6 Months or Less Diagnose for a Loved One.

Knowing how to offer comfort and support to a loved one who has a terminal illness can be challenging. What can you say or do? How can you help your loved one cope? How will you deal with your own grief? Get the facts about supporting a loved one who is terminally ill.My loved one has been diagnosed with a terminal illness. How might our relationship change?Your relationship with your loved one might not necessarily change because he or she has a terminal illness. If you're concerned, try to build on your relationship's strengths. It's also important to be open to new possibilities. A loved one's terminal diagnosis might improve your relationship. Or unresolved conflicts might present new challenges.Remember that your loved one is still the same person and will still have the same needs and desires as he or she had before the terminal illness. Many people facing terminal illness want to be treated as normally as possible, without always focusing on the illness.How can I help my loved one cope with a terminal illness?Let your loved one know that you're willing to listen to his or her concerns — and never underestimate the value of your presence. Even if it feels as if you're not doing anything, your presence sends an important message. Don't, however, try to be a counselor.Is there a typical emotional process that a person who has a terminal illness experience?Dying isn't a science. Don't assume that a loved one who has a terminal illness is going to go through a methodical process of coming to terms with death. It might not happen that way.Acceptance or accommodation might be the most desirable outcome of the grieving process — learning to live as fully as possible while accepting the presence of a terminal illness.But does your loved one have to accept that he or she has a terminal illness? Does your loved one have to accept that he or she is going to die before he or she expected? No. There's no right or wrong way to come to terms with death.How do you help a loved one who's in denial about his or her impending death?Denial is an important coping mechanism. Your loved one might be in denial because the reality is too frightening, too overwhelming, or too much of a threat to his or her sense of control. A denial is a form of natural protection that can allow your loved one to let reality in bit by bit and continue living as he or she contemplates death.As long as denial isn't causing your loved one significant harm — such as causing him or her to seek out painful treatments of no therapeutic value — then denial isn't necessarily bad.Your loved one might be afraid of pain. Perhaps your loved one is afraid of losing control of his or her bodily functions, mind or autonomy. Your loved one might also fear failing family or become a burden to others.To provide emotional and spiritual support to your loved one, invite him or her to talk about his or her fears. Sometimes, however, it's easier for a dying person to share what he or she fears and explore it with someone other than a family member, such as a Bereavement Professional as Dr. Nicholas Losito, Ph.D.

What are Advance Directives?

Advance directives center around the principles of your right to die and death with dignity. With an advance directive, you can express how much or how little you want done for you when you are no longer able to make these decisions.

• Advance directives are a way of making your voice heard when you can no longer communicate. They allow you to appoint someone to make your health care decisions for you when you no longer can and to administer or withhold treatment and procedures based on your previously stated wishes. Advance directives are not just for the elderly. All people who desire to direct their medical care in the future should complete an advance directive.
• All 50 states and the District of Columbia have laws regarding advance directives. Authorities also agree that no difference exists between withholding lifesaving treatment and withdrawing life-support treatment. This is especially important in a situation where someone is resuscitated despite his or her wishes because the advance directive could not be found and the person is put on life support. Once the advance directive is shown to health care professionals, life-support measures can be withdrawn according to the advance medical directive.
• An advance directive does not mean "do not treat." This is a common misperception and not correct. Of course, if you want it to mean do not treat, then that is something that your surrogate needs to know.
• Proper execution of an advance directive is a delicate task. A person should discuss this with loved ones and consider personal values and beliefs.

• It is also impossible to think about all the possible medical and social scenarios that may happen in the future during the course of a disease and person's lifetime. Thus, people often change their minds contrary to their living wills while still capable of making their own decisions. Living wills can be modified to reflect any such changes.

Definitions Involved in Advance Directives

Advance directives: An advance directive is a written document or series of forms that must be signed to be binding. The documents indicate an individual's choices about medical treatment.
Two types of advance directives are generally completed: a living will and a medical power of attorney (also referred to as designation of a health care surrogate or health care proxy).

• Living will: This written statement tells health care professionals what type of life-prolonging treatments or procedures to perform if someone has a terminal condition or is in a persistent vegetative state. Living wills should not be confused with a regular will. A living will addresses issues regarding your medical care while you are still living.
• Medical power of attorney (or designation of a health care surrogate): This legal document allows you to select any person to make medical decisions for you if you should become temporarily or even permanently unable to make those decisions for yourself. This person is also referred to as your attorney-in-fact or durable power of attorney for health care. Most people choose a family member, a relative, or a close friend as their surrogate decision maker. It is important that the designated person knows and understands your wishes and preferences and has a written copy of either your living will or medical power of attorney.

