This summer, over dinner with her best friend, Jackie Barden began talking about an uncomfortable topic: the possibility of dying alone.
“I have no children, no husband, no brothers,” Barden recalled 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. “There comes a point in life when you no longer rise up, but start to fall,” she told me. “And you start to wonder what the end will be.”
This is something many seniors living alone are wondering about, a population that already exceeds 16 million and continues to grow. Many have relatives or friends. But others have neither a partner nor children; Their relatives live far away or live separately from the few relatives they have left. Some have lost very dear friends due to age or illness.
More than 15 million people over 55 do not have a spouse or biological children; almost 2 million have no family.
Other older people have been isolated because they are sick, frail or disabled. Almost one in five have little or no contact with other people. Research shows that isolation becomes even more common as death approaches.
Who will be with these people who are aging alone when they reach the end of their lives? How many of them will die without someone they know or love by their side?
Unfortunately, we don't know: national surveys don't say who accompanies older people when they die. But dying alone is a growing concern as more and more people age without a partner, become widowed or divorced, or remain single or childless, according to demographers, researchers and doctors who specialize in caring for the elderly.
“We've always had patients who are left virtually alone at the end of life,” said Jaron Johnson, medical director of hospice and palliative care at Presbyterian Health Services, New Mexico's largest health care system. “But it wasn’t as common before as it is now.”
During the Covid-19 pandemic, families were unable to access hospitals or nursing homes when older relatives died. This was a period when most attention was paid to the potentially serious consequences of dying alone. But since then this issue has practically disappeared from view.
For many, including health care workers, the possibility of dying unaccompanied by anyone causes a feeling of abandonment. “I can’t imagine what it’s like, short of a terminal illness, to think, ‘I’m dying and I have no one,’” said Sarah Cross, assistant professor of palliative medicine at Emory University School of Medicine.
According to Cross's research, most people today die at home. But while many hospitals have programs called No One Dies Alone, where volunteers accompany patients in their final days, there are no similar services for those dying at home.
Alison Butler, 65, is an end-of-life doula living in Washington, DC. She accompanies people and their loved ones in the process of dying. She also lived alone for 20 years. In a long conversation, Butler admitted that she sees the idea of dying alone as a form of rejection. She fought back tears as she spoke about the possibility of feeling like her life “doesn't really matter or matter much” to anyone.
Lack of trusted people who can help terminally ill adults can also lead to treatment refusal and decreased well-being. Most seniors do not have the financial resources to pay for assisted living or home care assistance if they can no longer shop, bathe, dress, or move around the home on their own.
Economists and public policy experts warn that Medicaid cuts of nearly $1 billion under President Donald Trump's tax and spending law, which Republicans call the One Big Beautiful Bill Act, will likely worsen difficulties accessing adequate health care.
Medicare, the federal health insurance program for older adults, generally does not cover in-home services. The main source of this type of assistance for those without financial resources is Medicaid. But states may be forced to abandon Medicaid-funded home care programs as federal funding dwindles.
“I'm very afraid of what could happen,” said Bree Johnston, a geriatrician and director of palliative care at Skagit Regional Health in northwest Washington. She is convinced that more terminally ill older people who live alone will end up dying in hospitals because they will not have access to basic services.
“Hospitals are generally not the most humane places to die,” Johnston said.
Although home hospice care is an alternative covered by Medicare, it is often not sufficient for terminally ill older adults living alone. (Palliative care is for people with a life expectancy of six months or less.)
On the one hand, this service is underused: less than half of adults over 85 use it. On the other hand, “many people mistakenly believe that home-based agencies will provide support staff in the home and help with all the functional problems that arise at the end of life,” explained Ashwin Kotwal, assistant professor of geriatrics at the University of California, San Francisco School of Medicine.
But in reality, these agencies offer intermittent care and rely heavily on family members to help with things like bathing or feeding. Some agencies won't even accept people without guardians, Kotwal said.
And then there are hospitals. If an older person is conscious, staff can talk to them about their priorities and help them make important medical decisions, explained Paul DeSandre, director of palliative and supportive care at Grady Health System in Atlanta.
If the person is disoriented or unconscious, which is common, staff try to find someone who can tell them what the patient would like at the end of their life and possibly act as their legal representative. Most states have laws that appoint predetermined representatives, usually family members, for those who do not pre-select them.
If no one is found, the hospital asks the court to establish legal guardianship, and the patient becomes a ward of the state, which assumes legal responsibility for end-of-life decisions.
In the most extreme cases, when no one reacts, a person who dies alone may be classified as “unclaimed” and buried in a mass grave. It's also becoming increasingly common, according to the book Unclaimed: Abandonment and Hope in the City of Angels, published last year.
Dr. Shoshana Ungerleider founded End Well, an organization dedicated to improving end-of-life experiences. She suggested identifying lonely and seriously ill older people early and offering them greater support. He recommended keeping in touch with them regularly through calls, video calls or text messages.
And he reminded that not all older people have the same priorities at the end of life. Each one is different.
Barden, a widow from Massachusetts, for example, is focused on pre-arrangements: She has already arranged all the legal, financial and funeral arrangements.
“I have been very lucky in life. You need to look back and be grateful for the good and not dwell on the bad,” she told me. About imagining his death, he commented: “It will be what it should be. We can't control these things. I think I'd like to have someone with me, but I don't know what that would be like.”
Some people want to die the same way they lived: alone. One of them is 80-year-old Elva Roy, founder of Age-Friendly Arlington in Texas, who has lived alone for 30 years after being divorced twice.
When I spoke to her, she told me that she had thought a lot about dying alone and was considering a medically assisted death, perhaps in Switzerland if she became terminally ill. It's a way to maintain the sense of control and independence that has sustained her throughout her life as a single elderly person.
“Honestly, I don’t want anyone around me if I’m exhausted, weak or sick,” Roy said. “It won’t comfort me if someone holds my hand, wipes my brow, or watches me suffer. I feel very good about the possibility of dying alone.”
