11/11/17

Toronto vet helps pets to pass in comforts of home

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Home is a pet’s safe space and favourite place. This is where they lived and this is where they should be allowed to die, writes in-hospice veterinarian Faith Banks.

At first, they open the door to their home and greet me with “you have the worst job in the world”, followed by “how do you do this?”

They are pet owners and they are referring to the fact I am a hospice veterinarian. I am at their home because I am a mobile hospice veterinarian. I am at their home to help them say goodbye to their most loved companion, their family dog or cat.

When I enter their home, people often apologize for the dirty dishes still in the sink or the mess on the floor. I am blind to their clutter and I never judge them on the cleanliness of their home. What I do notice are the blankets and pillow on the couch.

You see, when an older pet is no longer able to make it upstairs to the owner’s bed, the owner’s bed gets moved to the family room couch. These are some of the final precious moments owners have with their pet and they don’t want to miss out on any of it by sleeping apart for their last few weeks or days together. It is a slumber of true love.

Goodbye at home is a gift

Being able to say goodbye at home is a gift people can provide to their beloved aging pets. Veterinary Aid in Dying, euthanasia or putting a pet to sleep are all terms for the final act of love pet parents are often called on to do for a pet that is suffering. This suffering may be physical and/or emotional and can deeply affect the owner as well.

From the Greek translation, euthanasia literally means “good death”. Our pets are most deserving of a good death, especially after the unconditional love and dedication they showered upon us during our memorable lives together.

When I began my in-home hospice and palliative care service, my goal was to ensure everyone had the opportunity to allow their pet to pass with dignity and love.

Comfort and privacy

Today, along with three other compassionate veterinarians, we are able to provide this service to pets and their owners in the comfort and privacy of their homes. Being able to provide this personal and meaningful service is an honour and responsibility I don’t take lightly.

Home is where the heart is and home is where the dog is. This is their safe space, their favourite place. This is where they lived and this is where they should be allowed to die.

Euthanasia at home, performed by a skilled veterinarian, ensures our pets are not stressed, are not in pain and have a peaceful, love-filled passing. Something they no doubt deserve, and something we all hope for ourselves.

So now, by the time I leave, “you have the worst job in the world” changes to “what an emotionally rewarding job you have” and “how do you do this?” changes to “thank you for doing this”.

Complete Article HERE!

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11/9/17

What ancient cultures teach us about grief, mourning and continuity of life

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By and

At this time of the year, Mexican and Mexican-American communities observe “Día de los Muertos” (the Day of the Dead), a three-day celebration that welcomes the dead temporarily back into families.

Festivities begin on the evening of Oct. 31 and culminate on Nov. 2. Spirits of the departed are believed to be able to reenter the world of the living for a few brief moments during these days. Altars are created in homes, where photographs

Altar to the dead in Yucatán, Mexico

and other personal items evocative of the dead are placed. Offerings to the deceased include flowers, incense, images of saints, crucifixes and favorite foods. Family members gather in cemeteries to dine not just among the dead but with them. Similar traditions exist in different cultures with different origins.

As scholars of death and mourning rituals, we believe that Día de los Muertos traditions are most likely connected to feasts observed by the ancient Aztecs. Today, they honor the memory of the dead and celebrate the continuity of generations through loving reunion with those who came before.

As Western societies, particularly the United States, move away from the direct experience of a mourner, the rites and customs of other cultures offer valuable lessons.

Loss of rituals

Funerals were handled in the home well into the 20th century in the U.S. and throughout Europe. Sometimes, stylized and elaborate public deathbed rituals were organized by the dying person in advance of the death event itself. As French historian Philippe Ariès writes, throughout much of the Western world, such death rituals declined during the 18th and 19th centuries.

What emerged instead was a greater fear of death and the dead body. Medical advances extended control over death as the funeral industry took over management of the dead. Increasingly, death became hidden from public view. No longer familiar, death became threatening and horrific.

Today, as various scholars and morticians have observed, many in American culture lack the explicit mourning rituals that help people deal with loss.

Traditions in ancient cultures

In contrast, the mourning traditions of earlier cultures prescribed precise patterns of behavior that facilitated the public expression of grief and provided support for the bereaved. In addition, they emphasized continued maintenance of personal bonds with the dead.

