End-of-Life Planning: 2020 Checklist
The end-of-life plan is your time to establish your legacy and shoulder the burden of difficult decisions — so your loved ones won’t have to. Those decisions involve your health care, your financial assets and liabilities, your funeral arrangements, and, the culmination of these, your overall estate plan. This checklist walks you through end-of-life discussion points on all four topics and summarizes the key end-of-life planning documents you may need.
1. Health care planning checklist
Even if you become incapacitated, you can retain some control over your healthcare. You’d do that by specifying your care choices now in an advance care directive, which is also known as a living will, advance directive, personal directive, or medical directive. All of these are the same thing — a legal document that states your preferences for end-of-life care and handling, including life support, resuscitation, hospitalization, and organ donation.
1.1 Life support
Life support encompasses a broad category of machines, medications, and treatments that keep the body functional through injury and illness. Doctors might put you on life support temporarily for an invasive surgery or to relieve symptoms of severe lung conditions like pneumonia or COVID-19.
Life support tactics become controversial, however, when they’re applied to someone who’s experiencing long-term health problems, from which recovery is unlikely. An individual who’s in an extended state of unconsciousness, for example, could be kept alive by a ventilator. If the patient has no documented preferences on life support, the decision to keep the ventilator on or turn it off resides with the family.
Deter that situation by stating your life support preferences ahead of time. This helps your family and your care team approach the situation appropriately. There are several types of life support to consider, including:
- Ventilator. A ventilator, or respirator, is used when the lungs aren’t functional on their own. The underlying cause might be a lung condition like COPD or edema, a chronic health condition like Lou Gehrig’s disease, or a spinal cord injury.
- Artificial nutrition. Artificial nutrition, also called tube feeding, may be combined with a respirator to deliver nutrition to the body when an individual is unconscious.
- Extracorporeal membrane oxygenation (ECMO). ECMO, or extracorporeal life support (ECLS), provides cardiac and respiratory support for the body. You may have heard it called a “heart-lung machine.” It’s only used following severe injury, such as heart or respiratory failure.
1.2 Resuscitate orders
Resuscitation refers to the CPR treatment protocol that’s used when your heart or breathing stops. CPR can include mouth-to-mouth resuscitation, use of a defibrillator to restart the heart via electric shock, or breathing tubes.
If you do not want CPR or other life support treatments, you’d document that in your advance care directive, tell your health care proxy, and inform your physician when you are admitted to the hospital. The physician then notifies hospital staff by placing a do-not-resuscitate (DNR) order and/or a do-not-intubate (DNI) order on your chart.
1.3 Use of nursing homes, hospitals, or hospice
Another decision to consider is the use of nursing homes, hospitals, or hospice care when your condition is terminal. You can and should research hospitals and nursing homes while you are healthy. Questions to ask include:
- Is the facility Medicaid- or Medicare-certified?
- What types of care does the facility provide?
- What are the costs of care and how are these billed?
- How are treatment plans determined? Do the patients continue seeing their own doctors?
- What types of activities are available?
- What kind of meals are served?
- What are the policies for admission, visitation, and discharge?
If you like the idea of spending your final days at home, you’ll need to choose an appropriate hospice care as well. These questions can help you narrow your choices:
- Is the hospice accredited and Medicare-certified?
- What responsibilities does the hospice take on? How does the family contribute?
- Do you have a 24/7 emergency line? What is the typical response time?
- Is there an option for respite care if my family caregiver needs a break?
- What if I need in-patient care? How would that be handled?
1.4 Organ and tissue donation
In the U.S., more than 110,000 people are waiting for an organ to extend their lives; an estimated 20 of those individuals will die daily before an organ becomes available. If you would like to donate your organs upon death, it’s critical to include those wishes in your healthcare directive. You should also let your physician know and get a donor card if one is available in your state. To remain viable, organs and tissues must be removed from the body quickly — which is why it’s so important to communicate your willingness to donate.
If you prefer not to donate organs or tissues, no advance instruction is needed. You could state this in your directive, but your organs will not be removed unless you have specifically authorized it.
1.5 Health care proxy or health care power of attorney
A health care proxy or health care power of attorney is a legal order giving someone else the right to make healthcare decisions for you when you are incapacitated. You can and should have both a health care proxy and an advance care directive. The reason you need both is simple: Your directive can’t possibly cover all health care scenarios. There will be gray areas, and decisions will have to be made. In those situations, a trustworthy individual who knows you and your preferences can review all the information and make the best decision on your treatment.
