End of life planning for seniors: what changes after 65

My father-in-law kept saying he'd "get around to it." He was sharp, healthy, lived alone, mowed his own lawn at 78. Then a fall, a hospital stay, and suddenly his daughter was making decisions about his care with no idea what he actually wanted. She guessed. She did her best. But she shouldn't have had to guess.

If you're over 65, or you're the adult child of someone who is, this isn't the general "everyone should have a will" talk. You've probably heard that one. This is about the stuff that only matters after a certain age: Medicare and Medicaid, Social Security survivor benefits, the difference between a POLST and an advance directive, what happens if cognitive decline starts before the paperwork is done, and how to have the conversation with kids who'd rather talk about literally anything else.

The general end of life planning guide covers the basics. This picks up where that leaves off.

The window is now

Here's the thing nobody says plainly enough: there is a window for this work, and it closes. Not because of some arbitrary deadline, but because the decisions you need to make require a clear mind. Powers of attorney, healthcare directives, beneficiary designations, long-term care preferences. All of these depend on what the law calls "legal capacity," which means you understand what you're signing and why.

If cognitive decline begins before these documents exist, your family may need to go through guardianship proceedings in court. That's expensive, slow, and public. It also means a judge decides who makes your decisions instead of you deciding.

The best time to plan was ten years ago. The second best time is today, while you're reading this and understanding every word of it.

Medicare, Medicaid, and the gap most people don't see

Most seniors have Medicare. Most seniors assume Medicare covers everything. It doesn't.

Medicare does not pay for long-term custodial care. It covers short-term skilled nursing after a hospital stay (up to 100 days, and only the first 20 are fully covered). It does not cover assisted living. It does not cover a home health aide who helps you bathe and dress every morning. For millions of seniors, this gap between what they need and what Medicare pays for is the single biggest financial surprise of their lives.

Medicaid does cover long-term care, but only after you've spent down most of your assets. The rules vary by state, and they're complicated. If you own a home, it may be protected while you're alive but subject to estate recovery after you die. If you transferred assets to your children within the last five years, there's a penalty period where you won't qualify.

This is where planning matters enormously. Talking to an elder law attorney about Medicaid planning isn't about hiding money. It's about understanding the rules so you don't accidentally disqualify yourself or leave your spouse with nothing.

What to do now: Find an elder law attorney in your state (not a general estate planner, specifically elder law). Ask about Medicaid spend-down rules, look-back periods, and spousal protections. If you have long-term care insurance, pull out the policy and read what it actually covers.

Social Security survivor benefits

If you're married, your spouse may be entitled to survivor benefits after you die. This is especially true if one of you earned significantly more than the other. The surviving spouse can receive up to 100% of the higher earner's benefit, depending on when they claim it.

But here's what trips people up: the timing of when you claim Social Security affects your survivor's benefit. If you claim early, your benefit is permanently reduced, and that reduced amount is what your spouse might be stuck with for the rest of their life. If the higher earner can afford to delay claiming until 70, the survivor benefit is as large as it can be.

This isn't abstract financial planning. For many older couples, especially women who earned less or left the workforce to raise children, the survivor benefit is the difference between being comfortable and being in trouble.

What to do now: Log into ssa.gov and look at your benefit estimates at different claiming ages. If you're married, compare both estimates side by side. If the numbers are confusing (they usually are), a fee-only financial advisor can walk you through the scenarios in about an hour.

POLST vs. advance directive: you probably need both

Most people have heard of a living will or advance directive. It's a document that describes what medical care you want if you can't speak for yourself. Everyone over 18 should have one. But after 65, there's another form that matters more in a medical crisis: the POLST.

POLST stands for Physician Orders for Life-Sustaining Treatment (some states call it MOLST or MOST). Unlike an advance directive, a POLST is a medical order signed by your doctor. It's printed on a bright-colored form that goes on your refrigerator or travels with you to the hospital. Paramedics are trained to look for it. It tells them whether to attempt resuscitation, whether to use a ventilator, whether to transfer you to a hospital or keep you comfortable where you are.

An advance directive says what you value. A POLST translates those values into standing medical orders.

The advance directive is for someday. The POLST is for the ambulance that shows up at 3 a.m.

What to do now: If you have a serious illness or are over 75, ask your doctor about completing a POLST at your next visit. Bring your advance directive so the two documents align. Make sure your healthcare proxy knows where both documents are. Put the POLST somewhere visible, not in a filing cabinet.

Long-term care: the conversation nobody wants to have

Where will you live if you can't live alone? This is the question adult children dread asking and parents dread answering. But not talking about it doesn't make it go away. It just means the decision gets made in a crisis, in a hospital hallway, with everyone scared and nobody prepared.

The options generally fall into a few categories:

Aging in place means staying in your home with increasing levels of support: grab bars, a walk-in shower, meal delivery, a home health aide a few hours a day, eventually maybe around-the-clock care. It's what most people say they want. It's also expensive and only works if the home is physically safe and there's a plan for when needs exceed what home care can provide.