Life-prolonging treatments: These are procedures that are not expected to cure your terminal condition. They generally are used to sustain life. Examples of life prolonging treatments include mechanical ventilator (breathing machine), kidney dialysis, and cardiopulmonary resuscitation (CPR).
Terminal condition: A terminal condition is an incurable (without cure) condition that is in its terminal stages.
Persistent vegetative state: This permanent coma or state of being unconscious is caused by injury, disease, or illness. No reasonable expectation of recovery exists.
Do not resuscitate (DNR): This document tells health care professionals and emergency personnel that if your heart stops beating (cardiac arrest) or if you stop breathing (respiratory arrest) that they are not to attempt to revive you by utilizing CPR, chest compressions, intubation, or shocking the heart.
Artificial nutrition and hydration: This procedure is the administration of nutrition and fluids through IV lines and feeding tubes. IV (intravenous) hydration is a common proactice in the hospital by which fluids are delivered into veins. Tube feeding introduces liquid food through a nasal or oral tube into the stomach. Sometimes intravenous (IV) antibiotics are also included in this category. The POLST form (Physician Orders for Life-Sustaining Treatment) addresses the patient's preferences regarding artificial hydration and nutrition. This form can be signed by the patient or their decision maker and the treating physician.

Prayer For Today.

Bereavement is diagnosed when the focus of clinical attention is a reaction to the death or loss of a loved one. As part of their reaction to the loss, some grieving individuals present with symptoms characteristic of a Major Depressive Episode (e.g., feelings of sadness and associated symptoms such as insomnia, poor appetite, and weight loss).

The bereaved individual typically regards the depressed mood as “normal,” although the person may seek professional help for relief of associated symptoms such as insomnia or anorexia. The duration and expression of “normal” bereavement vary considerably among different cultural groups.

The diagnosis of Major Depressive Disorder is generally not given unless the symptoms are still present 2 months after the loss. However, the presence of certain symptoms that are not characteristic  of a “normal” grief reaction may be helpful in differentiating bereavement from a Major Depressive Episode. These include:

1. Guilt about things other than actions taken or not taken by the survivor at the time of the death;
2. Thoughts of death other than the survivor feeling that he or she would be better off dead or should have died with the deceased person;
3. Morbid preoccupation with worthlessness;
4. Significant psycho-motor retardation;
5. Prolonged and serious functional impairment; and
6. Hallucinatory experiences other than thinking that he or she hears the voice of, or transiently sees the image of, the deceased person.

Prop-long Treatments

Prolonged grief is a mental illness that affects the patient physically, mentally and socially. As the disease progresses, the individual is at risk for developing a variety of complications that range from mild to severe.

As grief continues to linger, patients are more likely to slide into a deep, profound depression. They have no motivation to perform any task and would rather not interact with the people around them. In the worst cases of depression, the bereaved individual will turn to thoughts of suicide.Without treatment, truly depressed individuals are at a high risk for attempting to kill themselves.

Prolonged grief places a great amount of stress and tension on the affected person. High levels of stress can cause physical illness, the Mayo Clinic warns. Patients suffering from prolonged grief are more likely to suffer from high blood pressure and heart disease. Cancer rates are also elevated in people who suffered from complicated grief.

Unbearable grief often drives people to substance abuse. At first, they turn to mild substances such as alcohol or nicotine but as the grief lingers, patients graduate to more powerful substances like heroin or cocaine. Initially, the individual may turn to substance abuse to alleviate the symptoms of grief; however, over time, they will become addicted to the substance. Addiction to an illicit substance is a whole other disease that brings its own set of complications and usually exacerbates the effects of a grief disorder.

The most telling complication of prolonged grief disorder (PGD) is the inability to deal with daily living. Even the most mundane chores seem daunting to someone suffering from PGD. They will need care and monitoring from a dedicated caregiver. If the grief is not treated, patients will slowly deteriorate physically and psychologically.

The disease also adversely affects the friends and relatives of a person suffering from PGD. They often feel hurt and helpless when they are unable to help their loved one. Some people react with anger or frustration. In most cases, complicated grief places a massive burden on all of the patient’s relationships. Prompt, comprehensive treatment helps prevent any long-term damage to the patient’s interpersonal connections.

Treatment

There Is No Set Treatment Modaity that works in  every case of prolonged grief disorder. Most Medical Professional will design a Treatment Plan that Best Suits the Patient's Specific Symptoms and Life Situation.

The pharmacological options for complicated grief have yet to be established. Antidepressants are the most often used medications as they help patients deal with the symptoms of grief-associated depression. In most cases, pharmacological treatment is secondary to psychotherapy.The best treatment plans use a mix of psychotherapy and medications. In psychotherapy, therapists guide the patient into the basis and foundation of their grief. Patients are encouraged to explore their reaction to grief, their symptoms and their personal goals. An article in Clinical Psychology and Psychotherapy recommends that therapists attempt to redirect the patient’s goals from inward-directed goals (making themselves feel better) to outward-directed goals (goals related to outside events). Therapy should provide the patient with coping mechanisms that reduce feelings of blame and grief.

