US Fertility Rate Hits a Record Low…Again

The fertility rate in the United States fell to a record low for a second straight year, federal officials reported Thursday, extending a deep decline that began in 2008 with the Great Recession. The fertility rate fell to 60.2 births per 1,000 women of childbearing age, down 3 percent from 2016, according to the National Center for Health Statistics. It was the largest single-year decline since 2010, when families were still feeling the effects of a weak economy.

The country has been living through one of the longest declines in fertility in decades and demographers are trying to figure out what is driving it. Rates tend to drop during difficult economic times as people put off having babies, and then rise once the economy rebounds. But the rate has not recovered since the Great Recession. A brief uptick in 2014 did not last. The number of births has also declined, and last year was its lowest level since 1987. The fertility rate is the number of births per 1,000 women ages 15 to 44.

Demographers are baffled by this trend as each year they expect the fertility rate to grow and instead it continues to drop. In 2017, women had nearly 500,000 fewer babies than in 2007, despite the fact that there were an estimated 7 percent more women in their prime childbearing years of 20 to 39.

It’s possible this shift can be attributed to major social changes. One explanation could be that the new generation of millennial women is delaying having children even longer than the women who came before them, as prime childbearing years are also critical years for advancing in a career.

While the biggest falls have been among younger women, last year the birthrate even declined for women in their 30s, an unusual development according to demographers. The rate had been rising for that group, as more women delayed childbearing.

What this will mean for society at large is still uncertain. Fertility rates are essential measures of a society’s demographic balance. If they are too high, that can strain resources like housing and education. If they are too low, a country can face challenges replacing its work force and supporting its older adults, like in Russia and Japan. In the United States, declines in rates have not led to drops in the population, in part because they have been largely offset by immigration.

 

Source: New York Times

“Aging Pride”

Embracing the fate that awaits all of us, and casting it as something more virtuous than an affliction, is the project of “Aging Pride,” an extensive gambol through the art of our later years at the Belvedere Museum and one of the largest exhibitions of the season in Vienna.

Frank self-portraits by the printmaker Käthe Kollwitz, the photographer John Coplans and the painter Maria Lassnig are joined by biting videos and photographs that explore the social side of aging, by contemporary figures such as Martin Parr, Hans Op de Beeck, and Fiona Tan. The show is capacious and good-natured, though in a rapidly aging country like Austria, “Aging Pride” has a particular demographic bite. When the general population is getting older (and art audiences more so), we had better expect a few more gray hairs in our white cubes.

With nearly 200 works, ranging across a century and intermingling icons of art history with figures little known outside Austria, the show can charitably be called a grab bag. More than one of its galleries resembles a storeroom more than a carefully hung exhibition. (“Aging Pride” has been mounted not in the famous Upper Belvedere, the plush Hapsburg palace where tourists take lip-smacking selfies in front of Gustav Klimt’s “The Kiss,” but in the Lower Belvedere, where the royals actually lived.) With so many works in relatively little space, the curator Sabine Fellner has been obliged to group the art by clashing themes that cancel each other out more than they illuminate: desire and loneliness, retirement and reinvention, death and memory.

The virtues of “Aging Pride,” then, lie in the works themselves. Nudes of old people, men and women alike, play a crucial role in this exhibition — as markers of the body in evolution, and as test cases for the social meanings of desire and disgust. Ms. Lassnig, a hero of Viennese painting who died in 2014 at 94, appears here in the 1975 self-portrait “Butterfly,” her breasts drooping, her arms gaunt, her mouth pursed.

A more recent nude self-portrait on show is “Centered” (2002), by the American figurative painter Joan Semmel — whose unabashed paintings of herself unclothed influenced a generation of feminist successors. Ms. Semmel, who turned 70 the year she painted the work, sits with her right leg bent and her arm wrapped around her knee. She holds a camera in front of her face: a marker of authorship, but also a mask.

Compared with the paintings, the photographs of nude older people in the exhibition display less benevolence. A late suite of images by Mr. Coplans, a British artist (and co-founder of the magazine Artforum) who photographed his body with merciless objectivity, divides his nude, reclining body across four starkly cropped prints. His distended belly, flabby thighs and skin speckled by decades of exposure to the sun appear in a cool, even light, as if he were already on a mortuary slab.

But there are also more tender photographs, and not all the nudes are self-portraits: Juergen Teller photographs a then-64-year-old Helen Mirren in the bath, her nipples faintly visible beneath the soapy water, her face steely and seductively absolute. The image is a confident sally against double standards of sex appeal: If Denzel Washington can still draw looks in his early 60s, why can’t she?

Paintings of nude old people are relatively rare in art history, not only because of a cult of youth and beauty. More concretely, humans now live decades longer than they did just a couple of centuries ago. (When the Belvedere was built in the early 18th century, the life expectancy for European males was under 30.) In the catalog for “Aging Pride,” Ms. Fellner notes that the ranks of the elderly are set to expand 37.5 percent in Austria over the next 12 years alone. Low birthrates from Spain to Slovakia, combined with increasing life spans, will see Europe’s work force shrink nearly 12 percent by 2060: a phenomenon with not only worrisome economic consequences but political ones, too.

What sort of lives will these old Europeans lead? Loneliness is a risk — though changing work patterns and isolating technologies have seen a surge in loneliness among the young— and long-term relationships pose hazards of their own. Mr. Op de Beeck’s grave video “Coffee” (1999) shows an older couple in an overlit cafe, she staring into the distance, he slumping in his chair, bored, absent.

Increasing life spans and improving medical technologies have also introduced a growing danger in old age: that of dementia, of the body outlasting the brain. In a revealing series of black-and-white portraits by the Vienna-based photographer Regina Hügli, people with Alzheimer’s disease show expressions of delight, confusion, bemusement and utter vacancy.

But old age can also be a third act of life, permitting new identities and greater social independence. It need not entail a loss of sexual desire — western literature bulges with dirty old men, and women of a certain age, too, have the right to desire.

One of the delights of “Aging Pride” is a short video by the Austrian artist Carola Dertnig, who interviewed her grandmother, then 86, about a dream she had the night before: she had fantasized that she was in a forest, locked in the arms of “a hunk.” She is embarrassed to have such desires at her age, but only a little.

“Such a nice fellow I picked up in my dream,” the grandmother says wistfully, before the telltale strains of Barry White’s “Love’s Theme” play.

“Youth’s a stuff will not endure,” sings the downhearted fool in Shakespeare’s “Twelfth Night.” To grow old, though, is not only a chronological fact but also an inevitability of fading powers and sagging integument. To grow old is a social phenomenon, one we have the power to make better or worse if we want to; and Europeans, facing a stark demographic future, should probably get to work.

No art in “Aging Pride” speaks more eloquently to our collective power to reimagine old age than a clip from the German choreographer Pina Bausch’s “Kontakthof” — her 1978 masterpiece of lonely-hearts on the dance floor, which she created for her company of dancers in Wuppertal, Germany, but later restaged with volunteers over 65. The older dancers, wearing the same tight suits and slinky silk dresses that Bausch’s regular troupe had worn, go through the ritual preening they learned over decades; they get lucky or get humiliated, and come back for more. Their bodies are notably stiffer than the average professional dancer, but they are here, they are boogieing, and they are ready for love.

What Happens to People Who Die Alone?

Photo: Josh Haner, The New York Times

In a fascinating and heartbreaking piece written for the New York Times, N. R. Kleinfield tells the story of George Bell, and the 50,000 other people who die in New York City every year. To read the article with pictures click here.

They found him in the living room, crumpled up on the mottled carpet. The police did. Sniffing a fetid odor, a neighbor had called 911. The apartment was in north-central Queens, in an unassertive building on 79th Street in Jackson Heights.

The apartment belonged to a George Bell. He lived alone. Thus the presumption was that the corpse also belonged to George Bell. It was a plausible supposition, but it remained just that, for the puffy body on the floor was decomposed and unrecognizable. Clearly the man had not died on July 12, the Saturday last year when he was discovered, nor the day before nor the day before that. He had lain there for a while, nothing to announce his departure to the world, while the hyperkinetic city around him hurried on with its business.

Neighbors had last seen him six days earlier, a Sunday. On Thursday, there was a break in his routine. The car he always kept out front and moved from one side of the street to the other to obey parking rules sat on the wrong side. A ticket was wedged beneath the wiper. The woman next door called Mr. Bell. His phone rang and rang.

Then the smell of death and the police and the sobering reason that George Bell did not move his car.

Each year around 50,000 people die in New York, and each year the mortality rate seems to graze a new low, with people living healthier and longer. A great majority of the deceased have relatives and friends who soon learn of their passing and tearfully assemble at their funeral. A reverent death notice appears. Sympathy cards accumulate. When the celebrated die or there is some heart-rending killing of the innocent, the entire city might weep.

A much tinier number die alone in unwatched struggles. No one collects their bodies. No one mourns the conclusion of a life. They are just a name added to the death tables. In the year 2014, George Bell, age 72, was among those names.

