As a doctor, I’m trying to have more empathy for my patients — and myself

By Joseph Stern

“Well, then. I’m going to die, aren’t I?” my friend asked me from a bed in the emergency room. I faced him and his wife. I had worked with Alan Davidson for 20 years. A recently retired ER attending physician, he came in with new right-sided numbness one Saturday evening.

Initially, the ER team called a “code stroke,” rushing to take advantage of the precious minutes available to administer clot-busting drugs or open blocked arteries before the patient suffers more brain damage. A CT scan suggested not a stroke but a brain tumor. I was consulted when an MRI suggested a glioblastoma. We both knew his prognosis was likely poor.

Three days later, I took him to surgery, aware that he was trusting me with his life. When he awoke, Alan and I were pleased that his numbness was no worse and he had no weakness. The postoperative scan showed we had removed virtually the entire tumor.

When the pathology came back, I met with Alan, his wife, and his son. I sat on the edge of his bed and told him his diagnosis. Pathology suggested glioblastoma, a malignant brain tumor with a terrible life expectancy. Neither of us was surprised: We both knew this was coming. But he choked up as he expressed gratitude for the care he was receiving.

Holding back my own tears, I told him how honored I felt he trusted me enough to care for him. Previously, I would not have allowed myself to acknowledge my own gratitude to Alan or accept the depths of his gratitude to me: I would have pushed these feelings away.

More than 25 years earlier, I had faced a similar situation with different results. As a resident, I helped my supervising doctor remove a tumor from deep within the temporal lobe of a man in his 30s. The surgery went well, but we knew the patient’s prognosis was dismal. I entered the cramped consultation room and encountered, for the first time, his wife and three small children. They nervously awaited our report.

I couldn’t bring myself to tell them this was an incurable tumor from which the patient would die in the near future. Instead, I parsed my words. They were technically correct, yet detached. Overwhelmed, I had no idea how to face the patient’s family. What they needed was honesty and compassion. Instead, I avoided connecting, leaving someone else to fill in the gaps. To this day, I carry a sense of shame and failure: I avoided pain, but fell short as a physician.

Physicians develop detachment and emotional distance as a coping mechanism against the pain of grief, loss and failure. Yet our attempts to protect ourselves through detachment ultimately intensify feelings of loss and deprive us of resolution. I have come to see that these unresolved feelings contribute directly to professional burnout.

Mary Buss, director of ambulatory palliative care at Beth Israel Deaconess Medical Center and associate professor of medicine at Harvard Medical School, says that physicians are afraid of, and avoid, feelings of sadness. We reason, mistakenly, that being open to pain and loss could damage us; we fear losing our composure and appearing vulnerable. Yet accepting vulnerability is what most closely connects us with our patients. This is what they remember in the end, after all. Patients crave acceptance, appreciation, and acknowledgment; we all want this for ourselves.

As the brother of a patient, I discovered how it felt to be on the receiving end of care lacking in compassion as I observed occasional blunt, insensitive or confusing comments from the medical staff. I became determined to connect more deeply with my patients and my own emotions. Yet I wondered: How could I balance connection and detachment as a neurosurgeon? Did connecting emotionally with my patients mean I could no longer detach enough to be an effective surgeon? Would it be better to become a technician and leave the emotions to others

I found my approach through a conversation with Helen Riess, a psychiatrist and author of “The Empathy Effect: Seven Neuroscience-Based Keys for Transforming the Way We Live, Love, Work, and Connect Across Differences,” who explained that through the process of developing self- and other empathy, emotional armor could be replaced by “emotional agility.” Intrigued, I went on to read Susan David’s “Emotional Agility: Get Unstuck, Embrace Change, and Thrive in Work and Life,” which characterizes this healthier stance.

Emotional agility enables us to move easily between powerful emotions, recognizing feelings without becoming bogged down by them; to move fluidly through life’s demands without becoming stuck or overwhelmed.

Emotionally agile people derive power from facing, not avoiding, difficult emotions. By allowing ourselves to be vulnerable, physicians become better able to connect more deeply with our patients and ourselves. I came to appreciate that it is possible to move between dispassionate technical precision and intense emotional connection without having to choose between them.

I sat with Alan and his family after his surgery, and we talked until I had to return to the operating room for another case. As I left, Alan remarked that I seemed to get energy and joy from my work. I was surprised to realize that I did feel energized, not depleted; privileged to witness both the beauty and fragility of life. At that moment, I knew I had discarded my suit of emotional armor. In its place was something better and more powerful: emotional agility.

