Death and Dying, End-of-Life Care, End-of-Life Planning, Green Burials, Home Funerals, Hospice, Los Angeles

Los Angeles Death & Dying Mavens Produce Educational Workshop June 2, 2018

Thank you fine women of the Order of the Good Death, Undertaking LA, Going with Grace, and Death Doula LA  for all that went into producing an educational seminar for colleagues and the public at Atwater Playhouse in northeast Los Angeles, June 2.
For those of us who have been attending the ill since childhood, witnessing both sudden and prolonged deaths, and advocating in our own quiet ways for natural, holistic, spiritual energy for end-of-life care (honoring the wishes of the person whose life it is before/during/after)… your fresh, energetic voices are welcome!!
It was encouraging to witness Gen X-ers moving forth with generosity, and a sense of community spirit, and a pleasure to listen to your presentations conveying authenticity and dedication.
Death & Dying Los Angeles presenters Jill Schock, Amber Carvaly, Alua Arthur
What transpired at the unusual gathering?
The engaged audience of 50 colleagues and others got to listen, meet, greet, and ask questions, based on experiences as family caregivers, hospice companions, end-of-life planners, and coordinators of arrangements for families. A few were contemplating a career devoted to end-of-life. Each person who participated has been drawn to end-of-life work through past circumstances (common among most of us).
Amber Carvaly, assisted by Susana Alba, also of UndertakingLA, demonstrates how to shroud
We met author and natural death mortician Caitlin Doughty of the Order of the Good Death and UndertakingLA; Caitlin’s associate mortician Amber Carvaly; end of life doula, end-of-life planner, and attorney Alua Arthur; and end-of-life doula Jill Schock who is also a hospice chaplain.  These ladies, age 40 or under, are passionate and powerful and demonstrate strong skills related to their work. Their goal: educate the public about green/natural alternatives and choices available at death, and, share why planning ahead can save energy, time, $$, and grief.
What pleased me most is discovering that even though the ladies make their living this way, they do not seem to be commercial.  Their focus is on giving back, and being present for the ill and their families. I also admire their ability to get the word out effectively.
They offered up-to-date information about California state laws and regulations, medical forms, home funerals, death duties, their experiences as morticians or alongside the dying, and, various options for burial, etc.
A worthwhile event and recommended for anyone interested when they host another seminar.
Wendy Jane Carrel, Senior Care and End-of-Life Planner, Mexico; Caitlin Doughty, author, founder of Order of the Good Death, and UndertakingLA
The photo above demonstrates Caitlin’s marvelous sense of fun. Her best-selling books, which I recommend, reveal her unique humor (find When Smoke Gets in Your Eyes, and, From Here to Eternity). Even though she sat in the audience during the presentation, she actively participated with the three main presenters (her colleagues), as well as the attendees.
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Aging, Death and Dying, End-of-Life Care, End-of-Life Planning, Health & Wellness, Living Abroad, Mexico, Retirement

Death Café Ajijic, Mexico; Ex-Pats and Snowbirds Talk Gently about Mortality

A group of American, Canadian, and UK ex-pats and “snowbirds” recently gathered for the first Death Café Ajijic, Mexico. There were 18 persons present at Café El Grano including an anesthesiologist, a hospice nurse, a hospice social worker, a psychiatrist, teachers, and others. There were two facilitators who work with end-of-life planning and transitions.

If the term Death Café (excuse the brash wording, I prefer Sacred Conversation or The Conversation) is new to you, you may hear it more and more.  Death Cafes or Café Mortels began with Swiss sociologist Bernard Crettaz who held over 100 such meetings in his native country until recently. In 2011, Jon Underwood, inspired by Crettaz, created Death Cafes in England (see history at http://deathcafe.com/what/  ).

These all-volunteer social events to discuss death and dying respectfully and informally (no agenda) are now held in 52 countries including Australia, Europe, Canada, the U.S., and parts of Latin America where death has sometimes, but not always, been a foreboding and scary subject.  Buddhist, Hindu, or Muslim countries, and places with indigenous populations tend to consider death a natural part of life and honor it as such more easily. Most café organizers work with end-of-life, and tend to focus on alternative, kinder, spiritual ways of departing. Note: There is a Death Café in Singapore.

“At a Death Café… our aim is to increase awareness of death to help people make the most of their (finite) lives,” states the Café web site. Most of all, the Café encourages an exchange of stories and perspectives as a way to embrace death.

