"A Good Death"

Shelli Feder

What does compassionate care look like at the end of life? What does it mean to have a “good death” today?

Yale School of Nursing (YSN) Associate Professor Shelli Feder:

What we think is a good death has changed over the decades. There is no single good way of dying. It’s really about what matters most to that person and how they want to die and where they want to die and what they want to do before they die. Part of providing good hospice care is trying our best to make sure that that happens.

One of the most beautiful things about hospice is about reframing end of life and living with a critical or a life-limiting illness. Oftentimes by the time patients get to hospice, which too often is too late, they’re tired. They have been in and out of the hospital; they’ve been stuck a gazillion times for IVs; they’ve undergone tests; and they’re tired of all that intervention and invasiveness. Hospice is an opportunity to sit down and talk about what matters most to you right now. We can’t change the fact that you’re dying. But what we can change is how you’re feeling in this moment. That’s the definition of dying well.

I have come to realize that dying is about letting go, which sounds trite because what is dying but letting go of life? But prior to that final act one has to let go of dreams unfulfilled, wishes for one's children, legacies that won't be completed. Once one releases oneself from those burdens, the feeling can be liberating. Then, perhaps, you are ready to go.

Home Alone: the New Normal for Seniors

(Photo from futurity.org)

Being home alone is the new normal for millions of senior Americans:

More than 16 million people aged 65 and older in the U.S. live alone. That represents 28% of that age group, almost triple the share in 1950. Among the reasons: increased longevity, higher divorce rates among older adults and children more scattered than previous generations.

“It’s very likely most of us will live alone in old age,” says Elena Portacolone, professor at the Institute for Health & Aging at the University of California, San Francisco. Older adults with more financial resources have more care options, but even those with resources may find themselves hunting for in-home help.

Most people are unprepared to age alone. Only one-fourth of those living alone have someone who helps or would help with cooking, cleaning and getting groceries, and more than 80% haven’t planned for ongoing living assistance, according to an AARP 2023 report. At least one-fourth of older adults with dementia live alone.

Some crises take us by surprise. The growing alone-ness that has overtaken seniors is not one of these; it has been looming for years. Money can solve some of the problems, but it can't reverse the consequences of not having more children decades ago, or moving away from hometowns where siblings, cousins, and high school friends reside, or walking away from long-time marriages.

Although everyone can point to some things they are grateful for, too often they say that if they had to do it all over again, they would not change a thing. It's sad when people lie to others and even sadder when they lie to themselves.

Drawing of the Day

I identify with the guy on the left.

25 Pictures with Deep meaning 🧵

1. Just enjoy it pic.twitter.com/LwZmH2KqBM

— The Adventurous Soul (@TAdventurousoul) August 12, 2025

Another Reason to Get My Eyes Checked

2021: at the Costco optometrist

It's been four years since my last eye exam. Although the contact lenses and glasses still perform adequately, the eyeglass metal frames are bent, and it's probably time to make an appointment.

Here's an additional incentive: [bold added]

For years, doctors have known that high blood pressure, diabetes, smoking and excessive alcohol increase your risk of dementia.

More recently, a growing body of evidence also suggests a link to vision problems, leading to the influential Lancet Commission in 2024 to add untreated vision loss to the list of 14 modifiable risk factors for dementia. The commission, which issues periodic recommendations on public health matters, found that about 45% of dementia cases in the world are potentially preventable by addressing 14 modifiable risk factors — which also include high cholesterol, social isolation and hearing loss — and that 2% of cases can be prevented or delayed by addressing treatable vision loss.

That includes conditions like cataracts, glaucoma, age-related macular degeneration, nearsightedness, farsightedness and diabetic retinopathy (when blood vessels in the retina get damaged, often from poorly controlled diabetes).

A recent study published in JAMA also found that among roughly 2,800 older U.S. adults with dementia, an estimated 5% to 19% of dementia cases were attributable to vision impairment.