George Bell — a simple name, two syllables, the minimum. There were no obvious answers as to who he was or what shape his life had taken. What worries weighed on him. Whom he loved and who loved him.

Like most New Yorkers, he lived in the corners, under the pale light of obscurity.

Yet death even in such forlorn form can cause a surprising amount of activity, setting off an elaborate, lurching process that involves a hodgepodge of interlocking characters whose livelihoods flow in part or in whole from death.

With George Bell, the ripples from the process would spill improbably and seemingly by happenstance from the shadows of Queens to upstate New York and Virginia and Florida. Dozens of people who never knew him, all cogs in the city’s complicated machinery of mortality, would find themselves settling the affairs of an ordinary man who left this world without anyone in particular noticing.

In discovering a death, you find a life story and perhaps meaning. Could anything in the map of George Bell’s existence have explained his lonely end? Possibly not. But it was true that George Bell died carrying some secrets. Secrets about how he lived and secrets about who mattered most to him. Those secrets would bring sorrow. At the same time, they would deliver rewards. Death does that. It closes doors but also opens them.

ONCE FIREFIGHTERS had jimmied the door that July afternoon, the police squeezed into a beaten apartment groaning with possessions, a grotesque parody of the “lived-in” condition. Clearly, its occupant had been a hoarder.

The officers from the 115th Precinct called the medical examiner’s office, which involves itself in suspicious deaths and unidentified bodies, and a medical legal investigator arrived. His task was to rule out foul play and look for evidence that could help locate the next of kin and identify the body. In short order, it was clear that nothing criminal had taken place (no sign of forced entry, bullet wounds, congealed blood).

A Fire Department paramedic made the obvious pronouncement that the man was dead; even a skeleton must be formally declared no longer living. The body was zipped into a human remains pouch. A transport team from the medical examiner’s office drove it to the morgue at Queens Hospital Center, where it was deposited in one of some 100 refrigerated drawers, cooled to 35 degrees.

It falls to the police to notify next of kin, but the neighbors did not know of any. Detectives grabbed some names and phone numbers from the apartment, called them and got nothing: The man had no wife, no siblings. The police estimate that they reach kin 85 percent of the time. They struck out with George Bell.

At the Queens morgue, identification personnel got started. Something like 90 percent of the corpses arriving at city morgues are identified by relatives or friends after they are shown photographs of the body. Most remains depart for burial within a few days. For the rest, it gets complicated.

The easiest resolution is furnished by fingerprints; otherwise by dental and medical records or, as a last resort, by DNA. The medical examiner can also do a so-called contextual ID; when all elements are considered, none of which by themselves bring certainty, a sort of circumstantial identification can be made.

Fingerprints were taken, which required days because of the poor condition of the fingers. Enhanced techniques had to be used, such as soaking the fingers in a solution to soften them. The prints were sent to city, state and federal databases. No hits.

ONCE NINE DAYS had elapsed and no next of kin had come forth, the medical examiner reported the death to the office of the Queens County public administrator, an obscure agency that operates out of the State Supreme Court building in the Jamaica neighborhood. Its austere quarters are adjacent to Surrogate’s Court, familiarly known as widows and orphans court, where wills are probated and battles are often waged over the dead.

Each county in New York City has a public administrator to manage estates when there is no one else to do so, most commonly when there is no will or no known heirs.

Public administrators tend to rouse attention only when complaints flare over their competence or their fees or their tendency to oversee dens of political patronage. Or when they run afoul of the law. Last year, a former longtime counsel to the Bronx County public administrator pleaded guilty to grand larceny, while a bookkeeper for the Kings County public administrator was sentenced to a prison term for stealing from the dead.

Recent audits by the city’s comptroller found disturbing dysfunction at both of those offices, which the occupants said had been overstated. The most recent audit of the Queens office, in 2012, raised no significant issues.

The Queens unit employs 15 people and processes something like 1,500 deaths a year. Appointed by the Queens surrogate, Lois M. Rosenblatt, a lawyer, has been head of the office for the past 13 years. Most cases arrive from nursing homes, others from the medical examiner, legal guardians, the police, undertakers. While a majority of estates contain assets of less than $500, one had been worth $16 million. Meager estates can move swiftly. Bigger ones routinely extend from 12 to 24 months.

The office extracts a commission that starts at 5 percent of the first $100,000 of an estate and then slides downward, money that is entered into the city’s general fund. An additional 1 percent goes toward the office’s expenses. The office’s counsel, who for 23 years has been Gerard Sweeney, a private lawyer who mainly does the public administrator’s legal work, customarily gets a sliding legal fee that begins at 6 percent of the estate’s first $750,000.

“You can die in such anonymity in New York,” he likes to say. “We’ve had instances of people dead for months. No one finds them, no one misses them.”

The man presumed to be George Bell joined the wash of cases, a fresh arrival that Ms. Rosenblatt viewed as nothing special at all.

Meanwhile, the medical examiner needed records — X-rays would do — to confirm the identity of the body. The office took its own chest X-rays but still required earlier ones for comparison.

The medical examiner’s office had no idea which doctors the man had seen, so in a Hail Mary maneuver, personnel began cold-calling hospitals and doctors in the vicinity, in a pattern that radiated outward from the Jackson Heights apartment. Whoever picked up was asked if by chance a George Bell had ever dropped in.

THREE INVESTIGATORS work for the Queens County public administrator. They comb through the residences of the departed, mining their homes for clues as to what was owned, who their relatives were. It’s a peculiar kind of work, seeing what strangers had kept in their closets, what they hung on the walls, what deodorant they liked.

On July 24, two investigators, Juan Plaza and Ronald Rodriguez, entered the glutted premises of the Bell apartment, clad in billowy hazmat suits and bootees. Investigators work in pairs, to discourage theft.

Bleak as the place was, they had seen worse. An apartment so swollen with belongings that the tenant, a woman, died standing up, unable to collapse to the floor. Or the place they fled swatting at swarms of fleas.

Yes, they saw a human existence that few others did.

Mr. Plaza had been a data entry clerk before joining his macabre field in 1994; Mr. Rodriguez had been a waiter and found his interest piqued in 2002.

What qualified someone for the job? Ms. Rosenblatt, the head of the office, summed it up: “People willing to go into these disgusting apartments.”

The two men foraged through the unedited anarchy, 800 square feet, one bedroom. A stench thickened the air. Mr. Plaza dabbed his nostrils with a Vicks vapor stick. Mr. Rodriguez toughed it out. Vicks bothered his nose.

The only bed was the lumpy foldout couch in the living room. The bedroom and bathroom looked pillaged. The kitchen was splashed with trash and balled-up, decades-old lottery tickets that had failed to deliver. A soiled shopping list read: sea salt, garlic, carrots, broccoli (two packs), “TV Guide.”

The faucet didn’t work. The chipped stove had no knobs and could not have been used to cook in a long time.

The men scavenged for a will, a cemetery deed, financial documents, an address book, computer, cellphone, those sorts of things. Photographs might show relatives — could that be a mom or sis beaming in that picture on the mantel?

Portable objects of value were to be retrieved. A Vermeer hangs on the wall? Grab it. Once they found $30,000 in cash, another time a Rolex wedged inside a radio. But the bar is not placed nearly that high: In one instance, they lugged back a picture of the deceased in a Knights of Malta outfit.

In the slanting light they scooped up papers from a table and some drawers in the living room. They found $241 in bills and $187.45 in coins. A silver Relic watch did not look special, but they took it in case.

Fastened to the walls were a bear’s head, steer horns and some military pictures of planes and warships. Over the couch hung a photo sequence of a parachutist coming in for a landing, with a certificate recording George Bell’s first jump in 1963. Chinese food cartons and pizza boxes were ubiquitous. Shelves were stacked with music tapes and videos: “Top Gun,” “Braveheart,” “Yule Log.”

A splotched calendar from Lucky Market hung in the bathroom, flipped open to August 2007.

Hoarding is deemed a mental disorder, poorly understood, that stirs people to incoherent acts; sufferers may buy products simply to have them. Amid the mess were a half-dozen unopened ironing board covers, multiple packages of unused Christmas lights, four new tire-pressure gauges.

The investigators returned twice more, rounding up more papers, another $95. They found no cellphone, no computer or credit cards.

Rummaging through the personal effects of the dead, sensing the misery in these rooms, can color your thoughts. The work changes people, and it has changed these men.

Mr. Rodriguez, 57 and divorced, has a greater sense of urgency. “I try to build a life like it’s the last day,” he said. “You never know when you will die. Before this, I went along like I would live forever.”

The solitude of so many deaths wears on Mr. Plaza, the fear that someday it will be him splayed on the floor in one of these silent apartments. “This job teaches you a lot,” he said. “You learn whatever material stuff you have you should use it and share it. Share yourself. People die with nobody to talk to. They die and relatives come out of the woodwork. ‘He was my uncle. He was my cousin. Give me what he had.’ Gimme, gimme. Yet when he was alive they never visited, never knew the person. From working in this office, my life changed.”

