Life Is But A Dream – 12/29/14

What does “life is but a dream” mean?

Sometimes when something unbelievable happens, it’s so outrageous (usually in a good way) that it seems like you’re in a dream.

Life is what you make of it. So if you dare to dream, envision what you want it to be – it becomes your reality. It goes right along with the saying “You can be anything you want to be…”

In dreams anything is possible, impossible becomes possible. In life there are limitations with unseen forces that work along with our motives to confuse us more on the path to fulfillment. Life is but a dream – nothing is so easy as to dream it and make it happen right that moment without obstacles standing in way.

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Pain management struggles in the 21st Century

By Tracy Woolrich

According to the American Pain Foundation, there are more than 50 million Americans living with chronic pain. What is unfortunate however is that chronic pain is often improperly treated – or not treated at all. Those with chronic pain will tell you that they feel that there is a war being waged against those who are truly in pain. The answer is to find treatments that work, empower yourself and educate those in the community.


As a nurse with more than 30 years of experience I have witnessed more than my share of pain. During my student nurse days I remember the days of “Brompton’s Cocktail”. It originated in London’s Brompton Hospital and was a concoction made with morphine, cocaine, alcohol and chloroform water. It gained popularity in the 1970s through the Hospice movement with support of Elisabeth Kübler-Ross. However, with advancements during the 21st Century it no longer exists. I personally am glad, as from what I witnessed it did appear to reduce the patient’s pain however at a cost of the ability to have a level of awareness. The patient would be nearly in a coma from sedation. We have come a long way in the ability to control pain effectively. Obtaining and maintaining a proper dose however is another story.

In 2006, the American Pain Foundation surveyed their members and discovered that over 60 percent experienced breakthrough pain while taking routine pain medications. In addition, 75 percent also suffered from insomnia and depression. Activities of daily living were affected with over 25 percent indicating that even driving a car was too difficult to do.

chronic-painThat organization developed the Pain Care Bill of rights and encouraged patients to take an active position in their treatment plan. In my previous position working with chronic pain patients, I would frequently obtain guides and resource items from them to share with their healthcare providers.
In 2011, the Affordable Care Act required the Institute of Medicine to do a study about pain management. In that study it was reported that more than 100 million Americans are suffering from chronic pain. That is staggering and the highest numbers to date.

Despite the growing number of people that are in pain, the war on drugs rages on and in its path there is a tremendous amount of collateral damage. Patients that are truly in pain suffer, and organizations that become advocates and partners cannot sustain themselves. Regrettably in May 2012, the American Pain Foundation dissolved their organization due to lack of funding. They transferred a good deal of their education to other organizations and support groups in hopes of continuing their cause.

Their Pain Care Bill of Rights was a groundbreaking proposition in my opinion. It was an attempt to empower those in pain to take an active role in their care. One of the key concepts was the right to have your pain reassessed regularly and your treatment adjusted if your pain has not been eased.

Because of society’s drug addicted behavior, there have been more and more restrictions placed that are making it difficult for those in chronic pain to obtain relief. Misguided state and federal policies are restricting access to appropriate medical care for people in chronic pain. It is deterring even the most compassionate medical providers from treating anyone with pain conditions for fear of governmental scrutiny and penalties.

Better ways to manage pain are continually being developed. With relief as the goal, patients usually try various pain management techniques (often in conjunction) before they determine what works best for them. It is a very individual thing and may change over time.

There is a myriad of available medications that can be prescribed. From over the counter analgesics like NSAIDS (Motrin and Aleve) to Narcotics (Morphine, Hydrocodone, Codeine). While pain medications will assist in reducing the pain they do little to change the cause other than perhaps NSAIDS that may reduce swelling. As time goes on doses are often increased due to tolerance and often there are side effects such as constipation and stomach upset.chronic-pain-management

Exercise can assist with pain relief in individuals with arthritis. Yoga, tai chi and water aerobics are all very helpful. Some with Fibro and chronic headaches may find the stretching portion helpful.

Massage can reduce pain, increase tissue circulation, relax tight muscles and reduce swelling. In addition it can reduce anxiety and depression and help promote a better night’s sleep. Patients with headaches, arthritis and traumatic injuries will find this helpful. Those with Fibro may find it too painful. Cranial-Sacral work or Reiki may be more appropriate.

This uses a combination of combination of visualization, relaxation, visualization, and feedback from a machine that may help you to gain control of pain. Electrodes are attached to you and plugged into a machine that measures your muscle tension, blood pressure and heart rate. In time you are able to control your thoughts and tension and thus reduce pain and anxiety. It is very effective with headaches.

