02/19/18

We Need to Revolutionize End-of-Life Care — Here’s Why

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Because it’s time to start thinking about death differently.

By Laura Dorwart

When Victoria Chang’s mother was diagnosed with pulmonary fibrosis, she didn’t have a single person she felt she could turn to. Six years earlier, her father had a stroke that led to significant neurological changes, and now the young poet realized she alone would have to care for them both. None of her friends had sick or elderly parents, so she felt completely isolated.

What followed was a decade of navigating America’s imperfect end-of-life health care system, without much guidance from the doctors and specialists she so frequently encountered. When asked what she would have done differently over the course of the stressful years, Chang says, frankly, “Everything.”

“Everything was a learning curve, everything new,” she says, noting how she wished there had been more help for people like her. “Emotions were high, and we needed a case manager or a consultant or something. Hospice seemed to help, but in the end, there was only so much they could do.”

Chang’s experience caring for seriously ill loved ones is sadly not unique. Thanks to a combination of denial, a lack of know-how and flawed systems, most Americans don’t have the support they need when it comes to end-of-life care. According to a study by the California HealthCare Foundation:

Furthermore, a majority of those surveyed had not even communicated their end-of-life wishes to the loved one they would want making decisions on their behalf. That’s where Dr. Ira Byock, chief medical officer of the Institute for Human Caring at Providence St. Joseph Health, comes in. A renowned expert in palliative care and the author of The Four Things That Matter Most: A Book About Living and The Best Care Possible, Byock wants to reimagine health care as a more personal, approachable system. He wants to boost the person-to-person communication and eradicate denial — an approach he and his colleagues call Whole Person Care.

Dr. Byock

“[Whole Person Care] attends not just to your medical problems, but to your personal priorities, values and preferences,” explains Byock. “You’re someone with bodily needs but also have emotional, relational, social and spiritual parts of your life, all of which need to be attended to.”

This perspective may not seem all that radical, but it is clearly not the current practice. American medicine is good in that it’s a “problem-based system,” Byock says. “It is organized around your problem list on your chart. Everything we do, by design, responds to a problem on your list.” But life isn’t just a set of problems to be solved; patients have lives that extend well beyond the walls of hospitals and waiting rooms. Health care, in Byock’s opinion, should address this reality at all stages of life.

Perhaps most importantly, Whole Person Care includes patients’ families at every level of care. Byock emphasizes the significance of the familial role in a patient’s comfort, as well as the ripple effects of a single individual’s illness on loved ones and their network of relationships. “Whenever one person gets a serious diagnosis, everyone who loves that person shares in the illness. It’s a family and community issue.”

Chang, for one, can attest to the need for a system like Whole Person Care. “Looking back, I can’t remember the past decade because I was so busy helping everyone around me,” she says.

When asked what advice she would give to those caring for a family member or spouse dealing with a serious illness, Chang emphasizes the importance of self-care and finding community support in whatever form that might take. Remember that “it is OK to think about yourself and to take care of yourself,” she says. “Seek out groups to share with and to get emotional support. I only did this toward the end when I started reading about and writing to people on the pulmonary fibrosis foundation website. Those forums saved my life.” She also encourages folks in similar positions to consider their options, including daycare, homecare and facilities, and weigh the pros and cons of each.

Byock also encourages those faced with these situations to manage their own health: “People can experience wellbeing even in the midst of serious illness.”

Complete Article HERE!

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02/16/18

What is the Death Positive Movement?

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Some of us think of it often, others none at all. Sometimes we joke about it, other times fear it. No matter your approach or point of view, the fact remains: we will all inevitably die. It is literally the one thing we all have in common. And, on top of that, we will have to bear witness to the deaths of those around us. Yet, in spite of this irrefutable fact, Western culture doesn’t seem to be able to talk about the big “it.” Instead of allowing this commonality to bring us together, it often alienates us from each other. This is where the Death Positive movement comes in.

It is allude to in popular culture, through commercials, music, and other types of media. It is the subject of films and novels, and even television series. But even though we are in many ways surrounded by representations of death and grief, its presence and role in our own lives is something many feel afraid or uncomfortable speaking about. It is this internal and societal conundrum that many of us experience that is the focus of the “Death Positive” Movement.