He is 52, also divorced, and without children, but he keeps expanding his base of friends. Every day, he sends them motivational Instagram messages: “With each sunrise, may we value every minute”; “Be kind, smile to the world and it will smile back”; “Share your life with loved ones”; “Love, forgive, forget.”

He said: “When I die, someone will find out the same day or the next day. Since I’ve worked here, my list of friends has gotten longer and longer. I don’t want to die alone.”

IN HIS QUEENS CUBICLE, wearing rubber gloves, Patrick Stressler thumbed through the sheaf of documents retrieved by the two investigators. Mr. Stressler, the caseworker with the public administrator’s office responsible for piecing together George Bell’s estate, is formally a “decedent property agent,” a title he finds useful as a conversation starter at parties. He is 27, and had been a restaurant cashier five years ago when he learned you could be a decedent property agent and became one.

He began with the pictures. Mr. Stressler mingles in the leavings of people he can never meet and especially likes to ponder the photographs so “you get a sense of a person’s history, not that they just died.”

The snapshots ranged over the humdrum of life. A child wearing a holster and toy pistols. A man in military dress. Men fishing. A young woman sitting on a chair in a corner. A high school class on a stage, everyone wearing blackface. “Different times,” Mr. Stressler mused.

In the end, the photos divulged little of what George Bell had done across his 72 years.

The thicket of papers yielded a few hazy kernels. An unused passport, issued in 2007 to George Main Bell Jr., showing a thick-necked man with a meaty face ripened by time, born Jan. 15, 1942. Documents establishing that his father — George Bell — died in 1969 at 59, his mother, Davina Bell, in 1981 at 76.

Some holiday cards. Several from an Elsie Logan in Red Bank, N.J., thanking him for gifts of Godiva chocolates. One, dated 2001, said: “I called Sunday around 2 — no answer. Will try again.” A 2007 Thanksgiving Day card read, “I have been trying to call you — but no answer.”

A 2001 Christmas card signed, “Love always, Eleanore (Puffy),” with the message: “I seldom mention it, but I hope you realize how much it means to have you for a friend. I care a lot for you.”

Cards from a Thomas Higginbotham, addressed to “Big George” and signed “friend, Tom.”

A golden find: H&R Block-prepared tax returns, useful for divining assets. The latest showed adjusted gross income of $13,207 from a pension and interest, another $21,311 from Social Security. The bank statements contained the biggest revelation: For what appeared to be a simple life, they showed balances of several hundred thousand dollars. Letters went out to confirm the amounts.

No evidence of stocks or bonds, but a small life insurance policy, with the beneficiaries his parents. And there was a will, dated 1982. It split his estate evenly among three men and a woman of unknown relation. And specified that George Bell be cremated.

Using addresses he found online, Mr. Stressler sent out form letters asking the four to contact him. He heard only from a Martin Westbrook, who called from Sprakers, a hamlet in upstate New York, and said he had not spoken with George Bell in some time. The will named him as executor, but he deferred to the public administrator.

Loose ends began to be tidied up. The car, a silver 2005 Toyota RAV4, was sent to an auctioneer. There was a notice advising that George Bell had not responded to two juror questionnaires and was now subpoenaed to appear before the commissioner of jurors; a letter went out saying he would not be there. He was dead.

If an apartment’s contents have any value, auction companies bid for them. When they don’t, “cleanout companies” dispose of the belongings. George Bell’s place was deemed a cleanout.

Among his papers was an honorable military discharge from 1966, following six years in the United States Army Reserve. A request was made to the Department of Veterans Affairs, national cemetery administration, in St. Louis, for burial in one of its national cemeteries, with the government paying the bill.

St. Louis responded that George Bell did not qualify as a veteran, not having seen active duty or having died while in the Reserves. The public administrator appealed the rebuff. A week later, 16 pages came back from the centralized satellite processing and appeals unit that could be summed up in unambiguous concision: No.

Another thing the public administrator takes care of is having the post office forward the mail of the deceased. Statements may arrive from brokerage houses. Letters could pinpoint the whereabouts of relatives. When magazines show up, the subscriptions are ended and refunds requested. Could be $6.82 or $12.05, but the puny sums enter the estate, pushing it incrementally upward.

Not much came for George Bell: bank statements, a notice on the apartment insurance, utility bills, junk mail.

EVERY LIFE DESERVES to come to a final resting place, but they’re not all pretty. Most estates arrive with the public administrator after the body has already been buried by relatives or friends or in accordance with a prepaid plan.

When someone dies destitute and forsaken, and one of various free burial organizations does not learn of the case, the body ends up joining others in communal oblivion at the potter’s field on Hart Island in the Bronx, the graveyard of last resort.

If there are funds, the public administrator honors the wishes of the will or of relatives. When no one speaks for the deceased, the office is partial to two fairly dismal, cut-rate cemeteries in New Jersey. It prefers the total expense to come in under $5,000, not always easy in a city where funeral and burial costs can be multiples of that.

Simonson Funeral Home in Forest Hills was picked by Susan Brown, the deputy public administrator, to handle George Bell once his identity was verified. It is among 16 regulars that she rotates the office’s deaths through.

George Bell’s body was hardly the first to be trapped in limbo. Some years ago, one had lingered for weeks while siblings skirmished over the funeral specifics. The decedent’s sister wanted a barbershop quartet and brass band to perform; a brother preferred something solemn. Surrogate’s Court nodded in favor of the sister, and the man got a melodious send-off.

The medical examiner was not having any luck with George Bell. The cold calls to doctors and hospitals continued, but as the inquiries bounced around Queens, the discouraging answers came back slowly and redundantly: no George Bell.

In the interim, the medical examiner filed an unverified death certificate, on July 28. The cause of death was determined to be hypertensive and arteriosclerotic cardiovascular disease, with obesity a significant factor. This was surmised, based on the position in which the body was found, its age, the man’s size and the statistical likelihood of it being the cause. Occupation was listed as unknown.

City law specifies that bodies be buried, cremated or sent from the city within four days of discovery, unless an exemption is granted. The medical examiner can release even an unverified body for burial. Absent a corpse’s being confirmed, however, the policy of the medical examiner is not to allow cremation. What if there has been a mistake? You can’t un-cremate someone.

So days scrolled past. Other corpses streamed through the morgue, pausing on their way to the grave, while the body presumed to be George Bell entered its second month of chilled residence. Then its third.

IN EARLY SEPTEMBER last year, a downstairs neighbor complained to the public administrator that George Bell’s refrigerator was leaking through the ceiling and that vermin might be scuttling about.

Grandma’s Attic Cleanouts was sent over to remove the offending appliance. Diego Benitez, the company’s owner, showed up with two workers.

The refrigerator was unplugged, with unfrozen frozen vegetables and Chinese takeout rotting inside. Roaches had moved in. Mr. Benitez doused it with bug spray. He plugged it in to chill the food and rid it of the smell, then cleaned it out and took it to a recycling center in Jamaica. A few weeks later, Wipeout Exterminating came in and treated the whole place.

Meanwhile, the medical examiner kept calling around hunting for old X-rays. In late September, the 11th call hit pay dirt. A radiology provider had chest X-rays of George Bell dating from 2004. They were in a warehouse, though, and would take some time to retrieve.

Weeks tumbled by. In late October, the radiology service reported: Sorry, the X-rays had been destroyed. The medical examiner asked for written confirmation. Back came the response: Never mind, the X-rays were there. In early November, they landed at the medical examiner’s office.

The X-rays were compared, and bingo. In the first week of November, nearly four months after it had arrived, the presumed corpse of George Bell officially became George Bell, deceased, of Jackson Heights, Queens.

COLD OUT. Streaks of sunshine splashing over Queens. On Saturday morning, Nov. 15, John Sommese settled into a rented hearse, eased into the sparse traffic and drove to the morgue. He owns Simonson Funeral Home. At age 73, he remained a working owner in a city of dwindling deaths.

At the morgue, an attendant withdrew the body from the drawer, and both medical examiner and undertaker checked the identity tag. Using a hydraulic lift, the attendant swung the body into the wooden coffin. George Bell was at last going to his eternal home.

The coffin was wheeled out and guided into the back of the hearse. Mr. Sommese smoothed an American flag over it. The armed forces had passed on a military burial, but George Bell’s years in the Army Reserves were good enough for the funeral director, and he abided by military custom.

Next stop was U.S. Columbarium at Fresh Pond Crematory in Middle Village, for the cremation. Mr. Sommese made good time along the loud streets lined with shedding trees. The volume on the radio was muted; the dashboard said Queen’s “You’re My Best Friend” was playing.

While the undertaker said he didn’t dwell much on the strangers he transported, he allowed how instances like this saddened him — a person dies and nobody shows up, no service, no one from the clergy to say a few kind words, to say rest in peace.

