The Four Stages of Life

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Life is a bitch. Then you die. So while staring at my navel the other day, I decided that that bitch happens in four stages. Here they are.

Stage One: Mimicry

We are born helpless. We can’t walk, can’t talk, can’t feed ourselves, can’t even do our own damn taxes.

As children, the way we’re wired to learn is by watching and mimicking others. First we learn to do physical skills like walk and talk. Then we develop social skills by watching and mimicking our peers around us. Then, finally, in late childhood, we learn to adapt to our culture by observing the rules and norms around us and trying to behave in such a way that is generally considered acceptable by society.

The goal of Stage One is to teach us how to function within society so that we can be autonomous, self-sufficient adults. The idea is that the adults in the community around us help us to reach this point through supporting our ability to make decisions and take action ourselves.

But some adults and community members around us suck.1 They punish us for our independence. They don’t support our decisions. And therefore we don’t develop autonomy. We get stuck in Stage One, endlessly mimicking those around us, endlessly attempting to please all so that we might not be judged.2

In a “normal” healthy individual, Stage One will last until late adolescence and early adulthood.3 For some people, it may last further into adulthood. A select few wake up one day at age 45 realizing they’ve never actually lived for themselves and wonder where the hell the years went.

This is Stage One. The mimicry. The constant search for approval and validation. The absence of independent thought and personal values.

We must be aware of the standards and expectations of those around us. But we must also become strong enough to act in spite of those standards and expectations when we feel it is necessary. We must develop the ability to act by ourselves and for ourselves.

Stage Two: Self-Discovery

In Stage One, we learn to fit in with the people and culture around us. Stage Two is about learning what makes us different from the people and culture around us. Stage Two requires us to begin making decisions for ourselves, to test ourselves, and to understand ourselves and what makes us unique.

Stage Two involves a lot of trial-and-error and experimentation. We experiment with living in new places, hanging out with new people, imbibing new substances, and playing with new people’s orifices.

In my Stage Two, I ran off and visited fifty-something countries. My brother’s Stage Two was diving headfirst into the political system in Washington DC. Everyone’s Stage Two is slightly different because every one of us is slightly different.

Stage Two is a process of self-discovery. We try things. Some of them go well. Some of them don’t. The goal is to stick with the ones that go well and move on.

Stage Two is a process of self-discovery. We try things. Some of them go well. Some of them don’t. The goal is to stick with the ones that go well and move on.

Man sitting on cliff looking out over clouds

Stage Two lasts until we begin to run up against our own limitations. This doesn’t sit well with many people. But despite what Oprah and Deepak Chopra may tell you, discovering your own limitations is a good and healthy thing.

You’re just going to be bad at some things, no matter how hard you try. And you need to know what they are. I am not genetically inclined to ever excel at anything athletic whatsoever. It sucked for me to learn that, but I did. I’m also about as capable of feeding myself as an infant drooling applesauce all over the floor. That was important to find out as well. We all must learn what we suck at. And the earlier in our life that we learn it, the better.

So we’re just bad at some things. Then there are other things that are great for a while, but begin to have diminishing returns after a few years. Traveling the world is one example. Sexing a ton of people is another. Drinking on a Tuesday night is a third. There are many more. Trust me.

Your limitations are important because you must eventually come to the realization that your time on this planet is limited and you should therefore spend it on things that matter most. That means realizing that just because you can do something, doesn’t mean you should do it. That means realizing that just because you like certain people doesn’t mean you should be with them. That means realizing that there are opportunity costs to everything and that you can’t have it all.

There are some people who never allow themselves to feel limitations — either because they refuse to admit their failures, or because they delude themselves into believing that their limitations don’t exist. These people get stuck in Stage Two.

These are the “serial entrepreneurs” who are 38 and living with mom and still haven’t made any money after 15 years of trying. These are the “aspiring actors” who are still waiting tables and haven’t done an audition in two years. These are the people who can’t settle into a long-term relationship because they always have a gnawing feeling that there’s someone better around the corner. These are the people who brush all of their failings aside as “releasing” negativity into the universe or “purging” their baggage from their lives.

At some point we all must admit the inevitable: life is short, not all of our dreams can come true, so we should carefully pick and choose what we have the best shot at and commit to it.

But people stuck in Stage Two spend most of their time convincing themselves of the opposite. That they are limitless. That they can overcome all. That their life is that of non-stop growth and ascendance in the world, while everyone else can clearly see that they are merely running in place.