Interventions

While in the midst their grief, most people are unable to even consider treatment. The longer the grief lasts, the less likely they are to seek treatment for their depression. If left alone, people with prolonged grief are likely to suffer severe complications.

Luckily, most grief-stricken individuals are surrounded by friends and relatives who are willingly to support and help them. Most relatives will recognize the symptoms of prolonged grief disorder and suggest the subject seek medical help. This is usually enough, but in some cases, the patient is resistant to treatment. They may believe that their grief is normal, that they deserve to suffer or that the grief is the best way to hold on to what initially caused the grief.

Overcoming this resistance is usually too difficult for most families. Therefore, instead of approaching the patient on their own, families will employ a professional interventionist and stage an intervention. During the intervention, the team is able to vocalize the numerous adverse effects the prolonged grief has caused. Ideally, the patient will then consider the presented information and agree to undergo treatment.

If you have any questions about interventions, or would like help staging an intervention for your grief-stricken loved one, contact Dr. Losito today. Dr. Losito Is here to help.

Compassion Fatigue

Every career path has its stressors and can cause burnout, but for funeral directors, burnout and

 stress are more prevalent. Funeral director burnout, commonly known as compassion fatigue, can happen to even the most dedicated individuals. Whether you’ve been helping families bury their loved ones for many years or have just started, it’s important to find ways to keep stress at bay and reduce your chances of burnout/compassion fatigue.

Compassion Fatigue

So what exactly is compassion fatigue? It is known as funeral director fatigue syndrome by some, and is the more medical or formal term for burnout. It can be characterized by these symptoms:

• Isolation
• Irritability & impatience
• Energy loss & exhaustion
• Depression & physical complaints
• Detachment & cynicism

Battling Compassion Fatigue

How do you combat burnout? First, take time for you. In any high-stress situation, neglecting yourself over a long period of time to give to others will eventually take a toll on you. Maintaining a healthy lifestyle, including diet, rest, and exercise will go a long way toward keeping equilibrium in your life.

Make your time off count. In a family-run funeral home, the atmosphere is generally more laid back. If you’re not busy and your family is nearby, take a little break to spend time with them, like a few minutes hiking/walking and enjoying the outdoors, or a mini-date with your spouse. The little things you make time for will keep you grounded and balanced with work/family life.

Set some boundaries for work. Funeral directors have been expected to be in a 24/7 on-call position for years, but with technological advances, it’s easier to pull away a little and still ensure your responsibilities are handled without losing the personal touch you’re accustomed to giving. Call answering services, remains removal services, and paperwork and filing assistance are a few of the services available to funeral directors. You’ll gain more time away from the funeral home and can handle some situations remotely, making it easier to take a vacation or rest at home.

No matter how long you have been a funeral director, the stress can get to you and cause burnout. In order to reduce your chances of experiencing compassion fatigue, review some of these stress-inhibiting actions that can do a great deal to keep burnout from taking over and ruining your happy life or cause you to rethink your choice as a funeral director.

Grief and Grieving - Treatment Overview

Grief  itself is a natural response that doesn't require medical treatment. But sometimes people need help getting through the grieving process.

Initial grief

• Medicine. During the initial days of grief, anxiety or sleeplessness can make it difficult to function. If you suffer more than a few days of severe agitation, talk to your doctor about whether a short-term prescription sedative medicine can help you. (Doctors disagree about the usefulness of medicines for people who are grieving. Some doctors believe that giving medicines for anxiety or sleep may interfere with the ability to grieve.)

• Counseling. If you find that obstacles to grieving are making it difficult to function after a loss, talk to Dr. Losito at 877-867-8556 , attend a bereavement support group, or both. Counseling and support groups can also help you work through unresolved grief from a past loss.

Chronic grief and complications

If you or someone you know exhibits suicidal behavior  (such as thinking you cannot stop yourself from harming or killing yourself), call 911 or other emergency services immediately.

If you find that a major loss has caused complications, such as depression, prolonged anxiety, post traumatic stress disorder (PTSD), or severe and prolonged grief, see your doctor and a grief counselor for treatment.

If you have a chronic medical condition that has been made worse by the emotional and physical stress of grief, see your doctor immediately.

My Own Bereavement

My father died at noon on my Birthday when I was 36years old, so I can understand why people grieve during the Holy Season;  Although, my father had been ill for few years, I felt the bizarre combination of shock, loss, and relief. I even felt joy because he was finally out of pain and with Jesus. During the next few months, those emotions constantly bounced around inside of me until I felt like my mind was playing the old children’s game of Fruit; consequently, I was not able to look at a French Fry in the Face for many months. 

Basket Turn Over. One day, I was able to feel joyful, the next, I grieved, the next I felt totally lost.