The undertaker was a Christian, and believed that George Bell was already in another place, a better place, but still. “I don’t think everyone should have an elaborate funeral,” he said in a soft voice. “But I think burial or cremation should be with respect, or else what is society about? I think about this man. I believe we’re all connected. We’re all products of the same God. Does it matter that this man should be cremated with respect? Yes, it does.”

He consulted the mirror and blended into the next lane. “You can have a fancy funeral, but people don’t pay for kindness,” he went on. “They don’t pay for understanding. They don’t pay for caring. This man is getting caring. I care about this man.”

At U.S. Columbarium, he steered around to the rear, to the unloading dock. Another hearse stood there. Yes — a line at the crematory.

Squinting in the sun, Mr. Sommese paced in the motionless air. After 15 minutes, the dock opened up and the undertaker angled the hearse in. Workers took the coffin. Mr. Sommese kept the flag. Normally, it would go to the next of kin. There being none, the undertaker folded it up to use again.

The cremation process, what U.S. Columbarium calls the “journey,” consumed nearly three hours. Typically, cremains are ready for pickup in a couple of days. For an extra $180, the columbarium provides same-day express service, which was unneeded in this case.

Some 40,000 cremains were stored at the columbarium, almost all of them tucked into handsome individual wall niches, viewable through glass. Downstairs was a storage area near the bathrooms with a bronze tree affixed to the door. This was the Community Tree. Behind the door cremains were stacked up and stored out of sight. The budget alternative. Names were etched on the tree leaves. Some time ago, when the leaves filled up, doves were added.

Several days after the cremation, the superintendent stacked an urn shaped like a small shoe box inside the storage area. Then he nailed a metal dove, wings spread, above the right edge of the tree. It identified the new addition: “George M. Bell Jr. 1942-2014.”

ON ALTERNATE TUESDAYS, David R. Maltz & Company, in Central Islip, N.Y., auctions off 100 to 150 cars; other days, it auctions real estate, jewelry and pretty much everything else. It has sold the Woodcrest Country Club in Muttontown, N.Y., four engines from an automobile shredder, 22 KFC franchises. Items arrive from bankruptcies, repossessions and estates, including a regular stream from the Queens public administrator.

In the frosty gloom of Dec. 30, as a hissing wind spun litter through the air, the Maltz company had among its cars a 2011 Mustang convertible, multiple Mercedes-Benzes, two cars that didn’t even run and George Bell’s 2005 Toyota. Despite its age, it had just over 3,000 miles on it, brightening its appeal.

In a one-minute bidding spasm — “3,000 the bid, 3,500, 35 the bid, 4,000…” — the car went for $9,500, beating expectations. After expenses, $8,631.50 was added to the estate. The buyer was Sam Maloof, a regular, who runs a used car dealership, Beltway Motor Sales, in Brooklyn and planned to resell it. After he brought it back, his sister and secretary, Janet Maloof, adored it. She had the same 2005 model, same color, burdened with over 100,000 miles. So, feeling the holiday spirit, he gave her George Bell’s car.

In a couple of weeks, the only other valuable possession extracted from the apartment, the Relic watch, came up for sale at a Maltz auction of jewelry, wine, art and collectibles. The auction was dominated by 42 estates put up by the Queens public administrator, the thinnest by far being George Bell’s. Bidding on the watch began at $1 and finished at $3. The winner was a creaky, unemployed man named Tony Nik. He was in a sulky mood, mumbling after his triumph that he liked the slim price.

Again after expenses, another $2.31 trickled into the Bell estate.

On a sun-kindled day a week later, six muscled men from GreenEx, a junk removal business, arrived to empty the cluttered Queens apartment. Dispassionately, they scooped up the dusty traces of George Bell’s life and shoveled them into trash cans and bags. They broke apart the furniture with hammers. Tinny music poured from a portable radio.

Eyeing the bottomless thickets, puzzling over what heartbreak they told of, one of the men said: “Depression, I think. People get depressed and then, Lord help them, forget about it.”

Seven hours they went at it, flinging everything into trucks destined for a Bronx dump where the rates were good.

Some nuggets they salvaged for themselves. One man fancied a set of Marilyn Monroe porcelain plates. Another worker plucked up an unopened jumbo package of Nike socks, some model cars and some brand-new sponges. Yet another claimed the television and an unused carbon monoxide detector. Gatherings from a life, all worth more than that $3 watch.

A spindly worker with taut arms crouched down to inspect some never-worn tan work boots, still snug in their box. They were a size big, but he slid them on and liked the fit.

He cleaned George Bell’s apartment wearing the dead man’s boots.

THE PEOPLE NAMED to split the assets in the will were known as the legatees. Over 30 years had passed since George Bell chose them: Martin Westbrook, Frank Murzi, Albert Schober and Eleanore Albert. Plus, there was a beneficiary on two bank accounts: Thomas Higginbotham.

Elizabeth Rooney, a kinship investigator in the office of Gerard Sweeney, the public administrator’s counsel, set out to help find them. By law, she also had to hunt for the next of kin, down to a first cousin once removed, the furthest relative eligible to lay claim to an estate. They had to be notified, should they choose to contest the will.

There was time, for George Bell’s assets could not be distributed until seven months after the public administrator had been appointed, the period state law specifies for creditors to step forward.

Prowling the Internet, Ms. Rooney learned that Mr. Murzi and Mr. Schober were dead. Mr. Westbrook was in Sprakers and Mr. Higginbotham in Lynchburg, Va. Ms. Rooney found Ms. Albert, now going by the name Flemm, upstate in Worcester.

They were surprised to learn that George Bell had left them money. Ms. Flemm had spoken to him by phone a few weeks before he died; the others had not been in touch for years.

A core piece of Ms. Rooney’s job was drafting a family tree going back three generations. Using the genealogy company Ancestry.com, she compiled evidence with things like census records and ship manifests, showing Bell relatives arriving from Scotland. Her office once produced a family tree that was six feet long. Another time it traced a family back to Daniel Boone.

Ms. Rooney created paternal and maternal trees, each with dozens of names. She found five living relatives: two first cousins on his mother’s side, one living in Edina, Minn., and the other in Henderson, Nev. Neither had been in contact with George Bell in decades, and didn’t know what he did for a living.

On the paternal side, Ms. Rooney identified two first cousins, one in Scotland and another in England, as well as a third whose whereabouts proved elusive.

When that cousin, Janet Bell, was not found, protocol dictated that a notice be published in a newspaper for four weeks, a gesture intended to alert unlocated relatives. With sizable estates, the court chooses The New York Law Journal, where the bill for the notice can run about $4,000. In this instance the court picked The Wave, a Queens weekly with a print circulation of 12,000, at a cost of $247.

The cousin might have been in Tajikistan or in Hog Jaw, Ark., or even on Staten Island, and the odds of her spotting the notice were approximately zero. Among thousands of such ads that Mr. Sweeney has placed, he is still awaiting his first response.

Word came that Eleanore Flemm had died of a heart attack, on Feb. 3 at 66. Since she had outlived Mr. Bell, her estate would receive her proceeds. Her heirs were her brother, James Albert, a private detective on Long Island who barely remembered the Bell name, along with a nephew and two nieces in Florida. One did not know George Bell had existed.

Death, though, isn’t social. It’s business. No need to have known someone to get his money.

On Feb. 20, a Queens real estate broker listed the Bell apartment at $219,000. It was the final asset to liquidate. Three potential buyers toured it the next day, and one woman’s offer of $225,000 was accepted.

Three months later, the building’s board said no. A middle-aged couple who lived down the block entered the picture, and, at $215,000, was approved. Their plan was to fix up the marred apartment, turn their own place over to their grown-up son and then move in, overwriting George Bell’s life.

Meanwhile, Mr. Sweeney appeared in Surrogate’s Court to request probate of the will. Besides the two known beneficiaries, he listed the possibility of unknown relatives and the unfound cousin. The court appointed a so-called guardian ad litem to review the will on behalf of these people, who might, in fact, be phantoms.

In September, Mr. Sweeney submitted a final accounting, the hard math of the estate, for court approval. No objections arrived. Tallied up, George Bell’s assets amounted to roughly $540,000. Bank accounts holding $215,000 listed Mr. Higginbotham as the sole beneficiary, and he got that directly. Proceeds from the apartment, other accounts, a life insurance policy, the car and the watch went to the estate: around $324,000.

A commission of $13,726 went to the city, a $3,238 fee to the public administrator, $19,453 to Mr. Sweeney.

Other expenses included things like the apartment maintenance, at $7,360; a funeral bill of $4,873; $2,800 for the cleanout company; $1,663 for the kinship investigator; a $222 parking ticket; a $704 Fire Department bill for ambulance service; $750 for the guardian ad litem; and $12.50 for an appraisal of the watch that sold for $3.