In healthy individuals, Stage Two begins in mid- to late-adolescence and lasts into a person’s mid-20s to mid-30s.4 People who stay in Stage Two beyond that are popularly referred to as those with “Peter Pan Syndrome” — the eternal adolescents, always discovering themselves, but finding nothing.

Stage Three: Commitment

Once you’ve pushed your own boundaries and either found your limitations (i.e., athletics, the culinary arts) or found the diminishing returns of certain activities (i.e., partying, video games, masturbation) then you are left with what’s both a) actually important to you, and b) what you’re not terrible at. Now it’s time to make your dent in the world.

Stage Three is the great consolidation of one’s life. Out go the friends who are draining you and holding you back. Out go the activities and hobbies that are a mindless waste of time. Out go the old dreams that are clearly not coming true anytime soon.

Then you double down on what you’re best at and what is best to you. You double down on the most important relationships in your life. You double down on a single mission in life, whether that’s to work on the world’s energy crisis or to be a bitching digital artist or to become an expert in brains or have a bunch of snotty, drooling children. Whatever it is, Stage Three is when you get it done.

Tattooed man with baby

Stage Three is all about maximizing your own potential in this life. It’s all about building your legacy. What will you leave behind when you’re gone? What will people remember you by? Whether that’s a breakthrough study or an amazing new product or an adoring family, Stage Three is about leaving the world a little bit different than the way you found it.

Stage Three ends when a combination of two things happen: 1) you feel as though there’s not much else you are able to accomplish, and 2) you get old and tired and find that you would rather sip martinis and do crossword puzzles all day.

In “normal” individuals, Stage Three generally lasts from around 30-ish-years-old until one reaches retirement age.

People who get lodged in Stage Three often do so because they don’t know how to let go of their ambition and constant desire for more. This inability to let go of the power and influence they crave counteracts the natural calming effects of time and they will often remain driven and hungry well into their 70s and 80s.5

Stage Four: Legacy

People arrive into Stage Four having spent somewhere around half a century investing themselves in what they believed was meaningful and important. They did great things, worked hard, earned everything they have, maybe started a family or a charity or a political or cultural revolution or two, and now they’re done. They’ve reached the age where their energy and circumstances no longer allow them to pursue their purpose any further.

The goal of Stage Four then becomes not to create a legacy as much as simply making sure that legacy lasts beyond one’s death.

This could be something as simple as supporting and advising their (now grown) children and living vicariously through them. It could mean passing on their projects and work to a protégé or apprentice. It could also mean becoming more politically active to maintain their values in a society that they no longer recognize.

Old Woman Praying

Stage Four is important psychologically because it makes the ever-growing reality of one’s own mortality more bearable. As humans, we have a deep need to feel as though our lives mean something. This meaning we constantly search for is literally our only psychological defense against the incomprehensibility of this life and the inevitability of our own death.6 To lose that meaning, or to watch it slip away, or to slowly feel as though the world has left you behind, is to stare oblivion in the face and let it consume you willingly.

What’s the Point?

Developing through each subsequent stage of life grants us greater control over our happiness and well-being.7

In Stage One, a person is wholly dependent on other people’s actions and approval to be happy. This is a horrible strategy because other people are unpredictable and unreliable.

In Stage Two, one becomes reliant on oneself, but they’re still reliant on external success to be happy — making money, accolades, victory, conquests, etc. These are more controllable than other people, but they are still mostly unpredictable in the long-run.

Stage Three relies on a handful of relationships and endeavors that proved themselves resilient and worthwhile through Stage Two. These are more reliable. And finally, Stage Four requires we only hold on to what we’ve already accomplished as long as possible.

At each subsequent stage, happiness becomes based more on internal, controllable values and less on the externalities of the ever-changing outside world.

Inter-Stage Conflict

Later stages don’t replace previous stages. They transcend them. Stage Two people still care about social approval. They just care about something more than social approval. Stage 3

people still care about testing their limits. They just care more about the commitments they’ve made.

Each stage represents a reshuffling of one’s life priorities. It’s for this reason that when one transitions from one stage to another, one will often experience a fallout in one’s friendships and relationships. If you were Stage Two and all of your friends were Stage Two, and suddenly you settle down, commit and get to work on Stage Three, yet your friends are still Stage Two, there will be a fundamental disconnect between your values and theirs that will be difficult to overcome.