I get regular audio exams and updated my hearing aids last year. I should do the same with vision, not only because of the importance of sight but to keep senility at bay.

“When you’re depriving your brain of key sensory inputs like vision or hearing, those parts of the brain aren’t going to function as well,” [UCSF neurologist Dr. David] Soleimani-Mangooni said. “With decreased function, you can start to lose synapses or connections between cells of the brain. That can be a risk, potentially, for further cognitive changes.”

Bay Area: Last Stop?

(Image from first for women)

I bought Steve Martin's album A Wild and Crazy Guy in 1978 and found this bit to be hilarious:

You.. can be a millionaire.. and never pay taxes! You can be a millionaire.. and never pay taxes! You say.. “Steve.. how can I be a millionaire.. and never pay taxes?”

First.. get a million dollars.

Now.. you say, “Steve.. what do I say to the tax man when he comes to my door and says, ‘You.. have never paid taxes’?” Two simple words. Two simple words in the English language: “I forgot!”

The transcript does not do justice to his delivery, which was replete with pregnant pauses, shrugged shoulders, and goofy expressions. Plus, the two-part answer to "how can I be a millionaire and pay no taxes?" that began with "first get a million dollars" struck me as funny, and if you don't agree, dear reader, well, we laugh at different things.

I thought of Steve Martin's routine when I came across an article in the Chronicle about why many of us choose to live out our final years here: How to financially prepare to spend the rest of your life in the Bay Area . Certainly the drawbacks of staying in the Bay Area--or California in general--have been well publicized:

there’s plenty of talk about the bad. You don’t have to look far on the internet to find people blasting California for its high taxes, housing costs and homelessness. California has the top marginal state individual income tax rate at 13.3%, according to the Tax Foundation.

"But that’s not the whole story."

[Estate planning, trust and probate law attorney James] Cunningham broke down the hidden benefits in a post on his firm’s website titled “Why Retiring in California May Actually Be a Smart Idea.” For instance, though marginal rates are high, you’ll pay a lot less on your presumably diminished retirement income compared to some states with flat tax rates. California is one of the states that doesn’t tax Social Security benefits, and doesn’t tax capital gains when a spouse dies. And you’ll dearly miss that Prop. 13 property tax cap if you move somewhere like Texas.

Bay Area retired acquaintances have told me that the primary factor that caused them to stay or leave was the state of their finances. Those who have a paid-up house and enough savings and retirement income to live on (daunting prerequisites, like "first get a million dollars") consider other factors, such as where their children and friends live, the quality of medical care, and, last but far from least, the temperate weather all year long.

If I had to bet, the Bay Area is our last stop, but circumstances can easily change.

Summer, winter, or fall the Foster City weather is nearly the same.

Inflammaging

Almost every death of a person I know in my age cohort is attributable to cancer.

The following hypothesis has previously made sense: medicine has advanced to such an extent that fewer people are dying of heart attacks, strokes, or sudden trauma; chronic diseases are far more difficult to treat, hence there are more deaths from cancer. However, the aforementioned is only a partial explanation; researchers have discovered that aging immune systems are less able to fight off cancer. [bold added]

(Image from Science Direct)

...studies of individual immune cells in human lung tumors, as well as in old mice, have revealed how chronic, or pathogenic, inflammation in older people—dubbed inflammaging—interferes with the immune system and fuels cancer growth...

Inflammation is the immune system’s reaction to a threat. Immune cells circulate in the body, attacking invaders such as viruses and cancer and calling for backup—more immune cells—when necessary. Working correctly, they can beat back Covid-19 or heal a cut on the finger. But the immune system can also overreact, fueling inflammation that gets in the way of healing or leads to disease. It misfires like this more as people age....

Often the assumption is that older people get sick more easily because their immune systems weaken, says Dr. Thomas Marron, a thoracic medical oncologist who heads the early-phase trials unit at Mount Sinai’s Tisch Cancer Institute. That does happen, he says, but at the same time, “we really are seeing this sort of hyperactivation.”