Weeks later, Alan was readmitted to the hospital with increasing right-sided numbness. I read him a draft of this essay as he sat in his hospital bed, unable to control his computer or phone yet intellectually forceful and emotionally attuned. He said that he wanted me to tell his story. He felt strongly this message must be shared, agreeing that doctors often carry a burden of private grief and perceived failures.

We spoke of his children, his grandchildren, his wife. He told me of professional mistakes and a sense of failure that haunted him, yet he also spoke proudly of the thousands of patients he had cared for, their individual stories and faces no longer distinct but flowing through him.

Sitting at my friend’s bedside, I saw Alan forgive himself. He always tried to do his best.

Sometimes, he failed. Just as I often felt powerless, unable to pull someone from the wreckage I saw coming, yet I had done my best. As a resident years ago, knowing that a young husband would not live for long and that his children would lose their father, I had done all I could do — except to allow the enormity of this loss to wash over me, to share it with his family and to accept it, as Alan was doing in his own life

Alan reinforced for me that it is possible to be a skilled surgeon and also a caring and emotionally connected doctor; to hold someone’s hand, and to be present. I couldn’t repair my failed conversation with that family, but I can learn from my mistakes. As long as I continue to practice, there will be another opportunity to try to get things right.

And, as Alan told me, these lessons hold for our lives beyond practice. Part of emotional agility is self-compassion, often a sticking point for physicians. We tend to be unforgiving of ourselves (and of our colleagues). Just as we need to recognize and admit our failings, we also need to let them go. We must forgive ourselves and each other.

These are essential steps toward accepting our vulnerability and achieving emotional agility. Only then can we abandon our detached and defended selves and make the connections that sustain and enrich us.

Alan Davidson, born Jan. 6, 1942, died June 26, 2020. Joseph Stern is a neurosurgeon in Greensboro, N.C. He is the author of “Grief Connects Us: A Neurosurgeon’s Lessons on Love, Loss, and Compassion,” published in May by Central Recovery Press. His website is josephsternmd.com.

Complete Article HERE!

End-of-life care: people should have the option of general anaesthesia as they die

By and

Dying patients who are in pain are usually given an analgesic, such as morphine, to ease their final hours and days. And if an analgesic isn’t enough, they can be given a sedative – something to make them more relaxed and less distressed at the end of life. We have recently written about a third approach: using a general anaesthetic to ensure that the dying patient is completely unconscious. This has been described previously, but largely overlooked.

There are two situations when a general anaesthetic might be used in dying patients. The first is when other drugs have not worked and the patient is still distressed or in pain. The second is when a patient has only a short time to live and expresses a clear wish to be unconscious. Some dying patients just want to sleep.

But what type of anaesthesia are we talking about? If you need surgery or a medical procedure, there are three options. First, being fully awake, but having local anaesthesia to block the pain. Second, you could be partly sedated: you would be less stressed or worried about it, but you might remember some of the procedure afterwards. Finally, you could have a general anaesthetic and be out cold, with no memory of the procedure afterwards.

Any of these might be appropriate, depending on the procedure and depending on the person. But the option with the highest chance that you won’t feel anything is, of course, general anaesthesia.

These same three options could be offered to a dying patient. Some people might want to be as awake as possible. (Like the poet Dylan Thomas, they might not wish to “go gentle into that good night”.) Some might want to be sedated, if necessary. Others might want to be completely asleep.

The choice of general anaesthesia at the end of life is potentially popular. Last year, we surveyed more than 500 people in the UK about end-of-life options. Nearly 90% said they would like the option of a general anaesthetic if they were dying.

You might wonder, is this not just euthanasia by another name? Giving someone medicines to ensure that they are unconscious as they die naturally is different from giving someone medicine to end their life. General anaesthesia is legal, whereas in many countries, including the UK, euthanasia is illegal. This means that the option of anaesthesia could be available now for dying patients in the UK without changing the law. France has recently recognised the right for dying patients to be unconscious.

Wouldn’t it be too risky?

There are side-effects with all medicines, but recent advances mean that it is possible to give anaesthetic medicines to patients close to death without affecting their breathing. The medicine is given slowly, and the patient made unconscious gradually over 15 to 20 minutes. The medicine can be slowed or stopped at any point.

Tray of anaesthetic drugs.
Tray of anaesthetic drugs.

Previous studies that have used anaesthesia at the end of life, have continued the medicines for one to 14 days until the patient died naturally.

