On Death and Dying, and Advisors

One of the great benefits of a conference like FPA’s national gathering is that important but often overlooked issues get the attention they deserve, not just the arcane but even the quotidian. Like, say, death.

Doctors do a poor job of telling their patients that they’re dying, with serious repercussions for patients and their families. Advisors don’t do much better, despite the fact that terminally ill people’s biggest worries at the end of life tend to be financial ones. Those insights came on Sunday from two physicians — one who is also a certified financial planner — at the FPA Experience conference in Orlando, and the advisors in attendance were engaged throughout the hourlong early-morning session.

The session — "Communication During Advanced Illness: Addressing Client Needs" — was presented by Carolyn McClanahan, MD and CFP, and Anna Wright, also an MD (and a mentor of McClanahan, she revealed during the session). Among McClanahan’s points were the importance of advanced directives, the “beauty” of hospice care and that clients with terminal illness worry most about money. Specifically, they worry about how to finance their health care, how to keep the family’s finances from being devastated during that care, and how to manage their financial and other affairs as the illness progresses.

It turns out that physicians and financial planners are very much alike in one way: they tend to be problem solvers. So when a client tells an advisor that they have a terminal illness, the knee-jerk reaction might be to try to figure out how to prolong life—“Have you consulted a specialist?” or “Are you using the best hospital?” Instead, suggested Wright, allow your clients to “share the emotional aspects of the illness,” permitting them to voice their concerns. Only after doing so will the client be able to address the financial, tax planning or estate planning issues that should be taken care of before that terminally ill person is too sick to make decisions.

McClanahan said it was appropriate to ask clients what their plans are for treatment, since part of the advisor’s job is to help with cash-flow planning during illness. To do so, it’s important for the advisor to “understand the client’s health care mindset.”

That mindset is a measure of how the client wants to be treated medically, as either a “maximizer,” who wants every extraordinary measure taken to prolong life, or as a “minimizer,” who wants to be treated medically but not taken to extraordinary lengths to prolong a life that may be extremely painful. She suggested to the advisors in the audience that they read “Your Medical Mind,” by Drs. Jerome Groopman and Pamela Hartzband. McClanahan said that most physicians tend to be maximizers due to their training and their personalities, though that may be changing with younger doctors who now are trained in hospice care and geriatrics.

Regarding hospice, McClanahan noted that most insurers will pay for up to six months of hospice care — candidates for hospice are expected to live from as little as six months up to 12 — but that hospice is underused and often used very late: the average hospice stay, she said, is only 19 days.

Wright said that for many terminally ill people, especially for minimizers, palliative care is a good option. She defined palliative care as multidisciplinary medical care for patients suffering from a number of chronic diseases and cancers at all stages, curable or not, that focuses on relieving symptoms and suffering and improving the quality of life of the patient. Wright suggested that primary care physicians might be the best doctor to recommend palliative care, since many oncologists, for example not only are maximizers but also tend not to “do a good job of treating symptoms that often come with treatment” for cancer.

Both women spoke matter-of-factly about illness, dying and death while not minimizing the importance of emotions to patients and their families. While McClanahan said planners’ concerns “should be about cash flow,” she urged planners who have clients with terminal diagnoses to “finally put death and taxes in the same sentence.”

What about clients who are in denial about their mortality? Wright said that preparing for death does not decrease your chances of a cure, and that studies had shown that your chances of a cure actually improve when a patient prepares for death. For advisors, concluded McClanahan, “come up with a plan that deals with both death and survival,” and create an action plan to deal with the client’s financial needs and other practical concerns.

If you have a client with a terminal illness, she suggested you take the following practical steps:

1. Meet earlier in the day with those clients, before 1 p.m., since the very ill, especially those being treated for illness, physically and emotionally  fade as the day progresses

2. Have the client bring a trusted person with them to your meeting who can take notes and recall the conversation later (though some privacy and even fiduciary concerns may be involved)

3. Keep the meetings simple and short

4. Repeat details and provide any directions or decisions in written format

5.  Provide frequent comfort breaks

6. Speak in a calm, soft voice (many treatments leave seriously ill patients very sound-sensitive)

7. Limit interruptions and districtions

8. Finally, if you see the client fading, end the meeting, since they’ve “already checked out.”

In response to a question from an attendee about how to deal with clients showing some cognitive decline, such as occurs with Alzheimer’s, McClanahan says that long before that development might occur, she sends a letter to all her clients asking what they want to do if their facilities begin to dissipate (and sent a shout-out to fellow advisor Cheryl Holland of Abacus Planning Group for providing the idea in the first place).

 

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