Archives: Aging, Disability, Death, Dying

This month the Journal of General Internal Medicine highlights a recent study of geriatric conditions in homeless individuals aged 50-75 in and around the Boston area.  The study shows that when the elderly become homeless they tend to become chronically homeless and that they experience a decline in mental and physical abilities comparable to individuals twenty years older.  Dr. Margot Kushel offers a thoughtful editorial on how some creative solutions could both be cost-effective in the long run, treat the elderly homeless humanely and, perhaps, bring an end to chronic homelessness.

“The average age of individuals experiencing homelessness is rising. Between the early 1990s and 2003, the proportion of homeless adults aged 50 and older increased from 11% to nearly one-third1. This trend continues. Demographic research has shown that for the last 20 years, adults born in the second half of the “baby boom” (mid-1950s to 1964) have experienced a sustained elevation in their risk of experiencing homelessness2. As this population ages, so does the average age of the homeless population…Widespread homelessness has persisted for 3 decades, but the face of it has changed. With the specter of large numbers of frail, older people living on our streets, there is a moral imperative to intervene. In light of a poor economic climate that may both place more vulnerable older individuals at risk of homelessness and threaten the safety net that cares for them, demographic projections of a continued rise in the proportion of homeless adults who are over aged 50, and compelling data describing the frailty of this population, we may have an economic incentive to do so as well…Read More…”

Yesterday’s NYTimes reported on the ongoing work of the American Psychiatric Association to revise the Diagnostic and Statistical Manual of Mental Disorders, or D.S.M.  One contentious issue has been the debate over whether or not to include or exclude grief or bereavement in the clinical diagnosis of depression (it is currently excluded).  This is not to say that you can not be grieving when you are diagnosed as clinically depressed, it just means that if loss is the only precipitating event to symptoms of depression, than other interventions are tried before a diagnosis and treatment plan for clinical depression are made.

“Under the current criteria, a depression diagnosis requires that a person have five of nine symptoms — which include sleeping problems, a feeling of worthlessness and a loss of concentration — for two weeks or more. The criteria make an explicit exception for normal grieving, which can look like depression.

An estimated 8 to 10 million people lose a loved one every year, and something like a third to a half of them suffer depressive symptoms for up to month afterward,” said Dr. Wakefield, author of “The Loss of Sadness.” “This would pathologize them for behavior previously thought to be normal.”

To show my hand, I fall in the camp that continues to exclude grief from the clinical definition of depression.

Well, if reading about Medicare Advantage Plans was not exciting enough for you, check out my newest piece up at HuffPost on Ritual and the Hunger Games trilogy.  Yes, the books are like Pixie Stix for your brain, but come on, who doesn’t love Pixie Stix!!

I read an interesting article from Dr. Richard Leff, an oncologist, who raises some critical concerns about gaps in coverage for elderly cancer patients who enroll in Medicare Advantage Programs.  If you are wondering what Medicare Advantage programs are, see here for a quick overview, but basically, the elderly can enroll in an Advantage plan which will often cover such things as dental or eye care, but the deductible, co-pays, and as Dr. Leff points out, the co-insurance may vary dramatically from traditional Part A and B Medicare. As a side note, when you enter hospice care, you always revert back to traditional Medicare–I’m not sure why, but it does make billing a lot easier for hospice organizations, which I am fairly confident is not the reason that it reverts but is a nice side effect for hospices.

Dr. Leff highlights the problem:

“While the stress associated with a cancer diagnosis and treatment is severe, in many cases patients and families are subjected to the additional stress of unexpected insurance gaps that leave them with unimaginable and unmanageable bills. In some instances, this problem may actually prevent patients from receiving optimal care. Yet, we as oncologists and our national organizations do little or nothing to help patients prevent this serious problem. Nowhere is this issue more apparent than in the growing Medicare Advantage plan arena. Dental care and vision care are wonderful, but how important are they if the plan you joined only covers 70% of the cost of your cancer care…

Unfortunately, otherwise well informed people who would never take the risk of Medicare part B without a Medigap policy, are now moving toward Medicare managed care products unaware that they may be facing 20 to 30 percent coinsurance costs for expensive outpatient therapies including chemotherapy. But not all Advantage programs are equal and the best have much more comprehensive coverage for outpatient therapies. In addition the information about the coverage is available if you really want to find it, thanks to a great effort by Medicare to require full plan disclosure. So why do people make the decision to join a less comprehensive plan? Because Medicare Advantage plans market the immediate availability of wellness services (which are also important) that a member can use right now and don’t proactively point out the gaps that may exist should members be faced with a serious illness.”