That left about $264,000 to be split between Mr. Westbrook and the heirs of Ms. Flemm. Some 14 months after a man died, his estate was settled and the proceeds were good to go.

For the recipients, George Bell had stepped out of eternity and united them by bestowing his money. No one in the drawn-out process knew why he had chosen them, nor did they need to. They only needed to know him in the quietude of death, as a man whose heart had stopped beating in Queens. But he had been like anyone, a human being who had built a life on this earth.

HIS LIFE BEGAN small and plain. George Bell was especially attached to his parents. He slept on the pullout sofa in the living room, while his parents claimed the bedroom, and he continued to sleep there even after they died. Both parents came from Scotland. His father was a tool-and-die machinist, and his mother worked for a time as a seamstress in the toy industry.

After high school, he joined his father as an apprentice. In 1961, he made an acquaintance at a local bar, a moving man. They became friends, and the moving man pulled George Bell into the moving business. His name was Tom Higginbotham. Three fellow movers also became friends: Frank Murzi, Albert Schober and Martin Westbrook. The men in the will. They mainly moved business offices, and they all guzzled booze, in titanic proportions.

“We were a bunch of drunks,” Mr. Westbrook said. “I’m a juicer. But George put me to shame. He was a real nice guy, kind of a hermit. Boy, we had some good times.”

In the words of Mr. Higginbotham: “We were great friends. I don’t know if you can say it this way, but we were men who loved each other.”

They called him Big George, for he was a thickset, brawny man, weighing perhaps 210 pounds. Later, his ravenous appetite had him pushing 350.

He had a puckish streak. Once a woman invited him and Mr. Higginbotham to a party at her parents’ house. Her father kept tropical fish. She showed George Bell the tank. When he admired a distinctive fish, she said, “Oh, that’s an expensive one.” He picked up a net, caught the fish and swallowed it.

One day the friends were moving a financial firm. After they had fitted the desks into the new offices, George Bell slid notes into the drawers, writing things like: “I’m madly in love with you. Meet me at the water cooler.” Or: “There’s a bomb under your chair. Your next move might be your last.”

Dumb pranks. Big George being Big George.

Friends, though, found him difficult to crack open. There were things inside no one could get out. You learned to suppress your questions around him.

He had his burdens. His father died young. As she aged, his mother became crippled by arthritis. He cared for her, fetching her food and bathing her until her death.

He was fastidious about his money, only trusted banks for his savings. There was a woman he began dating when she was 19 and he was 25. “We got real keen on each other,” she said later. “He made me feel special.”

A marriage was planned. They spoke to a wedding hall. He bought a suit. Then, he told friends, the woman’s mother had wanted him to sign a prenuptial agreement to protect her daughter if the marriage should break apart. He ended the engagement, and never had another serious relationship.

That woman was Eleanore Albert, the fourth name in the will.

Some years later, she married an older man who made equipment for a party supply company, and moved upstate to become Ms. Flemm. In 2002, her husband died.

Distance and time never dampened the emotional affinity between her and George Bell. They spoke on the phone and exchanged cards. “We had something for each other that never got used up,” she said. She had sent him a Valentine’s Day card just last year: “George, think of you often with love.”

And unbeknown to her, he had put her in his will and kept her there.

Her life finished up a lot like his. She lived alone, in a trailer. She died of a heart attack. A neighbor who cleared her snow found her. She had gotten obese. Her brother had her cremated.

A difference was that she left behind debt, owed to the bank and to credit card companies. All that she would pass on was tens of thousands of dollars of George Bell’s money, money that she never got to touch.

Some would filter down to her brother, who had no plans for it. A slice went to Michael Garber, her nephew, who drives a bus at Disney World. A friend of his aunt’s had owned a Camaro convertible that she relished, and he might buy a used Camaro in her honor.

Some more would go to Sarah Teta, a niece, retired and living in Altamonte Springs, Fla., who plans to save it for a rainy day. “You always hear about people you don’t know dying and leaving you money,” she said. “I never thought it would happen to me.”

And some would funnel down to Eleanore Flemm’s other niece, Dorothy Gardiner, a retired waitress and home health care aide. She lives in Apopka, Fla., never heard of George Bell. She has survived two cancers and has several thousand dollars in medical bills that could finally disappear. “I’ve been paying off $25 a month, what I can,” she said. “I never would have expected this. It’s crazy.”

IN 1996, GEORGE BELL hurt his left shoulder and spine lifting a desk on a moving job, and his life took a different shape. He received approval for workers’ compensation and Social Security disability payments and began collecting a pension from the Teamsters. Though he never worked again, he had all the income he needed.

He used to have buddies over to watch television and he would cook for them. Then he stopped having anyone over. No one knew why.

Old friends had drifted away, and with them some of the fire in George Bell’s life. Of his moving man colleagues, Mr. Murzi retired in 1994 and died in 2011. Mr. Schober retired in 1996 and moved to Brooklyn, losing touch. He died in 2002.

Mr. Higginbotham quit the moving business, and moved upstate in 1973 to work for the state as an environmental scientist.

He is now 74, retired and living alone in Virginia. The last time he spoke to George Bell was 10 years ago. He used a code of ringing and hanging up to get him to answer his phone, but in time, he got no answer. He sent cards, beseeched him to come and visit, but he wouldn’t. It was two months before Mr. Higginbotham found out George Bell had died.

It has been hard for him to reconcile the way George Bell’s money came to him. “I’ve been stressed about this,” he said. “I haven’t been sleeping. My stomach hurts. My blood pressure is up. I argued with him time and again to get out of that apartment and spend his money and enjoy life. I sent him so many brochures on places to go. I thought I understood George. Now I realize I didn’t understand him at all.”

Mr. Higginbotham was content with the fundaments of his own life: his modest one-bedroom apartment, his 15-year-old truck. He put the inheritance into mutual funds and figures it will help his three grandchildren through college. George Bell’s money educating the future.

In 1994, Mr. Westbrook hurt his knee and left the moving business. He moved to Sprakers, where he had a cattle farm. When he got older and his marriage dissolved, he sold the farm but still lives nearby. He is 74. It was several years ago that he last spoke to George Bell on the phone. Mr. Bell told him he did not get out much.

He has three grandchildren and wants to move to a mellower climate. He plans to give some of the money to Mr. Murzi’s widow, because Mr. Murzi had been his best friend.

“My sister needs some dental work,” he said. “I need some dental work. I need hearing aids. The golden age ain’t so cheap. Big George’s money will make my old age easier.”

He felt awful about his dying alone, nobody knowing. “Yeah, that’ll happen to me,” he said. “I’m a loner, too. There’s maybe four or five people up here I talk to.”

In his final years, with the moving men gone, George Bell’s life had become emptier. Neighbors nodded to him on the street and he smiled. He told lively stories to the young woman next door, who lived with her parents, when he bumped into her. She recently became a police officer, and she was the one who had smelled what she knew was death.

But in the end, George Bell seemed to keep just one true friend.

He had been a fixture at a neighborhood pub called Budds Bar. He showed up in his cutoff blue sweatshirt so often that some regulars called him Sweatshirt Bell. At one point, he eased up on his drinking, then, worried about his health, quit. But he still went to Budds, ordering club soda.

In April 2005, Budds closed. Many regulars gravitated to another bar, Legends. George Bell went a few times, then transferred his allegiance to Bantry Bay Publick House in Long Island City. He would meet his friend there.

THE SIGN at the entrance to Bantry Bay says, “Enter as Strangers, Leave as Friends.” Squished in near the window was Frank Bertone, sipping soup and nursing a drink. He is known as the Dude. George Bell’s last good friend.

In the early 1980s, not long after moving to Jackson Heights, he stopped in at Budds in need of a restroom. A big man had bellowed, “Have a beer.”

That was George Bell. In time, a friendship was spawned, deepening during the 15 years that remained of George Bell’s life. They met on Saturdays at Bantry Bay. They fished in the Rockaways and at Jones Beach, sometimes with others. Mr. Bell bought a car to get out to the good spots, but the car otherwise mostly sat. They passed time meandering around, the days bleeding into one another.

“Where did we go?” Mr. Bertone said. “No place. One time we sat for hours in the parking lot of Bed Bath & Beyond. What did we talk about? The world’s problems. Just like that, the two of us solved the world’s problems.”

Mr. Bertone is 67, a retired inspector for Consolidated Edison. Over the last decade, he had spent more time with George Bell than anyone, but he didn’t feel he truly knew him.

“One thing about George is he didn’t get personal,” he said. “Not ever.”

He knew he had never married. He spoke of girlfriends, but Mr. Bertone never met any. The two had even swapped views on wills and what happens to your money in the end, though Mr. Bertone did not know George Bell had drafted a will before they met.

Mr. Bertone would invite him to his place, but he would beg off. George Bell never had him over.

Once, some eight years ago, Mr. Bertone trooped out there when he hadn’t heard from him in a while. George Bell cracked open the door, shooed him away. A curtain draped inside the entryway had camouflaged the chaos. Mr. Bertone had no idea that at some point, George Bell had begun keeping everything.

