\tJudith Graham and Oona Zenda<\/p>\n
\t\tIllustration by Oona Zenda<\/a>\t<\/p>\n This summer, at dinner with her best friend, Jacki Barden raised an uncomfortable topic: the possibility that she might die alone.<\/p>\n \u201cI have no children, no husband, no siblings,\u201d Barden remembered saying. \u201cWho\u2019s going to hold my hand while I die?\u201d<\/p>\n Barden, 75, never had children. She\u2019s lived on her own in western Massachusetts since her husband passed away in 2003. \u201cYou hit a point in your life when you\u2019re not climbing up anymore, you\u2019re climbing down,\u201d she told me. \u201cYou start thinking about what it\u2019s going to be like at the end.\u201d<\/p>\n It\u2019s something that many older adults who live alone \u2014 a growing population, more than 16 million strong in 2023<\/a> \u2014 wonder about. Many have family and friends they can turn to. But some have no spouse or children, have relatives who live far away, or are estranged from remaining family members. Others have lost dear friends they once depended on to advanced age and illness.<\/p>\n More than 15 million people 55 or older don\u2019t have a spouse or biological children; nearly 2 million have no family members at all.<\/p>\n Still other older adults have become isolated due to sickness, frailty, or disability. Between 20% and 25% of older adults<\/a>, who do not live in nursing homes, aren\u2019t in regular contact with other people. And research shows that isolation becomes even more common as death draws near.<\/p>\n Who will be there for these solo agers as their lives draw to a close? How many of them will die without people they know and care for by their side?<\/p>\n Unfortunately, we have no idea: National surveys don\u2019t capture information about who\u2019s with older adults when they die. But dying alone is a growing concern as more seniors age on their own after widowhood or divorce, or remain single or childless, according to demographers, medical researchers, and physicians who care for older people.<\/p>\n \u201cWe\u2019ve always seen patients who were essentially by themselves when they transition into end-of-life care,\u201d said Jairon Johnson, the medical director of hospice and palliative care for Presbyterian Healthcare Services, the largest health care system in New Mexico. \u201cBut they weren\u2019t as common as they are now.\u201d<\/p>\n Attention to the potentially fraught consequences of dying alone surged during the covid-19 pandemic, when families were shut out of hospitals and nursing homes as older relatives passed away. But it\u2019s largely fallen off the radar since then.<\/p>\n For many people, including health care practitioners, the prospect provokes a feeling of abandonment. \u201cI can\u2019t imagine what it\u2019s like, on top of a terminal illness, to think I\u2019m dying and I have no one,\u201d said Sarah Cross, an assistant professor of palliative medicine at Emory University School of Medicine.<\/p>\n Cross\u2019 research shows that more people die at home now than in any other setting. While hundreds of hospitals have \u201cNo One Dies Alone\u201d programs, which match volunteers with people in their final days, similar services aren\u2019t generally available for people at home.<\/p>\n Alison Butler, 65, is an end-of-life doula who lives and works in the Washington, D.C., area. She helps people and those close to them navigate the dying process. She also has lived alone for 20 years. In a lengthy conversation, Butler admitted that being alone at life\u2019s end seems like a form of rejection. She choked back tears as she spoke about possibly feeling her life \u201cdoesn\u2019t and didn\u2019t matter deeply\u201d to anyone.<\/p>\n Without reliable people around to assist terminally ill adults, there\u2019s also an elevated risk of self-neglect and deteriorating well-being. Most seniors don\u2019t have enough money to pay for assisted living or help at home if they lose the ability to shop, bathe, dress, or move around the house.<\/p>\n Nearly $1 trillion in cuts to Medicaid planned under President Donald Trump\u2019s tax and spending law, previously known as the \u201cOne Big Beautiful Bill Act,\u201d probably will compound difficulties accessing adequate care<\/a>, economists and policy experts predict. Medicare, the government\u2019s health insurance program for seniors, generally doesn\u2019t pay for home-based services; Medicaid is the primary source of this kind of help for people who don\u2019t have financial resources. But states may be forced to eviscerate Medicaid home-based care programs as federal funding diminishes.