As Ariès explains, during the Middle Ages in Europe, the death event was a public ritual. It involved specific preparations, the presence of family, friends and neighbors, as well as music, food, drinks and games. The social aspect of these customs kept death public and “tame” through the enactment of familiar ceremonies that comforted mourners.

Grief was expressed in an open and unrestrained way that was cathartic and communally shared, very much in contrast with the modern emphasis on controlling one’s emotions and keeping grief private.

In various cultures the outpouring of emotion was not only required but performed ceremonially, in the form of ritualized weeping accompanied by wailing and shrieking. For example, traditions of the “death wail,” which allowed people to cry their grief aloud, have been documented among the ancient Celts. They exist today among various indigenous peoples of Africa, South America, Asia and Australia.


 
In a similar way, the traditional Irish and Scottish practices of “keening,” or loudly wailing for the dead, were vocal expressions of mourning. These emotional forms of sorrow were a powerful way to give voice to the impact of individual loss on the wider community. Mourning was shared and public.

In fact, since antiquity and throughout parts of Europe until recently, professional female mourners were often hired to perform highly emotive laments at funerals.

Such customs functioned within a larger mourning tradition to separate the deceased from the world of the living and symbolize the transition to the afterlife.

Rituals of celebration

Mourning rituals also celebrated the dead through carnival-like revelry. Among the ancient Greeks and Romans, for example, the deceased were honored with lavish feasts and funeral games.

Such practices continue today in many cultures. In Ethiopia, members of the Dorze ethnic community sing and dance before, during and after funerary rites in communal ceremonies meant to defeat death and avenge the deceased.


 
In not too distant Tanzania, the burial traditions of the Nyakyusa people initially focus on wailing but then include feasts. They also require that participants dance and flirt at the funeral, confronting death with an affirmation of life.

Similar assertions of life in the midst of death are expressed in the example of the traditional Irish “merry wake,” a mixture of mourning and celebration that honors the deceased. The African-American “jazz funeral” processions in New Orleans also combine sadness and festivity, as the solemn parade for the deceased transforms into dance, music and a party-like atmosphere.


 
These lively funerals are expressions of sorrow and laughter, communal catharsis and commemoration that honor the life of the departed.

A way to deal with grief

Grief and celebration seem like strange bedfellows at first glance, but both are emotions that overflow. The ritual practices that surround death and mourning as rites of passage help individuals and their communities make sense of loss through a renewed focus on continuity.

By doing things in a culturally defined way – by performing the same acts as ancestors have done – ritual participants engage in venerated traditions to connect with something enduring and eternal. Rituals make boundaries between life and death, the sacred and the profane, memory and experience, permeable. The dead seem less far away and less forgotten. Death itself becomes more natural and familiar.

Funerary festivities such as Day of the Dead create space for this type of contemplation. As we reminisce over our own losses, that is something we could consider.

Complete Article HERE!

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11/8/17

Time to Have the Talk! Sex and the Cancer Patient

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By Roxanne Nelson, BSN, RN

“So how is your sex life?”

That is a question that a great many cancer patients would love to hear from their oncologists, but unfortunately, sexuality is not a topic that gets much attention.

A panel of experts here at the Palliative Care in Oncology Symposium (PCOS) 2017 tackled the subject of sex and the cancer patient and presented preliminary data demonstrating how “low-tech” interventions can make a dramatic difference for patients.

Sexuality is a somewhat taboo topic in oncology care, and perhaps even moreso in palliative care, explained panel member Anne Katz, PhD, RN, certified sexuality counselor at Cancer Care Manitoba, Canada. “But we know that this is important to patients and their partners across the cancer journey.”

She cited a study (Psychooncology. 2011;21:594-601) that found that fewer than half (45%) of all cancer patients had a conversation with their healthcare provider about sex. By cancer type, 21% of lung cancer patients had such a conversation, as did 33% of breast cancer patients, 41% of colorectal cancer patients, and 80% of prostate cancer patients.

Men, it seems, get the “sex talk” a lot more frequently than women do.

According to Dr Katz, the “whole thing is skewed” by prostate cancer. More than twice as many men speak to their providers about sex as compared to women.

“If we didn’t talk about nausea, if we didn’t talk about constipation, we would be regarded as negligent, even indulging in malpractice,” Dr Katz pointed out. “Yet we are leaving out conversations about this very important quality-of-life issue, which persists into end-of-life care.