The Dude, Mr. Bertone, told a story. A few years ago, George Bell was going into the hospital for his heart and had asked him to hold onto some money. Gave him a fat envelope. Inside was $55,000.

Mike Kerins, a bartender, interrupted: “Two things about George. He gave me $100 every Christmas, and he never went out to eat.” He had confessed he was too embarrassed because he would have required three entrees.

George Bell had diabetes and complained about a shoulder pain. He took pills but skipped them during the day, saying they made him feel like an idiot.

Both the Dude and Mr. Kerins sensed he felt he had been bullied too hard by life. “George was in a lot of pain,” Mr. Kerins said. “I think he was just waiting to die, had lived enough.”

It was as if sadness had killed George Bell.

His days had become predictable, an endless loop. He stayed cloistered inside. Neighbors heard the regular parade of deliverymen who brought him his takeout meals.

The last time the Dude saw George Bell was about a week before his body was found. Frozen shrimp was on sale at the shopping center. George Bell got some, to take back to the kitchen he did not use.

Mr. Bertone didn’t realize he had died until someone came to Legends with the news. Mr. Kerins was there and he told the Dude. They made some calls to find out more, but got nowhere.

Why did he die alone, no one knowing?

The Dude thought on that. “I don’t know, man,” he said. “I wish I could tell you. But I don’t know.”

On the televisions above the busy bar, a woman was promoting a cleaning product. In the dim light, Mr. Bertone emptied his drink. “You know, I miss him,” he said. “I would have liked to see George one more time. He was my friend. One more time.”

How Doctors Choose to Die

When faced with a terminal illness, medical professionals, who know the limits of modern medicine, often opt out of life-prolonging treatment. An American doctor explains why the best death can be the least medicated – and the art of dying peacefully, at home.

Ken Murray, MD, is a former clinical assistant professor of family medicine at USC. Taken from an article originally published at Zócalo Public Square:

Years ago, Charlie, a highly respected orthopaedist and a mentor of mine, found a lump in his stomach. He asked a surgeon to explore the area, and the diagnosis was pancreatic cancer. This surgeon was one of the best in the country. He had even invented a new procedure for this exact cancer that could triple a patient’s five-year-survival odds – from five per cent to 15% – albeit with a poor quality of life. Charlie was uninterested. He went home the next day, closed his practice, and never set foot in a hospital again. He focused on spending time with his family and feeling as good as possible. Several months later, he died at home. He received no chemotherapy, radiation, or surgical treatment. Medicare didn’t spend much on him.

It’s not a frequent topic of discussion, but doctors die, too. And they don’t die like the rest of us. What’s unusual about them is not how much treatment they get compared to most Americans, but how little. For all the time they spend fending off the deaths of others, they tend to be fairly serene when faced with death themselves. They know exactly what is going to happen, they know the choices, and they generally have access to any sort of medical care they could want. But they go gently.

Of course, doctors don’t want to die; they want to live. But they know enough about modern medicine to know its limits. And they know enough about death to know what all people fear most: dying in pain, and dying alone. They’ve talked about this with their families. They want to be sure, when the time comes, that no heroic measures will happen – that they will never experience, during their last moments on earth, someone breaking their ribs in an attempt to resuscitate them with CPR (that’s what happens if CPR is done right).

Almost all medical professionals have seen what we call “futile care” being performed on people. That’s when doctors bring the cutting edge of technology to bear on a grievously ill person near the end of life. The patient will be cut open, perforated with tubes, hooked up to machines, and assaulted with drugs. All of this occurs in the intensive care unit at a cost of tens of thousands of dollars a day. What it buys is misery we would not inflict on a terrorist. I cannot count the number of times fellow physicians have told me, in words that vary only slightly: “Promise me that if you find me like this you’ll kill me.” They mean it. Some medical personnel wear medallions stamped “NO CODE” to tell physicians not to perform CPR on them. I have even seen it as a tattoo.

To administer medical care that makes people suffer is anguishing. Physicians are trained to gather information without revealing any of their own feelings, but in private, among fellow doctors, they’ll vent. “How can anyone do that to their family members?” they’ll ask. I suspect it’s one reason physicians have higher rates of alcohol abuse and depression than professionals in most other fields. I know it’s one reason I stopped participating in hospital care for the last 10 years of my practice.

How has it come to this – that doctors administer so much care that they wouldn’t want for themselves? The simple, or not-so-simple, answer is this: patients, doctors, and the system.

To see how patients play a role, imagine a scenario in which someone has lost consciousness and been admitted to hospital. As is so often the case, no one has made a plan for this situation, and shocked and scared family members find themselves caught up in a maze of choices. They’re overwhelmed. When doctors ask if they want “everything” done, they answer yes. Then the nightmare begins. Sometimes, a family really means “do everything,” but often they just mean “do everything that’s reasonable”. For their part, doctors told to do “everything” will do it, whether it is reasonable or not.

That scenario is a common one. Feeding into the problem are unrealistic expectations of what doctors can accomplish. Many people think of CPR as a reliable lifesaver when, in fact, the results are usually poor. I’ve had hundreds of people brought to me after getting CPR. Exactly one, a healthy man who’d had no heart troubles (for those who want specifics, he had a “tension pneumothorax“), walked out of the hospital. If a patient suffers from severe illness, old age, or a terminal disease, the odds of a good outcome from CPR are infinitesimal, while the odds of suffering are overwhelming. But, of course, doctors play an enabling role here, too. The trouble is that even doctors who hate to administer futile care must find a way to address the wishes of patients and families. Imagine, once again, the A&E ward with those grieving, possibly hysterical, family members. They do not know the doctor. Establishing trust and confidence under such circumstances is a very delicate thing. People are prepared to think the doctor is acting out of base motives, trying to save time, or money, or effort, especially if the doctor is advising against further treatment.

Some doctors are stronger communicators than others, and some doctors are more adamant, but the pressures they all face are similar. When I faced circumstances involving end-of-life choices, I adopted the approach of laying out only the options that I thought were reasonable (as I would in any situation) as early in the process as possible. When patients or families brought up unreasonable choices, I would discuss the issue in layman’s terms that portrayed the downsides clearly. If patients or families still insisted on treatments I considered pointless or harmful, I would offer to transfer their care to another doctor or hospital.

Should I have been more forceful at times? I know that some of those transfers still haunt me. One of the patients of whom I was most fond was a lawyer from a famous political family. She had severe diabetes and terrible circulation, and, at one point, she developed a painful sore on her foot. Knowing the hazards of hospitals, I did everything I could to keep her from resorting to surgery. Still, she sought out outside experts with whom I had no relationship. Not knowing as much about her as I did, they decided to perform bypass surgery on her chronically clogged blood vessels in both legs. This didn’t restore her circulation, and the surgical wounds wouldn’t heal. Her feet became gangrenous, and she endured bilateral leg amputations. Two weeks later, in the famous medical centre in which all this had occurred, she died.

It’s easy to find fault with both doctors and patients in such stories, but in many ways all the parties are victims of a larger system that encourages excessive treatment. Many doctors are fearful of litigation and do whatever they’re asked to avoid getting in trouble. Even when the right preparations have been made, the system can still swallow people up. One of my patients was a man named Jack, a 78-year-old who had been ill for years and undergone about 15 major surgical procedures. He explained to me that he never, under any circumstances, wanted to be placed on life support machines again. One Saturday, however, Jack suffered a massive stroke and was admitted to A&E unconscious, without his wife. Doctorsdid everything possible to resuscitate him and put him on life support. This was Jack’s worst nightmare. When I arrived at the hospital and took over Jack’s care, I spoke to his wife and to hospital staff, bringing in my office notes with his care preferences. Then I turned off the life support machines and sat with him. He died two hours later.

Even with all his wishes documented, Jack hadn’t died as he’d hoped. The system had intervened. One of the nurses, I later found out, even reported my unplugging of Jack to the authorities as a possible homicide. Nothing came of it, of course; Jack’s wishes had been spelled out explicitly, and he’d left the paperwork to prove it. But the prospect of a police investigation is terrifying for any physician. I could far more easily have left Jack on life support against his stated wishes, prolonging his life, and his suffering, a few more weeks. I would even have made a little more money, and Medicare would have ended up with an additional $500,000 (£314,500) bill. It’s no wonder many doctors err on the side of over-treatment.

But doctors still don’t over-treat themselves. Almost anyone can find a way to die in peace at home, and pain can be managed better than ever. Hospice care, which focuses on providing terminally ill patients with comfort and dignity rather than on futile cures, provides most people with much better final days. Amazingly, studies have found that people placed in hospice care often live longer than people with the same disease who are seeking active cures.