“The body is just basically like a flower bed primed to grow cancer as you get older,” he says.

As a person ages, the immune system has to work harder to kill infections or mutations, like cancer. But the immune system itself is aging and produces fewer of the type of immune cell that targets and kills cancer cells. At the same time, it makes more of a type of immune cell that responds initially to infections. Known as myeloid cells, with aging they become more inclined to overreact and create inflammaging. These inflammatory cells may provide a “hit” necessary for older cells with mutations to turn cancerous, says [Dr. Miriam] Merad of Mount Sinai.

Combatting defective immunity systems is only of several approaches that are being explored in the race to cure cancer. 54 years after Richard Nixon announced a War on Cancer the path to an eventual victory no longer appears to be impossible.

AI: Filling a Need for Seniors

(Pinterest image)

On Saturday we posted concerns about out-of-control artificial intelligence. Today we note how AI can make a big difference in the mental health of seniors: [bold added]

Research shows that phone calls with an empathetic listener can help reduce loneliness among older adults, leading to improved mental health. In-person interactions are even more effective. But nursing-home residents don’t always get many visits or calls.

The first Meela test phase, involving 23 RiverSpring Living residents, produced promising results, giving hope to the idea that AI can be used for a lot more than workplace efficiency and homework help.

Meela was founded by Josh Sach, a former tech product manager who was inspired to create a solution to the loneliness epidemic after seeing his late father-in-law experience isolation. The name of his companion bot comes from the Hebrew word “mila,” meaning “word.” He and his team listened to more than 2,000 voices before choosing a soothing-sounding, middle-aged voice actress.

Sach declined to say which tech company’s AI model powers Meela, but he said it already had strong safeguards and that his team added additional guardrails to ensure Meela doesn’t give medical, legal or financial advice. While it isn’t intended for clinical mental-health treatment, Meela is designed to deliver cognitive behavioral therapy—validating residents’ feelings and suggesting solutions to problems.

Meela remembers prior conversations with residents, who have to consent to their conversations being recorded and transcribed. Sach says the transcripts are retained for the duration of the account, unless someone requests their deletion. They aren’t available for users or their families. And where applicable, the recordings and transcripts are handled in accordance with HIPAA, a federal patient-protection law, and the care facility’s instructions.

In the first phase, participants’ depression and anxiety levels were measured before talking to Meela and 30 days after. Those with moderate to severe depression or anxiety were found to have demonstrated notable improvements after speaking with Meela at least once a week.

Participants spoke to Meela for an average of 10 minutes at a time, but some talked for more than an hour. Staffers also noticed that study participants were engaging in more social activities after talking to the bot, says Dr. Zachary Palace, medical director of RiverSpring Living’s nursing home.

Part of our church's ministry is to visit nursing homes and engage with residents. Many do not have any visitors and are happy to converse with complete strangers, even for just an hour. AI doesn't get tired, and it's clear that carefully tailored AI can provide regular mental health benefits to our senior citizens.

Very Old School

100 y.o. tax preparer Else Rike (Hagerty/WSJ)

The WSJ features nonagenerian and even centenarian tax preparers: [bold added]

After more than 70 years as an independent tax preparer, [100 y.o. Else M.] Rike knows how to pace herself. She aims to finish at least three returns a day in the weeks before April 15.

Unlike other tax preparers, she doesn’t rely on software to guide her choice of deductions and exemptions or to do the sums. Instead, she punches keys on a Sharp desktop calculator, setting a tiny roll of printing paper atwirl, and then uses an electric typewriter to enter the numbers onto Internal Revenue Service forms.

“I’m not that tech-oriented,” she says. “I don’t have the computer figure it out. I do my own figuring.” Ever since childhood, she says, “math was always sort of my thing.”