What prompted a Death Café in Ajijic?

First, a number of retired ex-pats and visitors die in Mexico unexpectedly, and, they die without a health care directive and/or an end-of-life plan. There is a need for continued conversation and education.

Second, Loretta Downs, MA, has been speaking to locals at a popular venue, Open Circle (as well as at In the Heart of Awareness, the Buddhist center), about end-of-life for several years.  She flies in from Chicago every January to deliver her talks. About 300 + persons show up to listen as she encourages her audiences to become friendly with the idea of mortality and to prepare for it – think about it, and express to others what you want.  See http://www.endoflifeinspirations.com.

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Wendy Jane Carrel and Loretta Downs, End-of-Life Guides, Planners, and Educators; Co-Hosts of Death Cafe Ajijic 2018

Third, yours truly, Wendy Jane Carrel, MA, has been speaking to ex-pats around Ecuador for three years and subsequently in Mexico with the same passionate message – make friends with your demise, please make a plan.

It seemed natural for Loretta and I to team up to host a Café for Lake Chapala.

My interests had been reinforced as a result of volunteering two years at Juntos Contra el Dolor, the only 24/7 palliative care hospital and hospice in the state of Jalisco, a model for Mexico. I was given the gift of observing how painful chronic and terminal illnesses are treated, the politics of medicine, the politics of opioids, cultural difficulties related to dying, family constellations, and the difficulties of running a non-profit in a rich country (yes, rich in many resources) with little tradition of philanthropy. Most of all, I learned the concept of a “good death” requires much education and outreach in Mexico as well as at home.

Loretta’s friend Nancy Gershman, who produces Death Café NYC, gave us welcome pointers before the Ajijic meeting. We followed Nancy’s advice – small tables of 3-4 for intimate conversation, one of us (Loretta) to circulate and ensure participant exchanges were flowing, see that anyone who was recently grieving the loss of a loved one was comfortable, followed-up by an evaluation to learn what we could do better the next time.  https://www.meetup.com/Death-Cafe-New-York-City/

Cafe El Grano, nice partitions for intimate conversation
Cafe El Grano, Ajijic, Mexico – nice partitions and small tables for intimate conversation – also a most accommodating owner 😉

Because Loretta and I travel often, she is based in Chicago, and I in LA, we may not be producing other cafes until January 2019 unless another healthcare worker can pick-up in our absence.

Note: If you have not heard of Ajijic, it’s a sleepy Lake Chapala village, with a population of around 10,000, an hour south of Guadalajara. It is a popular tourist destination. Lake Chapala is home to around 20,000 full-time retirees from north-of-the border.

The DeathCafe.com web site indicates there are 9 death cafes in Mexico. I could only find one. It is located in Mexico City. See http://deathcafe.com/deathcafe/1695/ .

I have so much more to learn. I am now eager to return home to attend hospice social worker and end-of-life guide Betsy Trapasso’s Death Café LA https://www.facebook.com/deathcafelosangeles/   or Maggie Yenoki’s gathering in Pasadena https://www.facebook.com/deathcafepasadena/

References

https://www.counterpunch.org/2018/01/12/what-happens-at-a-death-cafe/   excellent overview of a Death Café gathering in Sonoma, California by Shepherd Bliss

https://www.theguardian.com/healthcare-network/2017/mar/09/death-cafe-learn-talk-dying-patients

https://www.washingtonpost.com/news/acts-of-faith/wp/2017/07/10/the-founder-of-death-cafe-has-died-but-his-movement-to-accept-the-inevitable-end-of-life-will-live-on/

https://www.facebook.com/DEATH-Cafe-Singapore-402018853254286/  a unique look at what Death Café Singapore is paying attention to

https://www.prospectmagazine.co.uk/magazine/take-me-to-the-death-cafe

Aging, Alzheimer's, Assisted Living, Assisted Living Mexico, CCRC's in Mexico, Health & Wellness, Life Planning Communities Mexico, Living Abroad, Mexico, Mexico Senior Living, Senior Care Mexico

Guidelines for Choosing Assisted Living/Nursing Care in Mexico

Gardens at Casa de las Lunas in Puerto Vallarta with independent living, assisted living and respite care, private pay

According to realtors at Lake Chapala, Mexico, and the information desk at the Lake Chapala Society in Ajijic, the popular ex-pat retirement destination has received more than double the no. of potential renters, buyers, and information hungry folks from Canada and the U.S. than in years before. (Other popular retirement destinations are also seeing an increase in activity – see no. 3 below).