Generally speaking, people project their own stage onto everyone else around them. People at Stage One will judge others by their ability to achieve social approval. People at Stage Two will judge others by their ability to push their own boundaries and try new things. People at Stage Three will judge others based on their commitments and what they’re able to achieve. People at Stage Four judge others based on what they stand for and what they’ve chosen to live for.

The Value of Trauma

Self-development is often portrayed as a rosy, flowery progression from dumbass to enlightenment that involves a lot of joy, prancing in fields of daisies, and high-fiving two thousand people at a seminar you paid way too much to be at.

Street graffiti showing abstract human portrait

But the truth is that transitions between the life stages are usually triggered by trauma or an extreme negative event in one’s life. A near-death experience. A divorce. A failed friendship or a death of a loved one.

Trauma causes us to step back and re-evaluate our deepest motivations and decisions. It allows us to reflect on whether our strategies to pursue happiness are actually working well or not.

What Gets Us Stuck

The same thing gets us stuck at every stage: a sense of personal inadequacy.

People get stuck at Stage One because they always feel as though they are somehow flawed and different from others, so they put all of their effort into conforming into what those around them would like to see. No matter how much they do, they feel as though it is never enough.

Stage Two people get stuck because they feel as though they should always be doing more, doing something better, doing something new and exciting, improving at something. But no matter how much they do, they feel as though it is never enough.

Stage Three people get stuck because they feel as though they have not generated enough meaningful influence in the world, that they make a greater impact in the specific areas that they have committed themselves to. But no matter how much they do, they feel as though it is never enough.8

One could even argue that Stage Four people feel stuck because they feel insecure that their legacy will not last or make any significant impact on the future generations. They cling to it and hold onto it and promote it with every last gasping breath. But they never feel as though it is enough.

The solution at each stage is then backwards. To move beyond Stage One, you must accept that you will never be enough for everybody all the time, and therefore you must make decisions for yourself.

To move beyond Stage Two, you must accept that you will never be capable of accomplishing everything you can dream and desire, and therefore you must zero in on what matters most and commit to it.

To move beyond Stage Three, you must realize that time and energy are limited, and therefore you must refocus your attention to helping others take over the meaningful projects you began.

To move beyond Stage Four, you must realize that change is inevitable, and that the influence of one person, no matter how great, no matter how powerful, no matter how meaningful, will eventually dissipate too.

And life will go on.

Footnotes

  1. Often this occurs because the adults/community themselves are still stuck in Stage One.
  2. Some people who get stuck in Stage One get stuck because they come to believe that they will never be able to fit in. These people usually succumb to some form of distraction, depression or addiction.
  3. I put normal in quotes because, really, what the fuck is normal?
  4. Stages can overlap to a certain extent. Transitioning between them is never black/white. It happens gradually. And often with some emotional stress and major lifestyle changes.
  5. This applies to the rare individuals who are talented and capable enough to still remain highly influential and relevant into their 70s and 80s as well. Stage Three doesn’t end until the desire for some peace and quiet outweighs one’s ability to affect change in the world. Some people die without ever leaving Stage Three.
  6. For more on this, see The Denial of Death by Ernest Becker.
  7. Research shows that generally people become happier and more satisfied as their lives go on.
  8. One way to think about it is that people who are stuck at Stage Two always feel as though they need more breadth of experience, whereas Stage Three people get stuck because they always feel as though they need more depth.

Complete Article HERE!

What Does The Executor of An Estate Do

by Maria Angel

Executor

If you’re researching estate planning or creating a will, you’ll find the term “executor of an estate” pop up a lot. That’s no fluke. The executor of an estate plays a key role in making sure your final wishes are looked after, dealing with everything from funeral planning and shutting off credit cards to contacting financial institutions and selling off real estate. The executor of an estate has a lot on their plate. Let’s talk about the short-term and long term tasks an executor has to cover.