TENS Units
Transcutaneous electrical nerve stimulation uses low voltage electrical stimulation to block pain signals to the brain. This is accomplished through the placement of small electrode patches on the skin that is attached to a portable unit that emits a small electrical charge. It is used for pain in a localized area. Individuals with nerve pain such as diabetic neuropathy or trauma may find this useful.

Meditation / Relaxation
Through the use of guided imagery and meditation techniques, muscles can have reduced tension and general relaxation. Those with all forms of pain will find this helpful especially headaches and nec/back pain.

Deep breathing
Yoga type diaphragmatic deep breathing involved clearing your mind and focusing on slow deep breaths that are rhythmic. This method of breathing involves breathing in and out, slowly, deeply, and rhythmically. It is through its process of inhaling through the nose and exhaling through the mouth you can release tension and induce relaxation. All those in pain will find this helpful.

Water Therapy
Warm water baths or hot tubs can be soothing and relaxing for muscle and joint pain. Water aerobics is often easier on the joints and can increase range of motion. Patients with arthritis and fibromyalgia may find this helpful.

Hot showers or baths, hot packs, heating pads and paraffin wax baths to hands and feet are especially helpful with arthritic pain.

Cold therapy is a preferred treatment for some people as opposed to heat therapy. Most chiropractors will advice to use cold to reduce swelling and numb the pain to local injuries. Cold compresses or the simple act of wrapping a plastic bag filled with ice cubes, or frozen gel packs can be applied locally. Those with Reynaud’s should avoid the cold.

Pain Management Clinics
Pain clinics are for those who cannot be helped by medical and surgical treatment options by their primary doctors. It usually involves prescription drug management, physical therapy, nerve blocks and relaxation therapy. Often primary care doctors will refer you to such a clinic for pain management if you suffer from chronic pain. This is twofold. It may help to reduce your pain while allowing the attending doctor to eliminate having to explain his pain prescriptions to state and federal agencies!

Support Groups
Sometimes connecting with others that have similar circumstances can not only provide a wealth of information but inspiration to keep going. Only another person experiencing the same level of struggle can understand.

Take home message
Encourage your health-care provider to inform you about the possible causes of your pain, and possible treatments including alternative therapy. Request to have your pain be reassessed regularly and your treatment adjusted if your pain has not improved. Request a pain management referral if your pain does not subside.

Are there other methods you have used to reduce pain? Please leave a comment and explain your experience.
Complete Article HERE!

‘Warehouses for dying people’: Are we prolonging life or prolonging death?

By Peter Whoriskey

The doctor floated through the intensive care unit, white lab coat flapping, moving from room to room, scanning one chart and then another, often frowning.criticalcare_4c1

Unlike TV dramas, where the victims of car crashes and gun shots populate the ICU, this one at Sentara Norfolk General, as in others in the United States, is more often filled with the wreckage of chronic disease and old age.

Of 10 patients Paul Marik saw that morning, five had end-stage kidney disease, three had chronic respiratory ailments, some had advanced dementia. Some were breathing by virtue of machines; others had feeding tubes; a couple were in wrist restraints to prevent them from pulling off the equipment.

For a man at a highly rated hospital surrounded by the technology of medical miracles, Marik sounded a note of striking skepticism: Patients too often suffer in vain attempts to prolong life, he said, because of the mandate to “do everything.” The urge to deploy every last aggressive medical technique, in other words, was hurting people.

“I think if someone from Mars came and saw some of these people, they would say, what have they done to deserve this punishment?” said Marik, gesturing to the surrounding rooms. “People might say we are prolonging life, but we end up prolonging death.”

aggressive end-of-life care3Critics of U.S. health care have long marshaled evidence against the overuse of aggressive end-of-life care, but the idea that many Americans are dying badly — subjected to desperate treatments in ways that are not only expensive but painful and medically futile — has gained currency of late.

This fall, a photogenic 29-year-old with brain cancer made the cover of People magazine with the decision to end her life on her own terms. About the same time, Medicare proposed that doctors be paid for discussing with patients their options for treatment — or not — at the end of life. And on the best-sellers lists is “Being Mortal,” a surgeon’s critique of the way the United States handles decline and death.

In it, author Atul Gawande warns, among other things, that “spending one’s final days in an ICU because of terminal illness is for most people a kind of failure.”