Late on that Christmas afternoon, I returned to my apartment. When I opened the door I heard joyful voices singing, “We Wish You a Merry Christmas!” In my haste, I had left the Christmas music playing. The colorful lights on our tree were cheerfully twinkling, seeming to mock my father’s death. “How could anybody die on Christmas day?” I asked myself. Everything felt surreal. I felt a little crazy, but later I learned that my feelings were the normal responses to shock and grief.

Until my father died, I had not experienced the death of anyone close to me. I had no idea how to bear grief. I decided to ignore my grief and pretend that my father was still alive until the very next Christmas. That sounds a little crazy, but I know now that it was the only way I could temporarily cope. I had to finally face the loss of my father and learn how to bear grief. In fact, that very next Christmas continued to face this Holy Day could not be same from previous Christmases.  Christmas was the Holy Day my Father provided a sense of care and concern to all. Now this had to be restructured to something completely all new. 

Your grief

I know that many people are experiencing loss at this time of year, especially. For example, you may have been divorced since the last Christmas or one of your sons or daughters may be at war or a friendship may have been broken over the last year. Perhaps it’s health problems that have robbed you of many activities that were common to your life before this year or someone you love may have died.

Grief is an experience that is common to everyone. Nobody who has ever lived on this earth has been able to avoid it, but it often comes to us when we least expect it. We can easily be overwhelmed and stuck in grief for years, if we do not have some understanding of it.

Getting Through Grief

Since my father died, I have learned three things that have helped me deal with grief.

1. Grief usually comes in waves, which lasts about 20 to 30 minutes.

The body cannot sustain such strong grieving for much longer than that. After my father died, I had been afraid that such strong grief would just consume me. I feared that my grief would drag me down into a dark hole and I would never be able to come out again.

When I found out that the waves had a limit, I felt safe to let go, to cry, or talk or write my feelings down. In the months that followed, the grief waves also came less and less. I learned that the Holy Spirit is the God of all comfort (2 Cor.1:1-3) and I learned to ask Him to enter those grief waves with me. He did and He brought comfort. The grief hurt, but I wasn’t nearly as afraid.

2. Emotions don’t know time and space.

Memories are stimulated through the senses. For example, you may hear a familiar song that takes you emotionally back to a very sad place. The smell of potpourri may cause you to think of familiar previous family rituals that can no longer occur. The sight of a Christmas ornament can remind you of people who are no longer alive.

A few years after my father died, an uncle came to visit us. As I hugged him, I smelled Old Spice cologne, which had been my father’s favorite. Suddenly, I felt like a helpless 36 year-old whose heart had just been broken. I didn’t know how to come forward emotionally and I got stuck in a miserable emotional state that Christmas.

Now I remind myself to pay attention to my senses before each holiday season begins. I begin to say to myself, “That was then and this is now.” I learned to pause between the stimuli and my response. I began to practice enjoying what I have “now,” rather than automatically letting myself move emotionally backward in my mind. I have learned to celebrate the season for what it is “right now” in my life, remembering the birth of Jesus, counting the ways His birth has brought blessings and joy into my life.

This was a discipline that I had to practice and, year by year, this process has helped me live in the present.

3. Confine and assign time to your feelings

We don’t need to ignore our feelings altogether, but it’s helpful to deliberately make a time and place for them.

I began to set aside a period of time to think about my father. Sometimes I wrote about him in a journal. Other times I talked about him to my children, sometimes I lit a Christmas candle and gave thanks for him. I also looked through a scrapbook of my childhood. However, I placed a time limit on my grief and nostalgia.

I had to exercise my will to do this, making a decision to invest most of my energy into the family members who were still with me, serving friends and strangers who had needs. I invested my energy more and more into serving than grieving, and creating new memories, rather than looking back.

Years from now, you may find yourself writing or telling your grief story. Your pain will be less, because you will have experienced the Lord’s comfort. You will have also practiced the process of grieving. You will know that every day is a new day. Every day will train you to help others in grief, just as our Lord promised.

There’s no doubt that the holidays can be a sad time for those of us who are experiencing loss. But with God’s strength and grace, He can help us make it through the sadness finding peace and healing that is found in Him –The Prince of Peace. Jesus continues to seek and find us at Christmas, bringing hope to our hurting hearts.  

Dr. Nicholas Losito, Ph.D, CISM,  is the Clinical Director of Hand of  Compassion. He is available for further consults and support during the Christmas season and right through into the New Year. 

When a loved one dies, grief can feel like a dagger in your heart. Often, grief triggers raw, intense emotions. You might wonder how you'll ever pick up the pieces and heal your wounds — yet not feel as if you're betraying your loved one's memory.

There are no quick fixes for the grief and anguish that follow a loved one's death. As you face your grief, acknowledge the pain and know that it's part of the healing process. Take good care of yourself, and seek support from friends and loved ones.

Although your life will never be quite the same, the searing pain of grief will eventually become less intense. Accepting your new "normal" can help you reconcile your losses and move on with your life.