The First Priorities of the Executor of An Estate

We know. The first thing that usually comes to mind when thinking about what an executor of an estate does is read the will and give beneficiaries what they’re owed. Well definitely get to that part. But the very first priorities of an executor rarely have anything to do with money. Instead they deal with pressing issues like:

  • Guardianship of children: One of the most challenging tasks as an executor of an estate is finding a guardian for children if their parents are both dead. You can certainly turn to the will to see if it’s named a guardian, or you’ll have to look into childcare or contact child protective services.Executor2
  • Securing the death certificate: Working with a funeral director or whoever else is handling the deceased’s remains, the executor of an estate will make sure that certified copies of the death certificate are available. This is an important task since it will allow the executor of an estate to handle future responsibilities like closing out bank accounts or transferring ownership of assets.
  • Carrying through on funeral arrangementsGenerally within a week of a death you’ll want to hold a funeral, and it’s up to the executor of an estate to go through all of the details with a funeral director like opting for a burial or a cremation, choosing what type of ceremony to have, and coordinating the event with family and loved ones.
  • Informing credit card companies of the passing: It can be incredibly easy to take advantage of a deceased’s credit cards right after they pass. As a result, one of the first things an executor  will do is contact the credit card companies and let them know that the cardholder has died. This lets the companies safely shut off the account to prevent any future transactions.
  • Store valuables in a safe place: Just as credit cards are susceptible to thieves, so are valuables like jewelry or cars. The executor of an estate will want to make sure that these items are in a secure place before they can be sold or given to family and loved ones.

This is just the tip of the iceberg for the executor. As you can see, a lot of these early responsibilities are extremely time sensitive and make sure that no one is being taken advantage of.

The Second Priorities of the Executor of An Estate

Once these primary responsibilities are tackled the executor of an estate must then move on to additional tasks that will help fully disperse the deceased’s assets. In truth, these are usually the sorts of things people think about when talking about estate execution. These responsibilities include:

  • Look for the will: As obvious as this sounds, an estate executor will need to first find the deceased’s will, assuming Screen Shot 2015-12-15 at 7.43.19 PMthere is one. Ideally the deceased will have written up a will and shared it with their executor, if not more people.
  • Beginning the probate process: Whenever there is an estate disbursement, it must go through probate. This is the legal process that names the estate executor, ensures that creditors are paid off and beneficiaries get the proceeds from the estate. The executor of the estate enters the estate into probate to get the process going. If there’s a will, it gives the executor of an estate a solid roadmap to use while the estate goes through probate.
  • Tackle real estate holdings: All mortgages will have to be paid off first, since part of the probate process requires creditors getting what they’re owed. Once any home-related debt is paid off, the executor of an estate will either make sure real estate deeds are transferred over to beneficiaries or sell the real estate and pass the proceeds on.
  • Liquidate the home: To properly get the home ready for sale, it will need to be cleared out. When liquidating a home or other real estate holdings, the executor of an estate can hold an estate sale, work with consignment stores, or donate the items to charity.
  • Close financial accounts: The deceased no doubt had checking and savings accounts, if not CDs or investment accounts. Armed with those death certificates we mentioned earlier, the executor of an estate will close the accounts and collect the cash as part of the larger estate to help pay off creditors and share the proceeds with beneficiaries.
  • Transfer retirement and life insurance accounts: When retirement and life insurance accounts are setup, they generally ask for beneficiaries. This is great because it generally means they are exempt from probate and possibly estate taxes. The proceeds, however, do need to make it to the beneficiaries. The executor of an estate can help with this by contacting these companies and ensuring that the funds are paid out.

If you haven’t figure it out yet, being the executor of an estate is not for the faint of heart. It requires juggling a lot of tasks in a timely manner.

What Does a Good Executor of An Estate Look Like

With all of the tasks an executor of an estate has to juggle, there are certain personality traits you’ll want to look for before naming your executor:

  • Strong communicator: This skill is especially handy right after someone has died. It can take a lot of work and finesse to coordinate all of the family and loved ones through the funeral and memorial services.
  • Good multi-tasker: From managing real estate and financial accounts to finding guardians for children, the executor of an estate will have a lot on their plate. You’ll want to pick someone that isn’t phased by juggling all the big and little things that will come their way.
  • Solid conflict resolver: As the person tasked with carrying out a will’s final wishes, the executor of an estate can come across a lot of family strife. It’s best to pick an executor that can take this in stride and keep moving forward.

Nope, this isn’t the easiest bunch of characteristics to find in one person. But, with all the tasks this person needs to tackle, you can see why it would be ideal to bundle these traits together.

Complete Article HERE!

Dying Parents with Young Children need more Support, Study Says

By CHERI CHENG

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90 percent of dying mothers worry about their young children.

Dying parents with young children could benefit from more support and care, a new study concluded.

“What is unique about patients with young children is the extraordinary psychological suffering related to parenting,” lead study author Dr. Eliza Park explained reported by FOX News. “The patient in these situations truly is the entire family unit.”