This will not be for everyone. It may not be possible for those who are dying in their own home. And some people will not want it. But we have the means to offer dying patients a gentle alternative end to their days. We believe that there is a strong ethical case to make the option of general anaesthesia at the end of life more widely available.

Complete Article HERE!

Does Marijuana Have A Place In Hospice?

Marijuana is used in hospice care to ease spiritual and existential suffering, with some studies showing an important therapeutic role for patients faced with the despair of a terminal illness.

BY Kate-Madonna Hindes

As Americans continue to age, hospices are exploring new ways to bring peace and calm to the often slow and painful process of end-of-life care. According to the CDC, in 2015, an estimated 1.4 million individuals on Medicare were patients in a hospice setting.

Quadrupling in size in the last 20 years, hospices are investing in creating a patient-centric approach that dismantles beliefs that hospices are cold, and unfeeling institutions. From massage to aromatherapy, some hospices are offering new additions to their programs including music and integrating family into meaningful experiences. While many hospices are focused on offering a thoughtful quality of care, many end-of-life-care specialists are also advocating for marijuana.

A MorseLife Hospice and Palliative Care study focused on advances in hospice care found changing attitudes on medical marijuana. They cited that, “87% of Americans support the use of medical marijuana as a treatment option for terminally ill patients, with nearly three in five Americans (58%) expressing strong support.”

The American Academy of Hospice and Palliative Medicine recently shared a video on how hospices can integrate medical marijuana into care, heralding more change in the market to accepting marijuana as a part of a patient’s care plan.

Pathways Home Health advocates for marijuana in hospice care, stating:

“Marijuana is used in the hospice care setting to ease spiritual and existential suffering, with some studies showing an important therapeutic role for patients faced with the despair of a terminal illness, as well as the loss of function that accompanies it. A mild euphoria or sense of well-being can ease a patient’s mind, body and spirit as they come to terms with their fate.”

Not Telling Your Doctor About Marijuana Use Can Hurt You

Stuck in political limbo

While some hospice programs are embracing medical cannabis, some are facing uncertainty about whether or not to allow medical marijuana, even when it’s legal inside their particular state. With an ever-expanding list of states that allow marijuana both medically and recreationally, hospices are taking an evidence-based, risk-management-forward approach to ensure they comply legally and ethically.

Changing attitudes are allowing for researchers to gain more insight and information regarding the role cannabis and CBD can both play in hospice and palliative care settings. Published in the Journal of Palliative Medicine, an October 2019 study focused on the responses of over 300 palliative care professionals from over 40 states on the use of medical cannabis. The study found “overwhelming support” for the use of medical cannabis in a hospice setting:

Regardless of legal status, hospice staff members were overwhelmingly in agreement that MC (medical cannabis) is appropriate for hospice patients to have access to and use.

Citing barriers such as legal status, clinical safety, and societal influence, the study believes opportunities exist to better support hospice providers and patients with education, research and policies that elevate the use of medical cannabis.

With new patients entering hospice every day and both clinicians and doctors looking to supplement old pain medicines with newer more effective treatments, marijuana will remain a top topic for years to come.

Complete Article HERE!

3 biggest regrets people have at the end of life

Hospice chaplain shares common regrets she hears from people who have less than six months to live.

By A. Pawlowski

Sitting at the bedside of dying patients, Tenzin Kiyosaki sees every day how regrets can haunt people at the end of life.

The former Buddhist nun works as an interfaith hospice chaplain for Torrance Memorial Medical Center in the South Bay area of Los Angeles, tending to the spiritual and emotional needs of people who have less than six months to live, and listening to their concerns.

When her brother, “Rich Dad Poor Dad” author Robert Kiyosaki, asked her what the dying talk about, she mentioned some of the common concerns she heard over and over. Kiyosaki shares them in her new book, “The Three Regrets: Inspirational Stories and Practical Advice for Love and Forgiveness at Life’s End.”

It’s also a nudge for younger, healthier people to take action to resolve or prevent regrets now.

Kiyosaki wants people to remember that death doesn’t only come to the old.

Remembering that you are going to die is the best way I know to avoid the trap of thinking you have something to lose. You are already naked. There is no reason not to follow your heart. — Steve Jobs

No one knows when their time is up, whether because of an accident or illness.

Life is impermanent not only for you, but your family, friends and loved ones. Kiyosaki’s own mother passed away suddenly at 49, leaving the family in shock.

“Understanding that death can come at any time can help you see how precious life is and how to really get on with our ambitions and our dreams, and to be kind to each other,” Kiyosaki, 72, told TODAY.