Several years ago, my older cousin Torch (born at home by the light of a flashlight) had a seizure that turned out to be the result of lung cancer that had gone to his brain. I arranged for him to see various specialists, and we learned that with aggressive treatment of his condition, including three to five hospital visits a week for chemotherapy, he would live perhaps four months. Ultimately, Torch decided against any treatment and simply took pills for brain swelling. He moved in with me.

We spent the next eight months having fun together like we hadn’t had in decades. We went to Disneyland, his first time. We’d hang out at home. Torch was a sport nut, and he was very happy to watch sport and eat my cooking. He even gained a bit of weight, eating his favourite foods rather than hospital food. He had no serious pain, and he remained high-spirited. One day, he didn’t wake up. He spent the next three days in a coma-like sleep and then died. The cost of his medical care for those eight months, for the one drug he was taking, was about $20.

Torch was no doctor, but he knew he wanted a life of quality, not just quantity. Don’t most of us? If there is a state-of-the-art of end-of-life care, it is this: death with dignity. As for me, my physician has my choices. There will be no heroics, and I will go gentle into that good night.

The Importance of Sleep

Not getting enough sleep is tied to everything from lack of productivity to Alzheimer’s and type 2 diabetes.

You undoubtedly realize that sleep is important, if for no other reason than you’ve experienced the grogginess and detrimental productivity effects firsthand after a night of little to no sleep. You probably also realize that a chronic lack of sleep is bad for your health, making you vulnerable to other illnesses and conditions.

However, there’s still much that scientists don’t fully understand about sleep, and we’re constantly uncovering new information about how sleep-related habits affect our health. The more we learn about sleep, the more important we understand it to be — and the latest findings confirm that a chronic lack of sleep is even worse than you thought. Here are three new eye-opening studies on subject of sleep:

ALZHEIMER’S DISEASE

Alzheimer’s disease is a complex form of dementia, which develops with age and grows progressively worse, limiting your cognitive functions, impairing your memory, and even interfering with your sense of identity. It’s a frightening disease we still don’t fully understand, but researchers at the Alzheimer’s Association International Conference in London recently revealed they discovered correlation between lack of sleep and Alzheimer’s disease. Their study focused on sleep-disordered breathing, like sleep apnea, but may apply to a broader population struggling with getting adequate sleep.

TYPE 2 DIABETES

In one study focusing on children, losing just one hour of sleep each night was enough to increase the prevalence of risk factors for type 2 diabetes, including insulin resistance and blood glucose levels. We’ve known for some time that a lack of sleep can lead to obesity and other related health problems, but this study indicates that sleep may have a relationship with diabetes as well. It also illustrates that to have negative health consequences, your lack of sleep doesn’t have to be especially significant; just losing an hour could have an impact.

RISK-SEEKING BEHAVIOR

According to a report by the University of Zurich, a lack of sleep may also trigger intensified risk-seeking behavior. Subjects who got fewer than the recommended 8 hours of sleep per day were more likely to take risks in a controlled study, favoring scenarios with higher prizes — but also with a higher risk of nothing. What’s more, subjects weren’t aware of this increased tendency. If you don’t get enough sleep, you could take more risks in your daily life, leading to unintended consequences like spending too much money or even putting your health at risk.

HOW TO GET MORE SLEEP

At this point, you probably understand just how severe the effects of losing sleep can be, but it’s not like you’ve deliberately chosen to get less than a full night’s sleep on a consistent basis. Like most Americans, you’re probably overworked with an incredibly busy schedule, and sleep is often one of the lowest priorities on your list.

So what can you do to make more time for sleep, and get a better night’s rest overall?

  • Invest in a better-quality mattress.If you’re sleeping on a years-old, worn-out mattress, it’s no wonder why you wake up feeling tired in the morning. A new mattress can be a big investment, but it’s almost always worth the money. With a new mattress that’s better suited to your sleeping habits, you’ll get to sleep faster and stay asleep consistently.
  • Watch your habits.There are many habits that can affect how much sleep you get, including how much caffeine you consume throughout the day (and when you consume it — even a few hours before bedtime can interfere with sleep), whether or not you physically exercise, and how long you spend staring at a digital screen before bed.
  • Take a closer look at your schedule.If you feel like you’re too busy to sleep, consider taking a second look at your schedule. In Western culture, there’s a lot of pressure to fill up our schedules to seem important and socially integrated, so your daily activities might have some fluff or unnecessary tasks that can be skipped or delayed. Draw a line between professional time and personal time, and make sleep a higher priority.

Sleep is even more important than you probably realized, but it’s entirely within your power to reshape your sleeping habits for good. Make sleep your first priority, scheduling time for it the way you’d schedule a meeting, and work the rest of your schedule around it. In time, it will become the new normal, and you’ll improve your health and productivity — not to mentioning lowering your risk for Alzheimer’s disease and type 2 diabetes.

 

A Poem in Favor of the Human Practice of Dying

Tithonus

by Alfred Lord Tennyson

The woods decay, the woods decay and fall,
The vapours weep their burthen to the ground,
Man comes and tills the field and lies beneath,
And after many a summer dies the swan.
Me only cruel immortality
Consumes: I wither slowly in thine arms,
Here at the quiet limit of the world,
A white-hair’d shadow roaming like a dream
The ever-silent spaces of the East,
Far-folded mists, and gleaming halls of morn.

Alas! for this gray shadow, once a man—
So glorious in his beauty and thy choice,
Who madest him thy chosen, that he seem’d
To his great heart none other than a God!
I ask’d thee, ‘Give me immortality.’
Then didst thou grant mine asking with a smile,
Like wealthy men, who care not how they give.
But thy strong Hours indignant work’d their wills,
And beat me down and marr’d and wasted me,

And tho’ they could not end me, left me maim’d
To dwell in presence of immortal youth,
Immortal age beside immortal youth,
And all I was, in ashes. Can thy love,
Thy beauty, make amends, tho’ even now,
Close over us, the silver star, thy guide,
Shines in those tremulous eyes that fill with tears
To hear me? Let me go: take back thy gift:
Why should a man desire in any way
To vary from the kindly race of men
Or pass beyond the goal of ordinance
Where all should pause, as is most meet for all?

A soft air fans the cloud apart; there comes
A glimpse of that dark world where I was born.
Once more the old mysterious glimmer steals
From thy pure brows, and from thy shoulders pure,
And bosom beating with a heart renew’d.
Thy cheek begins to redden thro’ the gloom,
Thy sweet eyes brighten slowly close to mine,
Ere yet they blind the stars, and the wild team
Which love thee, yearning for thy yoke, arise,
And shake the darkness from their loosen’d manes,
And beat the twilight into flakes of fire.

Lo! ever thus thou growest beautiful
In silence, then before thine answer given
Departest, and thy tears are on my cheek.

Why wilt thou ever scare me with thy tears,
And make me tremble lest a saying learnt,
In days far-off, on that dark earth, be true?
‘The Gods themselves cannot recall their gifts.’

Ay me! ay me! with what another heart
In days far-off, and with what other eyes
I used to watch—if I be he that watch’d—
The lucid outline forming round thee; saw
The dim curls kindle into sunny rings;
Changed with thy mystic change, and felt my blood
Glow with the glow that slowly crimson’d all
Thy presence and thy portals, while I lay,
Mouth, forehead, eyelids, growing dewy-warm
With kisses balmier than half-opening buds
Of April, and could hear the lips that kiss’d
Whispering I knew not what of wild and sweet,
Like that strange song I heard Apollo sing,
While Ilion like a mist rose into towers.

Yet hold me not for ever in thine East:
How can my nature longer mix with thine?
Coldly thy rosy shadows bathe me, cold
Are all thy lights, and cold my wrinkled feet
Upon thy glimmering thresholds, when the steam
Floats up from those dim fields about the homes
Of happy men that have the power to die,
And grassy barrows of the happier dead.
Release me, and restore me to the ground;
Thou seëst all things, thou wilt see my grave:
Thou wilt renew thy beauty morn by morn;
I earth in earth forget these empty courts,
And thee returning on thy silver wheels.

The Dementia Directive

Dr. Barak Gaster, an internist at the University of Washington School of Medicine, had spent three years working with specialists in geriatrics, neurology, palliative care and psychiatry to come up with a five-page document that he calls a dementia-specific advance directive.

In simple language, it maps out the effects of mild, moderate and severe dementia, and asks patients to specify which medical interventions they would want — and not want — at each phase of the illness.

“Patients stumble into the advanced stage of dementia before anyone identifies it and talks to them about what’s happening,” Dr. Gaster said. “At what point, if ever, would they not want medical interventions to keep them alive longer? A lot of people have strong opinions about this, but it’s hard to figure out how to let them express them as the disease progresses.”

While a growing number of Americans over age 60, already have a standard advance directive, Dr. Gaster and his co-authors argue in the journal JAMA, the usual forms don’t provide much help with dementia.

“The standard advance directives tend to focus on things like a ‘permanent coma’ or a ‘persistent vegetative state,’” Dr. Gaster said. “Most of the time, they apply to a person with less than six months to live.”