For this study, the Park, who is a psychiatry researcher at the University of North Carolina at Chapel Hill, and colleagues, surveyed 344 single fathers with young children who had lost their partner due to cancer. The typical family included at least two children under 18-years-old with the youngest one being about eight-years-old.

The participants’ deceased spouses had an average age of 44. Roughly 43 percent of the women had cancer that metastasized by the time they were diagnosed. About 66 percent of them had received hospice care. 41 percent passed away at home and about 50 percent died at a location that they had picked.

Based on the fathers’ reports, 38 percent of the patients did not say their farewells to their children prior to dying. 26 percent of the women were not at peace with the fact that they were dying. 90 percent of the fathers stated that their wives had continued to worry about their children’s wellbeing.

“Having more time with their children without being a burden to their family is often their primary goal,” Denice Sheehan, a researcher at Kent State University College of Nursing, who was not involved with this study, said to FOX via email. “Mothers tend to worry about how their children will live without them, who will take care of them and nurture them throughout their lives.”

Sheehan is also the director of clinical research at Hospice of the Western Reserve located in Cleveland, Ohio.

The team did find that fathers who reported having better and clearer communication between the doctors and their wives in regards to the cancer prognosis were less likely to have signs of depression or grief. The researchers concluded that improved care and more support could help dying parents and their spouses deal with their fate.

Some limitations to the study included the lack of diversity and the inability for the researchers to assess depression and grief since the survey was conducted online and the answers were all self-reported. The participants were mainly white with income and education levels that were considered to be above average when compared to the income and education levels of the average widow.

The study was published in the journal, BMJ Supportive and Palliative Care.

Complete Article HERE!

New website will give people ‘greater control over their death’

By JAMIE BULLEN

Greater control: Compassion in Dying said too few people are planning for how they want to be treated at the end of their lives
Greater control: Compassion in Dying said too few people are planning for how they want to be treated at the end of their lives

A website which allows people to declare how they wish to be treated in the final weeks of their lives is set to launch this week.

Compassion in Dying, a charity that supports people to exercise their rights over end-of-life treatment, said MyDecisions.org.uk will give people greater control over their death.

The group said the website was created in response to fears not enough people were planning for how they want to be treated in the advanced stages of their life.

A statement on the MyDecisions.org.uk homepage reads: “You might not like to think about it but there might come a time when you’re too unwell to tell those caring for you – like your family or a doctor – what you do and don’t want to happen.”

Anyone visiting the site can fill out an “advance decision” where users can refuse any drugs or medical treatments that may be given to them at some time in the future.

The document, also known as a living will, is legally binding meaning any healthcare professional that ignores it risks going to court.

The website also allows people to make an “advance statement” to declare preferences, wishes and beliefs for those who might have to make choices for them should they lose the capacity to make their own decisions.

According to research commissioned by the charity, only 4 per cent of Britons made a record of their preferences last year.

The website is set to go live on Thursday.

Complete Article HERE!

10 Excuses You Tell Yourself Why You Don’t Need To Have The Conversation & 10 Reasons Why Those Excuses Don’t Hold Up

We did a survey in 2013 which found that “90 percent of people say that talking with their loved ones about end-of-life care is important yet only 30 percent of people actually have done so.” Clearly, knowing the importance of a conversation or behavior doesn’t always mean we’ll do it. How many diets and half-marathon training programs have begun in this vein? We know all the excuses a person is likely to tell themselves to avoid the conversation. Any of these look familiar?

Excuse1

“I know my loved one well enough to make the right call.”

There are plenty of reasons to have the conversation with your loved one beyond your belief that you know what they would want. Having a specific conversation about they would prefer could bolster your confidence, strengthen their trust and reward you with a new sense of intimacy. The conversation could really surprise you. You might discover something about your loved one that you never expected.

Excuse2

“I don’t need to have the conversation. I’m healthy and young.”

The Conversation Project is an initiative to encourage people to have these conversations before they are sick or terminal. If you’re healthy and well, it’s the perfect time to have the conversation. As we say, it’s always too soon, until it’s too late.

 

Excuse3

“If my loved one wants to have a conversation, they can come to me.”

This excuse is extremely powerful. It allows you to believe you’re up for the conversation while simultaneously avoiding it.. Don’t fall victim to this one. Your loved one might be thinking the same thing, trapping you both in a game of chicken, in which neither of you have important conversations about your health, your finances and your future because you’re waiting for the other to initiate it.