“Sexuality is much more than just intercourse. It is about touch and intimacy and about much more than what we do in the bedroom,” she said.

A recent study (J Cancer Surviv. 2017 Apr;11:175-188) again showed that a “preponderance” of men (60%) had a discussion about sex with their provider, whereas fewer than half as many women did (28%).

However, healthcare providers thought “they were doing a good job,” with almost 90% reporting that they were. “So there is a very large gap as to who is saying what and who is hearing what,” explained Dr Katz.

Another problem is that the cancer patient is much more likely to raise the topic with their provider, rather than the reverse. This is a problem, she pointed out, “because in every other area, we raise the topic with our patients, indicating that its important. By not opening the door, by not starting the conversation, we are saying to our patients that ‘this is not important and I don’t want to talk about it.’ ”

Panelist Sharon Bober, PhD, founder and director of the Sexual Health Program at the Dana-Farber Cancer Institute in Boston, Massachusetts, agreed with that summation. “We have to expand our perspective on what sexuality is, in the context of serious illness and palliative care. It’s too easy to be reductionist and think about whether some can or cannot have sex – this isn’t what it’s about.”

Sexuality, she noted, is a human experience across the lifespan. It’s a multidimensional experience that involves physiology, behavior, emotion, cognition, and identity.

“What we can take from some of the qualitative and survey work that’s been done to date is that expressions of sexuality can be a vital aspect of providing comfort and relieving suffering, maintaining connections in the face of life-limiting illness, and affirming a sense of self when other roles are lost,” Dr Bober explained. “When sexually is not made part of care, there is an implicit message that is it no longer important and/or the challenges cannot be addressed.”

Unfortunately, providers often took a medicalized approach, as was evidenced in one study (Contemp Nurse. 2007 Dec;27:49-60). Patient sexuality and intimacy were largely medicalized; the discussion remained at the level of patient fertility, contraception, and erectile or menopausal status, Dr Katz noted.

“There is a lot of active avoidance,” she said. She pointed out that the “patient reports the topic and the oncologist takes three steps back and flies out the door.”

Some of the reasons given for not discussing sexuality were reactions of colleagues, fear of litigation, and fear of misinterpretation.

The topic needs to be brought up in the context of quality of life, she emphasized, “but we need to open the door.”

There is the fear of not knowing what to say, but there is “Dr Google, there are books, there are experts, and if you don’t know, you will find the resources to refer patients to them,” Dr Katz said. “We have a responsibility to discuss sexual side effects of cancer treatment.”

Very Brief but Very Effective

Sexual function is profoundly disrupted by gynecologic cancer treatment, and 90% of patients with ovarian cancer report distressing changes in sexual function. “The good news is that ovarian cancer patients are living longer, and almost 50% of survivors will live many years post diagnosis,” explained Dr Bober. “But they often have to endure multiple surgeries and multiple rounds of chemotherapy, and sexuality and distress are generally not addressed.”

She pointed out that with ovarian cancer patients, “no one talks about this. The thought Is often that you have bigger fish to fry, you may not live anyway ― there are all kinds of reasons that this doesn’t get addressed.”

Dr Bober described an intervention that they devised at Dana Faber to address sexual dysfunction in ovarian cancer survivors. Not only was it brief, easily accessible, and “doable” by patients, but final results showed that it was quite effective.

The format was integrative. It was composed of a single half-day group intervention with a didactic teaching and experiential exercises, coupled with an individualized action plan. After the session was completed, the participants were asked to reflect on what was pertinent to them and what they were going to work on during the next 6 weeks.

The session was followed by a brief telephone call, in which the action plan was reviewed and additional support was offered if needed, to uncover additional challenges that needed to be addressed.

Because this was a pilot study, it did not include a control group per se, Dr Bober explained, but participants served as their own controls. This was accomplished by having a 2-month run-in period, during which women filled out surveys at baseline then waited for 2 months before completing the survey a second time before beginning the intervention. The purpose of the 2-month run-in period was to estimate changes in symptoms that could not be attributed to the intervention.

The design comprised three modules. Module 1 was targeted on sexual health education, which discussed vaginal health, enhancing arousal, and increasing low desire. Module 2 involved body awareness and relaxation training, in which participants learned pelvic floor education, progressive muscle relaxation, and body scan. Module 3 involved a mindfulness-based cognitive training, which sought to increase nonjudging awareness of automatic thoughts, with progression from avoidance/distraction to acceptance.