“We should clear the regrets now and go for our dreams rather than just hanging on to regrets that take up a lot of mental and emotional space.”

I did not live my life of dreams.

One patient always wanted to travel the world, but never did. “She felt like, ‘I never got out of here, I never got to do what I really wanted to do,’” Kiyosaki said.

For others, the “what if” regrets might center around never taking a chance on starting a business, applying for a dream job abroad or moving to a new city.

Kiyosaki urged people to examine whether they’re neglecting or putting off their dreams and if so, to turn it around and go for them now — it’s not too late. One terminally-ill woman she knew flew to Europe by herself despite all the obstacles in her way.

I did not share my love.

Many end-of-life patients are frustrated that they haven’t been able to share what’s really in their heart and say what they needed to say to their loved ones. For some, that might be “I love you.” For others, just being able to acknowledge, “I was absent, I was cruel, I was unavailable,” can transform a family and allow it to heal.

“I just feel like it’s important for people to see that they don’t have to live their whole life this way,” Kiyosaki said.

“Don’t fade away from life without saying what you need to say,” she writes in her book. “Find ways to say ‘I love you’ and express your love every day.”

I did not forgive.

This is perhaps the biggest regret many people have at the end. Old wounds and unfinished business rise to the surface, but holding on to past grievances hurts us, Kiyosaki writes, citing a quote from Buddha: “Holding on to anger is like grasping a hot coal with the intent of throwing it at someone else — you are the one who gets burned.”

The power of forgiveness is a gift you give to yourself.

Kiyosaki recommends an exercise: Imagine you have one year left to live. Who would you call? What would you do and say to be at peace? Do it now.

“If you just clear the regrets, you have so much more open heart and receptivity to the world,” Kiyosaki said. “Let’s turn it around and enjoy our lives because they are impermanent — we’re all going to face end of life.”

Complete Article HERE!

How to Deal with Loneliness If You’re Self-Isolated During the Coronavirus Outbreak

Whether you’re truly alone in this difficult period—or just feel alone—these tips from therapist Rachel Wright will help you feel more at peace with the situation.

By Rachel Wright

Humans have always been pack mammals. Go back in time, and you’ll see we like being part of groups and communities.

But then a thing called the internet came along, and it really halted a lot of that in-person connection. That’s why, before the coronavirus crisis even happened, we were already in a “loneliness epidemic.” Basically, before we were being forced to self-isolate, we were already feeling lonely and isolated.

It’s not that feeling lonely on its own is necessarily a bad thing—just like feeling jealousy or stress on its own is not necessarily a bad thing. They’re natural human emotions that you can’t entirely avoid; plus, they can trigger beneficial responses (like realizing your relationship is unhealthy or spurring you into action to get a big project done). But when you experience it chronically, which is what’s starting to happen with this loneliness feeling, that’s when it can start to have repercussions. When you feel lonely, it affects the activation of serotonin and dopamine—two feel-good neurotransmitters—in your brain. Their activation slows down, which can make you feel low, possibly depressed or anxious. And so it’s really challenging when you’re by yourself, and you’re also navigating anxiety, stress, or depression separately in addition to being alone. (More here: What Are the Psychological Effects of Social Distancing?)

How to Manage Loneliness During Social Isolation

If you’re living alone or feeling extremely lonely from lack of social interaction, these strategies could drastically help. Even if you’re surrounded by people but this whole situation has you ~in your feelings~, you can take advantage of some of these strategies as well.

1. Decide how often you want to connect through video.

It’s okay if one day is an all-day affair and you’re just going to be on your phone for most of the waking hours. And it’s okay if there’s a day where you want to put your phone down and not look at it at all and just be with yourself. Figure out what the right balance is for you. On average, I would say one to three face-to-face interactions a day is a healthy number. You don’t necessarily need to be interacting with the other person—for example, just watching an Instagram live could count—as long as you feel really connected and fulfilled by it. (If you’re stuck inside with a partner or S.O., these tips fo relationships and dating might help.)

2. Journal.

If you journaled before, great. If you didn’t, now’s the time to start. (Related: 10 Cute Journals You’ll Actually Want to Write In)

It is going to be very interesting to retroactively look back on how you felt throughout this coronavirus pandemic. Take the time to just sit with yourself and ask:

How am I feeling?

What am I thinking?

What am I doing?