Rike (pronounced Ricky) does have a computer, but she uses it only to print out forms. She doesn’t use email but does answer her cellphone or landline. To keep up with tax law, she relies heavily on a fat paperback, “U.S. Master Tax Guide.”

Mrs. Rike, like I do, subscribes to the Master Tax Guide. The MTG is sufficient for basic technical needs, and any problems it can't answer probably means the taxpayer needs to hire a specialist (e.g., closely held companies, foreign income, oil and gas) in that particular area. Specialists can be very expensive, and Mrs. Rike's price is right for her retired clientele:

“I don’t charge like others. I kind of try to do it by the hours that I put in or the number of pages of their returns,” she says. Most clients pay between $50 and $150. That includes a set of envelopes for estimated taxes, with the address labels neatly affixed.

At one point, Rike had around 300 customers. Now she has outlived most of them and serves about 80, including the children of former clients. “I don’t do too many difficult ones anymore,” she says. “I do mostly retired people.”

Her customers are loyal, and she enjoys her work. She has found what we are all searching for...life's purpose.

Use It or Lose It

Looking healthy (medium.com)

U.S. researchers found that (pre-GPS) professional drivers had a lower incidence of Alzheimer's disease: [bold added]

A new study found that U.S. taxi and ambulance drivers had the lowest percentage of deaths attributed to Alzheimer’s disease among more than 400 occupations. The drivers mostly worked before GPS navigation systems were widely used.

The researchers hypothesize that taxi and ambulance drivers could have a lower risk of developing Alzheimer’s because they are constantly using navigational and spatial processing, says Dr. Anupam Jena, a professor of health at Harvard Medical School and associate physician at Massachusetts General Hospital and senior author of the study.

Those on-the-fly decisions about how to get from point A to point B when a road is closed or blocked may protect the drivers’ cognitive abilities, the researchers speculate.

“They’re making decisions literally every few seconds about where to go, where to turn,” says Jena. “The way that your brain is used over the course of your career or the course of your life might impact the likelihood that someone develops dementia.”

The research supports other evidence that education and brain stimulation may help to at least delay symptoms of Alzheimer’s. An earlier study concluded that dementia risk was lower among people with cognitively stimulating jobs compared with those whose jobs were more repetitive, according to the 2021 research in the journal BMJ that looked at the occupations of more than 100,000 people across multiple studies...

A well-known 2000 study found that London cabdrivers had an enlarged part of their hippocampus. That section of the brain plays an important role in many cognitive functions, including spatial and navigational memory. The hippocampus is typically among the first parts of the brain that Alzheimer’s affects, which is why trouble with navigation and remembering directions is often an early symptom, says Wolk.

The theory goes that the brain, like muscle, grows stronger and bigger with use and makes individuals more resistant to the maladies of aging. (Earlier this year we had commented on the hypothesis that the human brain had been shrinking over millennia because more of its functions have been off-loaded to technology.)

Whether true or not, it can't hurt to use our brains more, especially now that there are many enjoyable (puzzles, education, social interactions) activities to choose from. And certain professions--like taxi and delivery-truck driving--allow one to earn a living and keep one's brain healthier for longer.

Hospital Chaplaincy

Spiritual care volunteers and staff at Stanford Hospital Chapel

Before an Episcopal priest can be ordained, he or she must complete several months of Clinical Pastoral Education (CPE). In CPE the students minister to non-Christians as well as Christians, much as priests do in the real world.

Clergy that I have spoken to have said that their most intense and rewarding experiences have occurred while they did their CPE as hospital chaplains. [bold added]

Hospitalized patients and their families often struggle with religious and spiritual quandaries but can’t attend their houses of worship or don’t have one. Chaplains thus fill crucial gaps. As the religious makeup of the U.S. has changed in recent years, their profession has begun to do so too. Board-certified chaplains are now increasingly trained to help patients of diverse beliefs. To learn about their vocations, I [note: Columbia prof. of psychiatry Robert Klitzman] recently conducted an in-depth study, speaking with 50 chaplains from across the country and from different faiths.