The Death Positive (or Death Positivity) Movement is represented by the general (and growing) movement toward opening platforms for discussion about the inevitability of death and dying. The movement focuses on the importance of encouraging open discussions on the reality of both our own death, and the death of others. This includes the creation of platforms and spaces where such discussions can transpire in a comfortable, honest, open, and curious environment; where individuals may come together with different perspectives and exchange them with one another.

It also has a very practical goal of teaching us how to speak to others (i.e. our parents and partners) about their end-of-life wishes, as well as our own. The hope is that death will become de-mystified, and that as a result, society (and the individuals that comprise it) will be able to prepare for death and the grief that often follows. More importantly, discussing death and dying actually enables us to think about our own immediate lives. It encourages us to lead the life we want to live, and appreciate the little things.

You may be wondering where it is that these death positive discussions take place? How can you become involved? We’ll give you hint- it doesn’t happen in mortuaries or creepy church basements over skeletons and ouija boards. There are in fact a number of platforms- both online and in physical spaces- where death positive discussions take place on a regular basis.

One of the most widely and regularly practiced organized series of discussions on death and dying are known as Death Cafés, and occur all over the world. First established in 2004 by Swiss social anthropologist, Bernard Cretan, with the intention of breaking the taboo surrounding discussing death, they have since been held in cities all over the world. At a Death Café people will gather over coffee and treats to discuss death, dying, and experiences of grief.

Much of this discussion enables the participants to understand what is most important in their lives, allowing them to focus on these positive elements to live more fully and happily. They are often held in different locations throughout a given city, but always with the intention of creating comfortable spaces to discuss personal experiences and questions about death, dying, grief, and all that’s in between.

We highly recommend taking part in a Death Cafe in your area!

Complete Article HERE!

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02/15/18

Writing a ‘Last Letter’ When You’re Healthy

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Participants in the Stanford Letter Project working on letters to their family members.

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Over the last 15 years, as a geriatrics and palliative care doctor, I have had candid conversations with countless patients near the end of their lives. The most common emotion they express is regret: regret that they never took the time to mend broken friendships and relationships; regret that they never told their friends and family how much they care; regret that they are going to be remembered by their children as hypercritical mothers or exacting, authoritarian fathers.

And that’s why I came up with a project to encourage people to write a last letter to their loved ones. It can be done when someone is ill, but it’s really worth doing when one is still healthy, before it’s too late.

It’s a lesson I learned years ago from a memorable dying patient. He was a Marine combat veteran who had lived on a staple diet of Semper Fi and studied silence all his life. A proud and stoic man, he was admitted to the hospital for intractable pain from widely spread cancer. Every day, his wife visited him and spent many hours at his bedside watching him watch television. She explained to me that he had never been much of a talker in their 50-plus years of marriage.

But he was far more forthcoming with me, especially when it became clear that his days were numbered. He spoke of his deep regret for not having spent enough time with his wife, whom he loved very much, and of his great pride in his son, who had joined the Marines in his father’s footsteps.

One afternoon, when I mentioned these comments to his wife and son, they looked incredulously at each other and then disbelievingly at me. They thanked me for being kind but stated that my patient was incapable of expressing such sentiments.

I wanted to prove my credibility and to make sure that his wife could actually hear her husband professing his love. I knew he was unlikely to speak to them directly. So I took my huge family camcorder with me the next morning on medical rounds and – with the patient’s consent — recorded an open letter from him to his family. When I gave them the taped letter as a keepsake, both his wife and son were moved to tears.

The experience inspired an idea that has grown into the Stanford Friends and Family Letter Project. With guidance from seriously ill patients and families from various racial and ethnic groups, we developed a free template for a letter that can help people complete seven life review tasks: acknowledging important people in our lives; remembering treasured moments; apologizing to those we may have hurt; forgiving those who have hurt us; and saying “thank you,” “I love you” and “goodbye.”

A letter by a project participant named Harvey Brown, written with the help of his wife, Wanda Brown.

While these may seem intuitive, many people don’t complete these steps before they die, leaving their family members with unanswered questions and regret.