Marik’s long-standing argument, which is notable in part for coming from an ICU doctor, is this: The nation has double or triple as many ICU beds per capita as other Western nations, it spends inordinate amounts of money in the last months of life, and worst of all, this kind of care isn’t what patients want.

His doubts about end-of-life care appear to be widely shared among his ICU colleagues.

A 2013 survey conducted in one academic medical center, for example, found that critical care clinicians believed that 11 percent of their patients received care that was futile; another 9 percent received care that was probably futile, it said.

Marik blames, in part, people’s unwillingness to face up to the inevitable.aggressive end-of-life care2

“Americans not only don’t want to die, they are unwilling to accept the reality of death,” said Marik, who is also a professor at Eastern Virginia Medical School and chief of critical medicine at the school. “Unfortunately, old people get diseases and die.”

It pays to provide treatment

The remedy lies, in part, with hospices, which are hired to take care of patients after they opt out of aggressive end-of-life care.

Amid rapid growth, that industry has been marked by infrequent government inspections and, in places, lapses in quality. But when the service has been properly provided, families sometimes describe it as a godsend, and experts say hospices serve a critical role in the U.S. health system.

A number of factors, economic and personal, keep many patients from enrolling in hospice care, however.

For starters, it pays to keep dying patients undergoing more treatment, according to experts.

“Financial incentives built into the programs that most often serve people with advanced serious illnesses — Medicare and Medicaid — encourage providers to render more services and more intensive services than are necessary or beneficial,” according to Dying in America, a massive report issued in September by the Institute of Medicine.

But strains at a more personal level also keep patients in treatment.

Doctors are reluctant to disappoint a patient with the grim truth, and knowingly or not, keep false hopes alive. Families meanwhile sometimes overestimate the power of modern medicine.

aggressive end-of-life careTake, for example, the use of CPR, the technique that can restart a heart, but which, particularly in the elderly, can result in broken ribs, and even if successful in reviving a patient, may lead to a much-diminished quality of life.

“Have you ever seen it done on television?” Marik asks, rolling down a corridor with a class of students behind him. “They all wake up right away. But in real life, only about 5 to 10 percent of people — if they’re over 70 — leave the hospital alive.”

Indeed, a 1996 New England Journal of Medicine an analysis of popular shows like “ER,” showed that two-thirds treated by CPR survived until discharge.

“When CPR became widespread in the ’60s, it wasn’t considered ethical to perform it on people who are unlikely to recover,” Marik said. “Now it’s done all the time, regardless of the consequences.”

‘A warehouse for the dying’

Marik has been making his argument in published papers at least as far back as 2006, and his criticism echoes others in the field. An ICU doctor in Gawande’s book, for example, complains that she is running “a warehouse for the dying.”

“We’re kind of powerless to change the system — this is what society expects of us and what we are legally required to do,” Marik said. “But many clinicians are frustrated.”

Nurses, who interact with patients more, may be just as adamant about the issue. They see patients grimacing as they clean wounds around tubes into the lungs or stomach; they see confused patients trying to remove breathing equipment; they treat the bed sores of patients immobilized for long periods.

“There are cases where you honestly feel like you are just causing more harm or pain to the patient and you wonder if their family really understands what’s going on,” said Karen Richendollar, a nurse at the intensive care unit at Sentara Leigh Hospital here.

Surveys of intensive care nurses at 14 ICUs in Virginia, published in 2007 in the journal Critical Care Medicine, found that the leading cause of moral distress arises from the pressure to continue aggressive treatment in cases where the nurses do not think such treatment is warranted.

“The distress comes when there is no hope that whatever we are going to do will provide any different outcome,” said Becky Devlin, the supervisor in the ICU here. “The patient is going to die anyway, and we are just prolonging things. That’s where the distress comes in.”

For example, Devlin and Richendollar said, a woman then in their care was more than 90 years old, with blood pressure and severe kidney problems as well as severe dementia. She was being fed through a tube and had a urinary catheter.

Most imposingly, the woman was breathing via a ventilator, and to prevent her from removing the tube that had been inserted into her mouth and down her throat, restraints tied her hands to the sides of the bed.

“No one can be comfortable with all of that,” Devlin said. “Some of the family members are against further treatment, but there are others that make the decisions and they want to keep going.”

End-of-life planning key

One key way to avoid unwanted treatment, according to experts, is to solicit a person’s preferences for end-of-life care before a crisis arrives.