While chaplains aid countless patients, they are in many cases marginalized and underfunded. The Centers for Medicare and Medicaid Services allows for direct reimbursement for spiritual services only within the Veterans Affairs system. Offering spiritual care for hospice patients enrolled in Medicare is mandatory but not directly billable. As a consequence, many hospitals have no chaplains; some rely on local volunteer clergy, who know only their own faith, or on other healthcare professionals to fill in for spiritual care...

Chaplains are often the only staff with time to talk to patients, whom they can therefore get to know well. I learned of one patient who phoned the on-call nurse every day at 2 a.m., complaining of pain. The staff tried altering his medicine without success. Finally, a chaplain spoke to the patient, who turned out to be carrying significant guilt from his mother’s suicide when he was 18. When the chaplain arranged for the man’s elder siblings to talk about it, they were “aghast,” the chaplain told me. “They reminded him that their mother had mental-health issues: ‘Don’t you remember?’ It was like a 50-pound weight had been lifted. After that, he never again called the nurses at night.”

Chaplains also serve as critical mediators in conflicts among patients, families and physicians. At another hospital, a teenager who was dying wanted to donate his organs. Soon he was brain dead and on life support, which surgeons planned to remove in the operating room. The boy’s family wanted to be present when he died, but the surgeons refused for fear that they’d disrupt the procedure.

Presented with an impasse, a chaplain negotiated a solution: The family would dress in sterile gowns and stay in the theater for three minutes. The family and physicians sang “Amazing Grace,” the boy’s favorite song. When he died, the mother said to the chaplain: “Thank you for that gift. . . . We got to sing my son into heaven.”

In my research it wasn’t uncommon to learn of medical professionals wary of spiritual care, which they saw as having no medical benefit. Yet spiritual counseling can help patients choose palliative care when the treatments available are both futile and painful.

In facing serious disease, millions of patients find themselves pondering the eternal. Most of us will die in hospitals, far from any religious institution, and might benefit from chaplains’ care. Our healthcare systems would do well to recognize and value them more.

Spending one or two nights in a hospital changes a person. Although WiFi is now commonplace, the hospital environment is not conducive to endless Internet surfing or scrolling through social media. The patient confronts thoughts he may not be accustomed to having, especially if he is non-religious.

In his hour of need, there may not be family members the patient is comfortable talking with, and he can't bother medical personnel, whose focus is usually confined to the health of our physical bodies.

That leaves the hospital chaplain, whose job has expanded to being ready to converse with those who are members of different faiths-or no faith at all. In an increasingly irreligious society the irony is that the need for chaplaincy services has never been greater.

Falling Into the Future

illustration: Kiersten Essenpreis/WSJ

Last spring I tripped over a garden hose and fell face forward onto the dirt. I thrust out my arms protectively and luckily wound up only with a scraped elbow. I am now extra mindful to concentrate on walking and keeping distractions like my phone at bay. I haven't fallen since.

Falling by the elderly has become an epidemic.

More than 1 in 4 people over age 65 fall each year...Every year, falls among older Americans result in about 3.6 million emergency room visits and 1.2 million hospital stays, at a cost of roughly $80 billion. Nationwide, 41,000 senior citizens die from falls annually, according to the Centers for Disease Control and Prevention. In recent years, prominent figures such as comedian Bob Saget, former Connecticut Sen. Joe Lieberman and Ivana Trump died after a fall...

Nationally, the death rate from falls jumped 41% from 2012 to 2022, the latest period for which statistics are available. Among seniors, the contributing factors for falls are frustratingly complex. Reaction to prescription drugs, impaired vision and even such basic things as loneliness or ill-fitting shoes often add to the risk of falling.