If you’re journaling and you’re starting to feel that discomfort of sitting with your own feelings, know that discomfort was probably there before and you’re just now accessing it. Stick with it and process through that—even if you feel your hand getting tired or like you can’t write as fast as your brain is going. You can also use a voice memo on your phone, especially if you’re more of a talker than a writer. There’s no rule that says the journaling has to be a pen and paper in a book with a lock; it can be anything you want. (Related: Journal Apps for “Writing Down” All Your Thoughts)

Another great journaling prompt is to focus on gratitude. It’s so easy for us to get caught up in what we don’t have anymore and what we’re missing—and it’s ok to write that down. But it can also be really helpful to acknowledge the things you’re really grateful for: Do you have food at home? Do you have toilet paper at home? Are you feeling healthy? Is your family healthy? All these things that, honestly most of us probably take for granted.

I like to sit down in the morning and do a brain dump—I write down anything that’s kind of swirling in my head that I just need to get out. Then I wrote down my gratitude and my intention for the day. And you don’t need to journal for a long time—for it to be beneficial you only need to journal for like one minute.

3. Keep a schedule—including time for self-care.

It can help to write out a schedule in the morning because it encourages you to notice the things that you look forward to that bring you joy—including making time to relax, just like you did when you were leaving the house more.

Just because we’re in a new, unprecedented time doesn’t mean that the things that felt relaxing before aren’t going to work now. If you liked to take a bath with a candle, take a bath with a candle. Think about what you did to relax before this pandemic, start there, and then if that’s not working, you can brainstorm some changes. (Related: The Self-Care Items Shape Editors Are Using At Home to Stay Sane During Quarantine)

And for people who are worried about money or looking for a job, you might be thinking ‘what if I don’t have time to relax? I don’t have time to sink into my feelings.’ Still, I’d say if you don’t take the time to relax and focus on yourself, you’re not going to be in a great place to be creative, to figure out finances, or find solutions. You need to take the time for yourself, no matter what socioeconomic or pandemic position you’re in. (Use these self-care ideas as inspiration.)

4. Get rid of “shoulds” and expectations.

Start from scratch because your expectations for yourself are now different. Collectively, we need to lower the bar for ourselves in a compassionate way. Think: ‘Yeah, I showered today, and that is a win.’ Sometimes our anxiety, our loneliness, or whatever emotion it might be, spikes and it’s hard to change out of sweats; it’s hard to exercise. So when we do these things, we should celebrate and honor the fact that we did it and not in a self-deprecating way. Like, truly, ‘we’re in the middle of a global pandemic, and I took a shower. I’m amazing.’ We need to do that for ourselves and for our friends and family as well.

What to Do When You’re Feeling Especially Anxious, Lonely, or Depressed

First of all, just know that you’re not alone; I don’t know anyone who has not felt some level of anxiety and or depression thus far through this. It’s a normal human emotional response to feel that way right now and period.

When you find yourself spiraling into one of these emotions (and it’s not a chronic issue that you have), imagine that you’re talking to a four-year-old version of yourself. How would you talk to that four-year-old if they said to you, “I’m scared that I’m not going to get to see my friends for two more months.” How would you respond to her? Ideally, you’d meet this little kid with compassion. But when we talk to ourselves, we’re normally like, ‘Ok, you have to push through this. You have shit to get done, you need to do this work.’ And the more that we try to shove it down, the more we try to escape those feelings, they’re just going to come back with even more force and angrier. Sometimes feelings are like that; we just need to acknowledge them with compassion and let ourselves feel them. (Related: Everything You Should Know About Anxiety Disorder)

With what’s going on right now, the fear and anxiety we’re all experiencing makes a lot of sense; there’s so much unknown, and anxiety is based in the unknown. So if you’re thinking, “I don’t like this and I’m feeling anxious,” well, nobody does. Let’s just get that out there—this sucks. It’s the worst feeling.

It can be really helpful to lean into anxiety and use coping tools, even if you’ve never experienced anxiety before. Things like learning about breathwork and practicing grounding breath, limiting your news intake to a certain amount per day (don’t just have CNN on in the background all day; we need to stay informed, but we also can’t take that in all day, every day), and acknowledging the feelings you’re having to someone that you trust and love. So if you’re feeling depressed, if you’re feeling anxious, call a friend, text a friend, and let them know. Say, ‘hey, my anxiety is spiking. I don’t need you to do anything about it. I just, I need to tell somebody.’

Is There Such a Thing as Too Much Internet-Based Socializing?