The cohort included 46 women with stage I-IV ovarian cancer who reported at least one distressing sexual symptom. The mean time since diagnosis was 6.3 years (range, 1 – 20 years). “Twenty years is a very long time to be dealing with distressing sexual problems,” emphasized Dr Bober.

Within this group, 13% were currently receiving chemotherapy, and 44% were currently taking medication for anxiety, depression, or pain.

In evaluating the program, 97% of the women found the it helpful, 100% found it easy to understand, and 95% found the it enjoyable.

With regard to helping sexual functioning, “There were no changes during the run-in period, for the most part, demonstrating that time alone did not change the situation,” said Dr Bober. “But at month 2 after the interactions, there was significant improvement over multiple domains of sexual function. And for the most part it held over to 6 months.”

Although the pilot study was not focused on mental health per se, there was significantly less psychological distress observed in the participants, especially regarding symptoms of depression and distress.

It was a small pilot study, she emphasized, but the implications are that brief sexual health rehabilitation in the context of serious illness is effective. “There was meaningful improvement in sexual function and emotional distress, and improvements at 6 months.”

Dr Bober emphasized that there is an enormous need for evidence-based intervention research, with interventions conducted outside of an academic center in order to reach more people. “There is a need for identify optimal methods for delivery,” she said. “In some of the palliative care literature, patients talk about struggling with this issue within 2 to 3 months before they die, so this is not something that is relevant only if you’re well.”

Pilot Study in Transplant Patients

Similar to other oncology settings, sexual dysfunction is a common long-term complication for survivors of allogeneic hematopoietic stem cell transplant (HCT), but it is rarely discussed, and interventions to enhance sexual function in this population are lacking.

The preliminary efficacy of a multimodal intervention designed to improve sexual function in allogeneic HCT survivors was very encouraging, reported Areej El-Jawahri, MD, instructor of medicine at Harvard Medical School and director of the Bone Marrow Transplant Survivorship Program at the Massachusetts General Hospital, Boston.

Dr El-Jawahri and her colleagues conducted a pilot study to assess the feasibility and preliminary efficacy of the intervention in a cohort of 50 patients. The participants were at least 3 months’ post transplant and had screened positive for distress caused by sexual dysfunction.

“There was a very wide age range, from 24 years to 75 years,” she said. “The median time from HCT at enrollment was 29 months, but there was also a wide range between 3 and 173 months.”

The primary endpoint of the study was feasibility: 75% of patients who screened positive would agree to participate and attend the first visit, and at least 80% would attend at least two intervention visits.

The majority of patients had acute leukemia (55%), and nearly 64% had chronic graft vs host disease (GVHD).

The format consisted of monthly intervention visits with trained study clinicians. The visits focused on assessing sexual dysfunction, educating and empowering patients to address this topic, and implementing therapeutic interventions that targeted their specific needs.

The PROMIS Sexual Function and Satisfaction Measure, Functional Assessment of Cancer Therapy-Bone Marrow Transplant (FACT-BMT), and Hospital Anxiety and Depression Scale (HADS) were used to assess sexual function, quality of life (QOL), and mood at baseline and 6 months post intervention.

The study met its primary endpoint of feasibility; 94% (47/50) agreed to participate, and 100% of this group attended at least two interventions. The median number of visits were two (range, two to five). The median duration of the first visit was 50 min; for the second visit, it was 30 min. In addition, 28% (13/47) had a partner attend an intervention visit.

Results were encouraging, Dr El-Jawahri pointed out. “Sexual activity in the group increased.”

Before the intervention, 32.6% of patients reported not engaging in any sexual activity; that number declined to 6.5% after the intervention.

In men, the following therapies were implemented: phosphodiesterase inhibitors (PDI) on demand (57%), psychoeducation (52%), penile constriction rings (48%), referral to a sexual health clinic (9%), daily PDI treatment (4%), topical GVHD treatment (4%), and hormone replacement therapy (4%).

For women, therapies included vaginal estrogen (67%), dilator (63%), lubricant (58%), psychoeducation (42%), topical GVHD treatment (42%), topical lidocaine (8%), and referral to a sexual health clinic (4%).

“All outcomes were clinically and statistically significant,” said Dr El-Jawahri.