 

Excuse4

“I’ll just decide based off what I would want.”

This excuse provides false comfort. No need to have the conversation because you know what you would do for yourself. Right? But this method of avoidance leads to an improbable and unrealistic scenario. Even if you are the designated health care proxy that doesn’t mean you’ll be the only one who cares about the outcome. You might find yourself having to explain your choices to other family members, friends and caretakers. This might open up a disagreement between family and loved ones who believe the person in question wouldn’t want that. And you’d be surprised how many decisions you might have to make. Imagine what happens when you need to make a decision and you don’t know what you would want.

 

Excuse5

“It makes me uncomfortable.”

The thought of having The Conversation can make a lot of people uncomfortable. Understandably. You do have the right to live your life with minimal discomfort, but consider this: we’ve heard from a lot of people who wished they’d had the conversation, rarely those who wished they hadn’t. Knowing what a loved one prefers can give you A LOT of comfort during a time when you most desperately need it.

 

Excuse6

“I don’t want to encourage my death by talking about it.”

We work with many diverse communities of various beliefs, cultures, and faiths. Each has their own history, experience and theological lens through which they view death. Our mission is to ensure that your fears aren’t holding you back from a very real and human experience.

 

Excuse7

“I don’t want to offend my loved one.”

Death doesn’t have to be an offensive topic, and if your loved one perceives it to be so, maybe you can start the conversation there. Ask them why they find death so offensive. A simple question can lead into a complex and profound conversation.

 

Excuse8

“I don’t need that kind of negativity in my life right now.”

Having the conversation doesn’t have to lead to a negative experience. Many people who had the conversation describe it as a positive, freeing experience rather than a negative one.

 

Excuse9

“I don’t even know what my career path will be let alone what I prefer about my end-of-life  care.”

If you’re in your twenties or thirties, it can be particularly difficult to focus on your end-of-life care. You’re focusing on surviving the hardship of life post-college. We know the #TheStruggleIsReal. But while it’s hard to relinquish the coziness of childhood irresponsibility, you must. Get your affairs together: start that 401K, use sunscreen, stop eating take-out every night, and have the conversation with your loved ones.

 

Excuse10

“Why do we need to have a conversation? Can’t my loved one just write everything down?”

Modern medicine is helping individuals live longer than ever before, and with that extended time on earth comes increased medical complications and a lot more decisions to be made at the end-of-life. People will often say, ‘if I am ever like that – pull the plug,’ but there is often no proverbial plug to pull. Instead, there is a number of cascading decisions left for your loved ones to make. Talking through your values with your family can give them the guidance to navigate the health care options presented to them. Questions like: “What matters most to them at the end of life?” “Do they want to be at home or in the hospital?”  “Do they mind visitors?” “Who do they want to make sure is there?”  “Is there a book they might want read to them?” “Do they want music playing or a ball game on in the room?” These are the questions you might find yourself considering. Conversations are organic; they are interactive. This conversation isn’t just about answering a set of medical questions, but exploring all the avenues you didn’t think were possible.

So really, what are you waiting for? Check out our Conversation Starter Kit and have the conversation today.

Complete Article HERE!

How Uganda Came To Earn High Marks For Quality Of Death

By Rae Ellen Bichell

african-palliative-care-association
A elderly patient with chronic debilitating back pain receives a bottle of liquid morphine during a home visit from a representative of Hospice Africa Uganda.

Food coloring, water, a preservative and a pound of morphine powder. These are the ingredients in Dr. Anne Merriman’s recipe for liquid morphine.

“It’s easier than making a cake,” says Merriman, a British palliative care specialist who founded Hospice Africa in Uganda in 1993 and helped design the formula that hospice workers in Uganda have used for 22 years to craft liquid morphine. The lightest dose, dyed green to indicate the strength and to make sure people don’t confuse it with water, costs about $2 per bottle to make. Stronger doses are dyed pink and blue. A 16-ounce bottle is about a week’s supply for most patients.Dr. Anne Merriman

Those cheap bottles of green, pink and blue liquid morphine have changed the way people die in Uganda — and are a key reason why Uganda has the best quality of death among low-income countries, according to global Quality of Death Index published by the Economist Intelligence Unit.