(A video showing people participating in the project can be seen here.)

The letter template, which is available in eight languages, allows writers to express gratitude, forgiveness and regret. In one letter, a participant wrote to his wife, Lily, “I wish I had loved you more.”

Many writers use the templates to express pride in their children in ways they might not do in person. One wrote to a son, Michael: “You are so courageous to change your major and do what it takes to be successful to reach your dreams.” Another wrote, “Life for us was never easy but you overcame obstacles.”

And some apologize. A man named Tyrone Scott wrote to his daughter, “I’m sorry that I wasn’t there when you were growing up. If I could relive my past, I would not have let your mother take you away from me.”

The letters can be a chance to let go of grudges. Shirley Jones wrote, “To Harold: You have forgotten to repay some of the personal loans you obtained from us. We are wiping your account cleared.”

So we invite you to use the “Dear Friends and Family” template and write your letter now while you still can.

Those with chronic or serious illness may use the illness letter template; there is also a healthy letter template for those in good health. In working with people from diverse cultural backgrounds, I found that some were reluctant to complete the “goodbye” task for fear that it might become a become a self-fulfilling prophecy. I recommend that people write only the parts they feel comfortable with.

Once the letter is written, you can choose to share it with your loved ones right away. You can also store it in a safe place or with a trusted person to be given to your family in the future. Some people prefer to use the letter as a living legacy document and update it over time.

It may take tremendous courage to write a life review letter. For some people, it evokes deep and troubling emotions. Yet it may be the most important letter you will ever write.

Complete Article HERE!

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02/12/18

Doulas provide compassionate end-of-life care at North Hawaii Hospice

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North Hawaii Hospice Volunteer Coordinator Bobbi Bryant developed an end-of-life doula program for volunteers earlier this year.

By Jan Wizinowich

Since 1986, North Hawaii Hospice has been providing end-of-life care and support for their local community members. The in-home care by their trained staff and volunteers has eased the journey out of life and given support to family and friends left behind.

Recently, through the efforts of Bobbi Bryant, the hospice’s volunteer coordinator, training has been offered to volunteers to become end-of-life doulas, returning to old wisdom and benefits that can be derived from it.

“Caring for the sick and dying before the Civil War happened in the home. It was just a continuation of women raising children. They cared for the elders at the end of their life,” Bryant said.

But with the rise of medical technology, the end-of-life stage was taken out of the hands of the family, and the knowledge and wisdom was lost.

“People were being brought to the hospital to die, and then they were embalmed so we weren’t really caring for people at the end of life. We lost our skills,” Bryant said.

The resurgence of end-of-life doulas are a reflection of the return of birth doulas beginning in the 1970s.

“Midwives to the dying have been around for a long time. It started as a result of the resurgence of birth doulas and midwives. The model transferred to how we can care for people at the end. There was a lack of education around the dying process and when people wanted to start caring for their loved ones, there was a lot fear. The conversation around death had come to a standstill,” Bryant reflected.

Recognizing the need for doula training, Bryant attended a conference on death and dying on Maui last April.

“When I came back, I spent the next several months creating a curriculum and trained 14 people including nurses, an ER doc and health aids,” she said.

The decision to enter hospice care can be difficult, but once made it can free the family and caregiver to focus on the patient.

“If you come for hospice support early, you can have so much support. There’s so much pain and suffering that isn’t necessary,” Bryant shared.

The North Hawaii Hospice team includes a lead, general and vigil doula. Initially, the lead doula meets with the family and the patient to provide information about all the ways they can assist them, and establishes a relationship of trust.

The doula’s role is to provide non-medical comfort and to be a facilitator; both subtle and profound. On a practical level, the doula does whatever needs to be done — offering companionship, running errands, assisting with household chores, providing healthful meals and helping with bathing and personal care.

“You just be there, be grounded and love them. You need a way to get trust from people. As soon as I get there, I get my hands on them. The medicine doesn’t always help. So when they’re in a lot of pain I’m running energy with that pain and helping them to move the pain through, and helping them to relax,” said Rose Riedesel, a hospice volunteer and healing body worker.