Among visitors intent on moving are travel aficionados looking for a unique cultural experience, the prospect of meeting stimulating people from all parts of the world, but more importantly, an opportunity to stretch their dollars.

And then there is senior living and healthcare, a subject of interest for most. For “sandwich-generation” boomers who lost savings and/or homes during the American recession of 2007-8, or spent savings for the education of millennial children or grandchildren, many are finding there may be little left for themselves or parents if assisted living or nursing care are ever required.

An added concern is that funding for Medicare and Medicaid in the U.S. are currently being challenged.

Alma, a non-profit home for 40 residents in San Miguel Allende

If the cost of assisted and continuing care in Canada (Canada takes care of its disabled, ill, and older adults through universal care programs but there is also private pay care) or the U.S. is not an option, there are more affordable options in other countries. The closest place to look is Mexico.

Here are guidelines for looking at assisted living and continuing care in Mexico, costing between $600 USD to $3500 USD/month, depending on the value of the American dollar and the Canadian dollar vs. the peso, the location, and the residence you choose:

  1. Take note – in Mexico the terms assisted living and “nursing home” are often one and the same, with exceptions. Care facilities are not known as they are north of the border – assisted living, rehabilitation, nursing home, and hospice. It is often an all-in-one approach. Also, with some exceptions, homes mix physically disabled residents with memory care residents.
  2. Select cities or areas you wish to be in for climate – coastal, desert, mountains. (Coastal tropical places cost a little more because A/C is expensive).
  3. If the future resident does not speak Spanish, seek places with ex-pat communities and English-speaking locals who are often a source of volunteers – Baja California Norte (Ensenada, Rosarito Beach, Tijuana), Cancun, Lake Chapala, Mazatlan, Mexico City, Puerto Vallarta. Or, choose smaller places such as Merida, and San Miguel Allende. Some care homes have all foreigners as residents, others locals and foreigners together. Usually one person on staff speaks English, sometimes more than one.
  4. Do the due diligence. Research places and determine costs. Most assisted living and “nursing homes” catering to foreigners have web sites in English easily found on Google Search.
  5. Consider private pay homes and non-profits, as well as residences run by nuns whether you are Catholic or not. Nuns often (but not always) provide quality care as most are nurses with a mission to serve, plus costs tend to be what Mexicans would pay if price is a consideration. Another level of care is found in government homes, some pleasant others not; some accept foreigners with residency cards. There are differences in every region of the country, and there are no rules.
  6. Note: no two places will be alike – financially, environmentally, socially, and in terms of care. Homes are not regulated with the strict standards one is accustomed to in Canada and the U.S.  However, there are places with quality care and high standards.
  7. Conduct site visits. Assess for yourself what might be an acceptable match in terms of environment and people. Would you or your loved one feel comfortable and safe? Do you like the space, the staff?  How are you welcomed? Do residents seem cared for or are they alone in “God’s waiting room” without attention and activities? Ask residents what they like best and what they don’t like. How clean is the home? Standards differ from place to place. Arrive at meal time… is there enough assistance for each resident? Is food fresh, nutritious, and nicely presented? Is it food you would or could eat? Does the home prepare meals compatible with health challenges? What about care plans and medication management? What about emergencies? How are these matters handled?
Patio at a private pay “nursing” home, Casa Nostra, at Lake Chapala

 

Casa de los Abuelos DIF (government) home for seniors, Morelia – these homes are intended for Mexican nationals but on occasion persons with residency visas who pay are accepted, depends on the place and availability

There are no simple answers for selection.

Ideally, we would all have perfect health to our last days and an abundance of funds which would allow us to receive the best possible care wherever we choose to live.

Note: CCRC’s (Continuing Care Retirement Communities, from independent living to demise), now referred to as Life Plan Communities, have not arrived in Mexico, with one exception. There are plans in the works for Life Plan Communities in Baja California, Cancun, and at Lake Chapala from American, Canadian, Mexican, and Spanish developers.

References:

https://www.youtube.com/watch?time_continue=2&v=6lYA7c1Pnuo   Ajijic, Mexico video 2017

http://www.pbs.org/newshour/bb/foreign-retirees-flocking-mexico/

https://www.seniorhousingforum.net/blog/2016/8/3/will-mexico-solve-senior-living-affordability-problem

Health & Wellness

International Coffee Day, September 30, 2017 – Is Coffee Good for Your Health?