Now, there is a small cynical side of me that wonders if he is having a hard time billing for expensive treatments which is why he is raising this concern, but I’m going to fight giving into that cynicism.  His words are a good reminder that we should all shop around for our insurance policies, especially when I am learning that even for those enrolled in high deductible/health savings account plans, which typically cover at 100% after the astronomically high deductible is met are starting to incorporate co-insurance.  If co-insurance, co-pays, deductibles, confuse you (which if they don’t, you are Einstein!), check out this helpful video.

If you are a loved one supporting someone contemplating enrolling in a Medicare Advantage Plan, definitely check out the terms for the co-insurance and I would talk to your oncologist if you have a history of cancer.

I love listening to life stories.  As a hospice chaplain, I loved sitting with our patients and their loved ones engaging in what many hospice teams call: “life review.”  When did you meet your spouse?  When was Reggie born?  What is your favorite holiday?  When did you learn you were ill?  These are the types of questions asked when doing life review, and the stories come pouring forth.

Of late, Elizabeth and I have been listening to the life stories of Gen X individuals whose Baby Boomer mom or dad, stepmom or stepdad, died in the fall of 2010.  Each story is unique and beautiful, full of grace-filled surprises found in the midst of daily survival.  As they review the life of the parent who has died through the lens of caregiving and grieving, we catch a glimpse of how the first wave of the Baby Boomers is aging and dying.

Most Baby Boomers are fascinated by the project and actually volunteer to talk with me themselves.   I have to then explain that although I’m sure that their life story is fascinating, it’s really their story as seen through their children and stepchildren’s eyes that we are wanting.  So, in order to be a part of the project they would have to die.  Their eyes widen and they proclaim, “Die? What?!?!?”  Mortality seems anathema to many Boomers which should not surprise us since optimism has long defined this massive generation.  A recent survey conducted by the McKinsey Global Institute highlights the enduring optimism of aging boomers:

86% say that “I have always believed I deserve a good life.”

78% believe that they control their own destiny and can handle anything life throws at them.

Despite a robust, optimistic outlook, the Baby Boomers will soon live the adage: “time and death waits for no one.”  As they baby step into old age, our society will face the burden of the largest elderly population ever.  According to the Federal Interagency Forum on Aging at AgingStats.gov

“The baby boomers (those born between 1946 and 1964) will start turning 65 in 2011…The older population in 2030 is projected to be twice as large as their counterparts in 2000, growing from 35 million to 72 million and representing nearly 20 percent of the total U.S. population.  The U.S. Census Bureau projects that the population age 85 and over could grow from 5.7 million in 2008 to 19 million by 2050. Some researchers predict that death rates at older ages will decline more rapidly than is reflected in the U.S. Census Bureau’s projections, which could lead to faster growth of this population.”

Baby boomers will live longer and in greater numbers than ever seen before with few youngsters to support them financially and physically.  According to page 10 of The Coming Generational Storm, Kotlikoff and Burns, compute that “by 2030, the senior to kid ratio will be 3 to 1!”

What will ensure that the Baby Boomers have space and time to age gracefully?  Who will take up that mantle?  That our current healthcare system is less than adequate to support the needs and expectations of the “silver tsunami” of the Baby Boomers is far from new.  Volumes have been and continue to be written on how Medicare and the long-term care system need massive overhaul, and so I won’t enter that minefield.  My mind goes to the home.  I think of how as the boomers begin to age, they will need “informal” or “family” caregivers by the thousands.  “Informal caregiving” can be defined as “unpaid care given voluntarily to ill or disabled persons by their family and friends.” (For a good primer on informal caregiving, see the 1998 study on informal caregiving conducted by the US Department of Health and Human Services)  Informal caregivers assist a parent, friend or neighbor with completing normal activities of daily living ranging from driving, grocery shopping, taking medication, managing money, to even more personally vulnerable activities like bathing, dressing, using the toilet, or eating.