Toward that end, Sentara, which was ranked this year atop the “Best Hospitals in Virginia” by U.S. News & World Report, joined a coalition of hospitals and agencies on aging that in November launched a program to promote end-of-life planning in the Norfolk and Virginia Beach area. It has set up a Web site, planning

The program hopes to inspire people to write down their wishes and appoint a health-care advocate to speak for them if they can no longer do so. Organizers will blanket the region’s religious group and elderly care organizations to encourage people to make end-of-life plans.

“Unfortunately when these situations [in the ICU] come up, families will say, ‘Doc, what should I do?’ But that’s not something that doctors can really answer,” said David Murray, director of the group, known as the Advance Care Planning Coalition of Eastern Virginia. “We need to hear from the patients or their representatives — earlier than we do now.”

Take, for example, one of Marik’s patients, a 72-year-old woman who’d come into the emergency room last month after her family found her confused.

Living at home, she’d long been beset by multiple health woes, mainly congestive heart failure and respiratory problems and bipolar disorder. Given her fragility, it would have been natural to have elicited her end-of-life wishes.

No one did, however, and at the hospital last month the hospital staff and the family spent several anguishing days discussing how best to proceed with her care.

Her labored breathing — her inability to draw in oxygen — was the central problem for the doctors. As she struggled for air, the carbon dioxide levels in her blood rose to dangerous levels. She grew anxious as a result, and this only worsened her breathing.

She was moved to the ICU.

The staff placed an oxygen mask called a biPAP around her head, fitting it snugly around her mouth and nose. The device forces oxygen from a hose into the nose and mouth, but it is often uncomfortable.

As a result, the patient was at risk of removing it. So in addition to being sedated, her hands were restrained — tied by cloth belts to the sides of her bed.

She could be heard that Monday calling out, at times, unintelligibly.

“Take me, Jesus,” she shouted at one point.

She wasn’t the only one bothered by the arrangement.

“The nurses and I were really uncomfortable — this poor little old lady,” Marik said. “She was an elderly demented lady with chronic end-stage lung disease. . . . We were subjecting her to a lot of pain and indignity with very little potential for gain. We shouldn’t be forced into that kind of situation, but we often are.”

By Wednesday, the hospital’s palliative medicine team met with family members, and in the coming days, the patient’s sister and daughter decided to forgo aggressive treatment and opt for measures meant primarily to keep her comfortable.

The uncomfortable mask and the wrist restraints came off. Her vitamins and cholesterol drugs were stopped. She was given medicine for her anxiety, which family members said had been a long-running source of trouble for the patient.

The patient was also prescribed morphine, a drug sometimes avoided until the end of life, but one that relieves pain and calms breathing. Nurses were instructed to give her morphine when her breaths exceeded 20 per minute.

Placed under hospice care, she was sent to a nursing home the next Monday.

There, the patient seemed to rally, regaining the ability to interact with family members. The color returned to her face. She even said she was enjoying music they brought in.

A few days later, after the family had the chance to call in distant relatives, she died.

Marissa C. Galicia-Castillo, a doctor in the hospital’s palliative medicine department, said it is common for patients to die in the ICU hooked up to machines.

“Fortunately . . . [this patient] was able to get out of the hospital into a more home-like environment, enjoy some familiar comforts, visiting and talking with loved ones before the natural end of her life,” she said.

But it wasn’t without the torment before the family decided that the aggressive measures may be introducing more pain than relief. Sometimes frail elderly patients languish weeks or months before family members opt for the comfort measures. Sometimes they die hooked up to multiple machines. In this sense, this patient constituted a success.

“We all knew she was dying, and that was the tragedy,” Marik said. “We knew we were just prolonging her death.”

Complete Article HERE!

Hump Day Humor – 12/10/14

Humor takes the sting away; it humanizes us; it helps us keep our perspective. Humor enriches us; it educates us; it brings us joy. Humor doesn’t dissolve the pain or make our life any less poignant, but it does help make things more bearable. That’s my philosophy, and I’m happy to share it with you on a weekly basis. I hope that if you enjoy what you see, you will take the opportunity to share it with others.

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Cemetery Art – 12/08/14

The task of interpreting the symbols on a headstone or memorial is a daunting one. Although most of the symbols that you will see DO have a textbook meaning, it is quite possible that the headstone or memorial you are looking at was put there simply because someone liked the look of it. Therefore, it will have no meaning beyond the taste of the deceased or those left behind to morn. The point is that many people choose a memorial motif not for its textbook meaning, but simply because they like the ornamentation or design, because it feels “right” or appropriate.

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