But a primary role for the doula is to sit, listen and be aware of what’s happening with the various aspects of the patient’s care in order to act as an information conduit between the medical care team and the patient.

“The doula is an adjunct to the professional people involved. They’ll find out some information that the care team needs to know and they’ll pass that on, or if the family needs some information the doula will pass that on to them,” Bryant said.

Emotional well-being is vital to ease the dying process. A big part of the doula’s role is to encourage the patient to “talk with people about their life and find places of deep meaning; a deep connection in life, the people who meant something to them in their life, the experiences, what their passions were and what their difficulties were. It allows the person to sink into this process of dying,” Bryant observed.

Another role for the doula is to notice any unresolved issues, which can cause anxiety and tension in the patient.

“They listen in the stories for anything that’s unresolved. Sometimes you’ll hear something about a family member who needs to be forgiven. We want that person to have as much relaxation as possible in the end,” Bryant said.

The lead doula also helps the patient and family with a vigil plan that includes the creation of a peaceful space, along with a team of doulas sitting in shifts when the active dying phase begins.

“They help create a beautiful space for the dying person to be in with things such as art, quilts, photos and a certain scent. They ask, ‘Would you like something read to you? Who do you want with you? Can somebody get into bed with you?’” Bryant said.

After the patient has passed, the doula assists the family in making arrangements, and follows up with them.

“The doula assesses how to help the family at that time and backs out. In a couple of days, they give the family a call and ask to come and talk about what happened, maybe a beautiful touch or an interaction before the person actually stopped speaking,” Bryant said.

Just as with the birth process, dying is a time of loving connection.

Complete Article HERE!

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02/4/18

His wife of 73 years was dying. A ‘death doula’ eased the way for her and his family

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Caretaker and end-of-life doula Lisa Jeansonne helps people who are dying stay in their homes rather than having to go to a hospital.

Jack Zito, 96, and Lisa Jeansonne, an end-of-life doula and caregiver, play Scrabble at Zito’s kitchen table on Jan. 24, 2018 in Sister Bay, Wis.

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John “Jack” Zito, 96, doesn’t give up easily. When his wife of 73 years was facing her final days last year, Zito put every ounce of energy and effort he could muster into caring for her so that his beloved Noni could die at home.

Noni died in May; she was 95. It was about a year before she died, as her health was rapidly deteriorating, that Lisa Jeansonne began helping Zito. An experienced end-of-life caregiver, Jeansonne’s gentle presence and calm demeanor was the balm Zito sought as he cared for his ailing wife.

Zito’s eyes moistened and he dabbed at them with a handkerchief in a recent interview, remembering his wife and the care Jeansonne lovingly gave her.

“That is why Lisa is here now,” Zito said. “She looks after me. When that time comes, she’ll be here to help me, too.”

Jeansonne would go on to receive specialized training from her employer to become an end-of-life doula — a professional who can provide comfort to a dying person, and support to that person’s family. It’s part of a growing recognition across Wisconsin and nationally that caring for the dying is a skill — for some, a calling — and can be a pillar for family members.

For Zito, Jeansonne’s care for Noni, given name Margaret, helped forge a lasting emotional connection.

Jack Zito, 96, looks at photographs of his children playing with a young Lisa Jeansonne, who now serves as caregiver for Zito and previously took on the role as an end-of-life doula for his wife, Noni, so she could die at home.

A World War II veteran and retired Chicago business owner, Zito has the strong, clear voice of a younger man. He enjoys puttering about the kitchen cooking, verbally sparring with Jeansonne as they duel in Scrabble games and “letting her” drive when the duo completes household errands. Noni’s death has left a chasm in Zito’s heart and Jeansonne’s companionship partially fills the void.

The Zitos literally landed in Door County after summers of sailing the Great Lakes when they retired to their favorite boating site. They immersed themselves in church and community activities in northern Door County from their home nestled in the woods near Sister Bay. Noni avidly painted watercolors of the area’s fabled scenery and wildlife, while Zito happily assumed the housework and cooking duties.

For decades their health was good and the couple relished visits from family and hosting barbecues with friends.

Old age began to catch up with the Zitos in 2016 when Noni was diagnosed with congestive heart failure. Zito said he knew the end was coming, but he was determined to care for Noni so that she could die in their cherished home in the northern Door County woods.