Continue to see out assistance from your local Primary Care Mental Health Provider and you are to contact Dr. Nicholas Losito, Ph.D, CISM, at Hand of Compassion.

Coping with reminders after a loss

When a loved one dies, you might be faced with grief over your loss again and again — sometimes even years later. Feelings of grief might return on the anniversary of your loved one's death, birthday or other special days throughout the year.

These feelings, sometimes called an anniversary reaction, aren't necessarily a setback in the grieving process. They're a reflection that your loved one's life was important to you.

To continue on the path toward healing, know what to expect — and how to cope with reminders of your loss.

Reminders can be anywhere

Certain reminders of your loved one might be inevitable, especially on holidays, birthdays, anniversaries and other special days that follow your loved one's death.

Reminders aren't just tied to the calendar, though. They can be tied to sights, sounds and smells — and they can ambush you. You might suddenly be flooded with emotions when you drive by the restaurant your partner loved or when you hear your child's favorite song. Even memorial celebrations for others can trigger the pain of your own loss.

What to expect when grief returns

Anniversary reactions can last for days at a time or — in more extreme cases — much longer. During an anniversary reaction you might experience:

• Sadness
• Loneliness
• Anger
• Anxiety
• Trouble sleeping
• Fatigue
• Pain

Anniversary reactions can also evoke powerful memories of the feelings and events surrounding your loved one's death. For example, you might remember in great detail where you were and what you were doing when your loved one died.

Tips to cope with reawakened grief

Even years after a loss, you might continue to feel sadness when you're confronted with reminders of your loved one's death. As you continue healing, take steps to cope with reminders of your loss. For example:

• Be prepared. Anniversary reactions are normal. Knowing that you're likely to experience anniversary reactions can help you understand them and even turn them into opportunities for healing.
• Plan a distraction. Schedule a gathering or a visit with friends or loved ones during times when you're likely to feel alone or be reminded of your loved one's death.
• Reminisce about your relationship. Focus on the good things about your relationship with your loved one and the time you had together, rather than the loss. Write a letter to your loved one or a note about some of your good memories. You can add to this note anytime.
• Start a new tradition. Make a donation to a charitable organization in your loved one's name on birthdays or holidays, or plant a tree in honor of your loved one.
• Connect with others. Draw friends and loved ones close to you, including people who were special to your loved one. Find someone who'll encourage you to talk about your loss. Stay connected to your usual support systems, such as spiritual leaders and social groups. Consider joining a bereavement support group.
• Allow yourself to feel a range of emotions. It's OK to be sad and feel a sense of loss, but also allow yourself to experience joy and happiness. As you celebrate special times, you might find yourself both laughing and crying.

When grief becomes overly intense

There's no time limit for grief, and anniversary reactions can leave you reeling. Still, the intensity of grief tends to lessen with time.

If your grief gets worse over time instead of better or interferes with your ability to function in daily life, consult a grief counselor or other mental health provider. Unresolved or complicated grief can lead to depression and other mental health problems. With professional help, however, you can re-establish a sense of control and direction in your life — and return to the path toward healing.

Reaching Out

Not the Panacea

Almost 19 million Americans have periods where they feel a lack of pleasure or interest in what was once pleasurable and interesting. They feel tired and heavy, potentially overly emotional or numb, and experience an onslaught of negative and self defeating thoughts that can keep  invading the mind over and over again. The more periods of this depressed mood we have in life, the more likely we are to fall back into them again. Why does this relapse occur and how can mindfulness offer hope?

Falling into a depression feels traumatic and just like getting bit by a dog causes us to be fearful of and oversensitive to dogs, our minds and bodies become oversensitive to associations with the depression causing our brains to flinch at any sign of a relapse.

Feeling low mood is normal for everyone, but if we’ve experienced depression in the past, this may be a trigger for a relapse. If we feel tired or if we notice sadness, the mind pops up with the worry “uh oh, that is how I felt when I was depressed, maybe I’m getting depressed”. Our minds begin to go in overdrive with negative self judgments, “I am a failure” or “I am weak” or “I am worthless”. It then tries to solve the mystery as to why we are becoming depressed again and the more it tries to solve this puzzle, the deeper it sinks into depression. Think of a worried, judging person coming at you trying to solve your problems when you’re already not feeling well. Probably not what you’re looking for. You see, it’s not the low mood that’s the problem here, it’s the way we get stuck in habitually relating to it that pours kerosene on the fire, with our minds continuing to fan the flame rolling us into a full blown depression.

The practice of mindfulness teaches us a different way to relate to our thoughts, feelings, and emotions as they arise. It is about learning to approach and acknowledge whatever is happening in the present moment, setting aside our lenses of judgment and just being with whatever is there, rather than avoiding it or needing to fix it. It’s the mind’s attempt to avoid and fix things in this moment that fuels the negative mood.

With Uncomfortable Emotions

If sadness is there, instead of trying to fix it or figure it out, we might just acknowledge the sadness, let it be and get a better understanding of what we need in the moment.