Assisted living provides housing, meals, and help with daily activities like bathing, dressing, and medication management. It doesn't provide skilled nursing care. Costs vary wildly by location but average around $4,500 to $5,000 a month nationally. Medicare doesn't cover it. Long-term care insurance might.

Nursing home care is for people who need 24-hour medical supervision. This is what Medicaid covers, but only after the spend-down. The average cost is over $8,000 a month for a semi-private room.

None of these options are fun to think about. But thinking about them now, when you can tour facilities, ask questions, and state your preferences, is a completely different experience from having your children scramble to find a bed somewhere after a stroke.

What to do now: Have the conversation with your family. Not "where do I want to go" in the abstract, but: "If I fell and couldn't manage stairs anymore, here's what I'd want to try first. If that didn't work, here's what I'd be okay with. And here's what I absolutely don't want." Write it down. The guide on family end of life planning covers how to navigate these conversations when emotions run high.

Downsizing while it's your choice

Downsizing at 70 is a project. Downsizing at 85 after a health crisis is a nightmare someone else handles for you.

If you're living in a house that's more than you need, with a basement full of things you haven't touched in years, consider whether this is the year to simplify. Doing it on your terms means you decide what goes where, which grandchild gets which piece of furniture, and what the next chapter looks like. It also makes Medicaid planning simpler if long-term care becomes necessary.

Planning for cognitive decline (while you still can)

This is the hardest section to write, and probably the hardest one to read. But it's the most important.

About one in nine people over 65 has Alzheimer's disease. Many more have some form of mild cognitive impairment. If it happens to you, there will come a point where you can no longer make financial, legal, or medical decisions for yourself.

Everything you want to have in place needs to exist before that point:

Durable power of attorney for finances. This lets someone you trust manage your money, pay your bills, and handle your assets if you can't. "Durable" means it stays in effect even after you lose capacity. Without this, your family goes to court.
Healthcare proxy / medical power of attorney. This names the person who makes medical decisions for you. Pick someone who will honor your wishes even when those wishes are hard to carry out.
A conversation about values, not just forms. Tell your proxy what "quality of life" means to you. What would make life not worth living? What would you want to keep doing as long as possible? The form gives them authority. The conversation gives them guidance.
A plan for financial oversight. If one spouse handles all the finances, the other spouse and at least one adult child should know the full picture: accounts, passwords, bills, income sources. Cognitive decline can start subtly, and financial mismanagement is often the first sign.

What to do now: If you don't have a durable power of attorney and a healthcare proxy, make an appointment with an attorney this week. Not this month. This week. If you already have them, review them and make sure the people named are still the right people.

When your adult children don't want to talk about it

You bring it up. They change the subject. Or they say "Don't talk like that, you're going to be fine," which sounds loving but is actually them asking you to stop.

This is incredibly common. Adult children avoid these conversations because of fear, discomfort, and the particular pain of imagining a world without their parents.

A few things that help:

Write it down and hand it to them. Some people can read what they can't hear. A letter that says "I've made some decisions and I need you to know about them" can land differently than a conversation over dinner.

Frame it as a gift, not a burden. "I'm doing this so you never have to guess. I'm doing this so you don't have to fight with your sister about what I would have wanted. This is me taking care of you."

Start small. You don't have to cover everything. Start with where your documents are. Next time, talk about your healthcare wishes. After that, finances. Build the habit of talking about it, and eventually it becomes less terrifying.

If you want more detailed guidance on working through the emotional side, the post on how to talk to your loved ones about legacy and end of life planning goes deeper.

The checklist (keep it simple)

Here's what to get done, in roughly this order:

Durable power of attorney for finances
Healthcare proxy / medical power of attorney
Advance directive (your values and wishes)
POLST form (if you have a serious illness or are over 75)
An updated will or trust
Beneficiary designations reviewed on all accounts and insurance policies
A written summary of your financial accounts, income sources, debts, and insurance policies
A conversation with your healthcare proxy about what "quality of life" means to you
A conversation with your family about long-term care preferences
Funeral and burial preferences written down and shared
A legacy letter to the people you love

You don't have to do all of this in a week. But try to do the first three within the next 30 days. Those are the ones that matter most in an emergency.

Do it because you love them

The real reason to plan isn't legal or financial. It's personal.

When you make these decisions yourself, clearly and in writing, you're saying to your family: I didn't want you to carry this alone. I thought about what would be hardest for you, and I handled it while I could.

That's not morbid. That's love, in its most practical form.

Your kids may not thank you for it now. But someday, when they're sitting in a hospital or standing in a lawyer's office, they'll find the folder you put together or the letter you wrote, and they'll know you were thinking of them.

When I Die Files gives you a private place to organize your wishes, write letters to the people you love, and make sure everything reaches the right hands at the right time.