2. Financial planning checklist
Any effort you put in to tidying up your finances will streamline the settlement of your estate after you’re gone. If you don’t already have your assets in trust, plan on creating a single document that lists what you own and what you owe. As you go through your assets and debts, make a note of any action items you want to complete while you’re living — such as paying off your mortgage. Here are six areas of your finances to review and inventory.
- Real estate and mortgages. List your properties, their addresses, and any associated mortgages.
- Bank accounts. Document your accounts, along with the bank name and address. For accounts that you don’t use daily, also list the balance and the date.
- Life insurance. If your life insurance beneficiaries don’t know about the policy, they won’t be able to file a claim and receive your death benefit. Write down the policies you have and be sure to communicate the policy information to those beneficiaries.
- Investments. Investments can include stock shares in a brokerage account or your collection of first-edition books.
- Debts. If you have outstanding debts when you pass, the courts will use other assets from your estate to repay those debts. To protect the inheritance that goes to your loved ones, pay down debt while you are living.
- Loans owed to you. Loans you made to others should be repaid to your estate even after you’re gone. If the loans aren’t documented, however, the courts won’t know to pursue repayment.
Keep your financial inventory in a safe but let a trusted loved one know where it is and how to access it.
3. Funeral planning checklist
More than 60% of people who create an end-of-life plan also design their funeral and pay the associated expenses ahead of time. Key decisions to make about your own final arrangements include:
- Whom to notify. The news of your passing will circulate among your immediate family, but you may also want more distant friends and acquaintances to be notified. Make a list, including contact information, of those who would like to pay their respects, so your family can let them know of your passing.
- Funeral home. Some factors that can help you choose a funeral home include location, types of services, pricing, and quality of the premises.
- Type of service. You could have a graveside service, an in-home service, or a memorial after the burial or cremation. You could even choose a destination memorial and a ceremonial spreading of your ashes.
- Treatment of remains. The choice between burial or cremation is a personal one with profound spiritual implications. You can ensure your wishes are followed by making these arrangements ahead of time, directly with the funeral home of choice. If you’d like to be cremated, you can additionally decide if you’d like the ashes kept in a mausoleum or scattered somewhere meaningful to you.
- Obituary. You can also write your own obituary or provide guidelines for a loved one to write it.
- Funeral expenses. Funding your funeral expenses while you’re living may reduce the cost of your ceremonies. It also takes financial pressure off your loved ones and ensures you have the type of funeral you want.
4. Estate planning checklist
An estate plan isn’t a single document or a single list of directives; it is a collection of activities, decisions, and documents that ultimately guide decisions about your minor children, your property, your health care, your funeral arrangements, and any business assets you own. The decisions you make with respect to your end-of-life health care, your finances, and your funeral arrangements are all part of the overall estate planning process.
If your estate is large or complex, you’ll need the assistance of an elder law attorney and a financial planner to create a solid estate plan. Here is an overview of the issues you’ll discuss with those advisors.
4.1 Ownership of assets
Ownership of assets is a primary concern in any estate plan. You can only bequeath property that’s fully yours to give away. Things like a car that’s collateral for a loan or a business that’s jointly owned with someone else are difficult to distribute without liquidation.
You and your advisor will review your list of assets and determine if there are any ownership issues that can be cleared up while you are living. Perhaps you want your son to own the business after you’re gone; that might require you to buy out your partner ahead of time. Or, you might want to put some property in joint tenancy with a spouse or adult child, so those assets can pass on to that loved one outside of probate.
Once you’ve established an ownership plan for your assets, you can choose beneficiaries to receive that property upon your passing. Your beneficiaries can be family, friends, or a trust. In most states, you can also designate a charitable organization as a beneficiary. You can even leave money to minor children, but that creates some legal challenges. It’s best practice to designate an adult to manage that money until the minor turns 18 (or 19 in Alabama). If you don’t specify a guardian of legal age for the money, the courts will.
You’ll name beneficiaries in your last will and testament, but also within certain financial accounts and assets. You might name a “payable-on-death” beneficiary on your brokerage account, for example. When you die, that financial institution will follow that beneficiary designation, regardless of what your will says. Life insurance works the same way.
If you don’t name beneficiaries, the state will decide how to divvy up your property during probate.