Back in the 1990s, two of the biggest barriers to good death in Uganda were simple: not enough doctors and not enough morphine. Largely through Merriman’s drive, Hospice Africa Uganda developed professional education in palliative care that would spread the responsibility to nurses, rather than relying on doctors. They helped make it mandatory for medical students in Uganda to study pain management – before Germany did. And Hospice Africa Uganda made liquid morphine.

“I had been one of the doctors who had said to people, ‘Sorry, there is no more we can do. You have to go home,'” says Merriman, of the time she spent working with cancer patients in Singapore starting in the 1960s. There, she says, “I found that patients with cancer were getting every treatment possible with chemotherapy, and then when it didn’t work they were sent home and they were dying in agony.”

So she sat down with a couple pharmacists from the National University Hospital and came up with a formula to make a liquid from pure morphine powder.

An HIV-positive woman
An HIV-positive woman, living alone in a one-room house, speaks with a visiting doctor.

Merriman would eventually be invited to Kenya to set up a hospice care program in Nairobi before founding her own organization in 1993, based in Uganda. At that time, palliative care in Africa only existed in Zimbabwe and South Africa, and the services, she says, were “started out by whites for whites.” Medication was prohibitively expensive for most patients. “The strongest they had there was codeine — if you had money. But if you didn’t have money, you only had aspirin and sometimes nothing at all,” says Merriman.

Today, the organization’s three hospice centers serve some 2,100 outpatients. “It’s not always the pain that’s their greatest worry,” she says. “It’s often ‘What’s going to happen to my children when I die?’ It may be spiritual problems, it may be cultural — things they have to carry out before they die. We try to help with all those kinds of things.”

Relieving pain is step one — and it has many benefits. Patients eat better, sleep better and live higher quality lives, even in their last days, says Merriman.

Cost was one obstacle to pain management that Merriman had to address. Another, which persists in many countries, was a deep-rooted fear of opioid painkillers.

Though morphine is considered the gold standard in palliative care for pain management, in many parts of the world fear of opioid addiction and misuse is so rampant it has a name: opiophobia.

Merriman ran up against opiophobia in Singapore and Uganda, where she says, people thought she was providing morphine so that patients could kill themselves. “And morphine can kill,” she says. But with the right regulations in place, and the right explanation to the patient and their relatives, she says, “it’s very safe.”

For over a decade, the Ugandan government has provided morphine free to the patients of prescribers who are members of a special registry, all trained through Hospice Africa Uganda.

“You’ve got to be careful, everything has to be signed for and we have to follow the regulations,” she says. “But for the last three years, we’ve been making morphine for the whole country.”

Merriman says of the 24,000 patients in total that they have prescribed oral morphine to, “we’ve had no addiction, no diversions. And the patients keep the bottle at home.”

In Uganda, she had to work hard to surmount the fear of opioids. For example, Hospice Africa Uganda worked with narcotics police, teaching them what morphine is and that it’s a legal medication.

“They need to understand that patients can take morphine and that they are not addicted, that it is handed to patients after careful assessment, and that it is a safe medication,” says Dr. Eddie Mwebesa, clinical director at Hospice Africa Uganda. Without police cooperation, he says, “there will be a lot of trouble with patients having their morphine in the home” and in transporting the drug between hospices or patient homes.

Clinicians prescribe the morphine and instruct patients to sip a dose from a marked cup. For adults, it’s usually about a teaspoon every 4 hours. Merriman says hospice workers frequently have to warn people about morphine — not because of the risk of addiction but to explain that it will not wipe out their illness. She says they feel so good after it, they often feel normal again. “They think we’ve cured them,” she says.

Even with the innovations in Uganda, there are still challenges. The organization estimates that only 10 percent of Ugandan patients in need of palliative care can access it.

“The biggest challenge we have right now is the sheer number of patients who need palliative care,” says Mwebesa — he puts the number at 250,000 to 300,000. But there is about one doctor for every 20,000 Ugandans, he says.

A palliative care physician
A palliative care physician visits an HIV-positive patient who lost her family to the AIDS epidemic. She’s resting on a mat outside her home.

Mwebesa says palliative care can cost about $25 each week for one patient. “It doesn’t sound like a lot,” he says, “But actually most people can’t afford it.” Only 2 percent of Ugandans have health insurance, so many families have to pay out-of-pocket to care for sick relatives.