The pressure to care for his dying wife was fatiguing and it was emotionally draining to watch Noni decline, he said. Although Zito insisted to his children, who are scattered across the nation, including in Door County, that he didn’t need help, his family arranged for a part-time caregiver from Advocates In-Home Care in Sturgeon Bay.

Since Zito was adamant he alone could care for his wife, he devised a plan. When the hired caregiver arrived for the first day of work, he was going to be friendly, and explain he had everything well managed.

That plan slowly melted when Jeansonne knocked on Zito’s front door about two years ago. Her handshake was firm and she looked him in the eye while explaining her role to help him.

Lisa Jeansonne, an end-of-life doula and caregiver, waters plants at 96-year-old Jack Zito’s Sister Bay residence on Jan. 24, 2018.

Later that day, a bond began to develop as Jeansonne and Zito sipped coffee at the kitchen table while Noni slept. Lisa said to Jack, “I know you. Your kids are about the same age as me and we used to play together in the summer.” Lisa refreshed his memory with tales of summers boating, swimming and fishing off of the Ephraim marina with his kids.

Zito’s eyes filled with tears as he told the story of that day, but he was also smiling. From the very first day, Zito said, he could see that Jeansonne’s quiet presence and easy manner was exactly the help he and his wife needed.

“That day, I saw how good Lisa was with my Noni, and, why she was practically like family,” Zito said.

New movement to die at home

While Jeansonne was hired as a caregiver, she also assumed a role that she has fulfilled dozens of times during earlier positions with families — giving specialized, attentive care to a family member who was dying.

The care Jeansonne provides isn’t medical. Rather, it focuses on doing whatever is needed to ensure the dying person is comfortable. It’s a holistic approach that offers emotional, spiritual and physical support to clients and families.

Jeansonne and other caregivers at Advocates In-Home Care are trained as end-of-life doulas. It’s part of a new movement to enable the dying to remain in their homes.

Similar to a doula who cares for and supports a woman through her pregnancy, an end-of-life doula supports a patient and the family through the dying process, said Marggie Hatala, a registered nurse and end-of-life doula in Door County.

Hatala also is a certified trainer for Doulagivers End of Life Elder Care Training Program and founded Doula Givers of Door County more than a year ago to offer free seminars about end-of-life care and also the training for certification as an end-of-life doula — or, as it is sometimes known, a “death doula.”

The end-of-life doula is there to listen and develop a relationship with the patient that transcends the illness and may last days, weeks or years depending on the prognosis, Hatala said.

“Dying and death has become institutionalized, that everyone dies in a hospital or nursing home,” Hatala said. “Most people want to die at home and they don’t want to die alone.

“People are awakening to the fact that there is a way to have a good death.”

About 25 percent of the Door County population is 65 years or older, according to the state data from 2015. In the same year, about 12 percent of the state’s population was 65 years or older.

Based on population trends, Wisconsin’s elderly population in the state will grow 72 percent by 2040, according to the Department of Health Services.

“This is happening throughout the United State — as the baby boomers are aging, there is going to be a growing need for in-home care,” Hatala said. “Door County already has a large aging population that wants to grow old in their homes.”

A former hospice nurse, Hatala said she was frustrated by being limited to providing medical care when she saw that patients wanted and benefited from having a person consistently with them as they were dying.

“I felt a true need to remain with a patient and their family without any agenda, simply to be present to them,” Hatala said. She became trained as a doula and later completed the certifications to teach and train others after she moved to Door County about five years ago.

In 2017, Hatala’s first class of caregivers from Advocates In-Home Care, including Jeansonne, became certified through Doulagivers of Door County program. Besides training to provide physical, emotional and spiritual support to the dying and their families, doulas also receive training to support family members following the death.

End-of-life doula care is paid for privately unless there is a portion of the service that is covered through the caregiver services provided to a client. The cost for end-of-life doula care is about $20 an hour.

Death can be frightening for an ailing patient and it also raises anxiety for family uncomfortable with death, said Mary Beth Williams, a hospice nurse and caregiver with Advocates In-Home Care. “Most people do not want to die alone, and they want to die at home where everything is familiar with people that they love.”