Everyone will hit a point where they need a break. For me, it was like day two of social distancing. Everyone was reaching out, and, on one hand, it was so wonderful: I would set my phone down for five minutes, and I’d come back to like four missed FaceTime calls and like 82 texts and I thought, “Wow, that’s amazing.”

But then it started creating anxiety: I felt like I had to respond to all of the things coming at me. So there’s a happy medium to find—whether you’re alone or with people. You can still have alone time and find time to socialize just like you would if this wasn’t going on. It’s really easy to think, “Well, I can’t meet up with people in person so I have to be constantly on Zoom or on Instagram with people.” Personally, my screentime shot up from an average of like four hours a day to, yesterday, I was on my phone for nine and a half hours!

That’s not healthy for anybody, even when you’re doing it to connect with other people. It’s really about finding what that “new normal” is for you. I don’t like the term “normal” because we get to times like this and we’re like, ‘I just want to go back to normal,’ and that way of thinking is just going to keep you feeling more frustrated and more stuck.

How to Deal with the Indefinite-ness of It All

Number one is acknowledging it. Say it out loud. If you’re home by yourself, even if you say it to your walls, say it out loud: “I don’t know when this is going to end, and that is scary. I don’t know when this is going to end, and that is horrific.” Whatever word is appropriate for what you’re feeling.

Next, make a list of things you want to do or would like to watch while you’re in quasi-quarantine. Give yourself a bucket list of things—maybe there’s a TV show that you’ve been wanting to watch but haven’t had the time, a project you’ve been meaning to start, or a skill you want to lean. Give yourself things that you can actually accomplish and look forward to within the confines of your home. Maybe Friday you’re working, but Saturday you plan to have a guitar lesson on YouTube—it’s something that you can then still look forward to, even if it’s small.

Lastly, make a post-quarantine bucket list, or a list of things that you want to do once this is all over. This concept is recommended to people when they’re going through things like cancer treatments. It really helps to make a list of what you want to do when you’re feeling healthy and when you can be with your friends again.

How to Deal with a Lack of Physical Touch

This is the hard part. I mean, it’s all hard; let’s just acknowledge that. But this is the one thing that is really hard to replicate and recreate without actually having another human being there with you. The good news is that it’s an opportunity to get into self-love and self-touch. We think of self-touch and most of our minds immediately go to masturbation—but if I’m going to talk about masturbation, I would say masturbation. I’m talking about self-touch as in, literally, take your arm and drag your finger on it. Rub your arm. Then increase the pressure by pressing more deeply. Then go get lotion and rub the lotion into that same part of your arm. Give yourself the physical contact and touch that you are craving from other people. It’s not going to replace it completely—there is no replacement for a human being touching another human being—but it will help in the meantime, and it’s way better than sitting just not touching yourself at all. (Related: The Benefits of Human Touch and How to Get More of It, No Matter Your Relationship Status)

And, yeah, also masturbation. It’s a great time to really take the time to explore your body in all of the ways sexual and non-sexual. Rubbed your feet? See what it feels like to rub your knees. Use this situation as an opportunity to be with yourself with less distraction. (Helloo, mindful masturbation!)

Complete Article HERE!

Depression symptoms increase over last year of life

Dark times.

By Lisa Rapaport

Many people experience worsening depression symptoms over their final year of life, and a U.S. study suggests that women, younger adults and poor people may be especially vulnerable.

For the study, researchers examined data on 3,274 adults who participated in the nationwide Health and Retirement Study and died within one year of the assessment. All of the participants had completed mental health questionnaires and provided information on any medical issues they had as well as demographic factors like income and education levels.

Rates of depressive symptoms increased over the last year of life, particularly within the final months, the study found. By the last month of life, 59% of the participants had enough symptoms to screen positive for a diagnosis of depression, although they were not formally evaluated and diagnosed by clinicians.

“Patients with depression have worse survival outcomes than non-depressed patients, making depression a critical issue to screen for and manage in the context of serious illness,” Elissa Kozlov of the Rutgers University Institute for Health, Health Policy, and Aging Research in New Brunswick, New Jersey, and colleagues write in the Journal of the American Geriatrics Society.

And, “psychological symptoms, such as depression, have a negative impact on patients’ quality of life as they near the end of life,” Kozlov and colleagues write.

Researchers had asked participants whether they experienced eight things over the previous week: depression, sadness, restless sleep, unhappiness, feeling like everything takes effort, lack of motivation and loneliness. People with at least three symptoms might screen positive for depression, the study team writes.

