Hiring an End-of-Life Enforcer

The chilling dilemma of “the unbefriended elderly,” who
don’t have family or close friends to make medical decisions on their behalf if
they can’t speak for themselves, generated a bunch of ideas the last time we
discussed it.

One reader, Elizabeth from Los Angeles, commented that as an
only child who had no children, she wished she could hire someone to take on
this daunting but crucial responsibility.

“I would much rather pay a professional, whom I get to know
and who knows me, to make the decisions,” she wrote. “That way it is an
objective decision-maker based on the priorities I have discussed with him/her
before my incapacitation.”

Last year, published in an article in The Journal of the
American Geriatrics Society proposing a new type of professional: the health

“These people would largely be drawn from retired social
workers or nurses, people in the helping professions,” Dr. Berman said. They
might also be clergy, or perhaps paralegals. “They would need to navigate the
health care system,” she added. “They could work comfortably and easily within
that world.”

The co-authors envisioned health fiduciaries undergoing up
to a year’s training (those already knowledgeable about medical matters and
end-of-life decisions would probably need far less), followed by certification
in individual states.

Health fiduciaries would need good communication skills, so
they could guide people as they prepared advance directives. They would meet
with physicians as needed to understand a client’s prognosis and options.
Because they would understand what their clients want and don’t want, they
could serve as their advocates when they couldn’t express their own choices.

Fiduciaries would probably work out of elder law firms or
geriatric care management practices, Dr. Berman figures, because clients might
retain them so many years in advance that they’d want that kind of continuity.

Hired help might be an improvement. “They’d be able to have
these conversations that families don’t have,” Dr. Berman said of health
fiduciaries. She is hoping an area agency on aging will step up to run a pilot

“A knowledgeable, compassionate person who understands the
system and what these choices involve and can answer your questions — that will
be attractive to many people,” she said.

Paula Span is the author of “When the Time Comes: Families
With Aging Parents Share Their Struggles and Solutions.”

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