I am neither a scientist, nor a physician. I am not a coffee expert.

What interests me (and probably you) is whether or not coffee is good for our health.

For a few years I stopped drinking coffee. I had read in a journal that coffee might create brittle bones. It may or may not be true. So for a while I drank alkalized water, and green tea, probably healthful alternatives.

But in recent years, traveling back and forth to Italy and around Latin America, I started drinking “macchiatos” or “cortados”. In San Francisco and Los Angeles I’ve been enticed by “Gibraltars”. Each of these treats are basically espressos with a little milk, miniature cappuccinos if you will. No sugar ever, no sweeteners of any kind. (Forgive me baristas, I do know there are subtle differences in the way you make each of the above coffees).

“Everything in moderation” was the mantra I kept in mind, and so I’ve continued.

On International Coffee Day I treated myself to an Illy Caffe from Italy – not organic, and not my favorite coffee. I still like Yemeni coffee best. But the Illy was wow!! The coffee cup and saucer in the photo below are part of a set gifted to me by sweet Norwegian neighbors, coffee lovers.

 

 

I did find an article about the possible carcinogenic effects of coffee roasting because of chemicals used. I’m assuming water processed coffee is still healthful. But I do not know. Nonetheless, there is legislation under consideration in the State of California to add warning labels to coffee bags and tins about possible carcinogenic effects from drinking coffee.

Here’s the article…

http://www.nydailynews.com/news/national/coffee-sold-california-carry-cancer-warning-labels-article-1.3520283

On the other hand, several articles speak to benefits – mainly increasing longevity, reducing the risk of stroke, reducing inflammation, boosting short term memory, helping headaches recede, and much more.

As I work in the areas of health and wellness with a focus on senior care, I’ve started to conclude that coffee, for those who enjoy it, and whose doctors have said it is okay to consume, might serve older adults well.

Articles about health benefits of coffee:

http://time.com/4962159/coffee-benefits-national-coffee-day/

https://www.caffeineinformer.com/7-good-reasons-to-drink-coffee

https://www.healthline.com/nutrition/top-13-evidence-based-health-benefits-of-coffee#section3

http://www.onemedical.com/blog/newsworthy/10-healthy-reasons-to-drink-coffee-2/

http://www.mercola.com/infographics/coffee-benefits.htm

http://time.com/4962159/coffee-benefits-national-coffee-day/

https://www.caffeineinformer.com/7-good-reasons-to-drink-coffee

https://www.healthline.com/nutrition/top-13-evidence-based-health-benefits-of-coffee#section3

http://www.onemedical.com/blog/newsworthy/10-healthy-reasons-to-drink-coffee-2/

http://www.mercola.com/infographics/coffee-benefits.htm 

http://www.cnn.com/2017/09/29/health/coffee-healthy-food-drayer/index.html

 

International Coffee Day web site is http://www.internationalcoffeeday.org

The International Coffee Organization is located in London, England and its web site is http://www.ico.org  .

 

Aging, Assisted Living Mexico, Mexico Grandparents Day/Dia del Abuelo Mexico, Mexico Senior Living, Senior Care Mexico

Mexico Celebrates Grandparents Day (Dia del Abuelo) August 28, 2017

Throughout Mexico, children and grandchildren make a point of spending time with their elders on August 28. They also bring gifts. This year, because the official day is Monday, most festivities and visits were held over the weekend.

Note: The tradition of celebrating Grandparents Day was instituted in 1983 under the presidency of Lazaro Cardenas. During the 1990’s, announcer Edgar Gaytan promoted the special day on a radio program dedicated to older adults.  It has become an important event for families.

 

Arriving at Ohana Assisted Living, San Juan Cosala, Jalisco, Mexico for Grandparents Day Celebration

This year, Ohana Assisted Living in San Juan Cosala at Lake Chapala in the state of Jalisco honored its residents with a grand party that included relatives and friends, staff, folkloric dancers, an extraordinary jazz band with musical choices remembered by the generation of residents, and a beautifully prepared buffet. The residents at Ohana are from Canada, Mexico, and the U.S.

Hosts Ana and Alonzo, both geriatric nurses who live on the lovely campus, warmly greeted all. They produced a memorable event.