Doulas work in tandem with medical professionals and hospice programs to provide care that integrates the emotional, spiritual and physical support clients and families seek. It’s different from being a hospice nurse, Williams said, because while the nurse in hospice care focuses on a patient’s medications, a doula’s role is to provide a patient with comfort.

“As a doula, you’re aware of the pain (a patient has) and the medications they are taking, but a doula finds other ways to provide comfort; for example, if someone is short of breath, a fan on their face or elevating their head might be beneficial,” Williams said.

Hatala also conducts online training classes for people throughout Wisconsin.

The participants in Hatala’s online classes are as diverse as the regions of the state where they live. They include a paralegal from Sheboygan, a retired minister from Manitowoc and a practitioner of alternative pain management therapies from Green Bay.

They shared similar stories of being drawn to doula care after exposure to aiding the dying and finding it was a fulfilling and gratifying experience.

The Sheboygan paralegal, Shannon Shaurette, was exposed to hospice care while her father was dying from cancer seven years ago at a Milwaukee hospice.

“The hospice workers were beyond amazing to my dad, my mom and the rest of our family … and after my father died I thought about volunteering at a hospice, but the timing wasn’t right,” Shaurette said.

A friend from Vermont told Shaurette about the growing movement to die at home with the support of an end-of-life doula. She started the classes because she wanted “to be able to bring the same feeling of comfort, peace and love to others, as the staff at the hospice did for my family,” she said.

Jack Zito, 96, sits at the kitchen table in his Sister Bay home on Jan. 24, 2018, while talking with Lisa Jeansonne, an end-of-life doula and caregiver, who currently helps Zito with chores and visits with him three times a week.

A way to a ‘good death’

For Zito, the care Jeansonne gave his wife made her “almost family.”

Prior to the day Noni died, she had been talking and sharing memories with family who had gathered at the Zito home. When she slipped into a deep sleep May 21, family members stayed at her side, holding her hand throughout the day. Zito was gone for a few minutes to make more coffee in the kitchen. When he came back, Noni had died.

“It was very peaceful,” he said. “People were with her, she was holding her son’s hand and she had a smile on her face.” Zito said he will be “eternally grateful” for the hospice care and Jeansonne’s attention to details that provided Noni and his family additional comfort.

Since Noni’s death, Jeansonne has continued to provide part-time care for Zito.

“I do the cleaning and we do grocery shopping, trips to the library or the hardware store together. We like to play Scrabble and Jack loves to read,” she said. “Jack can pretty much take care of himself, but I’m here for the help he does need.”

When Zito’s time arrives for his final journey, Jeansonne said, she will be there to help him and his family.

“He’s a wonderful man and adored his Noni. It’s a gift I can give him to make him as comfortable as possible,” she said.

Learn more about the end-of-life doula program

To learn more about Doulagivers of Door County, call Marggie Hatala at 920-495-1566 or check the website www.marggiehatala.com

Complete Article HERE!

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02/1/18

Death Brings Wisdom to Dying Patients

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By Mary Elizabeth Dallas

With terminal illness comes newfound, and profound, wisdom, researchers report.

They uncovered this silver lining of terminal illness as people in their final months tried to strike a balance between accepting their fate and making the most of the time they had left.

“The end of life presents a unique perspective,” explained senior study author Dr. Dilip Jeste, senior associate dean at the University of California, San Diego’s Center of Healthy Aging.

“This is an extremely challenging time, a confluence of learning to accept what’s happening while still striving to grow and change and live one’s remaining life as best one can,” Jeste said in a university news release. “It’s this paradox that, if embraced, can lead to even greater wisdom while confronting one’s own mortality.”

The study, funded in part by the U.S. National Institutes of Health and the American Cancer Society, involved 21 men and women between the ages of 58 and 97 who were in the final six months of their lives and receiving hospice care. About half of the patients were dying of cancer.

The researchers asked these people opened-ended questions about wisdom, such as “How do you define wisdom?” and “What experiences have influenced your level of wisdom?” The patients were also asked if their illness had altered their understanding of wisdom. Each of the interviews was recorded, enabling the researchers to analyze and interpret the responses.

