This summer, at dinner with her best friend, Jacki Barden raised an uncomfortable topic: the possibility that she might die alone.

“I have no children, no husband, no siblings,” Barden remembered saying. “Who’s going to hold my hand while I die?”

Barden, 75, never had children. She’s lived on her own in western Massachusetts since her husband passed away in 2003. “You hit a point in your life when you’re not climbing up anymore, you’re climbing down,” she told me. “You start thinking about what it’s going to be like at the end.”

It’s something that many older adults who live alone — a growing population, more than 16 million strong in 2023 — wonder about. Many have family and friends they can turn to. But some have no spouse or children, have relatives who live far away, or are estranged from remaining family members. Others have lost dear friends they once depended on to advanced age and illness.

More than 15 million people 55 or older don’t have a spouse or biological children; nearly 2 million have no family members at all.

Still other older adults have become isolated due to sickness, frailty, or disability. Between 20% and 25% of older adults, who do not live in nursing homes, aren’t in regular contact with other people. And research shows that isolation becomes even more common as death draws near.

Who will be there for these solo agers as their lives draw to a close? How many of them will die without people they know and care for by their side?

Unfortunately, we have no idea: National surveys don’t capture information about who’s with older adults when they die. But dying alone is a growing concern as more seniors age on their own after widowhood or divorce, or remain single or childless, according to demographers, medical researchers, and physicians who care for older people.

“We’ve always seen patients who were essentially by themselves when they transition into end-of-life care,” said Jairon Johnson, the medical director of hospice and palliative care for Presbyterian Healthcare Services, the largest health care system in New Mexico. “But they weren’t as common as they are now.”

Attention to the potentially fraught consequences of dying alone surged during the covid-19 pandemic, when families were shut out of hospitals and nursing homes as older relatives passed away. But it’s largely fallen off the radar since then.

For many people, including health care practitioners, the prospect provokes a feeling of abandonment. “I can’t imagine what it’s like, on top of a terminal illness, to think I’m dying and I have no one,” said Sarah Cross, an assistant professor of palliative medicine at Emory University School of Medicine.

Cross’ research shows that more people die at home now than in any other setting. While hundreds of hospitals have “No One Dies Alone” programs, which match volunteers with people in their final days, similar services aren’t generally available for people at home.

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

Without reliable people around to assist terminally ill adults, there’s also an elevated risk of self-neglect and deteriorating well-being. Most seniors don’t have enough money to pay for assisted living or help at home if they lose the ability to shop, bathe, dress, or move around the house.

Nearly $1 trillion in cuts to Medicaid planned under President Donald Trump’s tax and spending law, previously known as the “One Big Beautiful Bill Act,” probably will compound difficulties accessing adequate care, economists and policy experts predict. Medicare, the government’s health insurance program for seniors, generally doesn’t pay for home-based services; Medicaid is the primary source of this kind of help for people who don’t have financial resources. But states may be forced to eviscerate Medicaid home-based care programs as federal funding diminishes.

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

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

While hospice care is an alternative paid for by Medicare, it too often falls short for terminally ill older adults who are alone. (Hospice serves people whose life expectancy is six months or less.) For one thing, hospice is underused: Fewer than half of older adults under age 85 take advantage of hospice services.

Also, “many people think, wrongly, that hospice agencies are going to provide person power on the ground and help with all those functional problems that come up for people at the end of life,” said Ashwin Kotwal, an associate professor of medicine in the division of geriatrics at the University of California-San Francisco School of Medicine.

Instead, agencies usually provide only intermittent care and rely heavily on family caregivers to offer needed assistance with activities such as bathing and eating. Some hospices won’t even accept people who don’t have caregivers, Kotwal noted.

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

If they’re delirious or unconscious, which is often the case, staffers normally try to identify someone who can discuss what this senior might have wanted at the end of life and possibly serve as a surrogate decision-maker. Most states have laws specifying default surrogates, usually family members, for people who haven’t named decision-makers in advance.

If all efforts fail, the hospital will go to court to petition for guardianship, and the patient will become a ward of the state, which will assume legal oversight of end-of-life decision-making.

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

Shoshana Ungerleider, a physician, founded End Well, an organization committed to improving end-of-life experiences. She suggested people make concerted efforts to identify seniors who live alone and are seriously ill early and provide them with expanded support. Stay in touch with them regularly through calls, video, or text messages, she said.

And don’t assume all older adults have the same priorities for end-of-life care. They don’t.

Barden, the widow in Massachusetts, for instance, has focused on preparing in advance: All her financial and legal arrangements are in order and funeral arrangements are made.

“I’ve been very blessed in life: We have to look back on what we have to be grateful for and not dwell on the bad part,” she told me. As for imagining her life’s end, she said, “it’s going to be what it is. We have no control over any of that stuff. I guess I’d like someone with me, but I don’t know how it’s going to work out.”

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

When I reached out, she told me she’d thought long and hard about dying alone and is toying with the idea of medically assisted death, perhaps in Switzerland, if she becomes terminally ill. It’s one way to retain a sense of control and independence that’s sustained her as a solo ager.

“You know, I don’t want somebody by my side if I’m emaciated or frail or sickly,” Roy said. “I would not feel comforted by someone being there holding my hand or wiping my brow or watching me suffer. I’m really OK with dying by myself.”

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