be able to find a physician who makes house calls. You may not have a fierce and dedicated family member or health care advocate. You will have to navigate what the 2014 Institute of Medicine’s report on Dying in America called “a fragmented delivery system, spurred by perverse financial incentives” and a tragic “mismatch between the services patients and families need and the services they can obtain.” In such an environment, even a good-enough decline, and a good-enough death, is a triumph.
I have introduced you to some of the people, inside and outside medicine, who are improvising ways to make our last months, and theirs, more humane. They include street angels like the nurses who make house calls to the frail elderly in Santa Barbara, California, and the emergency room doctor in the Kaiser Permanente system who makes sure that the relatives of a dying person have places to sit, warm blankets, and the necessary privacy to say goodbye. They include a quiet army of physical therapists, occupational therapists, social workers, hospice nurses, and palliative care and geriatrics doctors who focus on keeping people functioning well and enjoying the best possible quality of life until it’s time for a good quality of death. They include the thousands of informal circles of people who organize the care of a dying friend, and the millions of paid caregivers who regard their poorly compensated work as a calling. It includes the nurses who wash and honor the bodies of the dead, bringing the sacred back into the hospital room with as much dignity as did the rituals of our ancestors. I hope you will find your way to such people, and when you can’t, to follow their examples and make up your own versions of what they do.
The challenge for our society is to take what are now scattered experiments, fueled mainly by philanthropies, Medicare pilot programs, and the altruism of individuals, and make them the standard of care for everyone undergoing the expected transitions of the last quarter of life. This will require a revolt from the bottom up. We deserve more, we should expect more, and the health care dollars to pay for it are already being spent, but mainly on expensive, harrowing technologies that do little lasting good. Some version of the PACE pathway, tailored to fit individual needs, should be available to every declining, incurably ill, and dying person in America. All fragile individuals should get physician house calls. Anybody who needs medical care at home should get hospice, not only those whose diseases march fast enough to predict death within six months.
To do so will require a change in the reimbursement system.
Today, the most poorly paid people in medicine are those who meet the needs of aging and incurably ill people, and are honest about the reality of death. An oncologist who spends hours with his patients, tries to understand what matters to them, explains the limits of medicine, and encourages them to explore hospice, will get poorer reviews from his patients, and make less money, than the one who never tells the truth and administers futile and grueling, but well-reimbursed, chemotherapies until days before death. A doctor who specializes in geriatrics will make less money than an internist with less training, and both will earn hundreds of thousands of dollars less per year than a cardiac surgeon or intensive care specialist. Penny-wise and pound-foolish medical insurance systems, including Medicare, continue to be stingy about funding physical therapy, which delays disability and supports continued well-being, while lavishly reimbursing $6,000 ambulance rides and $7,000-a-day intensive care units for people who fall because they didn’t get physical therapy. That system needs to be turned upside down, so that it better rewards practitioners who take time and put patients at the center of concern, and rewards deploying technologies less well. As it stands now, the reimbursement system is practically engineered to produce expensive, overly medicalized deaths, full of unnecessary suffering. It takes enormous gumption, savvy, support—and luck, and sometimes money—to find the way to a peaceful passage.
Our current system is structured for the convenience of the richest and most powerful one percent of the players in medicine—hospitals, insurance companies, specialists, academic medical centers, and commercial companies that sell drugs and medical devices for profit. It does a better job of benefiting them than it does at serving the patients who supposedly lie at the heart of medicine’s mission. It is time we, the silent majority who serve, or will serve, in the nation’s informal Caregiver Army, found our voices on every level, starting with the individual doctor’s office.
I hope this book will help you to navigate this bewildering situation wisely. I hope it will give you the tools to reverse incipient health problems while you still can; to get well-coordinated medical care when you can’t reverse them; and to recruit someone to protect you from aggressive treatment when you become fragile. I hope it encourages you to never be intimidated by a doctor, to remain the expert on your own life, and to keep your voice. Above all, I hope this book will help you shape your life, and your death, in ways that reflect what matters most to you. I hope that no matter where you die, someone brave will help you make room for the sacred.
But please remember that we create a new Art of Dying not to make things perfect. We work with the inadequate materials at hand to fashion something bearable, shared, and in its own way beautiful because it is sanctified by love.
People like the physician-writer Atul Gawande are making amazing strides in improving the culture of medicine from the top down, coaching doctors to hold more honest conversations with people confronting the unfixable. But training doctors to tell patients what they need to know is only one piece of the puzzle. It’s up to the rest of us, working from the bottom up, to create the political pressure to transform private and public insurance so that they financially reward such changes, and give us the practical and medical support we need near the end of life.
So find your voice. Your best conversations about aging, dying, and medicine will probably not take place in a doctor’s office. They’ll take place around your kitchen table, with you speaking your own kitchen table language to the people you love, and who love you. And then I urge you to take your voice out into the wider world, and keep telling your stories.