Ana and Alonzo, geriatric nurses, owners of Ohana Assisted Living

 

Fabulous Mexican summer fruit at Ohana Assisted Living, known for its quality meals and treats

 

Grandparents Day cake at Ohana Assisted Living, Mexico

 

Folkloric dancers near the Ohana Assisted Living pool

The dancers changed costumes three times and by the end of their performances they had gone from pastels to bright and colorful red, white, and black!! Loved the zapadiada dancing. Fun for all.

Grandparents Day Celebration with live jazz band at Ohana Assisted Living, Mexico

 

Former heavy weight wrestler. salsa teacher, and LA Times writer Ken in rehab after a fall in California, accompanied by adorable caregivers
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Bob, U.S. Air Force retired, with his caregiver who lovingly calls him “joven”, young one because of his bright spirit
Expats, Health & Wellness, Mexico

Alternative Healing Pop-Up Clinic at Lake Chapala Teams Americans, Canadians, and Mexicans

On Saturday, August 19, 2017, social worker/psychotherapist Toni Rahman, originally from Missouri, produced a Pop-Up Clinic to introduce alternative healing practitioners to each other at a Lake Chapala, Mexico refuge.

After a sage “cleansing” and blessing by Toltec shamanic student and host Craig Shanholtzer, nine persons introduced themselves and the work they do. An additional seven friends who support healing solutions came to learn and experience what the nine offer, and, to help get the word out to the community-at-large about resources at the lake.

It was a beautiful day spent on an inviting porch, in a splendid garden, or in quiet rooms either giving or receiving. “Magical”, “relaxing”, “wonderful” are the comments I heard.

 

Lake Chapala Pop-Up Clinic patio where participants were welcomed and got to know each other

 

Lake Chapala Pop-Up Clinic Healing Garden

 

Some healing arts folks who were present:

Toni Rahman, producer of the Lake Chapala Pop-Up Healing Clinic

Toni Rahman – psychotherapist, EMDR practitioner, angel card reader, and author of the newly released Being in My Body     http://www.ToniRahman.com

Kim Campbell – Canadian massage therapist with training in osteopathy

Doris Diaz, Kundalini yoga instructor

Doris Diaz – Kundalini yoga instructor, originally from Venezuela and Guadalajara, now a resident at the lake

Dara Eden, Reiki practitioner (far right)

Dara Eden – Usui Reiki Master Teacher/Intuitive Energy Healer, originally from California via one year in Vilcabamba, Ecuador    www.InnerChiMastery.com

Mahadevi – Thai massage therapist, ayurvedic consultations, from Colombia

Aracely Marquez – Mexican SCIO therapist (could not attend but will attend future Pop-Up Clinics)

Sophia Rose –  holistic therapist and coach, intuitive consultant, clinical hypnotherapist, and EFT practitioner from San Diego  www.catalystresource.com

Cynthia Rothchild – tantra teacher, watsu therapist, cosmic breathing teacher originally from Ohio  www.cincoelementosajijic.com

Earl Schenck, hands on healing and IET (Integrated Energy Therapy) practitioner for over 20 years

The next Lake Chapala Pop-Up Healing Clinic is scheduled for Saturday, September 23. The time and place will be announced on bulletin boards and in periodicals around Lake Chapala as well as on the sana-clinica.com web site sited below.

For more photos from the event click on this link:

http://sana-clinica.com/pop-up-clinic-ajijic-mexico/

Namaste mucho from Lake Chapala

Aging, Death and Dying, End-of-Life Care, Health & Wellness, Hospice, Palliative Care

Add Do Not Hospitalize to Your Advance Healthcare Directive or Five Wishes?

Can you have control over your end-of-life care? Is it possible to avoid aggressive medical treatment if you do not want it?

According to a Dartmouth Atlas study, 80% of terminally ill patients in the U.S. say they don’t want intensive treatments. 

My interpretation: Patients, whether terminally ill or not, are asking for comfort, quality of life for their last days, and relief from pain (palliative care).

The "End-of-Life Conveyor Belt": Dying patients are kept alive by machines, alone in a cold and sterile environment, their arms strapped down to the bed so that their catheters aren't dislodged. Photo: Getty Images, Jan Halaska / This content is subject to copyright.

