The old fear is becoming more common: "I will die alone."

Judith Graham and Una Zenda

Illustration by True Zenda

This summer, over dinner with her best friend, Jackie Bardeen brought up an uncomfortable topic: the possibility that she might die alone.

“I have no children, no husband, no siblings,” Bardeen recalls saying. “Who will hold my hand when I die?”

Barden, 75, has never had children. She has lived alone in western Massachusetts since her husband died in 2003. “You reach a point in your life when you stop climbing, you climb down,” she told me. “You start thinking about what it’s going to be like in the end.”

It’s something that many older people who live alone struggle with – a growing population, More than 16 million in 2023 – He wondered about. Many of them have family and friends they can turn to. But some do not have a spouse or children, have relatives living far away, or are separated from remaining family members. Others have lost dear friends they once relied on to old age and illness.

More than 15 million people age 55 or older do not have a spouse or biological children; Nearly 2 million have no family members at all.

Still other older people may have become isolated due to illness, frailty or disability. between 20% and 25% of the elderlywho do not live in nursing homes, are not in regular contact with other people. Research shows that isolation becomes more common as death approaches.

Who will be there for these lonely people as their lives come to an end? How many of them will die without people they know and care about by their side?

Unfortunately, we have no idea: National surveys do not capture information about who is with older adults when they die. But dying alone is a growing concern as more seniors age alone after widowhood or divorce, or remain single or childless, according to demographers, medical researchers and doctors who care for older adults.

“We’ve always seen patients who were essentially on their own when they transitioned to end-of-life care,” said Jerron Johnson, medical director of hospice and palliative care for Presbyterian Healthcare Services, the largest health care system in New Mexico. “But it wasn’t as popular as it is now.”

Interest in the potentially serious consequences of dying alone has increased during the COVID-19 pandemic, when families were denied access to hospitals and nursing homes as their older relatives died. But it has largely fallen off the radar since then.

For many people, including health care practitioners, this prospect triggers a feeling of abandonment. “I can’t imagine what it’s like, plus being terminally ill, to think about I’m dying and I have no onesaid Sarah Cross, MD, assistant professor of palliative medicine at Emory University School of Medicine.

Cross’s research shows that more people are dying at home now than anywhere else. While hundreds of hospitals have “No One Dies Alone” programs, which pair volunteers with people in their final days, similar services are not generally available to people at home.

Allison Butler, 65, is an end-of-life doula who lives and works in the Washington, D.C., area. It helps people and those close to them go through the dying process. She has also lived alone for 20 years. In a lengthy conversation, Butler admitted that being alone at the end of life feels like a form of rejection. She choked back tears as she talked about possibly feeling like her life “doesn’t matter and doesn’t matter deeply” to anyone.

Without people to rely on to help terminally ill adults, there is also a high risk of self-neglect and poor health. Most seniors do not have enough money to pay for living expenses or assistance at home if they lose the ability to shop, shower, get dressed, or move around the house.

Nearly $1 trillion in Medicaid cuts planned under President Donald Trump’s tax and spending law, formerly known as the “Big Beautiful Bill Act,” are likely to come into effect. Complex difficulties in obtaining adequate careEconomists and policy experts expect. Medicare, the government health insurance program for seniors, generally does not pay for home services; Medicaid is the main source of this type of assistance for people without financial resources. But states may have to eliminate Medicaid home care programs as federal funding dwindles.

“I’m really scared about what’s going to happen,” said Bree Johnston, a geriatrician and director of palliative care at Skagit Regional Health in northwest Washington state. She predicted that more seriously ill elderly people who live alone will end up dying in hospitals, rather than in their homes, because they will lack basic services.

“Hospitals are often not the most humane place to die,” Johnston said.

while Elderly care It is an alternative paid for by Medicare, and is often not suitable for seriously ill seniors who live alone. (Nursing homes serve people with a life expectancy of six months or less.) For one thing, nursing homes are underutilized: Less than half of seniors under 85 use hospice services.

“A lot of people believe, incorrectly, that hospice agencies are going to get a leg up on the ground and help solve all the functional problems that people have at the end of life,” said Ashwin Kotwal, MD, assistant professor of medicine in the department of geriatrics at the University of California San Francisco School of Medicine.

Instead, agencies typically provide only intermittent care and rely heavily on family caregivers to provide needed assistance with activities such as bathing and eating. Kotwal noted that some nursing homes will not even accept people who do not have caregivers.

That leaves hospitals. If seniors are clear, staff can talk to them about their priorities and guide them through the medical decisions that lie ahead, said Paul DeSander, chief of palliative and supportive care at Grady Health System in Atlanta.

If they are delirious or unconscious, which is often the case, staff typically try to identify someone who can discuss with them what this senior employee might want at the end of their life and perhaps serve as a substitute decision-maker. Most states have laws that designate default surrogates, usually family members, for people who have not named decision-makers in advance.

If all efforts fail, the hospital will go to court to petition for guardianship, and the patient will become ward of the state, which will legally oversee end-of-life decisions.

In extreme cases, when no one comes forward, the person who died alone may be classified as “unclaimed” and buried in a common grave. This is also increasingly common, according to “Unclaimed: Abandonment and Hope in the City of Angels,” a book about the phenomenon published last year.

Dr. Shoshanna Ungerleider founded End Well, an organization committed to improving end-of-life experiences. She suggested that people should make concerted efforts to identify elderly people living alone who suffer from serious illnesses early and provide them with expanded support. Stay in touch with them regularly through calls, video or text messages, she said.

Don’t assume that all older people have the same priorities for end-of-life care. They don’t.

For example, Bardeen, a widow in Massachusetts, focused on preparing in advance: all her financial and legal arrangements were in place and funeral arrangements were made.

“I’ve been very lucky in life: we have to look back and see what we have to be grateful for and not think about the bad part of it,” she told me. As for imagining the end of her life, she said: “It will be what it is. We have no control over any of that stuff. I think I would like to have someone with me, but I don’t know how it will go.”

Some people want to die as they lived, alone. Among them is Elva Roy, 80, founder of Age-Friendly Arlington, Texas, who has lived alone for 30 years after two divorces.

When I reached out to her, she told me that she had thought long and hard about dying alone, and that she was considering an assisted death, perhaps in Switzerland, if she became terminally ill. It’s one way to maintain the sense of control and independence that supports her as a single adult.

“You know, I don’t want anyone by my side if I’m emaciated or weak or sick,” Roy said. “I wouldn’t feel comfortable having someone hold my hand or wipe my forehead or watch me suffer. I’m really okay with dying alone.”

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