The program was efficacious in improving QOL and mood.

“This has very promising efficacy, but we need to conduct a randomized clinical trial, and there is a need to asses longer-term outcomes,” Dr El-Jawahri concluded. “It also has potential for adaptation to other types of cancer survivors as clinicians to deliver this kind of intervention and allow for dissemination.”

Complete Article HERE!

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11/7/17

How to Help Your Kids Cope With the Loss of the Family Pet

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Pets are part of the family, so it makes sense that losing one is tough on everyone, including our children. A pet’s death may be the first time they’ve ever experienced a real loss, and as a parent, it can be difficult to know how to start a conversation about life, death, and grieving in a way they can understand, but that won’t heighten their sadness.

Last week, we put our 12-year-old dog to sleep five weeks after he was diagnosed with lymphoma. It was a brief but rapidly debilitating illness, and I wondered if my kids would understand that a dog who was quite healthy only two months ago was now gone. Surprisingly, they took it much better than I did. My 3-year-old gave me a hug, then told me, “I don’t know why you’re crying, Mom. Gus was sick, and now he’s in heaven with grandma’s dog. He’s not sad he died. He’s still happy.”

After briefly wondering if my child was a pet psychic, I realized that his logic was pretty sound. While my son would miss our dog, he knew our pup had been suffering, and he was prepared for the death. He had processed the loss faster and more easily than I did precisely because he was a kid. If you’re dealing with the loss of a family pet, here’s how to help your children process their feelings.

  1. Make sure your child understands what death means. Gently make sure that your child understands that their pet’s death means the animal will never be physically present again. Don’t be alarmed if it takes awhile — even years depending on their age — for your child to understand that means that your pet can no longer breathe, feel, or ever be alive again. If the death was sudden or unexpected, explaining why or how your pet died might be important to help your child understand the permanence of the loss. Of course, consider your child’s age and ability to understand and only give them developmentally appropriate information.
  2. Be honest. Telling your child about the death openly and truthfully lets your child know that it’s not bad to talk about death or sad feelings, an important lesson as they will have to process many other losses throughout their lives.
  3. Follow your child’s lead. Sometimes children are better than adults at accepting loss, especially when they’ve known for some time that their pet had a limited life span or was ill. Don’t attempt to make your child’s grief mirror your own, but do validate any emotions that come up as your child goes through the mourning process, and be ready to talk when they have questions. Age-appropriate books like Sally Goes to Heaven and I’ll Always Love You can also help with communication.
  4. Don’t be surprised if your child grieves in doses. Children often spend a little time grieving, then return to playing or another distraction. This normal, necessary behavior prevents them from becoming overwhelmed and makes the early days of grief more bearable for them.
  5. Say a formal goodbye. Consider having a small memorial service where you can all say goodbye, discuss favorite memories, and thank your pet for being part of the family, even if the service is just in your backyard or around the kitchen table.
  6. Find a way to memorialize your pet appropriately. We often don’t realize how constant our pets were in our lives until they’re gone. By making a photo album, turning a collar into a Christmas ornament, or commissioning personalized art work through Etsy, your whole family will have a positive remembrance of your beloved pet for a lifetime.

Complete Article HERE!

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11/6/17

Don’t want ‘heroic measures’ as part of your end-of-life care? Have the conversation

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intubated patient in hospital, intubatation at intensive care unit room respiratory machine with oxygen ventilation monitor

By Allison Bond

For one month this spring, my job as a senior resident in a large teaching hospital entailed racing around the hospital, managing patients who had rapidly become sicker; I wore running shoes every day. I also led every code, orchestrating a team of doctors, nurses, respiratory therapists, and pharmacists in an effort to resuscitate patients after their hearts had stopped. Some of the very sick patients under my care had do-not-resuscitate orders, but most didn’t. For them, my team and I provided whatever treatments we could.

One night, a colleague asked me to see Mr. S, a middle-aged patient with worrisome vital signs.

Arriving at his bedside, my colleague, Dave, and I saw a sluggish, pale man — he’d been in the hospital for almost a month with life-threatening infections. He answered my questions with brief but cogent statements until he suddenly stopped moving, his eyes staring blankly at the wall. I felt for a pulse. There wasn’t one.