Photo: Getty Images, Jan Halaska

“The ‘End-of-Life Conveyor Belt’ where dying patients are kept alive by machines, alone in a cold and sterile environment, their arms strapped down to the bed so that their catheters aren’t dislodged.”

The photo and statement above are from an article by Jessica Zitter, MD, for the Houston Chronicle.  She says, “my patients need to understand their options and make their own decisions.”

 

In order to make one’s own decisions in the U.S., such as avoiding hospitalization and invasive treatment, one must create an Advance Healthcare Directive or Five Wishes (an alternative advance directive recognized in 42 states and the District of Columbia). You must declare your specific medical wishes BEFORE such events might occur.

Your wishes must be notarized. Then they are legal. Be aware they may not always be honored by ambulance services or doctors in hospitals. Ideally, you will have an advocate who is your healthcare proxy or surrogate for healthcare decisions – usually a loved one with a copy of your wishes in hand.

It is also wise to prepare a POLST Physician’s Order for Life Sustaining Treatment (California) or MOLST Medical Order for Life Sustaining Treatment(New York). This way your wishes will be registered on an electronic record should you land in a hospital.

What is usually included in a healthcare directive?

It is common to include a DNR (Do Not Resuscitate), DNI (Do Not Intubate), or DND (Do Not Donate) organs or your body. These are personal choices – saving and prolonging life at all costs or not, tubes or not, donating or not. It is also common to designate a healthcare proxy or surrogate for healthcare decisions as mentioned above, someone you trust to make decisions in the event you cannot.

A recent article on Huffington Post reported on a request some folks are now including, a DNH (Do Not Hospitalize). See link below for entire article.

http://www.huffingtonpost.com.mx/entry/do-not-hospitalize-orders_us_59666c35e4b0a0c6f1e54ed9

I am currently in Mexico exploring senior care, palliative care, and end-of-life issues. The Do Not Hospitalize order got me thinking, even though I am in good health. So last week I updated my Mexican healthcare wishes because American and Canadian Advance Healthcare Directives are not recognized or honored if something happens in Mexico (or most of Latin America where Napoleonic code prevails, and not common law). I have a similar document for Ecuador. When anywhere outside the U.S. I carry a copy of my Five Wishes anyway.

Note: I am grateful to hospitals, one saved my life as I was not expected to survive my birth. In certain cases, such as extreme bleeding or falls, there may be no other option than a hospital. It would be wise to specify exceptions for hospitalization in your document if you decide to mention the preference. In my experience, most people in frail health want to be kept comfortable with palliative care at home, especially for their last days. In this circumstance, caregivers must know not to take you to a hospital.

Additional note: If you are traveling in Latin America, do not have health insurance with worldwide coverage, and are able to state your wishes cogently, and need hospital care, go to a public hospital. If you are accepted at a private hospital you will not be able to walk out the door unless every peso is paid.

An estimated 62% of Americans do not have an Advance Healthcare Directive.

I urge you to create your healthcare wishes if you haven’t already. I advise carrying a copy when traveling by air, train, or sea. Keep a copy handy in the glove compartment of your car … in case of emergency and for peace of mind.

References:

https://www.agingwithdignity.org/   where you can order a Five Wishes form in English or several other languages

http://capolst.org/   California Physician’s Order for Life Sustaining Treatment. You can download the pink form, fill it out, submit to your physician, who will in turn enter it into a statewide electronic system

http://www.dartmouthatlas.org/data/topic/topic.aspx?cat=18

http://www.houstonchronicle.com/local/gray-matters/article/What-Ted-Cruz-doesn-t-get-about-dying-with-dignity-10985879.php?cmpid=fb-premium

https://en.wikipedia.org/wiki/Advance_healthcare_directive

http://www.npr.org/2017/08/09/542390784/a-physician-explores-a-better-path-to-the-end-of-life   NPR/Terri Gross interview with Jessica Zitter, MD, a palliative care specialist

https://www.iadvanceseniorcare.com/article/memory-care/advance-directive-struggle-alzheimers-resident?utm_campaign=Vertical%20-%20Memory%20Care&utm_source=hs_email&utm_medium=email&utm_content=55520297&_hsenc=p2ANqtz-_ZuLjuUATBQhAi_dTeVehajW7RuvMRO7pZriRKLrolsP_2zJWe7N3QKGPp2sAzxtLBK5GEqz075MHAwzmHqrY33xvXzQ&_hsmi=55520297    an article which speaks to the complexity of advance healthcare directives