Even though Uganda is far from perfect, it remains in many respects a model country for its neighbors. “We had the minister of Swaziland visit Uganda to see how Uganda reconstitutes oral morphine and then when we went back, they started doing the same,” says Dr. Emmanuel Luyirika, executive director of the African Palliative Care Association. He says the same happened with Rwanda and Malawi.

Merriman is now turning her attention to French-speaking countries in Africa. She says some countries in the region remind her a lot of Uganda back in the ’90s. “They’ve got a fear of morphine. Doctors don’t want to prescribe it because they think if they prescribe it, they’ll be accused of being addicts themselves,” she says. World Bank data shows the region has the world’s highest maternal mortality and lowest national health budgets. And people there largely pay for health care out-of-pocket.

“If you haven’t got money,” says Merriman, “you can’t even get an aspirin.” At age 80, she’s still determined to see that the dying don’t have to face such dilemmas when they seek relief from pain.

Complete Article HERE!

Wellness Corner January 2016 – California’s End of Life Options Act

by Veronica Jordan, MD

California’s End of Life Options Act

Calfornia’s End of Life Options Act

Imagine you are sick, really sick. Actually, you are dying. Things feel out of your control. You are in pain, or extremely weak. Perhaps you feel too ill to enjoy the things you love to do. You want to know your options – you want to know what the rest of your life will look like, but you also want to have some control over your death. Ideally, you’d like to die with dignity.

On Monday, October 5, 2015, California became the fifth state in the nation to legally protect a patient’s right to have a physician assist him/her in dying. The End of Life Options Act, modelled closely after Oregon’s 1997 Death with Dignity Act (DWDA), allows California physicians to provide life-ending prescriptions to patients diagnosed with a terminal illness.

As a primary care physician, it’s important that I understand the details of this new law, and as we all are potential patients, it may also be of interest to you. I want to start with a few interesting facts I found in reviewing Oregon’s 16 years of experience.

1) The number of Oregonians using physician assisted suicide has increased steadily since 1998, though these deaths are still a very small percentage of Oregon deaths. In 1998, there were 16 patients who died with assistance; in 2013, there were 73.  A total of 1,173 patients have received prescriptions, and 752 died with assistance.

2) Most Oregonians who use physician-assisted suicide are over age 65 (in 2013, the range was 42-96 years).

3) Most have cancer (65% in 2013, 80% in 2012). The second most common diagnosis is chronic lower respiratory disease (e.g. chronic bronchitis and emphysema).

3) 97% died at home.

4) 85% were enrolled in hospice care at the time of death.

5) The three most frequently mentioned end-of-life concerns are: loss of autonomy (93%), decreasing ability to participate in activities that made life enjoyable (88%), and loss of dignity (73%).

To whom does the CA law apply?

Per the new law, patients eligible to receive physician assistance must 1) be at least 18 years of age, 2) be residents of California, 3) be considered mentally competent, and 4) be diagnosed with a terminal illness and six months or less to live.

Patients must also be mentally and physically able to self-administer the aid-in-dying drug. Yes, each patient must be physically well enough to take the medication him/herself.

If a patient has a diagnosed “mental disorder”, the physician must refer him/her to a mental health specialist (psychologist or psychiatrist), who is responsible for determining the individual’s capacity to make medical decisions.

Which physicians can assist patients?

The process is legally mandated to be facilitated by a physician with “primary responsibility for the health care and treatment of an individual’s terminal disease”. This will include primary care physicians (i.e internists and family medicine physicians like myself) as well as specialists (e.g cancer doctors, heart doctors). In Oregon, by one measure, 64% of prescriptions were provided by primary care physicians.

How does an eligible patient actually get aid-in-dying?

First, a person who meets the above criteria must submit to their physician an oral request two times, at least 15 days apart. These requests must be done in person, face to face (not on email, telephone, etc) and documented by the physician. The physician must consult with patients in private to prevent coercion from family members.<

Second, a “consulting” physician must confirm the patient’s prognosis through a physical exam and review of medical record.

Third, the patient must submit a written request. The signed request must be witnessed by two people, who must attest the person (a) has capacity; (b) is acting voluntarily; (c) is not being coerced to make or sign the request. Only one witness can be related (blood, marriage, partnership, financial benefit), and only one can work at the healthcare facility where the person is getting treatment.

The patient must communicate with the physician to confirm 48 hours before taking the medications, and he/she must take the medications himself/herself.

The law will not take effect until 90 days after Congress adjourns the special session on healthcare.

Complete Article HERE!