“Call a code blue,” I said as calmly as I could, referring to the all-hands-on-deck alert that a patient’s heart had stopped. Dave began doing chest compressions, pressing rhythmically and firmly on Mr. S’s chest, taking the place of the heart in circulating blood throughout his body. I stood at the foot of the bed as the resuscitation team rushed in. A breathing tube wouldn’t pass down Mr. S’s windpipe, so a surgeon performed a cricothyrotomy, cutting a hole in the throat so we could insert a tube to help him breathe. As we paused chest compressions to check for a pulse, 15 wide-eyed faces looked to me to tell them what to do next. Although most in attendance had been involved in attempts to resuscitate patients before, the adrenaline-fueled brutality universal to codes is nearly impossible to get used to. Mr. S’s heart still wasn’t pumping, so we continued.

A few moments later, his arms flailed, thanks to the blood the chest compressions were sending to his brain and the rest of his body. The intern who had taken over for Dave paused in alarm. Another resident reassured her this simply meant her compressions were strong, and urged her to continue pushing.

After more compressions and injections of medicines to bring up the blood pressure and restart the heart, Mr. S’s began to beat faintly. Stable for the moment, we moved him to the intensive care unit. His prognosis was grave, so his family opted against future resuscitations. Later that day, his heart stopped again — that time forever.

We may have revived Mr. S, at least for a few hours, but I’m not sure we really helped him. Were our actions what he truly wanted?

Most people whose hearts suddenly stop don’t survive. Of the more than 200,000 Americans every year who go into cardiac arrest in the hospital, only about one-quarter make it out of the hospital alive. Of those, nearly 30 percent are seriously disabled.

Doctors often don’t adequately convey these grim outcomes; many patients remain falsely optimistic, tending to overestimate their chances of surviving a cardiac arrest. And few people understand what the resuscitation process truly entails, and how these efforts often lead to a painful, undignified death. Recent research also shows that patients and caregivers tend not to be on the same page when it comes to what level of disability or pain might be acceptable to a patient in the future, including after a code.

There’s got to be a way to close these gaps.

The solution starts with a conversation between doctors and their patients about what the end of life might look like. In an effort to make these discussions more common, Medicare now allows doctors to count such discussions, known as advance care planning, as a topic worthy of a doctor’s visit — and of reimbursement under a new billing code — if patients are open to it. Since this change took effect Jan. 1, 2016, nearly 575,000 patients and 23,000 providers have participated in such reimbursed conversations. Of course, there’s plenty of room for improvement: Although that’s almost twice as many conversations as predicted by the American Medical Association, it’s only 1 percent of all people enrolled in Medicare.

It may seem ridiculous to need to pay doctors to have these conversations. Yet given the myriad demands on doctors’ time, making this conversation reimbursable puts it on equal footing with measuring blood pressure, discussing an irregular heartbeat, and other topics long considered vital parts of a doctor visit. These conversations aren’t simply something that are nice to do; they are an incredibly important part of the way patients live and die.

Yet this initiative faces opposition by lawmakers whose fundamental misunderstanding of advance care planning risks seriously harming patients. One such example is the dangerously misnamed Protecting Life Until Natural Death Act, proposed by Rep. Steve King (R-Iowa) this past January. The bill calls for excluding end-of-life discussions from Medicare reimbursement, discouraging doctors from having these important conversations. That’s a problem because in the American medical system, the default position is to do everything possible to revive a patient unless he or she requests otherwise. And in reality, there’s nothing natural about a death prolonged by painful chest compressions, endless needle sticks, and a breathing tube forced down the throat, especially when such efforts are usually futile. In fact, some experts have proposed changing the term “do not resuscitate” to “allow natural death” to better reflect the realities of end-of-life care.

There’s no doubt heroic measures save some lives — but they aren’t what everyone wants. That’s why end-of-life discussions are essential for protecting patients and empowering them to make clear, well-informed decisions that let doctors do right by them. It’s absolutely vital that we keep these conversations going.

Complete Article HERE!

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11/5/17

This might be the most egregious tax proposal of them all

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Business Insider explains one of the Republicans’ most egregious proposed changes in the tax code:

The Republican tax plan repeals an itemized deduction that applies to healthcare expenses. That’s key for families with high medical costs, like those dealing with chronic conditions that require medical devices and other expensive equipment. Right now, those expenses can be deducted from their taxes, but under the Republican tax plan, they wouldn’t be able to.