In past generations, a less debilitated spouse would tend to be on the front lines of caregiving, but there are a shockingly high number of single boomers.  According to the same survey of the McKinsey Global Institute, by 2015, 46% of all boomers aged 65 and above will be unmarried, creating 21 million unmarried households.  For the same age group in 1985, there were only 10 million unmarried households.  In an age marked by high rates of divorce, either the role of an ex-spouse will change or an adult child will be forced to move forward in line to act as the primary caregiver and decision maker for an aging parent.  Considering that already the most common form of informal caregiving relationship is that of an adult child assisting an elderly parent, the increased caregiving burden on Gen X and Millenials of the future will demand creative work, family, financial, and practical solutions that just don’t exist yet.

According to the AARP, most informal caregivers provide an average of 21 hours of care per week, so basically a part-time job.  They paint a picture of informal caregiving where caregivers assume responsibility for their loved one’s day to day care, triage any health care crises, absorb financial burdens big and small, and tend to underestimate how much time and how stressful being a caregiver will truly be.    As a mother of three, these observations sounded a lot like caring for a toddler.  It shouldn’t have surprised me then when their data showed that

“a typical caregiver in the US is a 46-year-old woman who works outside the home.”

Hmmmm…that sounds a lot like me and my friends in a few years…we have jobs, kids, friends, hobbies and parents…and my anxiety rises as I think about 2030!  How will my life story be changing?

Rosalynn Carter once said,

“There are four kinds of people in this world: those who have been caregivers, those who currently are caregivers, those who will be caregivers, and those who will need caregivers.”

The next 30 years will be defined by the quality of care we provide for our elders.  How will the Baby Boomers age and die?  How are we as their kids going to care for them well and honor their memory and legacy?  What kind of lives will we review?

A terrific letter to the NYT editor today by Carol Levine of the Families and Health Care Project at the United Hospital Fund.

Hendrik Hartog’s Jan. 15 Sunday Review article, “Bargaining for a Child’s Love,” is a welcome corrective to the view that in earlier times families took care of their ill and aging members without expecting anything in return and without complaint. But Mr. Hartog himself has a too-rosy view of the current situation.

He says that today middle-class family members don’t do the work of “cleaning bedsheets, helping a parent into a bathtub, changing a diaper.” In fact, according to the 2009 National Alliance for Caregiving national survey, this is exactly what at least 21 percent of the country’s 48 million caregivers do, as well as managing complex medications, arranging transportation, financial and legal affairs, and countless other tasks.

Most insurance, including Medicare, does not pay for this “custodial” care. Only Medicaid offers some support of this kind, and private pay is extremely expensive. Moreover, families still fight over inheritances, whether they are large or small, tangible or sentimental. Human nature has not changed.

CAROL LEVINE
Director, Families and Health Care Project
United Hospital Fund
New York, Jan. 16, 2012

In healthcare, we often remind ourselves that the most stressful moments happen during transitions.  How you get from where you are to the ER, from the OR to recovery, from a hospital bed to home, from home to the doctor’s office, from the waiting room to the examining room, from your bed to the commode, from life to death…The sign of a quality healthcare provider can be seen in how smoothly they get you from here to there.

In the past few years, the Centers for Medicare and Medicaid (CMS) have begun to realize that our healthcare system is not structured to manage transitions well.  We rely heavily on the perseverance and strength of the informal caregiver, who tends to be the patient’s spouse, daughter, or neighbor, and who acts as home nurse, taxi driver, cheerleader, and comforter for the physically, mentally, and emotionally vulnerable among us.  These are people who know how to wait: they wait in the doctor’s waiting room while anxiously scanning the people around wondering what communicable disease will be their souvenir, they wait in the ER for admission, they sit in ER docking stations waiting to be seen while listening to the distress of those behind the adjacent curtain, they wait all night in hospital rooms in order to catch the doctor during the 5:30am rounds, they wait for tests, they wait for phone calls, and as they wait, they worry.

I’ve always been involved in the hospice spectrum of care which means that I enter at the end, and am chagrined to see that the model of care offered to the actively dying is one that is sorely lacking for the actively living.  We come to you, we talk to you at any time of day or night, we teach you, we sit with you, and we encourage and comfort you.  We do all this because it not only provides the highest level of care but also because it is infinitely cheaper than a hospitalization or institutionalized custodial care. It also allows us to be most attentive to the transition happening in front of us which helps us avoid the occurrence of more traumatic transitions, such as a pain crisis, ambulance ride, or hospital stay. Read More

I thought of Joan Didion as I sat in the waiting room of my eye doctor.  A woman in her 80’s came in the office and wanted to speak to the doctor’s assistant.  She explained, “These new glasses just don’t work!”  The young assistant smiled kindly but was distracted by all the other patients waiting for appointments.  She was an intrusion, and a loud and persistent one at that.  He finally sat next to her and explained that it takes a little time to adjust to a new prescription, that she should wait a week and then come back.  She rambled on about her old glasses; these new ones seem heavier and they shift differently when she reads, but she reads better with them on, so what should she do?  The assistant subtly smiled and sighed at the other assistants, and then repeated his same words about waiting a week.