Although it’s a terminal disease, dementia often intensifies slowly, over many years. The point at which dementia patients can no longer direct their own care isn’t predictable or obvious. Moreover, patients’ goals and preferences might well change over time. In the early stage, life may remain enjoyable and rewarding despite memory problems or difficulties with daily tasks.

“They have potentially many years in which they wouldn’t want a directive that says ‘do not resuscitate,’” Dr. Gaster said. But if severe dementia leaves them bedridden, unresponsive and dependent, they might feel differently — yet no longer be able to say so. Whereas a persistent vegetative state occurs rarely, Dr. Gaster tells his patients, dementia strikes far more commonly.

How commonly? That’s not a simple question to answer.

Researchers often cite the long-term Framingham study, which in 1997 estimated the lifetime risk at age 65 as 10.9 percent for men and 12 percent for women. But the participants in that study were overwhelmingly white. Among the populations facing higher dementia rates are African-Americans, Dr. Murali Doraiswamy, a neuroscientist at Duke University, pointed out. Last year, the journal Demography published a more representative model, estimating that for the cohort born in 1940, the lifetime risk at age 70 was 30.8 percent for men and 37.4 percent for women.

Dr. Gaster tells patients that “somewhere between 20 and 30 percent of us will at some point develop dementia.” Over the past year, as patients turn 65 and qualify for Medicare — which covers a visit to discuss advance care planning — he has offered them his dementia-specific directive, intended to supplement their other directives.

For each stage of dementia, the patient can choose among four options. “Full efforts to prolong my life” and “comfort-oriented care only, focused on relieving suffering” represent two ends of the spectrum.

Patients can also opt for lifesaving treatments — except when their hearts stop or they can’t breathe on their own, precluding resuscitation or ventilators. Or they can opt to receive care where they live but avoid hospitalization.

Similar efforts to deal with medical care for individuals with dementia include: The Conversation Project (whose dementia-related kit similarly presents choices at different stages), and Prepare for Your Care, an online guide that encourages users to incorporate their reasons for various decisions, but the new dementia specific directive uniquely represents a patient-doctor agreement.

 It’s crucial to talk to family, friends and doctors about the quality of life we find acceptable and unacceptable, which interventions we agree to or don’t — and then to document those decisions and circulate the document to designated decision-makers and everyone else who might be involved.

Finding a Roommate in Your Old Age

For baby boomers entering retirement, financial security is also increasingly hard to come by. Many Americans may think they have plenty of savings, but about half have not saved enough to maintain their pre-retirement living standards, according to a recent estimate by the Center for Retirement Research at Boston College. The rising cost of health care, increased life expectancy and lower interest rates only exacerbate the situation. In addition, a Fannie Mae survey found that baby boomers are more likely to be carrying mortgage debt into their retirement years than previous generations were. Due to failed investments, being the victim of fraud, or a number of other reason, increasingly Social Security is not covering all financial bases.

One solution to this dilemma is to find a roommate to share the cost of living.  The New York Foundation for Senior Citizens, a Manhattan-based nonprofit is a group has been operating a home-sharing service since 1981, matching people who have space in their homes with those in need of affordable housing. It is one of a number of similar programs that have emerged across the country as the population of older Americans grows, as a way to help people stay in their homes.

The concept of pairing older people with younger ones, particularly those who are not family members, is not a new one: It was popularized by Maggie Kuhn, an elder-rights activist who opened up her Philadelphia home to others for more than 20 years before she died in 1995. Today’s home sharing, however, is as likely to be between those of the same age as it is to be intergenerational. The crucial thing is that it involves two or more people sharing an apartment or a house to their mutual benefit. And finances often play a big role.

Sharing housing like this can be a benefit of the old and young alike. For those who are still working age, it’s getting harder to pay the rent: According to a StreetEasy survey, rents in the city rose twice as fast as wages between 2010 and 2017. The lowest rents (those up to $2,300) rose 4.9 percent annually since 2010, which means someone who paid $1,500 a month in 2010 likely paid nearly $600 more for the same place in 2017.

Susan Bendes, the shared housing coordinator at the Women’s Rights Information Center, in Englewood, N.J., said the nonprofit, which has found affordable housing for Bergen County residents since the 1970s, believes there is an urgent need for public policymakers to promote home sharing to seniors to prevent homelessness.

Statistics show that the number of older Americans who are homeless is growing. In 2007, homeless people 62 and older who sought shelter accounted for 2.9 percent of the country’s homeless population. By 2016, the percentage had risen to 4.7, according to estimates from the National Alliance to End Homelessness, a Washington, D.C., advocacy group.

Another options for Seniors looking for a roommate it so live with a retired peer. Silvernest is an online home-sharing and roommate-matching service geared toward older adults. While society’s penchant for independent living has clouded the conversation about how we age, there needs to be more dialogue about home-sharing for people of all ages. Although placing an ad and setting up a profile is free, Silvernest charges those who have rooms to rent about $30 to use the messaging service to communicate with potential roommates. Those seeking rooms pay the same amount, which covers a background check and gives them access to the listings.

Home sharing, of course, is not just for those who need the money. Taking in a tenant for little or no rent in exchange for household work suits many who have extra space.  People long for their houses to be “lived in” especially after loved ones have moved or passed away. Having full houses provides people with some amount of companionship – and essential element of human thriving.

When finding an roommate in your old age, it is advised to go through a nonprofit service or ask a trusted eldercare professional, friends or family to help properly vet the prospective roommates. Beyond Silvernest some similar services include:

  • Nesterly, an online portal that matches intergenerational roommates, will start offering services in New York this year after being introduced in Boston last fall.
  • HomeSharing Inc., a nonprofit in Bridgewater, N.J.

And before you sign a lease with a boarder, make sure to do a background check. You need a huge amount of trust and to be very clear with your expectations. But if you have the help you need to stay in your home — and the tenant gains affordable housing in exchange —  there’s much to gain socially and spiritually when young and old live together.

If Immigrants Are Pushed Out, Who Will Care for the Elderly?

One in four of the direct-care workers in the nation’s nursing homes, assisted living facilities and home care agencies are foreign-born, according to an analysis of census data by P.H.I., the New York research organization, and  under the Trump administration’s immigrations policy, the crack down on immigration and the deportation of immigrants currently residing in the United States will create a real deficit of care givers.

In the so-called gray market, where consumers hire home care workers directly and often pay them under the table, the proportion of foreign-born caregivers is likely far higher.

The growing work force shortage in direct care is affecting the entire industry, and it’s affecting older and disabled people and their families. Mostly, what drives the labor shortage is long-term demographic change. Older people are living longer, most developing chronic diseases and disabilities; the sheer numbers of baby boomers further increases the demand for assistance.

The population of working-age women, however, who typically provide care both paid and unpaid, has shrunk — and they have more career options than they once did. So providing care for older people, in their homes or in facilities, has become the classic example of a job native-born Americans would rather not take.

It’s physically demanding work that pays poorly — the median wage for home care workers was $10.49 an hour in 2016, P.H.I. reports — and usually doesn’t include benefits. The aides, mostly women, who serve in this crucial but low-income role frequently qualify for federal programs like food stamps or Medicaid. Their advocates have long argued for ways to improve these jobs, with more training and higher pay. For now, though, what P.H.I. calls the “caregiving gap” has been filled by immigrants.

The number of immigrants in direct care ballooned from 520,000 in 2005 to approximately one million in 2015, including those who work independently through state home care programs, P.H.I. estimates. In New York, California, New Jersey and Florida, more than 40 percent of direct-care workers are immigrants.

If large numbers of immigrants become unable to work or fearful of attracting unwanted attention this is going to create tremendous strain.  Already nursing homes are shutting down, or stopping admissions, because they can not hire enough people.

Excluding the gray market, the majority of aides and nursing assistants are American citizens. But P.H.I. has calculated that nearly 35,000 come from Haiti, El Salvador, Nicaragua and Honduras, whose immigrants have had temporary protected status in the United States.

The administration has so far terminated T.P.S. status for Haitians, Salvadorans and Nicaraguans; other nationalities may follow. Immigrants from Sudan, whose T.P.S. status was also terminated, will have to leave the United States as early as this fall.

Another nearly 11,000 direct care workers come from largely Muslim countries affected by the Trump travel ban and might leave if family members can never join them. An unknown number of workers are DACA recipients who might eventually be forced to leave.

Even when workers are legal residents, though, they may consider moving when relatives are deported. Whole neighborhoods and communities feel targeted.  If they’re afraid, if they won’t apply for jobs, there will likely be  more shortages. As that happens, the effects ripple through nursing facilities and home care agencies.

Eventually, especially in rural areas where home care workers have to travel long distances to clients, older adults (and younger ones with disabilities) may not be able to hire people who can help them remain in their homes. In cities and suburbs, older immigrants who want assistance from those who speak their native language could be similarly at a loss.

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