How would you like to die?

Getting to grips with the facts of death.

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The Covid-19 pandemic is serving as a wake-up call to us all. Suddenly the prospect of being very unwell and potentially dying sooner than we’d like or anticipated has hit us on a scale not seen since the influenza epidemic of 1918. It also highlights the importance of talking about death.

“What would we be doing now if you had died last night?” is a question one financial planner I know likes to ask early in a meeting with a potential new client. It captures the essence of why financial planning is such a critical profession, and why I think being a financial planner is such a privilege. Done well and with the right intent, it takes you right into the core of the life of every one of your clients. After all, who likes to talk about death? Very few of us. It’s something definitely to be delayed and preferably avoided. Who hasn’t in a moment of quiet optimism thought that perhaps they’ll be the exception that proves the rule?

While doctors focus on getting people healthy or delaying death, financial planners have the responsibility to ensure that people accept that death is inevitable. The Will. The Letter of Wishes. The Estate Plan. Life Insurance. All critical tools in the financial planner’s toolbox that help you ensure that your client and their family are prepared for the inevitable.

Yet one aspect of the conversation about death that both doctors and financial planners appear to avoid is a discussion on how a client would like to die. I’m not referring to the ongoing debate about euthanasia but the fact that at the end of their lives, people often have treatment that delays the inevitable, slightly, while incurring dramatic lifestyle and financial implications.

Many families have the experience of an older family member taking a sudden and unexpected turn in their health – perhaps a fall, heart attack, stroke or advanced cancer diagnosis. The next step is often surgery, possibly followed by intense treatment like chemotherapy. Unfortunately, often recovery falters, and the family member dies in hospital. The trauma. The emotional and financial cost.

My mother, who is about to turn 90, has made her four sons promise that this will never be the outcome for her. She doesn’t want surgery or treatment if her health turns against her. Her choice would be to die in her own bed, without surgery, surrounded by some level of familiar comfort and support. Less trauma. Less financial cost. Of course, there are instances where surgery and treatment can extend lives for years. The question is, are all possible outcomes discussed and considered first, or is it automatically survival at all costs?

The reality of the Covid-19 virus is that its arrival is undetectable and its impact unpredictable.

This dilemma at the time of death confronts most families at some point – whether it involves a grandparent, parent, or child. The problem is that few families have discussed how to handle a family member’s dying process before it happens. It is no surprise that the urge – instinctual, not rational – to survive kicks in when the chips are down.

So how can we introduce rational discussion into such an emotive topic?

Where doctors are clearly set on preserving life, there is often an opportunity for the financial planner to remind clients that unlike tax, death is not something we can avoid or evade. A conversation about how clients would prefer to live out their last days is critical.

Harvard medical professor and surgeon Atul Gawande’s book Being Mortal deals with this dilemma from a medical perspective. He describes how doctors inevitably seek to help clients avoid or evade death, almost at all costs. As a result the departure lounge for many people is the Intensive Care Unit of their nearest hospital. Sometimes this is inevitable for those who have had an unexpected trauma or accident. For many, though, as Gawande describes, this happens even after extended periods of treatment that have already compromised the patient’s quality of life.

The problem, Gawande suggests, is that doctors do not broach the subject of how patients would prefer to die – how they would like to live their last months, weeks, days and hours.

He suggests that it is instinctual for doctors to cure, even if this is not possible – to offer hope even where there is none. He gives the example of a cancer patient who undergoes chemotherapy that is likely to extend life by a few months while severely compromising quality of life. It will not “save” them, but the doctor doesn’t necessarily spell this out.

Gawande suggests that a better approach might be discussing with the patient how they would like to live the last few months of their life, and then within that context decide if chemotherapy would be appropriate or not. But Gawande also acknowledges how talking about such topics is difficult, and that invariably doctors have little or no training on how to embark on such conversations.

Given that these conversations with medical professionals not only have quality of life but also cost implications, as brutal as it may sound, the opportunity is there for financial planners to have these conversations with clients well before the survival instinct need kick in. But the conversations are uncomfortable – so how to have them?

Where doctors are clearly set on preserving life, there is often an opportunity for the financial planner to remind clients that unlike tax, death is not something we can avoid or evade.

A first step may be to introduce a broader life planning approach to the work of financial planning. A number of financial planners already do this, but they are in the minority. After all, it is much easier to talk about needs, numbers, products, markets, politics and even the drought.

George Kinder, the founder of the Kinder Institute of Life Planning, suggests that financial planners should be asking their clients at least three key questions:

Question One: I want you to imagine that you are financially secure, that you have enough money to take care of your needs, now and in the future. The question is, how would you live your life? What would you do with the money? Would you change anything? Let yourself go. Don’t hold back your dreams. Describe a life that is complete, that is richly yours.

Question Two: This time, you visit your doctor who tells you that you have five to 10 years left to live. The good part is that you won’t ever feel sick. The bad news is that you will have no notice of the moment of your death. What will you do in the time you have remaining to live? Will you change your life, and how will you do it?

Question Three: This time, your doctor shocks you with the news that you have only one day left to live. Notice what feelings arise as you confront your very real mortality. Ask yourself: What dreams will be left unfulfilled? What do I wish I had finished or had been? What do I wish I had done? What did I miss?

Rob Macdonald, Head of Strategic Advisory Services at Fundhouse.

I know planners who have tried asking clients these questions and found them often too challenging for both client and planner. It’s easier not to ask, even though as Kinder intends, these are questions to challenge clients on what they really see as important in their life – and may prompt changes in their life irrespective of their financial position. But these questions still don’t address the question of how the client wants to die.

Mitch Anthony, another proponent of Life Planning, suggests that the key to getting to know your client very well is to be curious. He also emphasises the importance of getting to know a client through discussing their past, present and future. It may be in that conversation about the future, even when a client is fit and healthy, that a financial planner could introduce the topic of how the client would like to die. It may start off as a very hypothetical conversation, but it will make it much easier for the financial planner, the client and the family to have a meaningful conversation about the dying process when that inevitability is real. Having such a conversation will undoubtedly have a significant influence over the client’s financial planning, but more importantly could have profound implications for the quality of their life in their last days.

The reality of the Covid-19 virus is that its arrival is undetectable and its impact unpredictable. Devastating for some, less so for others. Having the considered conversation with your clients about how they want to die may not be as viable in this Covid-19 season as when it’s business as usual. Covid-19 is an acute condition that strikes quickly.

But the pandemic certainly provides a very timely reminder of the importance of this conversation for all clients and their families, and the key role that a financial planner can play in helping them have that conversation.

www.fundhouse.co.za
References
  • Atul Gawande, Being Mortal – Illness, Medicine, and What Matters in the End, Profile Books in Association with Wellcome Collection, 2014.
  • George Kinder, The Kinder Institute of Life Planning, www.kinderinstitute.com.
  • Mitch Anthony, author of a number of books dealing with getting to know your client and life planning, www.mitchanthony.com