I wanted to kick him and say, “Don’t you know getting old sucks!  You think she wants to be here, feeling nauseous from her new glasses listening to some boy who looks about 12 tell her to live with it for a week!  Our lives are our eyes and one day you’ll be old and you’ll be so thankful that some 12 year old optometrist doesn’t roll his eyes at you!”

I sighed and remembered Joan Didion, “and then she got old…”

Elizabeth pointed me to an article in this month’s The Atlantic by Caitlin Flanagan who writes a searing and heartbreaking critique of Joan Didion, her work and personhood.  In part, she writes in response to Didion’s newest memoir Blue Nights, which chronicles the particulars of the death of her daughter as well as the generals of her aging process, but she traces her overall exposure to Didion as a person and writer to show how “the writer’s work is a triumph—and a disaster.”

“Ultimately Joan Didion’s crime—artistic and personal—is one of which all of us will eventually be convicted: she got old.  Her writing got old, her perspective got old, her bag of tricks didn’t work anymore…

…But she belonged to all of us, to her girl readers, and we wanted her back in the airport, with the rental car turned in, and the mohair throw over her lap, and the portable typewriter propped on the chair so she could type the days notes.  We wanted her on the floor of the studio watching the Doors wait around for Jim Morrison to show up, and we wanted her on the set of John Wayne’s latest picture.  We wanted her to stay on the road forever.”

As I read her words an image of a young man carrying his dying father into a river came to my mind and my husband reminded me that it comes from the movie, and even better book by Daniel Wallace, Big Fish.  Quite a story and a quick read that chronicles a son’s experience of his father and his father’s aging and death.  He expresses the shock that Flanagan alludes to when we realize our heroes are mortals:

“Death has come for my father.  Dr. Bennett opens his eyes and stares into the wild, distant empty space before him, and I can guess what he’s thinking.  Edward Bloom!  Who would have thought!  Man of the world!  Importer/Exporter!  We all thought you’d live forever.  Though the rest of us fall like leaves from a tree, if there was one to withstand the harsh winter ahead and hang on for dear life we thought it would be you. As though he were a god.” (107)

And yet his father, despite his fantastical stories that claim otherwise, is indeed human and aging:

“…he has the look dying people get in their eyes sometimes, happy and sad, tired and spiritually blessed, all at the same time…His barely middle-aged body looks as if it has been dug up out of the ground and resuscitated for another go at it, and though he has never had much hair in the first place…what little hair he did have is gone, and his skin color is a weird shade of true white, so that when I look at him the word that comes to mind is curdled.  My dad has curdled.” (67)

As his father nears death, they admit him to the hospital, which becomes a place that is far more surreal than any story his father ever told:

“I sat there and waited and stared at those marvelous machines.  This wasn’t life, of course.  This was life support. This was what the medical world had fashioned to take the place of Purgatory.  I could see how many breaths he was taking by looking at a monitor.  I could see what his frenetic heartrate was up to.  And there were a couple of wavy lines and numbers I wasn’t sure about at all, but I kept an eye on them as well.  In fact, after a while it was the machines I was looking at, not my father at all.  They had become him.  They were telling his story. (171)

But machines and aging and even death do not define the life of one we love.  The story ends:

“…I carried him out of the car and down the mossy bank to the river and stood there before it, holding my father in my arms.  And I knew what I was supposed to do then but I couldn’t do it.  I just stood there holding his body shrouded in a blanket on the banks of this river…and all of a sudden my arms were full of the most fantastic life, frenetic, impossible to hold on to even if I wanted to.  But then all I was holding was the blanket, because my father had jumped into the river.  And that’s when I discovered that my father hadn’t been dying after all.  He was just changing, transforming himself into something new and different to carry his life forward…” (178-9)

And so, yes, we get old, but perhaps we will find that we are most real in the story of the person we want to be.  Someone will believe and the rest is inevitable.