Under current law, individuals who spend over 10% of their income on medical expenses are allowed to deduct part of those costs from their taxes. The proposed new bill would remove that deduction. According to the Internal Revenue Service, for 2016 taxes, individuals were able to deduct in an itemized way “only the amount of your unreimbursed allowable medical and dental expenses that is more than 10 percent of your adjusted gross income [AGI].”

Who spends more than 10 percent of his or her AGI on medical expenses? Generally people at the end of life in nursing-care facilities, where many expenses are not covered by Medicaid or Medicare. CNBC reports:

“This would be a joke if the consequences weren’t so serious,” said Brad Woodhouse, campaign director of health-care advocacy group Protect Our Care, in a statement. “Republican leaders are determined to raise health-care costs for middle-class families who need it most — in this case people with high medical costs or those paying for long-term care.”

While it’s not a widely used tax deduction — about 5 percent of tax filers claim it — for the old and sick it can be significant.

It tends to be mostly … older people who do not have long-term care insurance, and end up in a nursing home,” said Richard Kaplan, a professor who specializes in tax policy and elder law at the University of Illinois College of Law.

The cost of living in a nursing home can easily run up to tens of thousands of dollars per year and wipe out the savings of elderly residents who are paying out of pocket. The deduction can be an important offset to taxes those Americans would owe on their retirement savings distributions.

“For people who are receiving long-term care and are paying for it themselves, this is going to be a huge deal,” said Kaplan.

Andy Slavitt, former head of the Centers for Medicare and Medicaid Services, tells me, “The medical deduction is one of the most popular and important tax credits, particularly for all of us as we age.” He adds, “It keeps many seniors and families out of bankruptcy when in need of end of life care. Ask anyone with chronically ill kids, parents, or spouses.” These are not only very sick, old people but very sick, old and non-rich people. (“AARP has calculated that about three-quarters of those who claim the medical expense deduction are 50 or older, and more than 70 percent have incomes $75,000 or below. Many of those expenses are for long-term care, which is typically not covered by health insurance. Long-term care can cost thousands or tens of thousands of dollars a year.”)

This move doesn’t recoup much revenue in the grand scheme of things. (“It will cost the government about $10 billion a year in lost tax revenues in 2018 and about $144 billion over the next 10 years.”) So why do it? Well, Republicans have given so many tax breaks to the rich and corporations that they are scrounging for ways to take benefits away from others.

Consider this: The giveaway to rich heirs by removing the estate tax and allowing heirs the “stepped-up basis” adjustment in assets comes to $300 billion. They are literally taking money from nursing home residents so that rich heirs won’t have to pay a dime of inheritance taxes on estates exceeding $11 million (for a couple).

Or think about elimination of the alternative minimum tax, something that costs President Trump and other very rich individuals millions or tens of millions. Repealing it would cost $695.5 billion. Literally, they are taking money from people in nursing homes so that Trump and people like him can pay less in taxes.

There’s only one word to describe this sort of trade-off: obscene.

Complete Article HERE!

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11/4/17

Here’s what traditional funerals are like in the Philippines

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Blindfolded bodies and hanging coffins – the unusual funerals of the Philippines

MANILA, PHILIPPINES – OCTOBER 31: A coffin is placed on a tombstone during a funeral at the Navotas public cemetery on October 31, 2011 in Manila, Philippines. The ‘Day of the Dead (Todos Los Santos), ‘All Saints’ Day,’ and ‘All Souls Day’ are feast days celebrated on the first and second of November each year in Latin cultures around the world during which family and friends of the deceased gather around these days at cemeteries to pray and hold vigils for those who have passed. In the Philippines, family members clean the tombs, leave flowers and often spend the night at the tomb eating and celebrating with loved ones.

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Here in Blighty, we tend to stick to the same tried and tested funeral traditions.

Save for religious elements, funerals in Glasgow aren’t too different from those in Preston; funerals in Wells are largely the same as funerals in Norwich.

This is not the case in the Philippines.

The country is largely Catholic (recent estimates suggest around 80 per cent) with a smaller demographic of Filipino Muslims. But in the more remote areas, tribal traditions, passed down over centuries, dictate some seemingly unconventional funeral customs that are practiced to this day.

From under-floor burials to hanging coffins, cigarette-smoking corpses to in-tree interment, each rite has the same intent: to offer the dead safe passage to the next life.