“There has also been research on dual tasks, like doing more than one thing at a time,” [Arkansas prof. Jennifer] Vincenzo notes. “It’s hard for you to focus on movement if you’re focusing on doing another task, talking on the phone or texting, so that if you have impaired balance or walking problems, you’re not going to pay attention to that and potentially fall.”

My parents fortunately suffered only minor injuries from falls at home. Being unable to get up by themselves, even with the help of their spouse, eventually prompted their move to assisted living.

I hope that I am years away from having to follow in their missteps, but the tumble that I took in the spring showed that it-will-never-happen-to-me is an attitude I no longer can afford to have.

Happy Birthday, Again

On my birthday I knocked over the dietary guardrails and ate a week's supply of beef, dairy (clam chowder and ice cream), and sugar.

The penalty will be short-term only (I hope), but the memory of this outing with the family will linger for months.

When I was a child, I liked opening presents and being the center of attention. After I grew up, birthdays came and went for 40 years with little recognition. Now I'm beginning to appreciate them more...

Another Group That is Falling Through the Cracks

Elena Portacolone (research gate photo)

We are used to hearing about vulnerable subsets of the American population who need a lot of help in taking care of themselves. Here's another one that numbers in the millions: [bold added]

]Sociologist Elena] Portacolone got to work and now leads the Living Alone With Cognitive Impairment Project at UCSF. The project estimates that that at least 4.3 million people 55 or older who have cognitive impairment or dementia live alone in the United States.

About half have trouble with daily activities such as bathing, eating, cooking, shopping, taking medications, and managing money, according to their research. But only 1 in 3 received help with at least one such activity.

Compared with other older adults who live by themselves, people living alone with cognitive impairment are older, more likely to be women, and disproportionately Black or Latino, with lower levels of education, wealth, and homeownership. Yet only 21% qualify for publicly funded programs such as Medicaid that pay for aides to provide services in the home.

Increased longevity is a societal good, but smaller families, that is, fewer relatives to check on a person, and the decline of churches and other community organizations have resulted in millions of aging, cognitively impaired adults falling through the cracks.

Saving One Dollar at 99 Ranch

This year I've started to look my age. I've lost hair, and what I have remaining has turned white. Which is background to the following:

We've been shopping at the local 99 Ranch Market for 20 years. As I was checking out, the middle-aged Chinese man at the register said, "I'll get you a senior discount." I didn't even know 99 Ranch had one. Sure, I shrugged.

He put his hands on his hips and bellowed, "Senior....senior!" Several customers turned their heads. Apparently the senior discount had to be approved by the manager. She came over in less than a minute and scanned her cellphone over a reader, authorizing the transaction. So 99 Ranch does use current technology, except for the part where cashiers yell for the manager.

I studied the receipt. The vegetables, ramen, and pastries cost $23.59, and the 5% senior discount saved $1.18. After writing the check to the U.S, Treasury for our 2023 income taxes, every penny counts.

Inflammaging

(Illustration: Jemal R. Brinson/WSJ)

Yet another portmanteau [a word blending the sounds and combining the meanings of two others, for example motel (from ‘motor’ and ‘hotel’) or brunch (from ‘breakfast’ and ‘lunch’)], but the WSJ says this one is important for our health. [bold added]

“Inflammaging” sounds like just another marketing buzzword wellness companies are throwing around. You would be wise to take the condition seriously.

A combination of inflammation and aging, the term describes a simmering form of inflammation—the immune system’s response to a perceived threat—that is chronic and low-grade, and builds stealthily as you age. It is associated with an increased risk of heart attack, cancer, Alzheimer’s and other conditions.

Inflammaging happens to everyone to some degree as we age, and some people don’t develop much. But scientists say we should pay closer attention. More research is showing the damage it can cause...

High levels of inflammation have been linked to an increased risk of death from any cause—a seven times higher risk compared with those with the lowest levels of inflammation, according to one study examining blood samples from more than 160,000 patients.