Every admission to hospice care begins with a doctor’s prognosis put in order form.  “Within the best of my knowledge, this patient will live for 6 months or less.”  Without this order, no hospice.  And yet, many hospice patients die the next day and a rare few live for years.  A few days ago, the National Hospice and Palliative Care Organization released their annual Hospice Facts and Figures Report for 2011.  Although the number of hospice patients served in 2010 has stayed about the same, the median length of stay in hospice dropped to 19.7 days and the average length of stay in hospice dropped to 67.4 days.  For a benefit that was intended to be used for 6 months, we’re not doing too well and haven’t for quite some time.  Prognosis is hard.

End of life care hero, Dr. Joanne Lynn, has studied and critiqued prognosis for years.  Based on the seminal SUPPORT study, that followed over 10,000 seriously ill patients in hospitals across the country for several years, she writes in Handbook for Mortals: Guidance for People Facing Serious Illness, that

“nearly half of the patients died within 6 months of their enrollment in the study.  But the best medical predictions by statistical methods and by the patients’ doctors had trouble sorting out who was “dying.” One week before death, the average patient still had a 40% chance of living 6 months.  Even on the day before death, the average patient still had a 10% chance of living 6 months.” (9)

Well, the search for more reliable methods for predicting mortality and debility in general continue.  A new prognosis tool, intended for physicans, has been released and is open to the public, in theory, to use.  I tried it myself, but the age range for patient prognosis begins at 60, so I had to quit.  Rumors of its release have circulated from some time, Paula Span wrote about it and over 72 of the 75 people who commented on her blog said that they would want to use it on themselves or a loved one.  Of course, professional interpretation is needed, but you can try it. As you will quickly see, the results are based on current indices that already exist and that doctors should already use for when you ask, “How long do I have, doc?”

Will you use it?  Do you want to know?  How will this knowledge shape what care you want and how you will plan for your financial future?  What role should this tool play in your doctor’s care plan for you?  What if this site were sponsored by your insurance company?  How will Medicare or Medicaid use this information?  Not that I really want to now, but I wonder where Sarah Palin is?  I mean, the site has been created by a PANEL of physicians who are predicting DEATH…

As someone involved in hospice care, I have been present to death as a chaplain many times and have honored the stories of those who have recently died in our care as an administrator thousands of times.  One common observation our diverse care team often has is the deep realization that death is not hard for those who die.  Granted, there are outliers, but we are getting better and better at treating the symptoms of terminal disease when the source of pain or discomfort can no longer be addressed directly, but overall our bodies know what to do at the end of life.

Standing in the shadow of death each day has actually left me and many of our team members oddly hopeful and at peace.  Our very being-mind, body, and soul-are fearfully and wonderfully made, and the mystery and beauty of our existence as both tangible and ethereal comes to the fore at liminal moments such as death.

Although I personally ascribe to a faith system that equips me with a narrative framework for making sense of what happens at the end of life, my observations of death’s inherent peacefulness is not shaped by that narrative.  In fact, I have encountered countless faith-based, philosophy-based, consumption-based, filial-based, etc.-based narrative frameworks for making meaning of life, but the physical journey at the end of life for the one dying has appeared to be equally merciful despite of how we try to make sense of it.  And how we try to talk about it!  I am one who loves to write about it and yet the words become 4 star Sudoku puzzles where somehow a series of numbers are the only verbs you can use.

You may have already seen this video but a friend shared it with me and I thought I might lift it up for reflection.  This young man’s observations are shared by many who have near-death experiences, and he restrains himself, to some extent, from placing a narrative framework on his experience.  But we are people of story, and story can give us comfort and hope. Condolences to his family.

Sick Teen\’s Video Goes Viral

“Stuart went out into the world full of the joy of possibility and the fear of dogs…” Stuart Little

Our family is on a road trip so we’ve been listening to books on CD.  When I heard this part of Stuart Little, a mouse born into a human family, I thought how wise little Stuart is to the face the world with an active eye to possibility tempered with life’s inevitable limitations.