With Self-Judgments

If self-judgments arise (e.g., I am weak, I am a loser) out of past sensitivities to having been depressed before, we can acknowledge that they are associations from the past, let them be, and then gently bring ourselves back to whatever we were doing. In doing this, we’re stopping the ruminative cycle that might occur between our thoughts, feelings, physical sensations and behaviors that can play off one another leading into another relapse (I call this “The Depression Loop” in the upcoming book Uncovering Happiness).

Now, this is easier said than done and it takes practice.

Confidence with Rumination Practice:

Let’s get our hands (or minds) into it. One way to practice mindfulness is to use the breath as an object of awareness. You can place attention at the tip of the nose or the belly and as you breathe in, just acknowledge the breath coming in and as you breathe out just acknowledge the breath going out. As if you were greeting and saying goodbye to an old friend. When the mind wanders, as it will always do, just say to yourself “wandering” and then gently bring your attention back to the breath just noticing it coming in and going out. Most of us catch the mind wandering and gently bring it back billions of times, so know that it is normal for the mind to wander often. You can do this for as little as 1 minute or as much as 30 minutes or more.

Practice this when you’re feeling well and you’ll be better able to recognize when your mind wanders off to ruminations and self judgments when you’re not feeling well.

What does this have to do with gaining confidence over rumination?

Like learning an instrument, you can develop more skill as you practice. When you’re not feeling well and the mind begins to ruminate, as you practiced with the breath, just label it as “ruminating” and then gently bring your attention back to whatever you were doing. Being more present may also give you the ability see the space between stimulus and response and see the “choice point” to  be more flexible and call a friend or do something that then gives you pleasure or connection with others.  This is what I’ve referred to as The Now Effect. 

Know that practicing is an act of self care and helps stop the cycle of rumination and cultivates more patience, compassion, and peace.  

Mindfulness is not a panacea for depression, but it’s a good foundation for preventing relapse.

As always, please write below with any comments, questions, thoughts, or additions that arise after reading this. Your comments below help provide a living wisdom for us all to share and benefit from.

What is “Palliative Care”?

The World Health Organization defines palliative care (PC) as “an approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness, through prevention of and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychological and spiritual.” To meet these multidimensional needs, PC is usually provided by a team including physicians, nurses, social workers, and chaplains. Patients can receive PC at any time along the trajectory of a serious or life-threatening illness. (This is distinguished from hospice care, a subset of PC that is reserved for end of life treatment.) PC can also be provided in conjunction with treatments aimed at life prolongation. For example, a patient with metastatic breast cancer may be treated by an oncologist who focuses on cancer treatment while a PC team focuses on management of symptoms (pain, nausea, shortness of breath, depression, anorexia, fatigue, spiritual distress, etc) and assists with advance care planning.

In the United States, PC is generally provided as an inpatient or outpatient consultation. Providers may request a PC consultation to assist with clarification of the patient’s goals of medical care, symptom management, communication between the medical team(s) and the patient and family, prognostication in advanced illness, advance care planning, and end of life (EOL) care. For instance, a common consultation is to help a patient with advanced liver disease to understand the severity of the illness and treatment options, and to manage pain, shortness of breath, and nausea.

The ultimate goals of consultation are to treat symptoms of advanced illness and to assist patients and families in understanding their prognosis, in expressing the goals (or most important factors) in their medical care, and in receiving medical care that is aimed at achieving their goals of care. For example, is the patient with liver disease more interested in staying in the hospital to receive intravenous therapies of marginal benefit or in returning home to spend time with family and friends?

Hospice Care
Hospice care, by contrast, is a specific type of palliative care for patients nearing the end of life. In the United States, hospice refers to a healthcare benefit provided through Medicare Part A or private insurance. A patient is eligible to receive hospice care if two physicians certify that he or she has a life expectancy of six months or less if the “disease runs its usual course.” In addition, the patient must choose to trade standard Medicare Part A (inpatient) coverage for the hospice benefit, which covers medical care that is usually provided in the home and is focused on comfort and relief of suffering rather than life prolongation. Patients with any end-stage disease (heart failure, dementia, COPD, HIV, cancer) are appropriate for hospice referral. Hospice care is the form of PC that most physicians are familiar with; however PC is a much broader discipline.

Discussing End of Life Care with Patients
In addition to focusing on the relief of suffering, palliative providers are often involved in discussions about advance care planning and EOL care. For example, we may discuss prognosis, current treatment options, and options for future care with a patient with end-stage COPD. Specifically we would talk about what is most important to the patient in the time they have left to live and how their medical care can help them to achieve these goals. We would review if the patient is interested in intubation/ICU care or care that is entirely focused on their comfort in the event of a future COPD exacerbation.