<\/p>\n \u201cI\u2019m really scared about what\u2019s going to happen,\u201d said Bree Johnston, a geriatrician and the director of palliative care at Skagit Regional Health in northwestern Washington state. She predicted that more terminally ill seniors who live alone will end up dying in hospitals, rather than in their homes, because they\u2019ll lack essential services.<\/p>\n \u201cHospitals are often not the most humane place to die,\u201d Johnston said.<\/p>\n While hospice care<\/a> is an alternative paid for by Medicare, it too often falls short for terminally ill older adults who are alone. (Hospice serves people whose life expectancy is six months or less.) For one thing, hospice is underused: Fewer than half of older adults under age 85 take advantage of hospice services.<\/p>\n Also, \u201cmany people think, wrongly, that hospice agencies are going to provide person power on the ground and help with all those functional problems that come up for people at the end of life,\u201d said Ashwin Kotwal, an associate professor of medicine in the division of geriatrics at the University of California-San Francisco School of Medicine.<\/p>\n Instead, agencies usually provide only intermittent care and rely heavily on family caregivers to offer needed assistance with activities such as bathing and eating. Some hospices won\u2019t even accept people who don\u2019t have caregivers, Kotwal noted.<\/p>\n That leaves hospitals. If seniors are lucid, staffers can talk to them about their priorities and walk them through medical decisions that lie ahead, said Paul DeSandre, the chief of palliative and supportive care at Grady Health System in Atlanta.<\/p>\n If they\u2019re delirious or unconscious, which is often the case, staffers normally try to identify someone who can discuss what this senior might have wanted at the end of life and possibly serve as a surrogate decision-maker. Most states have laws specifying default surrogates, usually family members, for people who haven\u2019t named decision-makers in advance.<\/p>\n If all efforts fail, the hospital will go to court to petition for guardianship, and the patient will become a ward of the state, which will assume legal oversight of end-of-life decision-making.<\/p>\n In extreme cases, when no one comes forward, someone who has died alone may be classified as \u201cunclaimed\u201d and buried in a common grave. This, too, is an increasingly common occurrence, according to \u201cThe Unclaimed: Abandonment and Hope in the City of Angels,\u201d a book about this phenomenon, published last year.<\/p>\n Shoshana Ungerleider, a physician, founded End Well, an organization committed to improving end-of-life experiences. She suggested people make concerted efforts to identify seniors who live alone and are seriously ill early and provide them with expanded support. Stay in touch with them regularly through calls, video, or text messages, she said.<\/p>\n And don\u2019t assume all older adults have the same priorities for end-of-life care. They don\u2019t.<\/p>\n Barden, the widow in Massachusetts, for instance, has focused on preparing in advance: All her financial and legal arrangements are in order and funeral arrangements are made.<\/p>\n \u201cI\u2019ve been very blessed in life: We have to look back on what we have to be grateful for and not dwell on the bad part,\u201d she told me. As for imagining her life\u2019s end, she said, \u201cit\u2019s going to be what it is. We have no control over any of that stuff. I guess I\u2019d like someone with me, but I don\u2019t know how it\u2019s going to work out.\u201d<\/p>\n Some people want to die as they\u2019ve lived \u2014 on their own. Among them is 80-year-old Elva Roy, founder of Age-Friendly Arlington, Texas, who has lived alone for 30 years after two divorces.<\/p>\n When I reached out, she told me she\u2019d thought long and hard about dying alone and is toying with the idea of medically assisted death, perhaps in Switzerland, if she becomes terminally ill. It\u2019s one way to retain a sense of control and independence that\u2019s sustained her as a solo ager.<\/p>\n \u201cYou know, I don\u2019t want somebody by my side if I\u2019m emaciated or frail or sickly,\u201d Roy said. \u201cI would not feel comforted by someone being there holding my hand or wiping my brow or watching me suffer. I\u2019m really OK with dying by myself.\u201d<\/p>\n KFF Health News<\/a> is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF\u2014an independent source of health policy research, polling, and journalism. Learn more about KFF<\/a>.<\/p>\n USE OUR CONTENT<\/p>\n