As the New Year fast approaches, countless folks will be utilizing the commitment device known as the “New Year’s Resolution” to weigh their limitations in the light of hope for the benefit of their future selves.  In Daniel Goldstein’s recent TED talk, he defines a commitment device as, “a decision you make with a cool head so that you don’t do something regrettable when you have a hot head.”  He uses ancient Odysseus, sailing past the island of siren song roped to the ship’s mast in rapturous torture with his crew’s ears safely deafened with wax rowing beside him, as the first example of a commitment device.  And although commitment devices can often be effective, they also often fail, as many of us can attest in February as we visit our failed resolutions in the cemetery of discipline and self-control. Read More

Cookies to make, early school pick-up to remember, church programs to attend, presents for teachers to make, caroling to come, gumbo to roux, new shirts to iron, presents to wrap, letters to mail…As my to-do list increases and my tolerance for sugar plums decreases, I understand each year where and when Christmas crankiness sets in.

Many years ago, three co-workers and I coined this phrase, “Christmas Crankiness” to define what we often feel in the dark weeks of December.  To combat this emotion and dread we committed to meeting weekly for Advent devotionals.  To read scripture, poetry and prayers, to light candles, and to sit in quiet thoughtfulness together in order to ponder how God is truly with us in the midst of our crankiness.

Choosing the path of devotions meant we were ready to battle our crankiness, which I think may be another word for the ancient demon of acedia.  This year, I read Kathleen Norris’ thoughtful and honest book, Acedia and Me.  She deftly shows how though often confused with depression, a disease that can be diagnosed and treated through therapy or medication, acedia can afflict us all.  Acedia is the spirit of not caring.  She writes on page 233 of how “acedia contains within itself so many concepts: weariness, despair, ennui, boredom, restlessness, impasse, futility.” She quotes Aquinas who wrote that “for despair, participation in the divine nature though grace is perceived as appealing, but impossible; for acedia, the prospect is possible, but unappealing.” She concludes that the worst that acedia can do to us is not only make us unable to care, but also take away our ability to feel bad about that.  Ah, Christmas crankiness. Read More

In the holiday classic, A Christmas Carol, the miserly and heartless Scrooge receives a dreamy wake-up call the night before Christmas.  Although the Ghost of Christmas Past embarrasses and grieves him and the Ghost of Christmas Present humbles and challenges him, it is the Ghost of Christmas Future that truly scares the bajeebies out of him thus stirring him to life transformation.

This year, I feel like the Ghost of Christmas Future, Christmas 2030 to be exact , is visiting me and scaring the requisite bajeebies out of me.  2030: the year when according to the Census Bureau the senior-to-kid ratio (yes, David, they use “kid”) will be 3 to 1.  In 2010 the Senior-to-Kid ratio was 2 to 1.

I just finished the alarming book The Coming Generational Storm by Boston University Professor of Economics, Laurence J. Kotlikoff, and reporter, Scott Burns. Written in 2004, they draw heavily on the data from Inquiries in the Economics of Aging, a study of over 5000 elderly conducted by the National Bureau of Economic Research in 1989. Although the data seems a bit dated, even then researchers found that:

“22.4 percent of elderly have no children

Another 19.8 percent had only one child

That 40.5 percent have no daughters

Most single elderly live by themselves

10 percent of those with children had no children within an hour’s distance

Over 40 percent of the “vulnerable” elderly live alone

Less than 20 percent of the elderly live with their children

Institutionalized elderly have less contact with children, not more

Transfers of money from child to parent (or vice versa) were rare, regardless of income”

These numbers are staggering and this is old data. Read More

If you’ve ever wondered if you can beat death in a foot race, well, here you are from this week’s Geripal blog:

“A group of Australian researchers in this study were very concerned about determining the speed at which the Grim Reaper (aka Death) walks.  Using data from a population based prospective study of 1705 older community dwelling men living in Sydney, Australia, the authors compared walking speed and mortality.  They further used receiver operating characteristics curve analysis to determine the optimal walking speed to avoid contact with the Grim Reaper.

Long story made short, older men who walked faster than 0.82 m/s were 1.23 times less likely to die than those who walked slower. No one walking at least 1.36 m/s (3 miles or 5 km per hour) died. The authors thereby concluded:

“The Grim Reaper’s preferred walking speed is 0.82 m/s (2 miles (about 3 km) per hour) under working conditions. As none of the men in the study with walking speeds of 1.36 m/s (3 miles (about 5 km) per hour) or greater had contact with Death, this seems to be the Grim Reaper’s most likely maximum speed; for those wishing to avoid their allotted fate, this would be the advised walking speed.”