The participants ranked traits associated with wisdom. The most important quality listed was having prosocial behaviors, followed by demonstrating social decision-making, emotional regulation, openness to new experiences, awareness of uncertainty, spirituality and self-reflection, as well as having a sense of humor and being tolerant.

The patients admitted that facing their own mortality and imminent death dramatically changed how they viewed wisdom. “My perspective, my outlook on life, my outlook on everything has changed,” said one of the patients. “It’s grown tremendously.”

One common experience among the terminally ill was their desire to find peace or acceptance as their health declined and they lost their ability to function normally.

According to study first author Lori Montross-Thomas, “It wasn’t passive ‘giving up,’ but rather an active coping process. They emphasized how much they appreciated life, taking time to reflect. There was a keen sense of fully enjoying the time they had left and, in doing so, finding the beauty in everyday life.”

Montross-Thomas is assistant adjunct professor in UCSD’s department of family medicine and public health.

One study participant said: “For all my life, being a Southerner and having been in beauty contests, I got up in the morning, put my full makeup on and did my hair every day. A lady was never in her nightgown unless she was giving birth! Now all that is very, very difficult for me… I’ve accepted it, and I’ve realized that I have to let it go… I try to take all this with as much graciousness as possible and I’ve realized that my friends really don’t care that I don’t have makeup on or I’m in my nightgown. They are just happy to see me out of bed sitting on a chair.”

The patients also found that living with a fatal disease stimulated growth, leading to more determination, gratitude and optimism. The researchers noted this path to increased wisdom ebbed and flowed as the patients struggled to find balance, peace and happiness at the end of their lives.

Many patients focused on looking for the positive instead of the negative. “I want them to remember me with a smile, laughing and giggling and doing some of the silly things we do,” one person said. “Why do you want to leave on a sad note? I do not want to be remembered being sad.”

Complete Article HERE!

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01/31/18

With the End in Mind & Letting Go review: Ways to have a good death

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By Gail Bell

In my early years in hospital pharmacy we made Brompton’s Cocktail in accordance with prevailing clinical guidelines, that is, “to order, for terminal patients”. The cocktail consisted of morphine crystals, cocaine powder, alcohol, syrup and chloroform water and it was given sparingly, on the fourth hour, to a patient in extremis.

In her welcome, engaging book, With the End in Mind, Dr Kathryn Mannix, revisits this practice, using it to highlight the days when medical morphine was spooned out cautiously, often in doses too feeble or too potent for the individual, the days, she writes “before we had worked out how to titrate painkillers”.

Informed by her staff that a new hospice admission was refusing morphine on the basis of bad memories of Brompton’s Cocktail, she visited the dissenter personally and discovered a retired psychiatrist who had once tutored her at medical school. In his experience, patients were rendered semi-conscious by the “industrial strength drug mixture”, unable to speak coherently or with dignity, attributes he could not accept for himself or put his family through. Mannix conquered the role reversal implications of ministering to her one-time mentor and employed her softly, softly conversational approach to bring him to a position where “he might allow that medicine had progressed” since the 1980s.

Mannix is a British palliative-care specialist who, in her own words has spent “half a lifetime … keeping company with the dying”. Her book is part memoir, part witnessing and a good part wise counsel in best practice for the dying. Her strong suit is conquering the moment with a quiet conversation, often begun in an atmosphere of heightened emotions, fixed beliefs and the competing interests of family gathered at the deathbed.

She is a natural storyteller with an eye for detail, dialogue and the telling moment. “I am offering the reader my eyes and ears, my seat at the table, my place in the conversations, and my perspective on events.”

As recently as 2016, Australian author, the late Cory Taylor, wrote in Dying: A Memoir: “For so many of us, death has become the unmentionable thing, a monstrous silence. But this is no help to the dying, who are probably lonelier now than they’ve ever been.”

