The Next Phase

The honest picture

The writing on the wall is hard to ignore. I'm old, and progressively less capable — though, I'd argue, also more interesting. The predictable losses are real: cognitive decline, broken hips, growing difficulty with what we nurses call ADLs (activities of daily living). The holy grail is "aging in place" — staying home, staying independent. For many of us, that dream will be at least partly denied. The question is what comes next, and on whose terms.

The classic conflict in this phase is autonomy (what we want) versus safety (what our families want for us). Loving kin take away the car keys — probably smart — and begin steering us toward institutions. That's not always the best or only option. It pisses us off but we're helpless. And it requires that we have done our thinking, made our wishes known, and set things up before a crisis forces everyone's hand.

The reflection exercise

If you're pondering questions like these, a useful place to start is with the texture of your current life. What does a good day look like for you now? A few honest questions to sit with:

• What demons obstruct your happiness? (Alcohol and skipped exercise are perennial candidates.)
• What are you unwilling to give up — independence, home, creative work, relationships?
• What are your fears? Pain, dementia, being a burden, dying alone?
• What does a "good death" mean to you?
• What conditions do you have that will likely progress — and what does that trajectory look like, honestly?
• Have you discussed POLST/MOLST with your doctor? (Physician Orders for Life-Sustaining Treatment.)
• Who do you trust to make decisions if you can't — and do they know your wishes not just as a document, but in their bones?
• Who is realistically available to help, versus who merely wants to?

The paperwork (do not skip)

Getting your legal and financial documents in order is one of the most loving things you can do for the people who'll care for you. Here's where I stand:

• ✓ Will and Trust Done, though it needs some updates to reflect current wishes and assets.
• ✓ Durable Power of Attorney Financial decisions if you're incapacitated. Done.
• ✓ Healthcare Proxy / Medical Power of Attorney Who speaks for you medically. Done.
• ✓ Advance Directive / Living Will What interventions you do and don't want. Done.
• ✓ POLST Form A medical order (not just a preference) for emergency responders. Per the instructions, this is to be completed once you have something terminal or serious.
• ✓ Beneficiary designations Reviewed on all accounts, life insurance, retirement funds. Covered in the will.
• ✓ Passwords documented Computers, social media, online banking — in a file my kids know the name of, and can probably guess the password to.

The options: where might we actually live?

Aging in place — at home

This is my own strategy. I am building an accessory dwelling unit (ADU) — sometimes called a granny flat, in-law unit, backyard cottage, or secondary unit. A live-in caregiver could someday occupy it. Home modifications are also on the list: grab bars (done — even able-bodied people find them useful, and they also serve as fat towel racks), ramps, stair lifts, smart home technology.

Worth investigating: co-care arrangements where younger adults share space in exchange for help. Also worth knowing about: PACE programs (Program of All-Inclusive Care for the Elderly), which wrap services around you to keep you home — home health aides, visiting nurses, day programs.

Community options

Active adult

55+ Communities

Social events, fitness centers, low-maintenance living. Emphasize engagement and personal growth. Often HOA fees, rules about modifications and pets, some require purchase. Example: The Glen at Heather Farm in Walnut Creek — not cheap, but comfortable, with interesting people and good food. We toured it and a close friend has signed up. Personally, I'm put off by the soulless condo-like feel but I do see the appeal.

Community

Cohousing & Intentional Communities

Shared housing with private spaces — a growing movement. Combines independence with genuine community. Example: Pleasant Hill Cohousing, which I've visited many times and find remarkable. I've written about cohousing at length.

Independent living

Independent Living Communities

Social connection and amenities, no home maintenance. You provide your own care. Can be apartments, cottages, or full campuses. For those who want community without needing much help yet.

Continuum

CCRCs

Continuing Care Retirement Communities offer the "age in place on a campus" model — independent, assisted, memory care, and skilled nursing all in one place. Entrance fees can be substantial; examine contracts very carefully (Type A, B, and C contracts vary enormously in what's covered).

More care

Assisted Living

Help with ADLs — meals, bathing, dressing, medications, housekeeping, transportation. More social than nursing homes; private apartments typical. Costs average $4,500–$6,000/month nationally, with wide variation.

Specialized

Memory Care

Designed for dementia: secured environments, higher staff ratios, specialized programming. A distinct category within assisted living, typically at higher cost.

Medical

Skilled Nursing Facility (SNF)

24-hour medical care and rehabilitation. Medicare covers short-term rehab; long-term is out-of-pocket or Medicaid. More intensive than assisted living — typically for recovery or when care needs exceed what home or AL can provide.

A note from experience

My father resisted leaving the home he'd lived in for decades. He knew he had to, eventually — routines like shopping had become difficult, and he was living on peanut butter. Worse: days would pass without him seeing another person.

Once he moved to assisted living in 2001, he loved it. Good meals, friendly people, a real community. He lived there until his death in 2006, at 92. When my sisters and I attended his memorial, we were moved by how many people mourned the loss of their friend. The loneliness he'd been living with at home was the part we'd underestimated.

And another note from experience

Though she is fit, one friend is adamant that her retirement home must be "level-in" (no stairs). She wants to be ready in case of the worst. I say, not so fast.

My mother, for the last forty years of her life, bounded down and up the five flights of her lower Manhattan brownstone walk-up. Even after dementia set in (and it became quite ghastly) for the last five of those forty years (it killed her in 2016 at age 92) she was down and up those stairs daily or more, like a happy mountain goat. My saintly sisters and I thank those stairs for her longevity. Level-in? Phooey.

On being coupled

Being part of a couple is, among other things, a logistical advantage in this phase. Partnered people often have a built-in advocate, companion, and fallback. Many who are single — often recently widowed, as is increasingly common in my cohort — actively seek a partner. The cynical shorthand: "a nurse and a purse." I am (or have) both, but what I actually hope for is a committed partner with whom to share ordinary days, and the less ordinary ones that lie ahead.

How do you pay for it?

• MedicareCovers hospital, doctor, short-term rehab — not long-term custodial care
• MedicaidCovers long-term care once you've spent down assets; rules vary significantly by state
• Long-term care insuranceI have it. If you have it too, read the policy carefully — understand exactly what it covers.
• Life insurance with LTC ridersI don't have this; I always figured I'd find other ways to provide for my issue — and indeed I shall.
• Home equitySell the house, or get a reverse mortgage. Talk to Marge — she knows this stuff.
• Veterans benefitsThe Aid & Attendance benefit is underused and significant if you served. I didn't serve, but I've
  worked at the VA, and it's great — better than private hospitals. America's heroes deserve no less.

At the end of things

When curative treatment is no longer the goal, or when it never was, there are choices to understand long before you need them.

Emotional and practical resources

• Being Mortal by Atul Gawande Essential reading on medicine and what actually matters at the end of life. Really good.
• The Conversation Project Starter kits for having the hard family talks before a crisis forces them.
• Five Wishes A document that combines a legal directive with personal and spiritual wishes.
• Death Cafés Informal community conversations about death — surprisingly warm, genuinely useful gatherings.
• Therapists specializing in aging Grief, meaning-making, and late-life depression are real and treatable. Worth finding someone good.
• Senior Centers and Peer Groups Our peers are our most honest resource. They know what we're going through because they're going through it too.

What our peers often say they wish they'd done sooner

1. Told the people they love what they meant to them.
2. Had the hard conversations before a crisis forced them.
3. Let go of the idea that planning is the same as giving up.
4. Visited facilities when they weren't desperate — so they could choose, rather than simply accept.