My great-grandparents, great-uncle, step-father and grandmother have all had long, extended end-of-lives in the last few years. They're a pretty good spectrum of desires and needs, and all were on the American equivalent of single-payer (Medicare).
My great-grandmother was the first to go. I've done a retrospective on her medical records, and she was massively misdiagnosed multiple times over her lifetime. Eventually all of the misdiagnoses compounded into kidney failure that caused cardiac issues (or maybe the other way round). She was a fighter, and wanted every single day of life she could have, so did two years of dialysis and heart meds until it didn't work. Nobody ever told her she was done, or to stop trying, or tried to ease her into hospice against her will.
My great-uncle went a few years later, of a shorter illness. He'd been in indifferent health for a couple years, but the last illness was a sharp decline. He had a living will that refused artificial ventilation, nutrition, and hydration. His children followed his wishes, but he never needed any of the three. His medical staff offered and wanted to start significant intervention options, without any discussion of hospice. My uncle just died faster than they could operate.
My great-grandfather became deeply apathetic after the deaths of his son and wife. He didn't want to outlive them, but did, by several years. He spent two years under hospice care, getting everything he needed for his comfort, and no interventions to extend his life. He died comfortably, at an extremely advanced age, at home.
My mother's second husband got his cancer diagnosis three days after he turned in his Medicare paperwork. He was in denial about his condition from day one until the day he died -- he was convinced he was going to beat stage IV. His medical staff did include hospice, but if he wanted a treatment, even a futile treatment, he got it. They bankrupted themselves on experimental and alternative treatments, and nobody ever told him to stop or tried to convince him to make the most of the time he had left.
My grandmother wore herself out caring for my great-grandparents and her long-term gentleman, as well as her own career. She was a geriatrics nurse, and had assembled for herself an end-of-life kit* because she didn't want to linger at all. She wrote the most binding living will that was possible when she wrote it, and updated it to the extent her very red, Evangelical state would allow. She had her first stroke in public, and it appears that the hospital where she was taken either a) lost her filed living will and DNR, or ignored it (Catholic). She was also badly underdiagnosed, and was released before the extent of the damage was clear. She didn't use the kit in the six months she was on her own. I don't know why she didn't, but I assume she forgot, or didn't think she was ready yet, or didn't want to be found, or a combination. When her condition got worse, she ended up in care because she lived 1000 miles from her MPOA (me) or any other family. I spent the next two years as her advocate, interpreting both her written instructions and the ones she was able to make while she still had speech, and those instructions were consistently, keep me comfortable, let me do as much as I can for myself, no interventions except for comfort. Which was an often monthly or weekly fight. She refused antibiotics (the nurse part of her brain never failed; she could identify most pills at 10 paces); I had to back her up. She didn't want nebulizers. She hated her walker and her wheelchair; I fought for PT when that was possible and took her anger when she had no choice. In her last months, her brain was more than half dead, due to massively blocked arteries. Her cardiologist really wanted to put in shunts, despite an 80% chance she'd die on the table and 0% chance she'd recover enough to even go back to assisted living. By then, Gran was mostly aphasic, and could usually only get 2 words at a time. But those two words were "No surgery." I followed her wishes. We signed the hospice paperwork about an hour before she died; she was fine on the Monday before Christmas, declined rapidly on Christmas morning and died on Boxing Day.
Four of the five died in red states. (I moved my grandmother to me, because I couldn't go to her, and I didn't know she'd made me responsible until it was way too late to change her wishes, and I wanted her in a state with better care.) I don't worry about death panels at all. I worry about people not being allowed to die, because a living patient is a profit center, and there are a lot of hospitals and doctors who look at their balance sheet rather than their patients' needs and desires.
*She was a teetotaler, but I found the kit when I cleaned out her house. A bottle of opiates, never used, in her name; a bottle of benzodiazepines, never used, in her name, from a different date and doctor; a bottle of vodka into which she'd dissolved candy (I think Jolly Ranchers - it was bright red and sour cherry, her favorite). They were all together, bound in a rubber band. She knew what she was doing.
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