There is a robust body of literature demonstrating that the majority of patients want to have these discussions with their providers, yet fewer than 50% of patients actually do (Reilly et al, Arch Intern Med 1994:154(20):2299–2308). Providers often cite barriers to having these conversations, such as a lack of training, lack of time, and concern that such discussions may harm patients or “take away their hope.”

Multiple studies have evaluated the effects of these conversations on patients’ treatment choices, quality of life, and mental health in addition to the effects on caregivers’ quality of life, mental health, and perception of the patient’s death. The Coping With Cancer study was a multisite prospective cohort study of 332 patients with metastatic cancer who progressed through first-line chemotherapy, and their caregivers (Wright et al, JAMA 2008:300(14):1665–1673). The 37% of patient/caregiver dyads who reported having a discussion about end of life care with their providers were compared to the dyads who reported not having these conversations. The patients who had the discussions were more likely to prefer medical care focused on relief of pain and suffering over life-extending treatments. These patients also were more likely to complete a DNR order and less likely to be admitted to the ICU, receive mechanical ventilation, or undergo a resuscitation attempt. Interestingly, patients who received less aggressive care experienced a better quality of life without a decrement in survival time. EOL discussions were not associated with patients feeling depressed, sad, terrified, or worried or meeting DSM criteria for a psychiatric disorder.

Their caregivers benefitted, too. Caregivers of patients who received aggressive care in the last week of life were more likely to develop major depressive disorder, experience regret, feel unprepared for the patient’s death, and report poorer quality of life and health after the patient’s death. This study supports the concept that EOL discussions and less aggressive EOL medical care are associated with better quality of life among patients and their caregivers.

Patients report that the manner in which EOL discussions are held is as important as the content of the discussions. According to current research, cancer patients in Western countries want realistic, truthful information that is delivered with a focus on what can be done (symptom management, emotional support, practical support, and maintenance of dignity). They value discussions in which the provider explores realistic goals as a means of fostering hope. Such goals might include control of pain and shortness of breath so patients can spend more time talking with their families. Patients feel that a discussion of what the future may hold should be well-timed. They want the information to be given when loved ones can be present and when the provider can spend an adequate amount of time with them. Lastly, patients value respect for their emotional state and an acknowledgement of the emotional, spiritual, and existential impact of having a life-threatening illness.

TCPR’S VERDICT: Given the heavy emotional burden associated with advanced illness, there has always been a significant role for psychiatry in PC. An important demonstration of this role is the inclusion of psychiatry as a specialty supporting the subspecialty of Hospice and Palliative Medicine. The challenge ahead is to further develop strategies for advancing the collaboration between providers of palliative and psychiatric care.

Bereavement Support

1. Smile. Put a smile on your face and in your eyes, voice and heart as often as possible.
2. Make eye contact. Look people openly, warmly and squarely in the eye.
3. Open your body language. While facing the person with whom you are talking, open your chest, your heart and your arms.
4. Address people by name. Honor people by calling them by name as you greet them, give them thanks, ask a question or bid them farewell.
5. Speak with a friendly tone. Warm your tone of voice with love and kindness.
6. Be present. Give your complete and undivided attention to others when they are speaking to you.
7. Express gratitude. Focus your attention on the goodness in others, verbalize all that you appreciate and give thanks.
8. Slow down. Breathe and gift yourself and others with time to address situations and transition from them.
9. Reflect empathy and compassion. Honor people’s emotional experiences. Normalize and validate their feelings so they feel heard, known and understood.
10. Have integrity. Keep your word. Do what you say you are going to do.  Live according to your values.
11. Have good manners. Be polite, conscientious and gracious.
12. Demonstrate thoughtfulness. Get out of your own head and be of service to others. Consider their feelings and experiences.
13. Give genuine compliments. Tell others their strengths, give positive feedback and express what you admire about them.
14. Give salutations. Make the effort to open and close verbal and email interactions with a nice greeting or closure, rather than abruptly asking for something with neither a hello nor goodbye.
15. Be generous. Give and share whatever you can, whenever you can.
16. Be kind. Be the bigger person. Kindness is a choice. 
17. Show compassion. Demonstrate self-compassion by cutting yourself some slack extend this same compassion to others.
18. Be patient. Breathe and breathe out. Patience is a virtue.
19. Demonstrate self-awareness. Notice the impact you have on others by paying attention to their facial expressions, tone and body language. Consider how what you are saying will feel to them and how it will impact them. Make adjustments accordingly.
20. Be truthful. The truth has different layers and sometimes the deepest layer is hurtful or inappropriate. Speak the truth from the deepest layer that is appropriate. Speak from a place of kindness.
21. Be reliable. Follow through with responsibilities and commitments with competency and effective communication.
22. Be forgiving. Each time somebody else makes a mistake it is an opportunity for you to extend kindness and compassion and to let go of resentments that keep you tethered to the past.
23. Apologize. We are human and nobody is perfect. When you make a mistake, make an amend or extend a sincere and timely apology.
24. Take responsibility. Drop the defensiveness and the excuses and accept responsibility for yourself, your actions and your behaviors.
25. Express love. Be open-minded and non-judgemental. Extend love to yourself and to others. Choose to be loving whenever possible—it is always possible.