Across the entire Health and Retirement Study population, including people who didn’t die within a year of their most recent assessments, about 23% of participants have at least three of these symptoms, the researchers also note.

In the current analysis, depression scores remained relatively stable from 12 to four months prior to death, then steadily increased. With four months to live, 42% of participants had at least three symptoms of depression, and with one month remaining, 59% did.

One year before death, women had higher depression symptom scores, with almost three symptoms on average compared to about two for men. With one month to live, both men and women had three or more symptoms and there was no longer a meaningful difference between the sexes.

Differences in depression scores based on age and income were also more pronounced one year before death, and became less pronounced closer to death, the study found.

However, the youngest and poorest participants had the highest depression scores at all points in time.

As death approached, nonwhite participants also had increasingly high depression scores.

And, one month before death, people without a high school education had the highest depression scores of all, averaging almost five symptoms.

The study wasn’t designed to prove whether or how terminal illness might impact mental health, or the reverse.

Even so, the results underscore the importance of screening for mental health problems and treating conditions like depression in the final months of life, the researchers conclude.

“Given the range of options to treat depression, unaddressed depressive symptoms in the last year of life must be a focus of both quality measurement and improvement,” the study authors write. “While depressive symptoms at the end of life are common, they are treatable and must be proactively addressed to reduce distress and ensure that everyone has the opportunity to experience a ‘good death,’ free of depressive symptoms.”

Complete Article HERE!

Solace after suicide…

My journey to forgiveness

by The Listener

For Katie Anders*, coping with suicide grief means remembering how her husband lived, not how he died.

Every suicide story that hits the headlines stirs the pain for those of us who have been bereaved by such a loss. The headlines are bigger and somehow more shocking when such high-profile names as Anthony Bourdain and Kate Spade join those of our loved ones. But the grief for those left is the same.

I lost the love of my life to suicide. He was middle-aged, very successful in his profession and loved by family and a wonderful group of friends.

Our communities have such a sense of helplessness and hopelessness in the face of suicides. It is in the crisis period leading up to a suicide that there is the chance for effective intervention, and yet there is little effective help.

And, yes, there is a still a stigma around mental health. For us, it meant we had to protect my husband’s reputation for when he returned to work. The professions are not a lot more enlightened than anyone else.

The crash happened one May day. I walked in on him sitting at his desk at work, and was shocked to find him weeping. He said, “I can’t do this any more.”

We visited our GP and at first it seemed like exhaustion; just plain burnout. We had just come back from three weeks’ travelling and he hadn’t slept well; he had returned to a mountain of work. It was a job he loved and in which he had quietly excelled. He was a gentle-natured man who worked in a world of ambitious colleagues and he had forged a different path to the top. He was respected by most, admired by many.

We quickly arranged for his work to be done by others and he took “stress leave”. Within weeks, it was clear the malevolent black dog of depression was stalking him. We did all the right things: exercise and a good diet. He had great support from loved ones. He began using antidepressants and sleeping tablets. We saw an occupational psychologist, who was enormously helpful. Yet still the black dog circled.

Weeks passed. Then one day I found him curled into himself on a chair, his back to me. I tried to engage him, but he wouldn’t look at me. I took his face in my hands, forcing him to meet my eyes. I demanded to know what he was thinking, but in reality I knew.

He had reached a tipping point. We urgently needed more expertise. An acquaintance who was a good psychiatrist agreed to see him immediately (and privately).

I was determinedly optimistic we would get through it. We were a “lucky couple” whose marriage had fulfilled each of us. We laughed a lot and loved a lot. We had lovely children, now grown and forging their own lives. Many saw our marriage as one of the successful ones; we both thought so, too.

His promise to me that he wouldn’t act on his thoughts seemed to be enough to hold him back from the edge – that and the increasingly heavy doses of medication he needed. We began cognitive behavioural therapy (CBT) with another psychologist.

A few weeks later, things seemed to be moving in the right direction until some odd things started to happen. The medication had tipped him into a manic state, so he had to withdraw from all the antidepressants. The psychiatrist felt that a prior serious head injury had probably caused the manic response, so mood-stabilising drugs were required.

Some normalcy began to return to our lives. My husband continued his programme of health and fitness and after a few weeks, he seemed well enough to return to work for short periods. We breathed easier.

But then an emotionally stressful event occurred: he was desperately concerned about someone close who was in strife overseas. His sleep was seriously disrupted and he was very worried. The depression was renewing its grip and as the antidepressants were now contraindicated, we were at a loss for effective solutions.