Mannix wants the lost vocabulary as well as the etiquettes of dying brought back to the death bed. She teaches families what to expect, to give each phase of the body’s shutting down a name. She begins with “the gradual increase in daytime sleeping, the gradual reduction in time spent awake” and ends at Cheyne-Stokes pattern breathing, cycles of fast-to-slow breaths, often with long gaps between, until the “gentle ending of the cycle”. The approach of death, she hopes, will one day be conceived more generally as a process, like birthing, moving stage by stage to an outcome.

The other string to Mannix’s bow is her qualification as a Cognitive Behaviour Therapist, a discipline she used to develop coping strategies for people facing impending death (she wrote Britain’s innovative CBT First Aid Plan for palliative care).

This psychological intervention is reported to dramatic effect in the case study of 22-year-old Mark, who was in the end stage of cystic fibrosis with no transplant available. He was incapacitated by panic attacks, gripped by fear and very angry. Mannix took his fear, put it on paper in a diagram and allowed him to discover how adrenaline was driving the circuit, creating a self-defeating increase in his panic.

The liberating effect of studying the pattern allowed Mark a few months of relative freedom from fear (including a pub outing with mates) before he developed a fatal chest infection. Mannix was called to see him and was greeted by Mark at his most triumphant: “You should be f—ing proud of me … I’m f—ing dying and I’m not f—ing panicking!”

Dr Charlie Corke is an Australian intensive-care specialist and a strong proponent of timely advanced-care planning. His book, Letting Go, walks the same terrain as Mannix but his map is the ICU of a busy hospital where decisions are made on the run, as it were, not in the relative quiet of a hospice setting. His patients arrive in ambulances, desperately ill, close to death, often unable to communicate their wishes, and reliant on a frantic relative’s instructions.

“Doctors and families feel a tremendous responsibility to do something to save (or extend) life,” he writes. “This happens however unpleasant the medical journey is likely to be — and however poor the outcome.”

In crisp, clear prose Corke confronts the reader with the scenario most of us in Western society are likely to face after a period of declining health and function: ambulance, hospital, unconsciousness, no plan in place, family disagreements about treatment, escalation of medical intervention, and finally, our last days spent “connected to machines, cared for by strangers, and separated from family”.

“Medical terminology will dominate our last days and weeks,” he writes.

While not denigrating his own profession, he takes a humanistic approach to its limits. The reader learns of the “covenantal ethic” whereby a surgeon promises to use his or her skills “to battle death on behalf of the patient. In return, the patient puts their trust in the surgeon and accepts whatever is required”. The covenant can have unwanted outcomes, notably when a surgeon has not been given prior permission “to stop if things [go] badly”.

Keeping in mind that “saving is what doctors do”, Corke advocates forward planning well in advance of old age and infirmity, in writing, with the added backup of an appointed decision maker.

He presents brief case histories to show how things can go wrong. Rosalie’s story, for instance, gives pause for thought when appointing a decision maker. She chose May, her only daughter, as her agent. May gave up her job to care for her mother and swore to sensitively respect her mother’s wishes. When Rosalie was taken to hospital after developing a severe infection, May acted upon her mother’s stated wishes: comfort care with no burdensome attempts at cure.

However, May’s five brothers arrived at the hospital and exerted pressure on May to instruct the doctors to do everything possible to “save Mum”. Rosalie was put on life support, had six operations, developed multiple organ failure and finally died. May, writes, Corke, “seemed crushed and guilty”. The message is clear, he summarises, inform everyone concerned beforehand and obtain reassurance that all will respect the bargain.

Making choices is hard. Corke suggests that “prior (well-considered) wishes should carry more weight than a later decision made in a crisis”. And he covers all the bases, from religious to legal ramifications, to distorted portrayals of the success rates of CPR in TV and film, and emotive journalism around withdrawing life support.

The book ends with practical tips and accompanying case histories, tying up Corke’s thesis with the kind of wise, informed advice we crave in the era of Dr Google, advice that may be more useful than we think in light of the recent Productivity Commission Report into palliative care in Australia. Seventy per cent of Australians wish to die at home, without pain and surrounded by family. The “without pain” part is the work of the severely underfunded palliative care sector. Fourteen per cent achieve that goal.

As a manual for how to avoid ending up in ICU, in what one of Corke’s patients called “the bad bit at the end”, Letting Go is a guide book for our age.

Complete Article HERE!

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