Blindfolds and cigarettes

Benguet is a landlocked province in the southern tip of the island of Luzon.

When someone dies here, friends and relatives start to convene at the deceased person’s house.

The body is cleaned, and a few of the men are dispatched to collect bamboo, which they then fashion into a chair – and this is where the body is seated.

Once secured in place with more bamboo and strips of cloth, the body is blindfolded so that the deceased does not have to bear witness to the suffering in the world.

A fire is lit to fend off insects and act as a beacon should the deceased’s spirit wander and be unable to find its way home.

This period lasts for eight days and, as you might expect, the body begins to decay.

This holds no fear for the Benguet people – in fact, they make jokes about the smell, and happily offer alcoholic drinks to the body during the mourning feast.

The night before the funeral, elders give a chanted, oral biography of the deceased and as the body is buried, mourners hit bamboo sticks together in the belief it will help the departed find their way to heaven.

The Benguet’s near neighbours, the people of Tinguian, also seat their dead in a prominent position, with a couple of small discrepancies: the Tinguian dress their deceased in their finest clothes then place a cigarette – which is frequently lit – between their lips.

For the llongot people in the mountains the east of Luzon, being seated is integral to burial, rather than the wake.

Corpses are buried sitting up and women have their hands tied to their feet to prevent their ghosts from roaming.

Home is where the heart is

The Apayao – also referred to as the Isnegs or Isnags – inhabit the area around the north of Luzon.

They live mostly along rivers, in large airy homes that sit atop wooden posts, and when they lose relatives, the custom is to bury them under the kitchen area.

It is a unique practice thought to be a sign of love and affection for the deceased.

A natural approach

Not all Filipino tribes keep their dead at home. Further north, the Caviteño have adopted an approach that returns their loved ones to the earth.

As they near the end of life, people of the Cavite venture into the forest and select a favoured tree.

As they ail, their family builds them a small hut in which the dying person will reside for their final days.

They are not alone: relatives and friends work to hollow out the chosen tree trunk as this is where the newly deceased will be buried.

The Cavite people return the deceased to nature as nature provided for them in life: trees are a source of fruit and fire wood that sustain life, so life is given back to the tree.

Closer to heaven

view of Sagada from the rice fields , a colourful village in north of Luzon island in Philippines South east asia

The people in the Sagada region have an interment ritual that is unusual, even among the Filipino tribes.

For more than 2,000 years the people in this mountainous area have hung their coffins from cliffs – coffins that are carved out of hollow logs by the elderly person about to make imminent use of it.

The theory is that by hanging the coffins in this way, the deceased are closer to heaven.

If a person is too frail or ill, the family makes the coffin on their behalf, and after the death the coffin is taken to a cave or hung to reach aspects of the cliff face, placed close to their ancestors.

Some of the coffins are more than a century old, which makes decay inevitable; the coffins eventually fall but this is part of the fulfillment of the rite.

Tourists are advised not to walk under the coffins, and certainly not to disrespect them by touching, but they they hold a unique beauty and can be observed using binoculars from a safe distance.

Ancient superstition

It may be less intensive, but it is customary for Filipinos to adhere to superstitions, or pamahiin sa patay, most of which are rooted in long-held beliefs.

These must be observed during the wake in order to avoid further deaths and bad luck in the family – and as Filipino wakes can last anything from a few days to a few weeks, this is no easy feat.

The Cebuano people have a long list of superstitions around death. They do not sweep the floor, lest the soul of the deceased be banished from the household.

Mirrors are covered, as it is feared the dead will attempt to show themselves in the reflection.

Mourners should avoid crying onto the glass screen of the casket, in case it impedes the spirit from journeying into the afterlife.

And should you sneeze during the wake, make sure someone pinches you – sneezing invites death but a pinch is meant to ward it off.

In the event of an unjust killing, a chick is placed on top of the coffin to bring justice.

While some of these traditions may seem unusual compared with the practices we have developed in the west, family is central to life and death in the Philippines.

The elderly remain at home until the end of life, which means most die surrounded by those they love – something the UK would do well to replicate.

Funerals are a chance for families to reunite, to reconnect and reinforce familial bonds, and often wakes are extended to accommodate overseas relatives.

Togetherness, family, grief and the comfort of ritual: mountains and oceans may separate us, but maybe we aren’t so different after all.

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