4.3 Financial power of attorney
A financial power of attorney is a document that gives someone else the power to make financial decisions on your behalf. The language within the power of attorney document defines how much power that individual has. It could range from complete authorization to buy or sell property in your name, to the ability to execute a single transaction on your behalf.
You might not love the idea of handing over the keys to your finances. But establishing a financial power of attorney with someone you trust eases a lot of strain later. You can, while you’re of sound mind and body, choose the right person and communicate your preferences. On the other hand, if your cognitive skills decline and you don’t have a power of attorney in place, the courts decide who takes over your finances. Unfortunately, if you’re already deemed incapable of making your own decisions, you won’t have much say in the process. That’s why it’s beneficial to solve for this problem proactively.
4.4 Last will and testament
Your last will and testament states your instructions for:
- Who will manage your estate, known as your executor
- How your property will be distributed among your beneficiaries
- Who will act as guardian for your minor children
- Who will manage any assets you leave to your minor children
- How you’d like your debts to be repaid
- Whether you’d like any debts owed to you to be forgiven
The last will and testament is a critical estate planning document. Even if you skip over other end-of-life planning strategies, you should create a written will. After you’re gone, the courts will assume the responsibility of distributing your assets according to your last will and testament. That process of estate settling is called probate.
4.5 Living trust
A living trust is a legal entity that owns your property and distributes it after your death, according to your instructions. Assets within a living trust are not subject to probate; they are passed along to beneficiaries without the court’s involvement. You do need a lawyer’s help to set up the trust, and then you must transfer your property into the trust. That means there’s a fair amount of upfront work required. But the benefit is that your loved ones won’t have to wait as long to receive their inheritance. They also won’t have to attend a series of tedious court proceedings.
A living trust is more expensive to set up and maintain than a will. However, your estate must absorb the legal costs of probate for willed assets — which means a will has its own expenses that are incurred once you’re gone. Most people do need a will, at least to appoint an executor, but your legal and financial advisors can help you decide if you also need a living trust.
Summary of end-of-life planning documents
Your comprehensive end-of-life plan will require the development of several legally binding documents and entities, including the advance care directive, health care proxy, living trust, and last will and testament.
Advance care directives
The advance care directive outlines your health care preferences in the event you are not able to communicate. As noted above, an advance directive normally addresses whether or not you want to be resuscitated, intubated, or hospitalized. Your choices are communicated to your health care workers via DNRs, DNIs, DNHs, or POLSTs, which are defined below.
- DNR. DNR stands for do not resuscitate. This is an order written by a physician upon your request. It instructs the facility staff not to use CPR should your heart or lungs stop functioning. The DNR is only in force at the facility where it is written. If you are transferred, you need to let your new care team know you don’t want to be resuscitated.
- DNI. DNI means do not intubate. Intubation is the process of inserting a tube into your body, usually to administer artificial ventilation. Like a DNR, the DNI order is written by a doctor at a facility upon your request and it is not portable.
- DNH. DNH means do not hospitalize. If you are at home under hospice care, the DNH lets your caregivers and emergency medical teams know that you do not wish to be transported to a hospital.
- POLST. POLST is an alternative to the DNR, DNI, and DNH. It is a portable medical order that communicates your preferences for resuscitation, intubation, and hospitalization, regardless of where you are or if you’ve been transferred to a different facility. Some states have different names for POLST, such as Louisiana Physician Orders for Scope of Treatment. You can learn more about how to create a POLST at Polst.org.
Health care proxy
A health care proxy, also known as a medical power of attorney, gives another person the authority to make care and treatment decisions on your behalf if you cannot. The person with that decision-making power is called your proxy or, sometimes, your health care proxy.
Financial power of attorney
A financial power of attorney authorizes someone else to make legally binding financial decisions for you. You can specify within the document if that individual should have full or limited access to your finances and property.
A living trust is a legal entity that holds property while you are living and then distributes that property after you’ve passed. Property within a living trust goes directly to your heirs without passing through probate.
Last will and testament
A last will and testament is a document that assigns an executor to your estate, lists your assets and assigns beneficiaries, and, if applicable, assigns guardians for your minor children and their property.
You’ve worked and saved for decades to amass enough wealth to leave a legacy behind. Protect that legacy and take control of your final days with a comprehensive end-of-life plan that addresses your medical treatment, your finances, your funeral arrangements, and the settlement of your estate.