The Cliff Plan

At a recent gathering of Arizonans to talk about the challenges and opportunities they expect to face in old age, one of the participants joked that she and her mother are on the “Cliff Plan:” if it gets to the point where they’re “drooling, bibbed or in diapers,” they want to be pushed off a cliff.

They could well fall off a financial cliff before they get to that point. A recent report projects that a couple retiring at 65 years of age in 2009 will need $240,000 on average to pay for medical expenses the rest of their lives – a 50 percent increase since 2002. Fully 65 percent of retired Americans are expected to lack sufficient income to pay for their living, medical and long-term care expenses. The analysis projects that the chances of a 65-year-old needing at least three months of nursing home care in retirement are one in three – a future Baby Boomers devoutly wish to avoid at all costs, judging from recent interviews.

It’s not the loss of income they fear most. It’s the loss of human dignity, of any semblance of quality of life, of not being able to salvage some measure of hope and self-respect, or even of self-identity. For many, they would rather die than face a future like this.

They likely won’t get much help from the healthcare system. An aging population that needs increasing amounts of expensive care to stay alive is a huge revenue generator. We expect clinicians to provide care, not to withhold it. As one intensivist told us, it’s hard to understand why we warehouse people in semi-vegetative states, “and when they get a fever or get sick, we’re forced to take care of them in an intensive care unit, and then ship them back to where they came fromÖ.It’s a very dehumanizing thing.”

A nurse practitioner in a long term care facility put it more starkly: “I have been literally forbidden to use the word ‘hospice’ or to talk about end-of-life care because they want everyone prolonged to generate revenue for the facility.”

Many of us exhibit a “deer in the headlights” reaction to these issues. We are so overwhelmed by their magnitude and seeming intractability that we are transfixed by inaction and a fatalistic acceptance of a future beyond our control. Yes, we need to save more for retirement and personal medical expenses. Yes, we need advance directives, surrogates who understand our wishes, more emphasis on community prevention and support systems, healthier lifestyles and behaviors, universal health insurance coverage. But how many are actively pursuing these goals? By all accounts, not nearly enough.

Ironically, a sense of naÔve fatalism about the future is offset by an equally naÔve sense of optimism about our own personal situation. We’re not the ones who will end up in nursing homes. We’re not the ones who will suffer serious falls, contract Alzheimer’s disease, or die forlorn and destitute. We plan on skiing when we’re 85 and traveling abroad when we’re 90. The future will work itself out. Always has, always will. C’est la vie.

Somewhere in the middle is where the Serenity Prayer lives: changing what we can, accepting what we can’t, and knowing the difference. But sage advice for our personal lives does not absolve us from the necessity of coming together as a nation now to address the mismatch between unlimited needs and desires on the one hand and limited resources on the other. In our zeal for living, we forget that dying is equally part of life, and a good life consists of both living and dying well.

Facing the prospects of botching both at the end of life is not a future any of us would consciously choose. Short of the Cliff Plan, we need policies and laws that make it possible for us to give each other the freedom and means to make life choices with a measure of responsibility, dignity and self respect when that time comes.

Feedback? Send it my way: Roger.Hughes@slhi.org.

*The Drift reflects the views of the author, and does not represent the
official view of SLHI’s Board of Trustees and staff.