When to Refer for Medical Treatment

When Grief develops into clinical depression one (1) and family does not know to pinpoint
the Symptoms accurately. For this reason the symptoms and the psychological aspects have been out lined for your education and understanding for this diagnose.

Signs and Symptoms:

Early morning awaking

Serious Weight Loss

Anhedonia:

"The loss of joy," is defined as a lack of the feelings of enjoyment or accomplishment that typically accompany pleasurable events such as socializing with friends, eating a good meal and sex. An individual who is experiencing Anhedonia may no longer feel a desire to go to work, attend classes, manage their health, interact with other people, or engage in hobbies or entertainment. Anhedonia is a common symptom of mood disorders such as major depressive disorder or dysthymic disorder, but it can also be experienced independent from a diagnosed mental health condition. -

Agitation: The Causes

Agitation can come on suddenly or over time. It can last for just a few minutes, or for weeks or even months. Pain, stress, and fever can all increase agitation.
Agitation by itself may not be a sign of a health problem. However, if other symptoms occur, it can be a sign of disease.  Agitation  with a change in alertness (altered consciousness) can be a sign of delirium. Delirium has a medical cause and should be checked by a health care provider right away.
 
Causes

There are many causes of agitation, some of which include:

• Alcohol intoxication or withdrawal
• Allergic reaction
• Caffeine intoxication
• Certain forms of heart, lung, liver, or kidney disease
• Intoxication or withdrawal from drugs of abuse (such as cocaine, marijuana, hallucinogens, PCP, or opiates)
• Hospitalization (older adults often have delirium while in the hospital)
• Hyperthyroidism (overactive thyroid gland)
• Infection (especially in elderly people)
• Nicotine withdrawal
• Poisoning (for example, carbon monoxide poisoning)
• Theophylline, amphetamines, steroids, and certain other medicines
• Trauma
• Vitamin B6 deficiency

Agitation can occur with brain and mental health disorders, such as:

• Anxiety
• Dementia (such as Alzheimer's disease)
• Depression
• Mania
• Schizophrenia

When to seek Dr. Losito's help for grief ?

If you recognize any of the above symptoms of complicated grief or clinical depression, talk to a mental health professional right away. Left untreated, complicated grief and depression can lead to significant emotional damage, life-threatening health problems, and even suicide. But treatment can help you get better.

Contact a grief counselor, Dr. Losito, if you:

• Feel like life isn’t worth living
• Wish you had died with your loved one
• Blame yourself for the loss or for failing to prevent it
• Feel numb and disconnected from others for more than a few weeks
• Are having difficulty trusting others since your loss
• Are unable to perform your normal daily activities

Common Symptoms of Grief

 

While loss affects people in different ways, many experience the following symptoms when they’re grieving. Just remember that almost anything that you experience in the early stages of grief is normal—including feeling like you’re going crazy, feeling like you’re in a bad dream, or questioning your religious beliefs.

• Shock and disbelief – Right after a loss, it can be hard to accept what happened. You may feel numb, have trouble believing that the loss really happened, or even deny the truth. If someone you love has died, you may keep expecting him or her to show up, even though you know he or she is gone.
• Sadness – Profound sadness is probably the most universally experienced symptom of grief. You may have feelings of emptiness, despair, yearning, or deep loneliness. You may also cry a lot or feel emotionally unstable.
• Guilt – You may regret or feel guilty about things you did or didn’t say or do. You may also feel guilty about certain feelings (e.g. feeling relieved when the person died after a long, difficult illness). After a death, you may even feel guilty for not doing something to prevent the death, even if there was nothing more you could have done.
• Anger – Even if the loss was nobody’s fault, you may feel angry and resentful. If you lost a loved one, you may be angry with yourself, God, the doctors, or even the person who died for abandoning you. You may feel the need to blame someone for the injustice that was done to you.
• Fear – A significant loss can trigger a host of worries and fears. You may feel anxious, helpless, or insecure. You may even have panic attacks. The death of a loved one can trigger fears about your own mortality, of facing life without that person, or the responsibilities you now face alone.
• Physical symptoms – We often think of grief as a strictly emotional process, but grief often involves physical problems, including fatigue, nausea, lowered immunity, weight loss or weight gain, aches and pains, and insomnia.

FINISH THE SENTENCE

Finish the following sentences.

The thing that makes me feel the saddest is .....

If I could talk to the person who died I would ask….

Since the death my family doesn’t….

My worst memory is….

If I could change things I would….

One thing that I liked to do with the person who died was…

When the person died I….

Since the death my friends….

After the death, school….

When I am alone….

Is there anyone you want to share this with?