Women with high levels of chronic inflammation had a 70% greater risk of a heart attack, stroke or death from a cardiovascular cause than those with low levels, according to a separate study published in August by researchers at Brigham and Women’s Hospital in Boston, who followed the women for 30 years.

Finding effective treatments for inflammation/inflammaging is still in the early stages:

A drug has to tamp down inflammation without blocking the immune system. Some patients who have atherosclerosis or are at high risk of cardiovascular disease are treated for inflammation with a low-dose version of the drug colchicine, approved by the Food and Drug Administration in 2023 for that use. The drug has been used for years to treat gout, a joint-pain disease.

Researchers are studying whether other drugs, including GLP-1s, can lower inflammatory markers. And Novo Nordisk and CSL Behring are testing potential anti-inflammatory medications in patients who have cardiovascular disease or are at high risk.

Some people have experimented with taking medications such as metformin and rapamycin to target inflammaging. Both drugs, approved by the FDA for other uses, have shown potential to target inflammaging, but more research in humans is needed.

Otherwise, the best ways to ward off inflammaging today? All the things you should be doing anyway: exercising consistently, not smoking, maintaining a healthy weight and eating healthfully.

Some research suggests the Mediterranean diet, which emphasizes nuts, whole grains, fish, fruits and vegetables, is particularly protective against inflammation. Red meat, by contrast, promotes inflammation.

Most important for brain health is seven to eight hours of sleep a night, said [Mass Gen's Rudolph] Tanzi. The brain gets rid of amyloid that triggers inflammation then, he said.

“Every time you go from dreaming or REM to deep sleep, I call it a rinse cycle.”

The good news for your humble blogger is that metformin (diabetes) and colchicine (gout) have already been prescribed. I'll continue to take them regularly because they may help to reduce chronic inflammation.

Because the upward trajectory of health advancement is so steep, the goal is to hang around until cures for inflammaging, cancer, Alzheimer's, etc. can be found.

HENRYs

In 1980 the "young urban professional" (YUP-py) was identified as a significant cohort, and ensuing demographic acronyms have never stopped coming.

DINKs (double income, no kids), BOBOs (bourgeois bohemians), WEIRD (Western, educated, industrialized, rich, and democratic) all have had their place in the sun. Now there are HENRYs (high earner, not rich yet). [bold added]

Fifteen years ago if you’d told April Little that she’d make $300,000 a year, she would have pictured a life free of financial stress.

“The white picket fence—I have the whole visual in my head,” says Little, 38 years old, a human-resources executive turned career coach in Rochester, N.Y. “I don’t want to sound ungrateful, but when I got to that proverbial mountaintop I realized there’s a lot of expenses. And I still don’t own a home.”

So go the plush-but-not-too-plush lives of the Americans who qualify as HENRY—high earner, not rich yet.

Little makes multiple six figures running her own business but carries $90,000 of college and grad-school debt. Child care and education for her three children would be so costly that she and her husband decided the better option was for him to leave his radio job to parent and home-school full time.

New census data show 14.4% of U.S. households bring in $200,000 or more a year, a near record. Yet the money doesn’t have the buying power those earners wish it did, partly due to the rising prices hammering us all and partly due to the supercharged costs of things like houses and cars. HENRYs describe feeling stuck on a hamster wheel—a nice one that other hamsters envy—but running in place nonetheless.

Oh come on, you’re thinking. You’re asking me to feel sympathy for Audi-driving, Chase Sapphire-loving, Whole Foods-shopping consultant types with kids in private school?

Well…not exactly. But what they’re feeling is a version of what a lot of Americans at every income level face—making more money but not feeling like there’s a surplus. The essence of being a HENRY is feeling a gap between what you have and what you think you need to be comfortable.

What these high earners consider essentials might be termed luxuries (or nonsense) by the rest of us, but it’s also true that it takes more money to feel rich these days. And their great fear is becoming a HENRE: high earner, not rich ever.