The psychiatrist hoped that since the relapse was in its early stages, we could work to stop its progression by using mindfulness meditation and more CBT and counselling. He was very low, but again, he reiterated his promise to me.

Three days later, he was dead. The black dog’s work was done.

*The writer’s name has been changed.

Questions and guilt

On the night he died, I sat at his bedside, shattered by the horrific development, the crashing grief threatening to crush us all. I was full of confusing questions and guilt. How could he have done this? How could he have walked past me as I slept and not woken me and sought my help?

Sometime in the wee hours, I decided to write him a final letter. And as I began, some things crystallised. I needed to forgive him before we let him go. I read him my letter aloud, then later repeated the words at his funeral. That night, wracked with the deepest pain, I told him, “The man who did this thing was a man in the grip of a fierce depression. It was the depression that broke the promise, not the man that we love. That’s why, distraught as I am, I have to forgive you, because all that I know and have experienced of you through all the years tells me that you never wanted to hurt us, never wanted to leave us.”

Some months later, I heard someone (also bereaved by suicide) on a radio programme put it very succinctly: her husband hadn’t been leaving her or her children, he was leaving himself.

Years before, I had read Elisabeth Kübler-Ross’ book On Death and Dying and, later, I trained and worked as a volunteer with terminally ill people, and learnt about bereavement support.

It’s accepted now that work around the stages and processes of grief was too rigid. Each grief experience is unique and people don’t necessarily experience all the stages or go through them in any particular order. For example, while others felt anger at my husband, I never have. Even pathetic attempts to somehow manufacture anger failed. How could I be angry at someone so broken?

In the aftermath, I felt the deepest sadness for him, for his loss, for all that he would never get to experience. I felt devastatingly sad for our kids. But for me, the grieving process was delayed by my upbringing. It held messages of “Don’t you feel sorry for yourself” and “Pick yourself up and get on with it”.

It took a long time to let myself feel the full devastation of my own loss. The numbing effects of shock meant that I walked around in a world that felt surreal, that simply couldn’t be true. This wasn’t how our love story was supposed to end. We were supposed to grow old together, travel, have grandchildren.

Tortuous paths

Suicide grief holds so many “If only …” and “What if …” questions. What if I had heard him get out of bed? What if I had handcuffed him to me to keep him safe? What if he had slept through those darkest hours before dawn and woken to sunshine?

The “what ifs” are where the self-torture lies. I felt so guilty that I struggled to want to live. Sometimes I still feel surprised that I didn’t die of the brokenness I felt.

Logic says there is no useful purpose in following these tortuous paths. But some years on, they still come into my mind and I speak to those thoughts as firmly and logically as I can.

I learnt a lot from my counsellor about self-forgiveness. It is more of a journey than a destination. Someone spoke to me about the idea of practising my husband’s presence rather than his absence. It seemed to break down some of the enormity of it all. If I had to completely and immediately accept his absence from my life, you might as well have asked me to swim the Atlantic. But if I could practise his presence, which permeated my life, while slowly adjusting to his loss, then it felt more like paddling in the waves at the water’s edge and not getting completely out of my depth.

Practising his presence is simply being mindful of his hand in the life I continue to live. It’s being able to access his way of thinking an issue through. His presence is in the millions of memories. It’s practising his habits of observing and appreciating the beauty around. He is visible in his imprinting on our kids … aspects of him in their personalities. It’s in watching rugby with my daughter and shouting the way he shouted. It’s in the kids’ love of language and awful puns. It’s in the thousands of photos taken over the years.

We remember how he lived and not how he died, but the truth is that suicide grief is a unique grief. People aren’t comfortable around it. I accept now that even if my life should suddenly become deliriously happy, the loss of such a precious partner through suicide will forever be a hugely black awfulness on its timeline.

Actress Dawn French said that when her father committed suicide, it was like a bomb went off in their family. It’s an apt description. My life is forever changed, my confidence diminished and my happy moments are often tinged with poignancy. At the risk of sounding overly dramatic, I feel my heart carries a permanent scarring.

Few understand the complexity and longevity of suicide pain. It isn’t easy, as one friend put it, to “move forward” as a simple act of will. If my husband had died of a heart attack or cancer, I know that grief might have been easier to move on from.

Yet I take joy in our amazing children, their partners and now a grandchild. I am fortunate in having some close friends. I try not to let the manner of his dying take more than it should. Above all, he wouldn’t want that and he would hate the pain that his suicide caused. Despite it all, I will be forever grateful that my life was greatly enriched by a truly lovely man.

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