The outlays for housing, private schools, transportation, and health care, not to mention education indebtedness, are often underestimated by 20- or 30-year-olds who think they have made it with a $200,000+ starting salary.

Even HENRYs whose futures look bright can't relax, since the loss of their high-paying job could be disastrous.

Speaking from the experience of being a previous generation's HENRY, I had visions of being able to quit when I was 40 but didn't achieve that psychological comfort zone until I was in my mid-60's. Hard work and technical abilities, while necessary, were IMHO not as important as finding a trustworthy life time partner and keeping one's health. (Having a little luck helps, too.)

A Financial Hit That Few Budget For

Christine Salhany spends about $240,000 a year
for 24-hour in-home care for her husband, Jimmy,
who has Alzheimer’s.(WSJ)

Everyone in my boomer circle of friends and relatives has been hit by the cost of caring for a loved one; it could be a parent, a spouse, or even themselves. It's a crushing financial burden: [bold added]

Americans want to grow old in their own homes. But pursuing that dream has gotten harder, and is putting huge financial and emotional strains on families.

In Nebraska, Christine Salhany spends about $240,000 a year for 24-hour in-home care for her husband who has Alzheimer’s. In Illinois, Carolyn Brugioni’s dad exhausted his savings and took out a home-equity line-of-credit to pay for home healthcare.

Traci Lamb closed her business to take care of her mom in Florida. And in California, Cheryl Orr delayed retirement to help pay for care and home modifications for her wife, who has dementia.

Soaring costs of in-home care, medical advances that extend lives but require ongoing help, and the growing ranks of older baby boomers are creating new pressures. Spouses, adult children and siblings are putting their lives on hold to care for relatives, wrestling with sleep deprivation and constant worry. Families are draining savings to hire help, pay for medical care, and modify homes...

The cost of paid in-home care has soared in recent years. The 2023 national median cost of a home health aide, hired through an agency, stood at $33 an hour, up from $20 an hour in 2015, according to Genworth, a long-term-care insurance company. Those needing round-the-clock in-home care can expect a median cost of about $290,000, which is more than double the annual median cost of a private room in a nursing home facility and four times the annual median cost of a private room in assisted living, according to Genworth.

Very few elderly have the nearly $1,000,000 in retirement savings to pay for long-term at-home care for, say, four years. Borrowing against, then selling the family home is an option if the patient is willing to move to assisted living.

I know three families that have tapped the value of their house; they were fortunate to have lived in the Bay Area, where suburban tract homes have appreciated by over a million dollars if held for at least 20 years. They have had to move away but consider themselves lucky to possess such a valuable asset.

If any politician can come up with a credible solution, he or she would win in a landslide.

But I'm Not Going to Correct Them

I think this is me.

Man Unsure If He’s Becoming More Virtuous With Age Or Just Too Tired To Sin https://t.co/shJFS7afwZ pic.twitter.com/uVwxHUDMEK

— The Babylon Bee (@TheBabylonBee) August 31, 2024

Helen at 101

Helen holds the newest twig on her family
tree, Hanzo, born June 3rd.

One year ago we gathered in Hawaii to celebrate Helen's 100th birthday.

This year, with most of the attendees traveling, we conferenced on Zoom. Everyone took turns reminiscing about favorite memories of Helen.

When talking with the nonagenarians and centenarians in my family, I've found that they are especially pleased when we mention moments that everyone, maybe even they, had forgotten. These moments are concrete evidence that they will be remembered after they're gone, proof that their lives had meaning.

May I be so lucky.

Happy Birthday, Mom

Yesterday was Mom's 95th birthday. The facility where she has lived for four years set up a conference room for her family to use. Her birthday cake was a chocolate cupcake with "9" and "5" candles, which she blew out with alacrity.

Those of us who weren't there were able to join the party on FaceTime.

Happy Birthday, Mom, and many more.